Social Behaviour and Network Therapy for Alcohol Problems

Alex Copello, Jim Orford, Ray Hodgson, Gillian Tober

• Publisher: Routledge
• Year: 2009
• Print ISBN: 9781583918029
• eBook ISBN: 9781135213305
• Topic: Psychology
• Subtopic: Addiction in Psychology
• Index: Psychology

Highly Commended in the Psychiatry category at the 2010 BMA Medical Books Awards!

This book serves as a manual for clinicians working with people with alcohol problems. The manual is based on previous research in addiction treatment, including family and social network interventions, as well the authors' own work developing and evaluating Social Behaviour and Network Therapy (SBNT) for example in the United Kingdom Alcohol Treatment Trial (UKATT).

Containing a range of ideas the book is guided by a key principle: the development of social support for a positive change in drinking behaviour.

Divided into three sections topics include:

• an introduction to the evidence base underpinning SBNT
• core components of the treatment
• common questions asked about the intervention.

Featuring a series of practical handouts, this book will be essential reading for clinicians, counsellors, nurses, psychologists and all those involved in the treatment of alcohol misuse and dependence.

PART 1
Background, evidence base, treatment content and format

CHAPTER 1
Theoretical and research basis for Social Behaviour and Network Therapy

BACKGROUND

Social Behaviour and Network Therapy (SBNT) is derived from a number of different social and family approaches to the treatment of alcohol problems and aims to work with a positive part of the client’s social network to provide a coherent set of coping strategies for both the person with the drinking problem and network members such as family, friends and work colleagues. These coping strategies can be used both within the treatment period and following treatment completion. Research evidence has informed the development of SBNT and some of this evidence is discussed. The following section is not meant to include a comprehensive review of the research literature in this area. Instead, our aim is to highlight some of the key evidence that has informed the development of SBNT. For a more detailed consideration of some of the areas discussed, the reader is referred to the research papers and reviews quoted.

Early overviews of the alcohol treatment literature (e.g. Holder et al. 1991; Finney and Monahan 1996) suggested that the social components of treatment for alcohol problems (e.g. Community Reinforcement, Social Skills Training, Behavioural Marital Therapy) were among those with the greatest evidence of positive treatment outcome when compared with other types of treatment. More recent reviews have confirmed this conclusion. After a comprehensive and systematic review of the alcohol treatment literature, Miller and Wilbourne (2002:276) concluded that ‘Attention to the person’s social context and support system is prominent among several of the most supported approaches’. In 2007 a systematic review of the clinical and cost-effectiveness of interventions involving families and friends in alcohol misuse and dependence analysed the results of thirty-four randomised controlled trials (Meads et al. 2007). Results suggested that compared with other interventions, therapies involving families and friends led to higher percentage of abstinent days, improved family functioning and were more effective at encouraging treatment entry rates for the problem drinker.

Research has supported the notion that social networks can be highly influential in terms of helping people with drinking problems to initiate treatment (e.g. Barber and Crisp 1995; Meyers and Smith 1995; Meyers et al. 1996; Miller et al. 1999), in affecting the course and outcome of interventions (e.g. McCrady et al. 1986, 1990; Stout et al. 1987, 1990; Stanton and Shadish 1997) and influencing the likelihood of relapse and long-term maintenance of change (e.g. Marlatt and Gordon 1985; O’Farrell et al. 1993; McCrady et al. 1999). In her paper entitled To have but one true friend’, Barbara McCrady (2004) explores the role that social networks play in the recognition and resolution of drinking problems. Important factors discussed by McCrady include the structure of social networks, the influence of social networks on the person with the drinking problem in terms of problem recognition and help-seeking, the influences on treatment outcome and the involvement of the networks both during treatment and after care. McCrady (2004) discusses the evidence for the positive and negative impacts that social networks can have. The author goes on to suggest that social networks of people with alcohol problems can both support and impede successful recognition and change and suggests that alcohol treatment needs to pay close attention to the role of social networks in terms of problem recognition; assisting treatment entry and involvement and support both during and after treatment periods.

Findings from the Project MATCH Research Group (1997), the largest study of treatment for alcohol problems, provide further evidence of the central role that social factors can play in drinking behaviour. Patients whose social network was supportive of their drinking had poorer outcomes in all treatment conditions. Mohr et al. (2001) conducted further analyses of the MATCH data specifically focused on friends within problem drinkers’ networks. The study found that those clients who reduced the proportion of drinking friends in their social networks drank less at follow-up when compared with clients who continued to have a high proportion of drinking friends. Also, the study reported that an increase in the number of non-drinking friends at follow-up was associated with a reduced number of drinks per drinking day. In addition, Longabaugh et al. (1993) had previously shown that poorer outcomes for drinking were associated with networks that were not supportive of abstinence in clients pursuing this goal. It therefore becomes important to attempt to both enhance and increase network support for the client’s chosen drinking goal as well as to decrease any support for the continuation of problem drinking.

THE IMPACT OF AN ALCOHOL PROBLEM ON SOCIAL NETWORKS

Previous research into the effects of drinking on close family (Orford et al. 1975, 2005; Yates 1988) or colleagues at work (Molloy 1989) illustrates the importance of a clear and shared understanding of the problem by all those affected. This research suggests that when individuals begin to drink heavily, people around them including family and friends do not always have sufficient knowledge to decide whether or not their drinking is excessive, and if they do know it is excessive, they often do not know what to do about it or how to respond. A common scenario is that members of the network either ignore the problem or talk to people other than the person experiencing the drinking problem about the situation. On occasions, their actions may unwittingly compound the drinking problem. The message that the network gives to the person with a drinking problem will affect the situation (Leventhal et al. 1980; Hasin 1994). SBNT addresses the problem of confusion in the network of the person with a drinking problem by helping both the latter and the network to come to a decision about whether or not a drinking problem exists. Providing information about drinking alcohol and its effects can be helpful in this process. The therapist also seeks to utilise the concerned network member’s desire to help and attempts to unify the message that the network gives to the person with the drinking problem.

In his book Fragmented Intimacy Peter Adams (2008) offers an insightful view of addiction problems within a social context. Discussing the initiation of treatment, Adams highlights the dangers of services that are normally focused on the individual with the addiction problem, adding further fragmentation into the social system. Family members, reassured by the fact that their loved one is in contact with expert help, may withdraw in order to allow the services to deliver their expert interventions. However, there is a danger that when progress is slow or problematic, family members and those close to the person with the addiction problem, who are mostly excluded from the process, become more confused and continue to distance themselves from their loved one. The social orientation of SBNT attempts to minimise this risk by focusing on and engaging with the social network.

FAMILY AND NETWORK TREATMENTS

There has been a comparatively recent change of emphasis in some of the treatments for alcohol problems involving the widening of the focus of attention to consider the potential value of including concerned friends and family members in treatment and this has been reflected in the higher number of published studies in this area. Two reviews (Copello et al. 2005, 2006a) proposed three types of interventions that involve family members and others concerned and affected by the alcohol or drug use of someone else:

interventions that aim to achieve engagement of the substance user through working with the affected social network (e.g. Pressures to Change, Community Reinforcement and Family Training)

interventions that involve both the users and family and friends jointly in treatment (e.g. Behavioural Couples Therapy, Network Therapy, Social Behaviour and Network Therapy)

interventions that focus on the needs of affected family members in their own right (e.g. Behavioural Exchange Systems; Training Interventions for partners of problem drinkers, the five-step intervention for affected family members).

Evaluations carried out to date suggest that a number of the family and network methods show promise, particularly those focused on problems related to alcohol misuse that have been the focus of most research in this area.

Promoting help seeking and engagement

As stated, some of the approaches have concentrated on working with the spouse and the family in the absence of the person with a drinking problem and some aspects of these approaches have been included in SBNT. An example of these types of intervention is the ‘pressures to change’ approach that uses the family to influence the person with a drinking problem. It starts by engaging the concerned family member in treatment and working with him/her by increasing the understanding of the problem through education, discussing setting up activities incompatible with drinking, exploring the partner’s response to drinking and finally preparing the family member to confront the person with the problem and request that he/she approaches services to obtain help with the drinking problem. In essence, this approach aims to create changes in the behaviour of those concerned and affected by the person with a drinking problem with the hope that the latter will be induced into treatment. In a controlled study (Barber and Crisp 1995) it was found that more people with drinking problems engaged in treatment services after their relatives were treated with the ‘pressures to change’ approach as compared with those who received no treatment. Unilateral family therapy is another approach that focuses on working with family members in the absence of the person with the drinking problem and has been shown to produce decreases in drinking in the untreated spouse (Thomas and Ager 1993).

Yates’ (1988) work constitutes a further example of an approach that actively initiates contacts with anyone who may be affected by the drinking and can potentially benefit the client in his/her efforts to change. Given that in a number of cases, people in the network will have partial information and perhaps not have combined forces to understand and respond effectively to the problem, professionals may need to be active in engaging potentially helpful parts of the social network in treatment and this is illustrated by the work of Yates. The following two cases reported by Yates (1988) illustrate some powerful ways of working by focusing beyond the individual client:

Case 1

This problem drinker’s case was brought forward by her mother...

Table of contents

• Contents
• Figures and tables
• About the authors
• Preface
• Acknowledgements
• Online resources
• Manual Manual format
• PART 1 Background, evidence base, treatment content and format
• PART 2 Core Core components Core components of SBNT
• PART 3 Elective topics, training and common questions
• APPENDICES Handouts Handouts and prompt sheets
• References
• Index