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The Association for Family Therapy 2002.

Published by Blackwell Publishers, 108 Cowley


Road, Oxford, OX4 1JF, UK and 350 Main Street, Malden, MA 02148, USA.
Journal of Family Therapy (2002) 24: 402422
01634445

A comparative study of family therapy in the treatment of opiate users in a London drug clinic
Dennis Yandoli,a Ivan Eislerb, Claire Robbins,c
Geraldine Mulleadyd and Christopher Daree
This study presents the results of a randomized treatment trial of family
therapy and two control treatments for 119 outpatient opiate users. All
treatments were combined with a methadone reduction programme. The
control treatments were: (1) a standard treatment (supportive
psychotherapy) and (2) a low contact intervention. Treatment outcome
was evaluated six and twelve months after the initial assessment. Both the
family therapy and minimal intervention groups had a significantly higher
number of drug-free days at six and twelve months, compared to the standard treatment, despite receiving fewer treatment sessions. Across all
treatments there was evidence for a gender difference in response to therapy in users who were in a couple relationship. In couples where both
partners were using drugs women did significantly better than men. Men
living with a non-drug-abusing partner fared better than men living with
a drug-using partner. Across the treatment groups diminution in drug use
was accompanied by improvements in psychosocial functioning.
Unemployment, sharing needles and injecting drugs were predictive of
poor outcome.

Introduction
It is often assumed that drug users lead a chaotic, transient
lifestyle isolated from their families, and many clinicians are therefore sceptical about the possibility of involving the family actively
in treatment. Although it is true that engaging families of drug
users is often difficult (Szapocznik et al., 1988), the perception

a
b
c
d
e

Senior Family Therapist/Manager, Institute of Psychiatry, London, UK.


Senior Lecturer in Clinical Psychology, Institute of Psychiatry, London, UK.
Clinical Nurse Specialist Family Therapy, Institute of Psychiatry, London, UK.
Clinical Psychologist, Institute of Psychiatry, London, UK.
Reader in Psychotherapy, Institute of Psychiatry, London, UK.
Address for correspondence: Ivan Eisler, Psychotherapy Section, Institute of
Psychiatry, De Crespigny Park, London SE5 8AF, UK.
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that this is due to the family being uninvolved does not accord
with the empirical evidence, as drug addicts are often quite closely
connected (some would argue too closely connected) to their
families. For instance, Vaillant (1966) found in a sample of drug
users in New York that 72 per cent were living with their families
at age 22, and 47 per cent by age 30. Stanton et al. (1982) found
that 66 per cent of eighty-five male heroin users either resided
with their parents or saw their mothers daily. In Britain, Bean
(1971) in a study of 100 drug offenders, with an average age of 20,
two-thirds of whom were using heroin, reported that 33 per cent
lived with their parents. Also in Britain, Crawley (1971) examined
134 opiate users (mean age 21 years) admitted to a treatment
service, and found that 62 per cent lived at home with their
parents. Similar findings have been found in many other studies
(cf. Stanton and Shadish, 1997). Stanton et al. (1982) have also
suggested that where the drug user is in a couple relationship this
is often unstable, compared with the misusers relationship with
his family of origin. The stress of treatment, particularly if the relationship was established during active drug use, frequently drove
the couple apart, with the drug user returning to his family of
origin. To what extent these patterns pre-exist the drug misuse
rather than being a consequence is unclear.
In the family therapy literature, aspects of family functioning,
which seem to encourage or maintain drug use by denying other
areas of conflict within the family system, have been described by
clinicians (Madanes et al., 1980; Stanton et al., 1982; Kaufman,
1985). Haley (1980) described the functional value heroin use
can attain in families, and there are indications from clinical studies that the family system plays an important role in maintaining
drug use (Harbin and Maziar, 1975). Del Orto (1974) emphasized the importance of family participation to minimize the risk
of relapse, and suggested that attempting to treat drug users without seeing the family was futile. Commonly, the user is described
as remaining enmeshed in his family of origin, forgoing his need
to separate normally. The goal of family-based treatment is therefore generally seen as being to focus attention on these patterns
of behaviour in order to bring about change in the drug users
status regarding his use of drugs, as well as his role within the
family system.
The enthusiasm of family therapists for their therapeutic
approach is not always matched by systematic evaluation of such
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Dennis Yandoli et al.

treatments. However, in the field of drug addiction there is a


growing number of studies providing support for the efficacy of
family therapy. Stanton and colleagues (Stanton et al., 1982)
devised a short-term structural-strategic family therapy approach
which, in combination with a methadone regime, they found to
be more effective in reducing drug use than either individual
counselling or taking part in a neutral family task. Szapocznik
and colleagues demonstrated the efficacy of family-oriented treatments with young drug-abusing subjects from a Hispanic ethnic
minority (Szapocznik et al., 1983, 1986). More recent studies have
shown family therapy to be more effective than individual counselling by probation officers (Hengeller et al., 1991; Borduin et
al., 1995), group therapy (Joanning et al., 1992) or family
psychoeducation (Lewis et al., 1990; Joanning et al., 1992). On the
basis of a meta-analysis of over 1500 cases Stanton and Shaddish
(1997) concluded that family/couples therapy is more effective
than individual counselling/therapy, group therapy or family
psychoeducation. Reviews by Liddle (1995), Carr (2000a, 2000b)
and Cormack and Carr (2000) have also concluded that family
therapy for substance abuse is gaining growing support from
empirical studies of treatment efficacy. The study cited in this
paper reports the results of a randomized treatment trial of
family therapy and two control treatments for adult opiate users
which provides further evidence for the effectiveness of family
therapy.
Methodology
Participants
Opiate users presenting to an inner-city drug dependency clinic
were selected for the following criteria: absence of a history of
psychiatric treatment; age over 18; not currently dependent
on alcohol; opiate usage of more than six months duration. To
be included in the study, patients also had to agree to be seen
with their partner or family, if required, during treatment. After
informed consent to participation in the study was obtained,
a urine sample was taken. Once three consecutive daily urine
specimens were positive for opiates, a full assessment interview
was arranged and the methadone reduction programme was
started.
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Over a fourteen-month period 423 drug users presented to the


clinic seeking treatment. Of these, 119 subjects met the criteria for
inclusion in the study and agreed to involve one or more family
members, if required. Eighty-two per cent were self-referred, and all
were using opiate drugs, either illicit or prescribed, on a daily basis.
The characteristics of the subjects at presentation are shown in
Table 1. Two-thirds of the subjects were male and their mean age
was 28.2 years. Over 80 per cent were either married or cohabiting.
Nearly two-thirds of the partners were also drug users. Of the
female drug users in the study, 71 per cent were in a partnership
with another drug user, compared with 43 per cent of the male drug
users. Half of those living with a sexual partner also had a child in
the household. Only a small proportion were living with their family
of origin (14 per cent) or were living alone (6 per cent). A quarter
of the subjects were in regular full-time employment, and half were
unemployed. Seven per cent gave their occupation as executive or
managerial, 23 per cent as administrative, personnel, clerical and
sales, 49 per cent as skilled manual and 19 per cent as unskilled.
Characteristics of drug use at presentation
The subjects were typically injecting drugs (70 per cent), a
smaller number smoking, inhaling or taking the drug orally. All
TABLE 1 Characteristics of subjects at presentation
Sex

Male
Female

Age (years)
Living arrangement Drug-using partner
Non-drug-using partner
Family of origin
Living alone
Employment
Full-time work
Part-time work
Unemployed
Occupation
Executive or managerial
Administration,
clerical or sales
Manual
Unskilled
2002 The Association for Family Therapy and Systemic Practice

63%
37%
x = 28.2; s.d. = 5.1
53%
28%
14%
6%
27%
20%
53%
7%
23%
50%
20%

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Dennis Yandoli et al.

of them were using opiates daily, although only just over onethird (35 per cent) described heroin as their drug of choice.
Nevertheless, 86 per cent reported that heroin was their major
problem drug, while the remaining subjects saw their main difficulty as being with either methadone (6 per cent), a combination
of various drugs (5 per cent) and occasionally barbiturates or
other drugs. The majority of the subjects were heavy (58 per
cent) or moderate (36 per cent) drug users using Gossop et al.s
(1987) criteria.1 The heavy drug use is reflected in the amount of
money that subjects reported to spend on drugs in a thirty-day
period (x = 883). There was a high level of criminal convictions
(33 per cent with one to five convictions, 9 per cent with six to ten
convictions and 17 per cent with eleven to thirty convictions; 18
per cent refused to give details about their criminal records, and
23 per cent said they had not been charged with a criminal
offence). The most frequent offences were shoplifting, drug
charges and deception. Some of the subjects had been charged
with burglary, assault and robbery, and one with homicide.
The assessment and allocation to treatment
Three members of staff, a psychiatrist, another member of the
clinic team and a member of the research team, carried out each
assessment. All the subjects were assessed using a standard semistructured interview covering demographic information, current
psychosocial functioning and drug use. The Addiction Severity
Index (ASI) (McLellan et al., 1980) was scored from this interview. Standard psychometric tests, the Tyrer Brief Anxiety Scale
(TBAS) (Tyrer et al., 1984) and the Montgomery and Asberg
Depression Rating Scale (MADRS) (Montgomery and Asberg,
1979) were also administered. Subjects were then randomly allocated either to family therapy (forty-one subjects) or to one of
two control treatments: standard clinic treatment (thirty-eight
subjects) or low contact (forty subjects). When a subject was
cohabiting with another drug user both partners were placed in
the same treatment group. In the non-family therapy modalities,

1 Heavy use = Heroin > 0.5g/day; Moderate use = Heroin 0.125g to 0.5g/day;
Low use = Heroin <0.125g/day (or equivalent: e.g. 60mg of methadone = 0.5g
street heroin) (Gossop et al., 1987).

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each of the drug-using members of a couple was treated by a


different therapist.
The random allocation resulted in relatively well-matched
groups. There were no significant differences between the three
groups on any of the social, demographic or drug-use variables with
the exception of the age of onset. The low-contact group had a
mean age of onset of 21.6 years (s.d. 4.1), whereas in the family therapy group the mean age was 24.2 (s.d. 5.6) and in standard treatment 24.7 (s.d. 5.5) (F=4.14; p < 0.02).
The treatments
1 Family therapy (FT). The family therapy was a combined structural and strategic approach following the model of Stanton et al.
(1982), which placed particular emphasis on developing appropriate boundaries and limits before introducing a strategic intervention. Patients in this group were allocated to one of the
research therapists, a social worker and a nurse both of whom
were trained in family therapy. The therapist made arrangements
on the day of assessment for the involvement of the patients
family or partner in future sessions. They were seen for one hour
for up to sixteen sessions, initially every two weeks and then
monthly or less often. Where the patient was in a couple relationship the therapist worked primarily with the couple.
Nevertheless, other significant relationships were always included
in the discussions during sessions, and other family members
(parents and/or children or other family members) 2 were also
invited to attend some sessions. Occasionally, if the family or partner did not attend a session, the individual was seen but the interview always focused on discussion of family relationships as well as
methadone reduction. Methadone was prescribed in a strict
reduction regime, reducing the daily dose by 5mg every two
weeks. The non-negotiable methadone reduction regime was
openly discussed, thereby modelling the achievement of these
goals with the subject and other family members.

2 We have used the term family therapy (rather than couple therapy)
throughout the paper to emphasize that even when the work was mainly with the
couple, conceptually, the family as a whole was always part of the therapists
consideration.

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2 Standard clinic treatment (ST). The therapists for this group were
members of the drug dependency clinic staff, which included six
nurses, a social worker, a consultant psychiatrist and two other
psychiatrists. The treatment was provided by members of the multidisciplinary team, most of whom came from a nursing background,
and the majority did not have extensive training in psychotherapy.
The treatment did not follow a clearly defined theoretical model and
is best described as pragmatic, supportive counselling combined
with information and advice on managing the drug problem and
related issues. The subjects had their methadone reduced slowly as
advised by the case manager or the clinic staff, who met regularly to
discuss the treatment of all their patients. Methadone was prescribed
in a flexible reduction regime, which sometimes included continuing on a stable dose or occasionally increasing the dose temporarily.
The pace of methadone reduction and frequency of appointments
were determined to a large extent by the expressed needs of the
clients. The course of treatment was open-ended.
3 Low contact treatment (LC). Subjects in this group were seen by one
of the two research therapists. It was a more structured, limited
approach than the standard treatment and discouraged dependency
on the therapist. On the day of assessment the therapist gave subjects
a package of information about local services, which might assist them
in remaining drug-free (i.e. housing, social services, self-help groups
and information about drugs and the treatment programme). They
were seen monthly for a standardized thirty-minute interview for up to
twelve months. Methadone was prescribed using the non-negotiable
methadone reduction regime used in the family therapy treatment
group, reducing the daily dose by 5mg every two weeks.
Assessment of outcome and data analysis
Outcome was assessed at six months and one year after the start of
treatment when all the initial screening measures were repeated.
Whenever possible, the assessment included those subjects who had
terminated treatment early. Subjects were contacted at their last
known address or through a contact person established at assessment. Frequency of opiate usage was seen as the main outcome
measure rather than the composite score from the Addiction
Severity Index, as opiate usage gives a clinically more meaningful
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picture than the ASI score. For the main outcome comparisons
subjects were categorized into three groups:
1 opiate-free (i.e. those using neither street drugs nor prescribed
methadone)
2 occasional users (those using less than twenty-five days per month)
3 regular users (those using twenty-five days or more per month).
We also report outcome data based on heroin usage alone (i.e. not
taking into account the usage of prescribed methadone).
The data were analysed using the STATISTICA for Windows
program version 5.5 (Statsoft Inc, 1999). For continuous data the
MANOVA test was performed. Categorical data were tested using
the chi-square and Fisher Exact Probability Test as appropriate. The
main comparisons between treatments were done on an intentionto-treat basis. For these analyses baseline data were used for subjects
who were in prison (one subject at the six-month assessment and
seven at the twelve-month assessment) or who were not available for
follow-up. To ensure that differential retention rates for the three
treatments did not bias the results, the analyses were repeated using
only those subjects for whom complete data were available at the
six- and twelve-month assessment dates.
Results
Of the 119 subjects originally assessed, 101 (85 per cent) were
followed up at six months. At six months the proportion of cases
followed up from each treatment group was similar (88 per cent in
FT, 84 per cent in ST and 83 per cent in LC). At twelve months only
eighty-four subjects (70 per cent) were seen, with the reduction in
numbers most noticeable in the standard treatment group of whom
only twenty-four (63 per cent) were available and willing to be seen
compared to twenty-eight (70 per cent) for the low-contact group
and thirty-two (78 per cent) for the family therapy group.
The mean number of sessions attended differed by treatment
group. Those in the family therapy group attended an average of 13.7
(s.d. = 6.5) sessions,3 those in the low-contact group 8.9 (s.d. = 4.1)
3 The average amount of therapist time needed per user in FT is in fact lower if
one takes into account that in some families both partners were using drugs. The
average number of sessions per user (10.1, s.d. 8.6) is not significantly different
from the LC group.

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sessions and those who received the standard clinic treatment a mean
of 18.1 (s.d. = 10.2) sessions (F = 3.6; p < 0.0001).
Overall changes in drug use and self-rating
Table 2 shows the drug use at six months and at one year. Overall
progress during treatment was largely maintained at one year.
Initially all subjects used drugs daily, at six months 12 per cent of
the total sample (14 per cent of those assessed) were drug-free and
at twelve months 8 per cent of the total (11 per cent of those seen)
were not using drugs. Just over 15 per cent had become occasional
or irregular users (i.e. using drugs less than twenty-five days per
month) at both six and twelve months. For those continuing to use
drugs the route of administration did not change significantly
during the study.
Changes in drug use were accompanied by changes in other
areas of the subjects life. At six months subjects who were drug-free
were less depressed than those using drugs, with the MADRS
depression scores significantly lower in the drug-free group (F=4.3;
p<0.02) than the users, regular or irregular. The regular drug users
rated their degree of dependence on drugs as significantly more
TABLE 2 Frequency of opiate use at six-month assessment
Heroin

Any opiate

At six months:
Heroin-free
Occasional use
Regular use
In prison or
unavailable for FU
Total

31 (26.1%)
37 (31.1%)
33 (27.7%)
18 (15.1%)

Opiate-free
Occasional use
Regular use
In prison or
unavailable for FU

119 (100%)

14 (11.8%)
18 (15.1%)
69 (58.0%)
18 (15.1%)
119 (100%)

At twelve months:
Heroin-free
Occasional use
Regular use
In prison or
unavailable for FU
Total

17 (14.3%)
29 (24.4%)
38 (31.9%)
35 (29.4%)

Opiate-free
Occasional use
Regular use
In prison or
unavailable for FU

119 (100%)

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9 (7.6%)
17 (14.3%)
58 (48.7%)
35 (29.4%)
119 (100%)

Family therapy in the treatment of opiate users

411

serious than those who were occasional users or drug-free (ASI


Degree of Drug Dependency F=5.8; p<0.005). There were no
differences overall in the subjects view of their ability to cope with
life, family relationships and leisure activities, but those who were
not using drugs rated themselves as significantly more confident
than those using occasionally or regularly (ASI Confidence F=5.3;
p<0.01). At six months, the drug-free group had lower Tyrer anxiety scores but the difference did not reach statistical significance.
At twelve months, there was again no significant difference in
anxiety scores. Depression scores (F=6.8; p<0.002), plus a number
of measures on the Addiction Severity Index (Degree of Drug
Dependency F=18.0; p<0.001, Coping with Life Generally F=1.2;
p<0.005, Relationships with the Family F=5.2; p<0.01, Leisure
Activities F=3.3; p<0.05 and Confidence F=6.43; p<0.005) were
all better in those who were drug-free compared with the regular
users. The occasional drug users had intermediate scores. At twelve
months the mean amount of money that subjects estimated they
had spent on drugs was 332 (s.d. 568) compared with 883 (s.d.
1150) at presentation.
Predictors of outcome
Of those who were unemployed at assessment, 72.5 per cent were
using drugs daily and only 2.5 per cent were opiate-free at twelve
months, whereas of those who had been in a job at the outset, 20
per cent were drug-free and another 20 per cent had significantly
reduced their usage (X2=6.1; p<0.05). Initially, half of the subjects
reported that they shared their needles. They were significantly
more likely to be using drugs regularly at one year than those who
did not (p=0.01, Fisher test).
Gender, family configuration and outcome
Overall there was no difference in outcome between men and
women (Table 3). However, outcome for men and women
depended on whether they were in a relationship with another drug
user. In couples where both partners were using drugs, the women
were significantly more likely to improve in terms of being drug-free
or reducing their overall use of drugs at twelve months (p=0.003,
Fisher test). Men living in a drug partnership fared worse than men
whose living arrangement did not include another drug user
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(p=0.03, Fisher test). There were relatively few drug-using women


who were not in a relationship with another user and their outcome
at one year was generally poor (85 per cent using drugs daily
compared with 74 per cent of males in a non-drug partnership and
63 per cent of women whose partners were also using). There were
no differences in outcome between individuals living alone or with
their family of origin and those living as a couple.
Differences in outcome for the three treatment groups
Overall there was a consistent pattern for family therapy to produce
better results at both six and twelve months, with 22 per cent and 15
per cent being drug-free at the two respective assessments
compared with 8 per cent and 8 per cent of the low-contact group
and 5 per cent and 0 per cent of the standard treatment group
(Table 4). Family therapy produced significantly more drug-free
subjects than standard treatment at six months (p = 0.03, Fisher
test) and at twelve months (p=0.02, Fisher test). The difference
between family therapy and low contact was just below the level of
statistical significance at six months (p = 0.06, Fisher test) and there
was no difference between the low contact and standard treatment.
If drug-free subjects are combined with occasional users, significant differences are found comparing family therapy with the other
two treatment groups. At six months 29 per cent of those in family
therapy were using heroin regularly and 68 per cent were using
TABLE 3 Gender, living arrangements and opiate use at twelve-month
assessment
Subjects living with a drug-abusing partner
Male
Female

Opiate-free

Occasional use

0 (0%)
3 (9.4%)

2 (6.3%)
9 (28.1%)

Regular use*
30 (93.8%)
20 (62.5%)

Subjects living alone or with a non-drug-abusing partner


Male
Female
*Includes

Opiate-free

Occasional use

5 (11.9%)
1 (7.7%)

6 (14.3%)
1 (7.7%)

Regular use*

those in prison or not available for follow-up

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31 (73.8%)
11 (84.6%)

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413

TABLE 4 Frequency of opiate use in the three treatments


Family
therapy

Low
contact

Standard
treatment

Total

Number followed up

36 (87.8%)

33 (82.5%)

32 (84.2%)

101

Heroin-free
Opiate-free
Occasional use (heroin)
Occasional use (any opiate)
Regular use (heroin)*
Regular use (any opiate)*

17 (41.5%)
9 (22.0%)
12 (29.3%)
4 (9.8%)
12 (29.3%)
28 (68.3%)

6 (15.0%)
3 (7.5%)
12 (30.0%)
9 (22.5%)
22 (55.0%)
28 (70.0%)

8 (21.1%)
2 (5.3%)
13 (34.2%)
6 (15.8%)
17 (44.7%)
30 (78.9%)

31
14
37
19
51
86

Total

41 (100%)

40 (100%)

38 (100%)

119

Number followed up

32 (78.0%)

28 (70.0%)

24 (63.2%)

84

Heroin-free
Opiate-free
Occasional use (heroin)
Occasional use (any opiate)

9 (22.0%)
6 (14.6%)
12 (29.3%)
8 (19.5%)

6 (15.0%)
3 (7.5%)
11 (27.5%)
7 (17.5%)

2 (5.3%)
0 (0%)
6 (15.8%)
3 (7.9%)

17
9
29
18

Regular use (heroin)*


Regular use (any opiate)*

20 (48.8%)
27 (65.8%)

23 (57.5%)
30 (75.0%)

30 (78.9%)
35 (92.1%)

73
92

Total

41 (100%)

40 (100%)

38 (100%)

119

At six months:

At twelve months:

*Includes

those in prison or not available for follow-up

either heroin or prescribed methadone. In the low-contact group


the comparable figures were 55 per cent for heroin (significantly
more than in FT, p = 0.01, Fisher test) and 70 per cent for all
opiates, and in standard treatment 45 per cent for heroin and 79
per cent for all opiates. At one year in the FT group the proportion
of those using heroin regularly had increased to 49 per cent but the
overall usage of opiates had in fact slightly reduced to 66 per cent.
In the two control groups the percentage of regular heroin use as
well as overall opiate use had increased in the LC group to 58 per
cent for heroin and 75 per cent for all opiates (not significantly
different from FT), and in the ST to 79 per cent for heroin and 92
per cent for all opiates. At one year the ST had significantly more
regular users than the FT group (for both heroin and all opiates; p
= 0.01, Fisher test) and was also worse in this respect than the LC
group in both heroin and overall opiate usage (p=0.04, Fisher test).
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Further analyses were performed to evaluate whether those who


were in a couple relationship responded differently to treatment
from those who were still living with their family of origin or on
their own. The findings were clearest for those living with a partner (some of whom were also users); nine out of thirty-three
subjects treated with couple/family therapy were drug-free at six
months (two were occasional users), compared with one out of
thirty-two subjects in the low-contact group (six occasional users)
and one out of thirty-one in the standard treatment (six occasional users) (X2 = 13.84, p< 0.01). The differences between the
treatments were less clear at one year. The number who were
drug-free or only occasional users was still significantly higher in
the FT group (four opiate-free, six occasional) compared with the
ST group with no drug-free subjects and only three occasional
users (p = 0.04, Fisher test), but the LC group showed similar
results (three opiate-free, five occasional) to family therapy. The
results for individuals living without a partner showed no clear
pattern at six months, but at one year again appeared to favour
family therapy, with four out of eight being drug-free or occasional users whereas all seven in the standard treatment were
using drugs daily (p = 0.05, Fisher test).
All the data analyses were also conducted including only those
subjects for whom complete assessment data were available at either
assessment point. The results were essentially the same for each of
the above comparisons.
Mortality rates
At one year, two patients had died (both from the FT group). At five
years, according to the Central Register of Births, Marriages and
Deaths, there were three further deaths (one from the FT group
and two from the ST group).4 There were no deaths in the lowcontact group. Thus the overall death rate at five years was 4.2 per
cent. The differences in death rates between treatment groups are
not statistically significant.

4 In the family therapy group one subject committed suicide and two died as a
result of an accidental drug overdose. In the standard treatment group one subject
died in a car accident and one of an accidental overdose.

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415

Discussion
Before discussing the findings, it is necessary to examine factors
that may have biased the results. The first question is about the reliability of the data. The most reliable information was obtained
about the number of deaths. Over five years the overall death rate
of 4.2 per cent may be compared with Oppenheimer and Stimsons
(1982) death rate of 12 per cent over seven years and Vaillants of
23 per cent over twenty years (Vaillant, 1973).
The assessment of drug use, on the other hand, depended largely
on self-report. An attempt was made to validate drug usage by urine
results, but incomplete data were obtained because of difficulties
arising when the interviews were conducted in the clients homes or
in prisons, rather than in the clinic setting. Where urine samples
were available, these were generally consistent with the subjects
self-report. In any case, attempts to compare self-reports of drug
users and analysis of urine at the time of assessment may be of
limited value, since a single urine screen only provides information
about drug use in the previous twenty-four hours. A positive urine
sample in someone claiming to be drug-free would show that the
subject was lying, but in others would be of little use. The only reliable assessment of frequency of drug use would be a continuous
daily urine screen over an extended period of time, which was
impractical in the context of this study. Given the nature of the
population under study, the self-report of the frequency of drug use
is bound to contain inaccuracies. The question is whether distortions arising out of self-reports of drug use are likely to vary between
the treatment groups. While we have no evidence for this, the possibility cannot be discounted.
The overall significance of the results also has to be viewed with
some caution due to the relatively high attrition rate from the study,
with 85 per cent of subjects seen at six months but only 70 per cent
at twelve months. The number of subjects traced was similar for all
groups at six months but at twelve months there were differences
between the three treatment groups. The highest number of
subjects was traced in the family therapy group and the fewest in the
standard treatment group. These differences make comparisons
between the treatment groups and changes within each group more
difficult to evaluate. The assumption that those who were not traced
or were imprisoned were using as frequently as at the start of the
study may be erring on the conservative side (but, given the nature
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Dennis Yandoli et al.

of the subject population, it is likely to give a more accurate picture


than excluding them from the analysis) and on the face of it could
have marginally favoured the family therapy group. The data analyses using only subjects with complete assessment data support the
conclusion that the differences between treatments were not
unduly affected by this assumption. It is therefore probably safe to
conclude that the more favourable result for the group that had
received family therapy is a reliable one.
Finally, a word of caution is needed concerning the overall size of
the sample. While the main comparisons between the three treatments are fairly robust, when the results are broken down further
(e.g. when considering interactions between type of treatment and
family configuration or the comparisons of outcome broken down by
gender and drug use in the couple) the numbers are small, and any
conclusions drawn from these findings can be only very tentative.
Overall the study showed that 12 per cent of clients stopped using
drugs at six months and tended to maintain their progress at twelve
months. This is similar to other studies with the exception of
Gossops (1987) study, in which an unusually successful outcome
followed inpatient treatment. The 8 per cent drug-free at twelve
months in the study is similar to the 10 per cent drug-free subjects
at one year reported by Vaillant (1973), and approximately 7 per
cent in Oppenheimer and Stimson (1982) at one year (rising to
more than 30 per cent over seven years). Oppenheimer and
Stimson (1982) excluded subjects who had died, were imprisoned
or whose drug use was uncertain, so the analysis of outcome at
seven years involved 79 per cent of the original sample, although 97
per cent had been traced. The likely effect of excluding this group
of subjects is to make the results appear more favourable than was
in fact the case.
At each of the assessments the subjects who were opiate-free
showed consistent improvement in depression scores and, to a lesser
extent, in anxiety scores, in association with overall improvement in
social functioning. The study shows that employment at the initial
assessment was a predictor of good outcome. It was unclear whether
the other positive prognostic indicators (not sharing needles and
not injecting) were secondary to the employment status or independent factors, as those who share needles may also be more
entrenched in a drug-using subculture. These findings may have
implications for treatment in that employed drug users are perhaps
more likely to benefit from short-term outpatient treatment,
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whereas unemployed drug users may require more intensive or


longer term treatment including inpatient detoxification.
Despite the clinically based predictions, different family configurations appeared to have little effect on outcome, though there may
be a differential effect depending on the type of treatment. The
findings with respect to the gender of the subjects were interesting
and have not been reported elsewhere. Females in a two-user
couple relationship had a relatively good outcome, in contrast with
females who were not involved in such a relationship. Females were
very rarely the sole drug user in a relationship. A possible explanation for this may be that women were more likely to become secondarily involved with drugs, having formed a relationship with a drug
user. Anecdotally in this population, it also seemed that drug-using
women were more likely to be ejected from their family of origin, in
contrast with male subjects who remained involved with and dependent on their families of origin despite their drug use.
There is one further important aspect of the study that has to be
considered when evaluating the overall results. Recent research has
shown that methadone withdrawal, a core treatment used for all
three groups in our study, may be less effective than methadone
maintenance in reducing illicit drug use and improving psychosocial functioning (Gerstein, 1992; Gossop et al., 2001). The length of
treatment, between six and twelve months for the low-contact and
family therapy groups and twelve months for most of the standard
clinic treatment, was short. The initial dose of methadone (mean =
40mg) was also low. In Gersteins review (1992), good outcome was
associated with long-term treatment and higher doses of
methadone (a minimum of 60mg). It could be argued that a more
powerful methadone treatment (i.e. a higher dosage and/or longer
term treatment) would have provided a stronger baseline outcome
for all three groups against which the additional benefits of the
specific treatments could be compared.
The main focus of the study was the comparison of family therapy with two control treatments. While the differences in outcome
between the three treatments were modest, there was nevertheless
a consistent pattern favouring those who were treated with family
therapy. This was particularly true for those subjects who were living
with a partner, whether this partner was a drug user or a non-user.
The advantage of involving the family in treatment was less clear for
those subjects who were still living with their families of origin but
the numbers in this subsample were the smallest, and this finding
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Dennis Yandoli et al.

has to be treated with caution. Surprisingly, of the two control treatments, the standard clinic treatment achieved the worst outcome,
with the low-contact group showing intermediate results.
Other differences were also found between the treatment groups
in terms of utilization of treatment facilities. The majority of the
family therapy group and of the low-contact group completed treatment within six months and both groups required significantly
fewer sessions than with the standard treatment. The improvements
found at six months in these two treatment groups were generally
maintained at one year without further treatment. The standard
clinic treatment group, which underwent a longer period of treatment and attended for a higher number of appointments, showed
a lower abstinence rate and more subjects were lost to subsequent
assessments. It is possible that the subjects continuing in this treatment longer than the interim assessment period of one year might
do better in the long term (Gerstein, 1992). Because of the short
interim assessment period it is not possible, at this stage, to
conclude that length of treatment is not a major factor in determining the eventual outcome. The low-contact group provides an
interesting comparison, being intermediate in its outcome results
and in the degree of co-operation with both six- and twelve-month
assessments. It was a more structured, limited approach than the
standard treatment and did not encourage dependency on the therapist and, similar to the family therapy treatment group, used a
non-negotiable methadone reduction regime. The encouragement
of the use of self-help groups in the low-contact group may also have
enhanced the results of what might otherwise be considered the
weakest form of treatment.
The less structured, open-ended nature of the standard clinic
treatment and the flexibility of the pace of methadone reduction
meant that the subjects in this group experienced a different relationship with their therapist, could control the treatment more, and
possibly experienced less anxiety and pressure to alter drug use
within a fixed time frame. The counsellors delivering the treatment
in this group had varied levels of therapeutic training (although all
of them had considerable experience of working in the drug addiction field) and this may have also influenced the results.
If one accepts that the drug use reported at six- and twelvemonth assessments reflected accurate patterns of behaviour, how
successful were the different treatments? Strang et al. (1987) have
pointed out that total abstinence is not the only criterion for
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successful treatment and damage limitation is an important goal.


Once an individual ceases to use drugs daily and/or can maintain
employment and a stable, non-criminal lifestyle, the problems of
drug use are significantly reduced. Our study suggests that this was
most likely to happen for subjects who received family therapy of
whom just under half were either abstinent or at least not using
daily. In the standard clinic treatment only 13 per cent of subjects
achieved this, although they were maintained in treatment longer.
Implications for clinical practice
Comparative treatment studies are often presented as if the principal question that needs answering is Which is the best treatment/best theoretical model/best aetiological explanation? A
finding, that one treatment is more effective than others, is then
used as an argument that this is the treatment of choice and that
other treatments should be relegated to second line or adjunctive treatment status. The implication is that the treatment of
choice should be the one that deals with the core dysfunction,
while the role of the other treatments is to help resolve some of the
associated problems. While few people would openly argue for
such a simplistic view, this is at least a subtext for many discussions
about the value of different treatments. Indeed, we ourselves have
presented the results of our study as if the main implication was
that family therapy should be the favoured treatment. Similarly,
non-family therapists, while perhaps recognizing that family therapy has a useful role to play, are more likely to view it as an adjunctive treatment aimed particularly at changing dysfunctional family
patterns.
In our clinical experience, however, the best treatment results are
usually obtained from a combination of treatments which is not
only a way of addressing different aspects of the problem but can
also maximize the strength of each specific treatment. Viewed in
this way, family therapy is best understood not as the main treatment or as a treatment to be used alongside other treatments but
rather as an approach that works best when it is integrated with
other aspects of treatment. We have no evidence to propose that the
main aim of the family interventions should be to change the structure or the dynamics of the family (although this may also take
place in some cases). It is probably more useful to think of family
therapy as a way of helping the family to examine how they may be
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Dennis Yandoli et al.

involved in finding ways of dealing with the different problems with


which both the user and the family have to contend.
One of the difficulties in involving families in treatment (particularly with adult clients) is that they often feel that the reason they
are being asked to sessions is that they are seen as the cause of the
problem. It is important therefore to emphasize that the aim of
involving them in the therapy is to explore how they can help.
This is likely to include discussions of how the whole family has
become affected by the drug addiction, which often becomes the
central organizing factor around which much of family life
revolves. Helping family members to disentangle themselves from
this can assist them in using their resources to fight the addiction
that has invaded their lives. Other aspects of the treatment (such
as methadone reduction or methadone maintenance) become
part of this conversation but do not necessarily have a central
focus.
The discussion with the family will aim to widen the choices
around both the drug-taking behaviour and also the familys
response to it. The family will need to consider the implications of
the different choices. How will things change if your partner is
going to be using methadone on a regular basis for a considerable
length of time?; How are you going to make sure that normal everyday disagreements are not covered up by arguments about drugs?;
How will your relationship be affected (positively and negatively) as
reliance on drug use diminishes?; What are the problems that you
might have to deal with when there are no drugs in your life?;
What will the drug user and other members of the family do
instead, now that drug use is not their central concern?; Is it the
users responsibility alone for stopping, and if he decides to stop (or
not to stop), how will you deal with this?. In all these examples the
primary aim of the therapy is to help family members to gain a new
perspective on how they address problems in their life in terms
which are wider than drug use alone.
Conclusions
This study adds to the evidence for the value of including the family
in the treatment of adult opiate users. Positive results were achieved
with a relatively small number of sessions with the couple or family
in comparison to the standard treatment. While family therapy on
its own is unlikely to provide a way out of drug-taking for most
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opiate users there is now compelling evidence that it should be used


routinely as a significant component of the overall treatment package in drug addiction.

References
Bean, P. (1971) Social aspects of drug abuse: a criminological study of a group of
London drug offenders. Journal of Criminal Law, Criminology and Police Science, 62:
8086.
Borduin, C., Mann, B., Cone, L. and Heggeler, S. (1995) Multisystemic treatment
of serious juvenile offenders: long-term prevention of criminality and violence.
Journal of Consulting and Clinical Psychology, 63: 569578.
Carr, A. (2000a) Evidence-based practice in family therapy and systemic consultation. II Adult-focused problems. Journal of Family Therapy, 22: 273295.
Carr, A. (2000b) Evidence-based practice in family therapy and systemic consultation. I Child focused problems. Journal of Family Therapy, 22: 2960.
Cormack, C. and Carr, A. (2000) Drug abuse. In A. Carr (ed.), What Works for
Children and Adolescents? A Critical Review of Psychological Interventions with
Children, Adolescents and their Families. London: Routledge.
Crawley, J.A. (1971) A case note study of 134 out-patient drug addicts over a 17month period. British Journal of Addiction, 66: 209218.
Del Orto, A. ( 1974) The role and resources of the family during the rehabilitation
process. Journal of Psychedelic Drugs, 6: 435445.
Gerstein, G.R. (1992) The effectiveness of drug treatment. In C.P. OBrien and
J.H. Jaffe (eds), Addictive States. New York: Rave.
Gossop, M., Green, L., Phillips, G. and Bradley, B. (1987) What happens to opium
addicts immediately after treatment: a prospective follow-up study. British
Medical Journal, 294: 13771380.
Gossop, M., Marsden, J., Stewart, D. and Treacey, S. (2001) Outcomes after
methadone maintenance and methadone reduction treatments: two-year
follow-up results from the National Treatment Outcome Research Study. Drug
and Alcohol Dependence, 62: 255264.
Haley, J. (1980) Leaving Home: Therapy with Disturbed Young People. New York:
McGraw-Hill.
Harbin, H.T. and Maziar, H.M. (1975) The families of drug abusers: a literature
review. Family Process, 14: 411431.
Hengeller, S.W., Borduin, C.M., Melton, G.B., Mann, B.J., Smith, L.A., Hall, J.A.,
Cone, L. and Fucci, B.R. (1991) Effects of multi-systemic therapy on drug use
and abuse in serious juvenile offenders: a progress report from two outcome
studies. Family Dynamics Addictions Quarterly, 1: 4051.
Joanning, H., Thomas, F., Quin, W. and Mullen, R. (1992) Treating adolescent
drug abuse: a comparison of family systems therapy, group therapy and family
education. Journal of Marital and Family Therapy, 18: 345356.
Kaufman, E. (1985) Family systems and family therapy for substance abuse: an
overview of two decades of research and clinical experience. The International
Journal of Addiction, 20: 897916.
Lewis, R.A., Piercy, F.P., Sprenkle, D.H. and Trepper, T.S. (1990) Family based
2002 The Association for Family Therapy and Systemic Practice

422

Dennis Yandoli et al.

interventions for helping drug abusing adolescents. Journal of Adolescent Research,


5: 8295.
Liddle, H.A. (1995) Efficacy of family therapy for drug abuse: promising but not
definitive. Journal of Marital and Family Therapy, 4: 511543.
McLellan, A.T., Luborsky, L., Woody, G.E. and OBrien, C.P. (1980) An improved
diagnostic evaluation instrument for substance abuse patients: the Addiction
Severity Index. Journal of Nervous and Mental Disease, 168: 2633.
Madanes, C., Dukes, J. and Harbin, H. (1980) Family ties of heroin addicts. Archives
of General Psychiatry, 37: 889894.
Montgomery, S.A. and Asberg, M. (1979) A new depression scale designed to be
sensitive to change. British Journal of Psychiatry, 134: 382389.
Oppenheimer, E. and Stimson, G.V. (1982) Seven year follow-up of heroin addicts:
life histories summarised. Drug & Alcohol Dependence, 9: 153159.
Stanton, M.D. and Shaddish, W.R. (1997) Outcome, attrition and family-couple
treatment for drug abuse: a meta-analysis and review of the controlled, comparative studies. Psychological Bulletin, 12: 170191.
Stanton, M.D., Todd, T. and Associates (1982) The Family Therapy of Drug Abuse and
Addiction. New York and London: Guilford Press.
StatSoft Inc (1999) STATISTICA for Windows. Tulsa, OK: StatSoft Inc WEB:
<http://www.statsoft.com>.
Stimson, G.V. and Oppenheimer, E. (1982) Heroin Addiction, Treatment and Control
in Britain. London: Tavistock.
Strang, J., Heathcote, S. and Watson, P. (1987) Habit moderation in injecting drug
addicts. Health Trends, 19: 1618.
Szapocznik, J., Kurtinez, W.M., Foote, F.H., Perez-Vidal, A. and Hervis, O. (1983)
Conjoint versus one-person family therapy: some evidence for the effectiveness
of conducting family therapy through one person. Journal of Consulting and
Clinical Psychology, 51: 889899.
Szapocznik, J., Kurtinez, W.M., Foote, F.H., Perez-Vidal, A. and Hervis, O. (1986)
Conjoint versus one-person family therapy: further evidence for the effectiveness of conducting family therapy through one person with drug-abusing
adolescents. Journal of Consulting and Clinical Psychology, 54: 395397.
Szapocznik, J., Perez-Vidal, A., Brickman, A.L., Foote, F.H., Santiesteban, D.,
Hervis, O. and Kurtinez, W.M. (1988) Engaging adolescent drug abusers and
their families in treatment: a strategic structural systems approach. Journal of
Consulting and Clinical Psychology, 56: 552557.
Tyrer, P.J., Owen, R.T. and Cicchetti, D.V. (1984) The brief scale for anxiety: a
subdivision of the comprehensive psychopathological rating scale. Journal of
Neurology, Neurosurgery & Psychiatry, 9: 970975.
Vaillant, G.E. (1966) A 12 year follow-up of New York narcotic addicts. III. Some
social and psychiatric characteristics. Archives of General Psychiatry, 15: 599609.
Vaillant, G.E. (1973) A twenty-year follow-up of New York narcotic addicts. Archives
of General Psychiatry, 29: 237241.

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