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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
403
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
2002 The Association for Family Therapy and Systemic Practice
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405
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%
406
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).
407
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.
408
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
2002 The Association for Family Therapy and Systemic Practice
409
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.
410
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%)
9 (7.6%)
17 (14.3%)
58 (48.7%)
35 (29.4%)
119 (100%)
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412
Opiate-free
Occasional use
0 (0%)
3 (9.4%)
2 (6.3%)
9 (28.1%)
Regular use*
30 (93.8%)
20 (62.5%)
Opiate-free
Occasional use
5 (11.9%)
1 (7.7%)
6 (14.3%)
1 (7.7%)
Regular use*
31 (73.8%)
11 (84.6%)
413
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
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
414
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.
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
2002 The Association for Family Therapy and Systemic Practice
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417
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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
2002 The Association for Family Therapy and Systemic Practice
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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