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| EDITORIAL |
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| Year : 2019 | Volume
: 24
| Issue : 1 | Page : 1-3 |
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Family-based interventions for substance use disorders must look at the local needs and service delivery
Siddharth Sarkar, Gauri Shanker Kaloiya
Department of Psychiatry and NDDTC, AIIMS, New Delhi, India
| Date of Web Publication | 4-Jun-2020 |
Correspondence Address:
Siddharth Sarkar
Department of Psychiatry and NDDTC, AIIMS, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmhhb.jmhhb_53_19
How to cite this article:
Sarkar S, Kaloiya GS. Family-based interventions for substance use disorders must look at the local needs and service delivery. J Mental Health Hum Behav 2019;24:1-3 |
How to cite this URL:
Sarkar S, Kaloiya GS. Family-based interventions for substance use disorders must look at the local needs and service delivery. J Mental Health Hum Behav [serial online] 2019 [cited 2023 Jun 5];24:1-3. Available from: https://www.jmhhb.org/text.asp?2019/24/1/1/285993 |
| Introduction | |  |
Substance use disorders often have a deep impact on the family members. Also, families have been utilized as strengths for developing interventions for individuals with substance use disorders.[1],[2] Substance use disorders not only put a considerable burden on the other family members, but may also precipitate violence toward family members and result in mental health issues, stigma, and stress among the family members. Meanwhile, involvement of family members as caregivers in the treatment process can empower them to influence and check the substance consumption and reduce the adverse consequences of substance use. Pragmatically, the family members can provide support, encouragement, supervision, engagement, and facilitation of the treatment processes, resulting in possibly better outcomes.
Due to the abovementioned considerations, several family-based interventions have been developed for the management of substance use disorders. While family involvement may be one of the aspects of care provision in some, family engagement may be one of the central contributory factors for other interventions. These family-based and family-related interventions include Community Reinforcement Approach and Family Training, Multi-Dimensional Family Therapy, Multi Systemic Therapy, and Behavioral Couples Therapy.[3],[4],[5],[6] The focus, theoretical background, methods, components, and purported outcomes might differ across the interventions. Similarly, the training of the therapist and team/infrastructure requirements might vary across these interventions. Nonetheless, many of these interventions have been shown to be effective in prevention and reduction of the rates and consequent harms of substance use, especially among the adolescent population.[7],[8] Family-based interventions have now been well recognized as forms of treatment for substance use disorders and have found place in relevant treatment guidelines.[9],[10]
| The Roadblock | | |
Despite the documentation of the efficacy of family-based interventions, issues still persist about the implementation of these interventions in different geographical, cultural, and service delivery contexts. Taking the example of India, a country with over a billion population, harboring highest numbers of adolescent and young adults who are vulnerable to substance use, the growing numbers of individuals affected with substance use disorders, and being a collectivistic society with significant burden of substance use on the family members, the potential role of family-based interventions could be immense.[11] However, the provision of family-based interventions has been rather slow and constrained in the country. Many factors could account for this, as mentioned in [Box 1] and discussed further.
One of the major challenges has been lack of integration of the medical model with psychosocial-based interventions for substance use disorders. Effective implementation needs sensitization and coordination of the roles of medical professionals, psychologists, and other team members so that care is provided to the purported recipients. When the medical professionals are aware, then they are in a better position to guide the prospective client(s) to seek help through family interventions. Thus, clinical exposure to family-based interventions of medical and psychiatry trainees will make them more receptive and attuned towards knowing which types of clients can benefit with such family-based treatment provisions.
Another challenge lies in the limited trained workforce for family-based interventions for substance use disorders. Presently, such interventions are delivered at selected centers/locations. This is also reflective of the fact that the number of clinical psychologists in a developing country like India might be a constraint. This calls for more training of personnel through dedicated short-term and long-term courses in these interventions. Capacity in terms of professionals who are likely to provide such therapeutic interventions needs to be developed further to address the prevention/health promotion and treatment needs of the population.
A yet another issue pertains to the cultural adaptation of the interventions. The family structure, values, and dynamics might be different in the oriental or developing world cultures than the Western societies where these interventions have been developed. In addition, the cultural attributes and outlook may make the practice of psychotherapy different in India as compared to other regions.[12] This does not mean that the interventions that are developed elsewhere cannot be utilized in India. However, this suggests that psychotherapeutic approaches might need to be tinkered with or culturally adapted to provide care to patients and family members in a manner that would be found useful and acceptable to them. Moreover, a gradually transitioning section of the population which is fairly well versed with the benefits of psychotherapy may be a driving force that requests for family interventions for alleviating mental ailments and distresses including substance use disorders. This may result in de-stigmatizing of mental health and encourage actively seeking psychological help, which could be provided in the framework of systematically conducted psychotherapy.
The conduct and outcomes of family interventions are often based on the suitability of the clients who are enrolled in such an intervention. Different interventions would have different expectations and may vary in approaches to discern client suitability. For example, some interventions conducted in the clinical setting may require patients to come for therapy sessions on a regular basis and complete the given homework assignments. For other interventions, the actual work might be conducted after going to the patient's home. In any situation, feasibility of conducting the clinical work would consider logistic issues such as approachability and accessibility, as well as ability of the family members and the patients to engage with the treatment processes.
A yet another pragmatic issue relates to funding and financing for the sessions. Resource constraints abound in any health-care setting, particularly so in developing countries, which grapple with issues related to balancing the budget between various health concerns including maternal and child health, infectious diseases, and noncommunicable diseases. Furthermore, attitudinal aspects and public perceptions might cause hindrance in adequately promoting public financing for substance use disorders, despite the substantial gains that could be achieved in terms of cost-effectiveness and quality of life. Out-of-pocket expenditures remain one of the important sources of paying for health-care expenses in India. Thus, financial and resource issues might be one of the pragmatic impediments for providing adequate care to those who might be otherwise benefitted from the help through family interventions.
| The Way Forward | | |
While challenges might be expected, they are not likely to be unsurmountable. Focused efforts aimed at families might help them and the individuals with substance use disorders. Some suggestions for utilizing families for management of patients and for family-based interventions are presented in [Box 2], and some of these are corollary to the challenges presented in [Box 1]. Among these, sensitizing of the health-care professionals about the varied options available for family interventions would be helpful. However, this also needs to be in synchrony with the availability of service provision of such family interventions and availability of trained professionals who are willing to undertake such therapies. Some of the therapies such as multisystemic therapy may need a network of dedicated service providers who are willing to work in a coordinated manner. Such networks are generally built through personal and individual commitment. Another consideration in the current world of evidence-based practice is of generating and disseminating the evidence of family-based interventions being proved effective (or not effective) in the local scenario. A systematic research outcome would be able to convince the clinical fraternity and funding agencies about promoting these interventions. The outcomes can be both related to end results (e.g., abstinence or family environment) and process (e.g., engagement with therapist or attendance of sessions). Cost-effectiveness data would be helpful from the point of view of health economists and public health experts for considering resource allocation. Qualitative information such as expectations, difficulties, and solutions might also help provide the rightful place of family-based interventions in the overall armamentarium of the treatment of patients with substance use disorders. In addition, looking at financing and funding options needs to be done so that care model can become sustainable.
The National Drug Dependence Treatment Centre, Ghaziabad, has opened a weekly Family Empowerment Clinic in 2017 aimed at helping the family members of patients with substance use disorders. The Clinic assesses patients and their family members and attempts to identify the suitability and applicability for family-based interventions in the cases. The clinic envisages to provide family therapy to clients under the supervision of faculties in clinical psychology and psychiatry and provide training to residents in psychiatry and superspecialty residents in addiction psychiatry. The clinic offers yet another modality of treatment, especially in cases where familial interaction patterns and dynamics are impediments to recovery, or where family members need additional support. Such clinics would give an opportunity to build replicable models and promote research in this field.
To conclude, family-based interventions may have a larger scope to play in the treatment of patients with substance use disorders and may help to improve outcomes. Such interventions are aimed at the betterment of not only the patients, but also the family members who can play a crucial role in the treatment process of patients with substance use disorders. More systematic research would help to strengthen the evidence in the field.
| References | | |
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| 2. | Mattoo S, Ghosh A, Basu A. Substance use and family burden: A narrative review. Indian J Soc Psychiatry 2019;35:158-63. [Full text] |
| 3. | Meyers RJ, Miller WR, Hill DE, Tonigan JS. Community reinforcement and family training (CRAFT): Engaging unmotivated drug users in treatment. J Subst Abuse 1998;10:291-308. |
| 4. | Henggeler SW. Multisystemic therapy: An overview of clinical procedures, outcomes, and policy implications. Child Psychol Psychiatry Rev 1999;4:2-10. |
| 5. | Liddle HA, Dakof GA, Parker K, Diamond GS, Barrett K, Tejeda M. Multidimensional family therapy for adolescent drug abuse: Results of a randomized clinical trial. Am J Drug Alcohol Abuse 2001;27:651-88. |
| 6. | O'Farrell TJ, Fals-Stewart W. Behavioral couples therapy for alcoholism and drug abuse. J Subst Abuse Treat 2000;18:51-4. |
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| 8. | Kumpfer KL, Alvarado R, Whiteside HO. Family-based interventions for substance use and misuse prevention. Subst Use Misuse 2003;38:1759-87. |
| 9. | Gaur N, Gautam M, Singh S, Raju VV, Sarkar S. Clinical practice guidelines on assessment and management of substance abuse disorder in children and adolescents. Indian J Psychiatry 2019;61:333-49. [ PUBMED] [Full text] |
| 10. | Clinical Guidelines on Drug Misuse and Dependence Update 2017 Independent Expert Working Group. Drug misuse and Dependence: UK Guidelines on Clinical Management. London: Department of Health; 2017. |
| 11. | Sarkar S, Ghosh A. The magnitude and vicissitudes of substance use disorders in India. Indian J Soc Psychiatry 2019;35:99-101. [Full text] |
| 12. | Hoch EM. Experiences with psychotherapy training in India. Psychother Psychosom 1990;53:14-20. |
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