Friendship that insists upon agreement on all matters is notworth the name. Friendship to be real must ever sustain the weight of honest differences, however sharp they be. Ghandi

The internet site which we propose to develop, based in the first instance around the self-help manual developed for our primary care work, will have two functions. One will be to support service providers and their clients who are involved in the specialist
and primary care demonstration sites. The second function is to provide a resource for those family members who are able to access it but who are not in contact with services. We know from the prevalence statistics and from our experience in working with primary care practices, that it is difficult to identify and reach concerned and affected family members. We hope a developing internet site, based on our work, will go some way towards filling that gap.

If there are alternative methods in dealing with alcoholism, and our recovery, I sure wish they'd make it publically known. Because I for one have a hell of a time sorting this stuff out.

Empirical Findings

There exists a convincing body of literature indicating that marital and family intervention approaches are more successful in substance abuse treatment than individual intervention alone (O'Farrell, 1992; O'Farrell & Fals-Stewart, 1999; Stanton & Shadish, 1997; Waldron & Slesnick, 1998). More specifically, evidence indicates that there is benefit associated with including focus on an individual's "real world" interpersonal relationships as a fundamental component of intervention efforts (Borovec & Whisman, 1996). Family intervention is associated with better compliance and better treatment outcomes for individuals with alcohol use disorders (McCrady & Epstein, 1996; O'Farrell & Fals-Stewart, 1999). Most recent studies of family intervention approaches involve out-patient treatment (Allen & Litten, 1999).
Family members, as significant others (SOs), play an important role in treatment outcomes. Alcohol treatment outcomes are more significant in situations of positive marital adjustment (Moos, Finney, & Cronkite, 1990). There is little doubt that the significant others in a person's life can actively encourage the individual to maintain problematic behaviors like excessive drinking. However, it is also important to note that involving a "supportive significant other" (SSO) in the process of therapy concerning substance problems is associated with improved retention and more favorable intervention outcomes (Miller & Heather, 1998; Zweben & Pearlman, 1983). O'Farrell (1995) reports that the involvement of spouses or significant others in behavioral couples therapy is associated with improved treatment engagement and reduced drinking behavior compared to individual therapy.

The "significant others" in a person's life can have a great influence on the individual's motivation for change-including a spouse, intimate partner, other family member, or friend (Burke, Vassilev, Kantchelov, & Zweben, 2002; Hasin, 1994). Motivation to change is positively affected by individuals in a person's environment who express concern, offer help, and reinforce the negative consequences of the problem-in a non-demanding way (Miller & Rollnick, 1991). In addition to legal consequences, pressure from family members and significant others is a powerful route to treatment and engagement (Stanton, 1997). Proper involvement of a significant other in the intervention process can help in identifying barriers and solutions, as well as providing corroborating or contrary information about what happens outside of the treatment setting (Burke, Vassilev, Kantchelov, & Zweben, 2002). These individuals can facilitate implementation of change strategies, promote self-efficacy, motivate, help recognize triggers, and act as an "early warning system" for relapse. There is some evidence that these individuals can help improve treatment compliance for alcohol medication regimes, as well, although this evidence is somewhat conflicted when different studies are compared to one another (O'Farrell, 1995).

Project MATCH results (a multi-year, multi-site controlled comparison study of different treatment approaches) indicate an interactive effect on treatment outcomes between the type of intervention modality and social support networks. Twelve-step facilitation (TSP) was found to be more efficacious than Motivational Enhancement Therapy (MET) among clients whose natural social networks supported and reinforced drinking behavior. MET was better than TSP, however, among clients whose social networks were determined to be low support for drinking (Project MATCH, 1997a, 1997b, 1998a). This project also found that individuals, in describing the factor most helpful in maintaining their motivation to change, most often identified spousal support as helping them transition from the action to maintenance stage of recovery (Project Match, 1997a). As noted by Burke, Vassileve, Kantchelov, & Zweben (2002), these findings are consistent with the results of other treatment outcome and natural recovery studies. For example, a relatively short, structured series of family therapy and "significant others" intervention sessions was associated with no difference in drinking outcomes among individuals who have high levels of social support for abstinence, but with distinctly improved outcomes for individuals with low levels of support for abstinence (Longabaugh, Beattie, Noel, Stout, & Malloy, 1993). The addition of a specific couples based Relapse Prevention (RP) training program (CALM-2) at the conclusion of a behavioral marital therapy program is associated with better long-term outcomes than behavioral marital therapy alone (O'Farrell, Choquette, Cutter, Brown, & McCourt, 1993; O'Farrell, 1995)-this is especially true for couples experiencing severe relationship problems.

O'Farrell (1995) summarizes a set of factors that predict acceptance and completion of marital and family therapy by alcoholics. Among the factors are: couple living together, or if separated, are willing to reconcile for the duration of treatment; couple enters treatment following a relationship-threatening crisis; other family members (including the partner) do not have alcoholism; the alcoholic and other family members are without serious psychopathology or other drug abuse; and an absence of family violence that has produced serious injury or is potentially life threatening. These factors are important because in order for treatment to be effective, the alcoholic must be retained in treatment and must participate in the process. McCrady, Epstein, and Hirsch (1999) have demonstrated that alcohol-focused behavioral couples therapy (ABCT) results in greater post-treatment marital happiness, fewer incidents of marital separation, and fewer incidents of domestic violence than general family systems approaches (also see NIAAA's "Alcohol Problems in Intimate Relationships: Identification and Intervention-A Guide for Marriage and Family Therapists," February, 2003).

In situations where both partners in a couple have a similar problem (e.g., both have problems with alcohol), there exists a clear advantage to working with them simultaneously (Allsop & Saunders, 1991). Furthermore, it is important to make control of the alcohol abuse the first priority in working with couples, rather than beginning with the marital relationship, because recurrent alcohol-related incidents and interactions undermine therapeutic relationship gains.

Many of our clients have had previous unsuccessful experiences with therapists who saw the couple in MFT without dealing with the alcohol abuse. The hope that reduction in marital or family distress will lead to improvement in the drinking problem rarely is fulfilled. (O'Farrell, 1995, p. 196).

Once the alcohol issues have come under some degree of control, it is important to begin addressing the family problems caused by drinking (e.g., legal problems, income and financial security issues, housing problems, and issues affecting the family's interactions with the social world), as well as other family issues that may have been overshadowed or obscured by the alcohol problems (O'Farrell, 1995).

In order for a significant other to be supportive of the change process, it may be necessary to address (1) his or her difficulties arising from attempting to cope with the partner's alcohol problems and (2) his or her ambivalence about changing behaviors that contribute to the target individual maintaining the drinking behavior, and (3) means of developing a consensus between the partners about the goals of treatment (Burke et al., 2002). Involvement of the significant other may be counterproductive if this individual is overwhelmed, overly angry and resentful, and/or uncommitted to change (Longabaugh, et al., 1993). Training the significant other may be especially important in situations where the alcoholic is not yet contemplating change and this individual can help move the person into treatment.

The Community Reinforcement Training (CRT) approach is based on an assumption that shifts in the patterns of reinforcement and contingencies can be used to change an alcohol abuser's behavior. The Community Reinforcement and Family Training program (CRAFT) engages family in the process, as well as providing family and supportive significant others with skills for self-protection from intimate partner violence, means of encouraging sobriety, abilities to encourage professional help-seeking, and knowledge of how to support the therapeutic process (Sisson & Azrin, 1986, 1993). In a small sample study, CRT (compared to standard treatment controls) was associated with an average 50% reduction in drinking prior to entering treatment and almost total abstinence during the three months after entering treatment; 6 of 7 alcoholic partners entered treatment compared to none of the 5 control group individuals (whose alcohol consumption did not change during the 3 months period).

In a similar vein, the Unilateral Family Therapy approach (Thomas & Ager, 1993) provides support and attempts to increase the well-being and functioning of individuals engaged in relationships with substance abusers. This approach prepares nonalcoholic partners with their own coping mechanisms, skills to enhance family functioning (e.g., reducing nagging and other forms of negative communication), and ways to facilitate sobriety (including treatment entry) on the part of the alcohol abusing partner. Unilateral Family Therapy (UFT) was associated with significantly greater chances that alcoholics will enter into treatment and/or reduce their drinking in small sample study (Thomas et al., 1987).

A more coercive approach, termed The Johnson Institute Intervention, involves training family and significant others to confront an alcohol abuser, request that he or she seek treatment, and impose consequences for not seeking help. The goal of this program is treatment engagement by the alcohol abuser. The approach is controversial (on practical and ethical bases), and there is limited evidence of effectiveness with the widely diverse population of individuals with alcohol use disorders (Connors, Donovan, & DiClemente, 2001).

Another approach which relies on Al-Anon concepts (i.e., detaching oneself from the other's drinking, accepting that they are powerless to control the alcoholic partner) prepares partners to cope with their own emotional distress and motivations for change, rather than attempting to motivate the alcoholic partner to change (Dittrich, 1993; Dittrich & Traphold, 1984). While it is not clear that the intervention is associated with changes in the drinking individual, there have been persistent improvements in some qualities among the supported partners. And, while there is not a base of controlled research concerning Al-Anon outcomes, there have been studies suggesting that Al-Anon members use fewer ineffective means of coping with the drinking (O'Farrell, 1995).

Controlled, randomized clinical trials are beginning to shape a picture of what is effective in family intervention. One such study compared the CRAFT, Al-Anon, and Johnson Institute Intervention approaches for effectiveness in getting an alcohol abuser into treatment. The highest overall treatment rate for the alcoholic family members was associated with the CRAFT therapy (64%). The vast majority of families in the Johnson Institute condition chose not to complete the intervention; 70% failed to follow-up with the critical confrontation session. Since the Al-Anon facilitation is not designed for engaging the alcoholic in treatment, it is not surprising that this was not a common outcome (Miller, Meyers, & Tonigan, 1999).

The bulk of the controlled clinical research trials that include a family component in alcohol treatment examine adults with partners, and possibly the children of adult alcohol abusers. However, it is also important to consider the role of family and significant others in the treatment of adolescents who struggle with alcohol problems (Brown, Myers, Mott, & Vik, 1994). For example, Integrated Family and Cognitive Behavioral Therapy demonstrated effectiveness on several outcome variables when used with adolescents meeting criteria for alcohol and marijuana use disorders (Latimer, Winters, D'Zurilla & Nichols, 2003). Similarly, Multidimensional Family Therapy resulted in better risk reduction and protection promoting processes than peer group therapy with adolescents referred to treatment for substance abuse and behavioral problems (Liddle, et al., 2004). This type of family based, multi-system, and developmentally oriented intervention targets the functioning of adolescents and their parents across multiple systems and a variety of known risk/protective factors.

It is also important to consider that the most important significant others in an individual's life may not be the most obvious ones-it may not be the spouse, it may be an adult's parent or grandparent, child, or best friend. Not only do these individuals have important contributions to offer in the assessment process, creating an accurate picture of the individual's "relational functions" involving them is often an important aspect of the overall assessment process, as well (Waldron & Slesnick, 1998).

There is evidence that identifies several potential barriers to effective family intervention with substance abuse. The first of these is a potential for violence occurring in the family. Where an acute risk of severe violence exists (violence that may result in serious injury or is life-threatening), the immediate intervention goals must be altered to prioritize safety, safety planning, and conflict containment (O'Farrell & Fals-Stewart, 1999). In these situations, it is recommended to treat the individuals separately (Murphy & O'Farrell, 1996). In some cases there may be legal restrictions in place (i.e., court orders, restraining orders, no contact orders) that preclude conjoint family sessions. A second major barrier is the presence of more than one actively substance abusing family member in the family-particularly if these individuals are partners in consumption. Another demonstrated barrier is the existence of high levels of blame and rumination from family members (usually the partner) toward the substance abusing individual. There may also exist practical barriers to social work intervention from a family perspective-for example, geographical distances; family members who are deceased, divorced, mission, incarcerated or otherwise separated; coordination of family members' schedules and child care responsibilities; securing reimbursement for services delivered to multiple individuals. Finally, social workers should attend to the outcomes emerging from recent large-scale, multi-service, service integration and coordination studies with women on welfare who experience problems with alcohol or other substances, compounded by risks for child protective services involvement and domestic violence (e.g., CASA WORKS for families, or TANF-MATE in Milwaukee, Wisconsin).

Collaborative recovery, to coin a term, could work wonders for some couples, I totally agree, and IS very different to 12 Steps. And I believe that it is probably happening a lot in the UK though rehabs, according to the experience of some al-anon people I know in different parts of the country.

Equus,

Yours truly has been involved in various 12 step programs for 25yrs. Including starting a whole new one. I've been reading books, doing conferences, working the program all those years up to my eyeballs. The whole concept of a 12 step program was invented by people who were doing research into cures for alcoholism. They didn't find a cure, but they found something quite useful. You're doing research for information that may be of use is absolutely wonderful and in no way contradicts or opposes anything in the 12 step programs. Whether you personally follow a 12 step program is also irrelevant. In fact, the two founders of AA, according to Bill Wilson (primary author of the "Big Book" ) were a Doctor and a Psychiatrist, neither of which were Alcoholics. So you are in good company.

Please do share what you find. All of us together can benefit.

Mike :-)