The prevalence of co-occurring substance use disorders is high in people with SMI (Regier et al., 1990
; Teeson, Hall, Lynskey, & Degenhardt, 2000
), and has a negative impact on family relationships (Dixon et al., 1995
; Kashner et al., 1991
; Salyers & Mueser, 2001
). However, little research has addressed the needs of families who have a member with a co-occurring disorder, despite the established benefits of family programs focusing on severe mental illness alone (Pitschel-Walz et al., 2001
) and addiction alone (Stanton & Shadish, 1997
). The family intervention for dual disorders (FIDD) program was developed as a comprehensive family intervention (20–30 sessions) for co-occurring disorders (Mueser & Fox, 2002
), which combines psychoeducation with training in communication and problem solving skills, both common ingredients in family programs for SMI (Falloon et al., 1984
; Mueser & Glynn, 1999
) and addiction (O’Farrell & Fals-Stewart, 2006
), informed by the concepts of stages of change in addiction (DiClemente & Prochaska, 1998
) and stages of treatment for co-occurring disorders (Mueser et al., 2003
; Osher & Kofoed, 1989
). For the present study, FIDD was compared to a shorter term (6–8 session) family psychoeducation (FPE) program based on the same educational curriculum but without any formal skills training.
Initial engagement rates (i.e., attending at least two therapy sessions) were moderately high among study participants (88% for FIDD, 84% for FPE), demonstrating that the family clinicians were able to initiate working relationships with most of the families. These high rates of engagement were expected considering that both clients and relatives had consented to participate in the study and family programs. In addition, it should be noted that the analyses of predictors of engagement and exposure to the family programs are constrained in this sample by the prior consent of the families, and that different predictors might emerge in a non-study clinical sample.
Three of the factors that predicted lack of engagement were related to the relatives, including unemployment of the key relative, greater perceived benefit by the relative of his/her relationship with the client, and lower levels of the relative’s perceived stigma related to the client’s SMI. Families with scheduling constraints due to the relative working were more likely to be successfully engaged in treatment, not less likely as might be expected. It is possible that the relative’s employment status served as a proxy for some other factor that more directly influenced engagement and exposure to the family program, such as the degree of investment in the client (higher for working relatives), level of social functioning (higher), funds for transportation to sessions (higher), or severity of overall psychosocial stressors (lower). It is also possible that unemployed relatives were more motivated to consent for the study in order to get the money paid for completing the study assessments, without fully intending to participate in the treatment programs themselves.
Interestingly, relatives who perceived greater stigma associated with the client’s illness, and who rated their relationship as providing fewer benefits, were more likely to be engaged in the family programs, with the perception of relationship benefits being the only significant predictor in the multiple regression analysis. Overall, these findings suggest that the experiences and attitudes of the key relative to participate in family treatment is a critical determinant of initial treatment engagement. Relatives in families who were successfully engaged were less satisfied with the client and may have had greater expectations of eventually benefiting from the relationship with the client those who were not engaged.
Although relative factors were important, client factors also were predictive of initial engagement. The presence of amphetamine use disorder and more severe alcohol use disorder among clients predicted lower rates of engagement, suggesting that the severity of the client’s substance abuse may interfere with the ability of the family to convene for the purposes of treatment or make members feel less hopeful about change, and thus less likely to commit to ongoing treatment. Latino ethnicity was also related to lower levels engagement in treatment, consistent with their lower rates of health and mental health service utilization in the U.S. (Hough et al., 1987
; Padgett, Patrick, Burns, & Schlesinger, 1994
; Samnaliev, McGovern, Clark, 2009
), and lower retention in mental health treatment (Dworkin & Adams, 1987
). The ethnic differences between the two sites may also explain the higher rates of engagement of families in Boston compared to Los Angeles. Although ethnicity and site predicted engagement in treatment, neither was a unique predictor in the multiple regression analysis. This finding suggests that Latino relatives and relatives enrolled in Los Angeles may have perceived more benefits in their relationship with the client, as this was the sole unique predictor of not engaging in treatment.
Despite the success in engaging families, the rates of therapeutic exposure of families to core defining components of each family program (i.e., completion of at least six psychoeducation sessions for FPE or three sessions in problem solving training for FIDD) were considerably lower, 61 and 55 percent, respectively. Among families who were engaged in treatment, the exposure rate for FIDD was 73 percent, compared to 69 percent for FPE. These rates are somewhat lower than Haddock and colleagues (2003)
rate of retention of families in their combined program of 72 percent for families, and 83 percent for clients.
The finding that rates of exposure to FIDD and FPE were similar despite different criteria for exposure that required significantly more FIDD sessions is noteworthy. One-half of the families who dropped out of FIDD did so within the first six sessions, compared to all of the families who dropped out of FPE, suggesting that many families may be primed to drop out of any intervention early in its course. These data highlight the critical importance of early work on developing the alliance in family dual disorder treatment. The remaining families who dropped out of FIDD before completing three problem solving sessions received 7–14 sessions. It is possible that the individual meetings clinicians had with each family member before beginning FIDD sustained their involvement longer in the program than FPE, but that despite this a similar proportion of families concluded that the program was not meeting their needs.
A number of different variables predicted exposure to the family programs. The most consistent pattern among the predictors was substance abuse problems, with the number of days of drug use on the timeline follow back calendar, the clinician’s rating on the ASI of the clients’ drug abuse severity, the client’s own self rating of the need for drug use treatment, and the presence of an amphetamine use disorder all associated with a lower rate of exposure to the family programs. Among these variables, the number of days of drug use was one of two unique predictors of exposure in the multiple regression analysis. This suggests that even when families have been successfully engaged in treatment, that drug use problems interfere with conducting the basic family work. The finding that the severity of drug abuse, but not alcohol abuse, is related to exposure to the family treatment programs is consistent with some research suggesting that drug abuse in people with schizophrenia is more strongly associated with disruptive and problematic family relationships then is alcohol use problems (Salyers & Mueser, 2001
). In addition, the interviewer’s rating of the likelihood that the client would complete the program was another predictor of engagement. This suggests that these problems were evident early on, even before clinical engagement of the family had begun to take place.
Families’ employment status and site were also predictive of exposure to the family program, similar to their predictive relationship to engagement in the program. However, neither of these variables was a unique predictor of exposure in the multiple regression analysis, indicating that other predictors were more important.
Gender was a significant and independent predictor of exposure to the family programs in the logistic analysis, with female clients and their relatives less likely to complete the program than men. It is unclear why female clients were less likely to complete the program than men. Dual disorders are much more likely to occur in men than women (Kavanagh et al., 2004
; Mueser, Yarnold, & Bellack, 1992
; Mueser et al., 1990
; Mueser et al., 2000
), leading to the possibility that programs targeting individuals with co-occurring disorders, including the programs in the present study, may have been more geared towards the needs of men than women, as well as their respective caregivers, leading to more dropout among female than male participants. Other clinical researchers have called attention to the special needs of women with dual disorders, and the importance of ensuring that treatments are adapted to address those needs (Brunette & Dean, 2002
; Brunette & Drake, 1997
; Brunette & Drake, 1998
A host of site differences in client and relative differences were apparent between Lost Angeles and Boston. In general substance abuse severity was worse in clients in Los Angeles, including higher rates of drug use, amphetamine use disorder, more severe clinician ratings of drug abuse, and more client need for treatment for drug abuse. However, rates of cocaine and opiate abuse were higher in Boston than Los Angeles, consistent with prior research indicating that the types of substances used in clients with SMI are subject to local market forces (e.g., prices, availability that may vary over time; Kavanagh et al., 2004
; Mueser et al., 1992
). The results are also consistent with data from the National Survey on Drug Use and Health from 2002 to 2005 (Substance Abuse and Mental Health Services Administration, 2009
), which found higher rates of amphetamine use on the west coast of the U.S. and higher rates of cocaine use in the northeast U.S. Clients recruited in Los Angeles were more symptomatic on the BPRS than those recruited in Boston. This difference may have be related to the lower use of mental health services by Latinos (Kouyoumdjian, Zamboanga, & Hansn, 2003
), resulting in more impaired Latino clients enrolling in such services compared to non-Latinos. There were also differences between the sites in the key relatives. Relatives enrolled in the study in Los Angeles perceived higher current benefits of their relationship with the client than relatives in Boston, as well as greater perceived stigma; both variables related to lower levels of engagement and treatment in the programs. However, relatives in Boston were more likely to report having gotten intoxicated over the past month than those in Los Angeles. These differences between sites in clinically important variables may account for why site was not predictive of engagement or exposure to the family programs when other important predictors were included in the multiple regression analyses.
Multiple family groups are an evidence-based treatment for families of persons with serious psychiatric illnesses (McFarlane, Link, Dushay, Marchal, & Crilly, 1995; McFarlane et al., 1995), and a few words about our inability to sustain multiple family groups at either site are in order. Groups were poorly attended from their inception, and rarely had more than 3–4 participants at a meeting. As the study progressed, the team increased its effort to improve attendance (e.g., more frequent reminders to families, scheduling more outside speakers, offering more appealing refreshments, setting expectations earlier in the single family treatment for transition to the multiple family groups) to no avail. While we do not have hard data on the issue, informal discussions with family members indicated that most of those who had a preference for meeting and interacting with other family members were already attending groups such as local chapters of the Alliance on Mental Illness when they joined the project, while the others were either too burdened by multiple care giving activities to attend more treatment or judged their needs were being adequately met by the family program.
The significant predictors of engagement in family work and exposure to the family programs suggests several possible avenues for modifying family interventions to make them more appealing to family members and more effective in engaging and retaining them in treatment. Among the predictors of engagement in the family program, factors related to the relatives appear to be more important than those related to the client, with three variables predicting engagement (relatives’ employment status, perceived benefits of the relationship, and perceived stigma). This pattern suggests it may be important to attend to developing an alliance with family members early in treatment. Relative impediments or concerns about the treatment should be addressed early, and motivational interviewing (Miller & Rollnick, 2002
) used to increase perceived benefits of participating in the program which is often targeted to clients, may benefit relatives as well.
While factors related to the relatives tended to be most strongly predictive of engagement in the family program, exposure to the family programs was more strongly related to client factors, in particular the severity of the clients’ drug abuse. These findings suggest that in order for family treatment to be effective with clients who have severe drug abuse problems, it may be critical to target drug abuse early and more directly than was done in the current programs. For example, developing strategies for families to impose limits setting on a relative with an active drug abuse problem could reduce some of the immediate effects of drug abuse on family functioning, and may facilitate more active participation in the program. Similarly, contingent reinforcement for abstinence from drug use could be explored as another strategy for addressing to drug use problems (Sigmon & Higgins, 2006
Overall, the fact that most participants were exposed to the core features of the respective interventions is noteworthy and suggests participants valued the treatment. However, many participants left treatment prematurely, highlighting the need to continue to refine dual disorder family programs to assure they are acceptable to clients and families