Introduction
The strain experienced by adults who are affected by the substance use of close relatives constitutes a large, underestimated and mostly unidentified health burden (Orford, Velleman, Natera, Templeton and Copello, Reference Orford, Velleman, Natera, Templeton and Copello2013). It is estimated that 1.6 million people in England and Wales are dependent on alcohol; drinking is not only problematic for the individual but can also have detrimental effects to the family. Psychological problems such as depression and anxiety are common ways in which the strain on family members of substance users is manifested (e.g. Ray, Mertens and Weisner, Reference Ray, Mertens and Weisner2007). Even taking a cautious estimate that for every adult with a significant alcohol or drug problem one close family member will be significantly affected, the potential prevalence would be high across the population and potentially higher amongst those seeking psychological help. Despite this, limited help is available to identify and address this distressing experience.
Recent years have seen a transformation of mental health services within the UK. The IAPT initiative began in 2008 and aims to ensure that psychological interventions are offered as frontline to those with mild to severe presentations of depression and anxiety. Those with milder difficulties are offered lower intensity interventions such as guided self-help, whilst those who show a higher level of difficulty are referred for individual psychological intervention, most frequently cognitive behavioural therapy (CBT).
Little is known about how many of the people seeking help within IAPT have difficulties related to a relative's substance abuse. This information is not collected routinely when people access the service and people may not voluntarily disclose this information. High levels of stigma and embarrassment found in these family members may act as a barrier to disclosure (Ahmedani et al., Reference Ahmedani, Kubiak, Kessler, de Graaf, Alonso and Bruffaerts2013). Therefore, problems related to their relative's substance misuse and potential impact on family members remain unidentified, not specifically addressed in treatment, and could adversely impact upon the family member's own recovery if ignored.
The development of IAPT services and routine outcome data collection presents a unique opportunity to identify the prevalence of family members affected by substance misuse within the family, who are accessing general psychological help. This initial, small-scale preliminary study aimed to investigate the prevalence of family members of substance misusers accessing an IAPT service for individual cognitive behavioural therapy for anxiety and/or depression. We aimed to establish the rate in a sample, describe the sample of people for whom this is an active problem, and to compare the affected family members, on entry to IAPT, with the remainder of the sample for whom this was not the case.
Method
The study design was based on quantitative point prevalence cross sectional survey methods. The aim was to estimate the number of people within an IAPT service who reported on a questionnaire that they were a family member of a substance user at a particular point in time. “Family member” was defined as those who self-identified in the questionnaire as having a relative whose level of alcohol/drug use was of concern to them at the point of entering IAPT. “Relative” was also self-defined by participants; information about their relationship to the participant was collected. Demographic information about the sample was collected and consent was obtained to access participants’ routine depression and anxiety scores that were collected following referral.
Sampling
Adult participants (aged 16 and upward) were recruited from one IAPT team in the English Midlands. All potential participants were receiving individual cognitive behavioural therapy (CBT) from a high intensity CBT therapist. Clients receiving other services offered by IAPT were excluded. Five therapists, selected due to the higher numbers of clients on their caseload and their motivation to be involved in the research, distributed questionnaires to all clients on their caseloads (a total of 101 clients) during a period of 6 months in 2013–14; 100 of 101 potential participants agreed to participate.
Measures
Participants were given a brief, purpose designed questionnaire consisting of eight questions. The first question identified whether the participant had a relative with an alcohol or drug problem. If the participant did not have a relative with such a problem they answered only the first question (yes or no). For those participants self-identifying as having a relative with such problems, further questions collected information about the substance user's relationship to the IAPT service user; their living arrangements and amount of contact with their family member. Participants were also asked whether they felt distressed by the person's substance use and whether they thought that this had contributed to the difficulties for which they were receiving help from IAPT. The questionnaire was designed by the authors based on questions used in previous studies and is available upon request.
Measures of depression and anxiety are routinely collected within the IAPT service at every clinical session. Depression is measured with the Patient Health Questionnaire-9 (PHQ-9 - Kroneke, Spitzer and Williams, Reference Kroenke, Spitzer and Williams2001). Anxiety is measured with the Generalized Anxiety Disorder-7 (GAD-7 - Spitzer et al., Reference Spitzer, Kroenke and Williams2006). Both measures have good reported reliability and validity.
Procedure
Ethical and Research and Development approvals were gained for the study. The principal investigator was a High Intensity Therapist who was studying for a postgraduate university degree. Five CBT therapists within one IAPT team recruited participants from their case load by giving out information sheets, consent forms and the prevalence questionnaire. As this was a point prevalence survey the aim was to sample as close as possible to 100% of each therapist's caseload in the recruitment period to gain a representative sample. The questionnaire was retrospective; time of its administration during the participant's CBT intervention was not relevant for the current study. Those wishing to participate returned the consent form and questionnaire in an envelope addressed to the researcher in order to protect anonymity. PHQ-9 and GAD-7 scores at treatment session 1 were taken from the service database.
Data analysis
Descriptive statistics were used to explore the sample as a whole. Differences between the two groups on measures of depression and anxiety prior to treatment commencing were compared using t-tests.
Results
The sample of 100 clients was made up of 40 men and 60 women. The sample appeared to be representative of national IAPT samples in terms of gender and was reflective of the ethnicity of the local area. The mean age (38.5) of the sample was similar to that of the service attenders as a whole (38). The largest proportion of the sample (46%) experienced mixed anxiety and depression.
Twenty-two participants reported that at the time of entering the IAPT service they had a family member whose level of alcohol and/or drug use concerned them. They were younger on average (34.6 years) than the remainder of the sample but similar in terms of gender and presentations. Demographic details of the family member sample are presented in Table 1.
The sample of family members identifying alcohol or drug misuse in a relative
There was a significant difference between the mean depression scores of the 22 participants who had substance using relatives (19.2, SD 4.0) compared to the 78 clients who did not (15.8, SD 6.1) (p < .05), but no significant differences in anxiety scores.
The 22 participants answering “Yes” to indicate that they had a relative whose substance use concerned them answered further questions. Thirteen answered “Yes” to the question “Does their substance use cause you any distress?” whilst five answered “Maybe” and four “No”. Nine participants believed that the substance use of their relative had contributed to the difficulties for which they were seeking help, seven said “maybe” it had, and six did not believe that it was contributing to the issues for which they were seeking support. Eight said “Yes” to both questions - it was causing distress and had contributed to the issues for which they had sought help. Four said “Yes”, the substance use had caused them distress, and “Maybe” it had contributed to their presenting problem. Only two people answered “No” to both questions. Of that sub-group of eight who were distressed and thought that the substance use contributed to their difficulties, only one lived with the substance user. Five of the eight were concerned about a parent's substance use, two about that of siblings, and one person had a child who was the substance user.
Discussion
Based on findings from the available literature, it was predicted that there would be a high rate of family members with relatives experiencing alcohol and drug problems within a sample of IAPT service users attending for psychological help. In this study 22 out of the 100 IAPT service users surveyed reported this experience. The majority of the 22 family members of someone with alcohol and/or drug problems indicated that they found the impact of this experience distressing and nearly half thought this had contributed to their presenting problems, with others believing that it might have contributed. About a third both found it distressing and also believed it had contributed to their presenting problems.
The 22 family members of someone with substance misuse had significantly higher depression scores than the group without a relative at commencement of therapy, putting them on average at the top of the “moderately severe” depression range. If these figures are replicated across all IAPT services we could suggest that a significant proportion of clients accessing IAPT services are experiencing significant impacts related to substance use in the family. Services do not routinely assess this and yet it may be a contributing factor to IAPT service users’ problems that remains unidentified, unaddressed and may limit recovery. Further research is needed to investigate this.
There were some other findings of note. We had expected that the largest group would be spouses/partners and that most would be living under the same roof with the substance users they were concerned about. It was therefore surprising that in the majority of cases the substance users were siblings or parents, and that most were not living with the substance using relative.
Limitations
There are obvious limitations to this small preliminary study. It involved only one IAPT team and the clients of only five IAPT therapists. Questionnaires were given out to participants at different stages of therapy, which may have had an impact on how they answered questions. Nevertheless, since this is to our knowledge the first study that has looked at this question, and since it provides some indication that a large minority of IAPT clients may be seeking help partly because of substance misuse problems in the family, we believe the study deserves replication and extension in other IAPT services, with much larger samples. The relationship between having a substance using relative and outcomes of CBT also warrants investigation. If the levels of prevalence were confirmed in larger studies, there are brief interventions and resources available to support family members that may be suitable for enhancing the service already being provided by IAPT by specifically targeting the stress emerging from this experience (e.g. Copello, Templeton, Orford and Velleman, Reference Copello, Templeton, Orford and Velleman2010).
Acknowledgements
The authors are grateful to Natasha Holt, Richard Heathcock, Gareth Lewis and Lisa Patterson and to the service managers, administrators and service-users that supported and took part in this research.
Disclaimer: The views expressed are those of the authors and not those of the provider, service or commissioner. The name of the provider organization has been withheld to ensure anonymity of patients and staff.
Ethical standards: The authors assert that all procedures contributing to this research comply with the ethical standards of the relevant national or international and institutional committees on Human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
Financial support: Data were collected as part of a self-funded MSc in CBT. This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflict of interest: The authors have no conflicts of interest with respect to this publication.
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