The ARISE Intervention. Using family and network links to engage addicted persons in treatment

Community reinforcement and family training: an effective option to engage treatment-resistant substance-abusing individuals in treatment

AIMS

Many individuals with substance use disorders are opposed to seeking formal treatment, often leading to disruptive relationships with concerned significant others (CSOs). This is disturbing, as untreated individuals are often associated with a variety of other addiction-related problems. Community Reinforcement and Family Training (CRAFT) provides an option to the more traditional treatment and intervention approaches. The objective of this systematic review was to compare CRAFT with the Alcoholics Anonymous/Narcotics Anonymous (Al-Anon/Nar-Anon) model and the Johnson Institute intervention in terms of its ability to engage patients in treatment and improve the functioning of CSOs.

METHODS

The electronic databases PubMed, PsycINFO, EMBASE, CINAHL and the Cochrane Library were consulted. Four high-quality randomized controlled trials were identified, with a total sample of 264 CSOs. Data were synthesized to quantify the effect with 95% confidence intervals, using the random effects model.

RESULTS

CRAFT produced three times more patient engagement than Al-Anon/Nar-Anon [relative risk (RR) 3.25, 95% confidence interval (CI) 2.11-5.02, P < 0.0001; numbers needed to treat (NNT) = 2] and twice the engagement of the Johnson Institute intervention (RR 2.15, 95% CI 1.28-3.62, P = 0.004; NNT = 3). Overall, CRAFT encouraged approximately two-thirds of treatment-resistant patients to attend treatment, typically after [corrected] four to six CRAFT sessions. CSOs showed marked psychosocial and physical improvements whether they were assigned to CRAFT, Al-Anon/Nar-Anon or the Johnson Institute intervention within the 6-month treatment window.

CONCLUSION

CRAFT has been found to be superior in engaging treatment-resistant substance-abusing individuals compared with the traditional programmes.

Family interventions in the treatment of alcohol and drug problems

Alcohol and drug problems affect not only those using these substances but also family members of the substance user. In this review evidence of the negative impacts substance misuse may have upon families are examined, following which family-focused interventions are reviewed. Several family-focused interventions have been developed. They can be broadly grouped into three types: (1) working with family members to promote the entry and engagement of substance misusers into treatment; (2) joint involvement of family members and substance misusing relatives in the treatment of the latter; and (3) interventions responding to the needs of the family members in their own right. The evidence base for each of the three types is reviewed. Despite methodological weaknesses in this area, a number of conclusions can be advanced that support wider use of family focused interventions in routine practice. Future research needs to focus on (1) pragmatic trials that are more representative of routine clinical settings; (2) cost-effectiveness analyses, in terms of treatment costs and the impact of interventions on costs to society; (3) explore treatment process; and (4) make use of qualitative methods. In addition, there is a need to define more clearly the conceptual underpinnings of the family intervention under study.

Assisting a concerned person to motivate someone experiencing cybersex into treatment: application of invitational intervention: the arise model to cybersex

Cybersex and Internet pornography addiction are new problem areas confronting couples and families. A most significant experience inducing family members to reach out to a therapist or an Interventionist for help with their addicted member is the realization that the individual they are living with has become a stranger. This article focuses on the changes in the attitude, emotions, and behaviors of the addicted individual from compulsive Internet pornography use and cybersex. Identifying these changes for the family members validates their experience of now living with a stranger. This article then presents the three-level empirically based, manual-driven method of Invitational Intervention, A Relational Intervention Sequence for Engagement (ARISE) as an effective tool for helping families to get their loved ones into treatment.

Linking human systems: strengthening individuals, families, and communities in the wake of mass trauma

This article presents an overview of the philosophy and practical principles underlying the Linking Human Systems Approach based on the theory of resilience in individuals, families, and communities facing crisis, trauma, and disaster. The Link Approach focuses on tapping into the inherent strength of individuals and their families and emphasizes resilience rather than vulnerability. It has been successfully used in combating critical public health problems, such as addiction, HIV/AIDS, and recovery from major trauma or disaster. Also, three specific models of Link intervention aimed at the individual, family, and community levels are discussed, with special emphasis on the family-level intervention. These interventions are directed toward mobilizing resources for long-term physical, emotional, psychological, and spiritual healing.

Family and peer interventions for adults: past approaches and future directions

Through the use of published literature and empirical research, the authors explore the differing conceptual frameworks, techniques, and effectiveness of various family interventions for change-resistant, substance-abusing adults. The 2 dominant programs in place to help families and friends deal with the addiction of an adult loved one are the Johnson Intervention and Al-Anon. Research on these 2 programs is presented, followed by an outline of promising alternative approaches. These include A Relational Intervention Sequence for Engagement, Community Reinforcement Training, Community Reinforcement and Family Training, Unilateral Family Therapy, and Pressures to Change. The effectiveness and appropriateness of these approaches in different situations are discussed. In addition, areas in need of further study are pointed out.

Outcomes with the ARISE approach to engaging reluctant drug- and alcohol-dependent individuals in treatment

Our goal was to explore, through a Stage I NIH clinical study, the effectiveness of a manual-driven, timely response method for helping the "concerned other" get resistant substance abusers into treatment/self-help with minimum professional time/effort. A manual-driven protocol, "A Relational Sequence for Engagement (ARISE)," was applied with 110 consecutive, initial calls/contacts from concerned others; no cases excluded for research, refusal, or other reasons. The research was conducted at two upstate New York outpatient drug/alcohol clinics. Participants were concerned others who called regarding a cocaine, alcohol, or "other drug" abuser (N = 110); participating family/friends: 11 ARISE clinicians; and 110 substance abusers. ARISE is a graduated continuum starting with the least demanding option/stage, increasing effort as needed to engage substance abusers in treatment/self-help. Stage I: Coaching the concerned other to arrange a meeting of significant others, inviting the substance abuser; Stage II: 1 to 5 additional meetings (median = 2); Stage III: A modified Johnson "Intervention." Primary outcome variables were substance abuser engagement (or not) in treatment/self-help; days between first call and engagement; clinician time/effort. Predictors were concerned other, substance abuser, and clinician demographics; number of participants per case; and Collateral Addiction Severity Index. ARISE resulted in an 83% success rate (55% at Stage I). Median days to engagement was 7 (IQR = 2 to 14). Average total time (telephone, sessions) per case was 1.5 hours. Treatment/self-help chosen was 95% treatment and 5% self-help. Number of family/ friends involved correlated 0.69 with a success/efficiency index. Conclusions. A call from a family member or concerned other for help in getting a loved one into treatment is a rich opportunity for treatment professionals and agencies to engage substance abusers in treatment. These initial calls are similar to referral calls from EAPs or probation officers looking to get an individual started in treatment. ARISE provides an effective, swift, and cost-efficient option for engaging substance abusers in treatment or self-help. The more significant others involved, the greater the success of treatment engagement.

A importância da família no tratamento do uso abusivo de drogas: uma revisão da literatura

Este artigo apresenta uma revisão da literatura sobre as duas fases do tratamento do adicto e de sua família: o engajamento e o tratamento propriamente ditos. Ressalta, através de diversos estudos, a necessidade do adicto ser atendido juntamente com a sua família para um resultado satisfatório do tratamento. Aponta para questões socioculturais importantes que interferem no tratamento realizado em Instituições. Enfatiza que o tratamento do adicto e de sua família contribui para o entendimento e as bases de uma ação efetiva de prevenção.

Getting reluctant substance abusers to engage in treatment/self-help: a review of outcomes and clinical options

This review examines the results from 19 outcome studies, involving 1,501 cases, within 10 different clinical approaches to getting alcohol or drug abusers to engage in treatment or self-help. Each approach is summarized and its "success rate(s)" presented. Comparisons are made across various subcategories, such as alcohol vs. drug abusers, adolescents vs. adults, and experimental conditions vs. controls. A distinction is drawn between "Dual-Purpose" approaches, which combine engagement with counseling of the concerned person who originally sought help for the substance abuser, and "Engagement-Primary" approaches, which generally confine their efforts (through working with family members and others) to getting the substance abuser into treatment/self-help. "Best bet" clinical options are presented in terms of which particular approach appears to have the edge with which kind of substance abuser.

Involvement of support networks in treatment

Alcohol dependence and abuse are biopsychosocially determined and ameliorated. However, social factors involved in effecting treatment outcomes continue to be understudied as a context in which psychological and biological factors are researched and also as a treatment focus in their own right. Yet the client's social setting and relationships during and after treatment are more important forces in the recovery process than formally defined alcohol treatment interventions. Though this has been so historically, it is even more likely now in managed care environments where treatments are highly circumscribed. This suggests that treatment interventions refocus toward targeting changes in the patient's social environment. Treatments involving spouses and families of the patient's social networks it has been shown, are incrementally effective. A high priority for research is to identify the set of conditions under which the wider social network can also be effective. Early results are promising though not well understood. The next generation of network therapies will focus on testing the conditions under which various components of the patient's social network are important in affecting patient outcomes. As with other therapies, an important focus for research is on identifying the active ingredients in these treatments that bring about favorable change in patients generally or that enhance the outcomes of the subset of patients particularly amenable to network interventions (patient-treatment "matching"). Recommended priorities for future research in network interventions are identified.

Social behaviour and network therapy basic principles and early experiences

The present paper reports on the basic principles of a treatment approach currently being used in a National Multicentre Randomised Controlled Trial of Alcohol Treatments in the United Kingdom (UK Alcohol Treatment Trial). The treatment: Social Behaviour and Network Therapy (SBNT) is novel as a package but has been developed by integrating a number of strategies found to be effective in other treatment approaches. The intervention is based on the notion that to give the best chance of a good outcome people with serious drinking problems need to develop positive social network support for change. A brief review of the evidence supporting social treatments for alcohol problems is followed by an outline of the feasibility work and the basic principles that guided the development of SBNT. Process data from the first 33 trial cases and 2 case vignettes are described and discussed. It is concluded that SBNT is a feasible and coherent treatment approach that can be delivered by a range of therapists in the alcohol field.

Behavioral and cognitive-behavioral treatments for alcoholism: research opportunities

This status report on behavioral and cognitive-behavioral treatments (CBT) for alcoholism is based on an article commissioned by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) for a review of its treatment research priorities. A number of gaps in knowledge and consequent research opportunities were identified. Additional work on cue exposure is needed to identify the most potent cues for drinking, and strategies for reducing the impact of drinking cues. Regarding contingency management, there is need for further studies with alcoholics, investigation of reinforcement schedules, and exploration of maintenance factors. With respect to the community reinforcement approach (CRA), research should identify its most effective elements and ways to sustain gains following treatment. The mediating role assigned to coping skills in the cognitive-behavioral model needs to be substantiated, and the effectiveness of various coping skills components must be determined. Further studies of relapse prevention (RP) are needed to improve the system for classifying relapse episodes, and to identify the most effective interventions for each type of episode. Studies of behavioral marital therapy should include identifying active ingredients, and testing hypothesized mediators of change. Patient-treatment matching strategies may help to identify clients likely to benefit from these strategies. Finally, given the overlap among these approaches, it is likely that research along the lines suggested will impact several of them and lead to a consolidation of their most effective elements into a common treatment package.

Strength in numbers: the ARISE method for mobilizing family and network to engage substance abusers in treatment. A Relational Intervention Sequence for Engagement

The model described in this paper takes into consideration two key findings: (a) In a given year, the vast majority (90-95%) of active substance abusers do not enter treatment or self-help groups, and (b) substance abusers have frequent contact with their families (60-80% either live with a parent or are in daily contact). This paper presents a method for mobilizing and collaborating with families and extended the support system toward working with resistance and getting the substance abuser into treatment. Principles and techniques are provided for convening and structuring intervention network meetings toward that end. This intervention network approach can be used either alone or as part of an overall model, ARISE (A Relational Intervention Sequence for Engagement). The ARISE model addresses both clinical and programmatic issues in treatment engagement for substance abusers.

Family connectedness and women's sexual risk behaviors: implications for the prevention/intervention of STD/HIV infection

The present study explores the relationship between connectedness with the intergenerational family and women's sexual risk-taking as a guide to the development of family-focused prevention and intervention. Cross-sectional interview data from a pilot study were analyzed for correlations between a number of self-reported, risky sexual practices, the range of extended family members with whom the respondent was in contact, and awareness of stories pertaining to intergenerational family history. Structured interviews were administered by female interviewers to 56 women from two contexts: a STD (sexually transmitted disease) Clinic (N = 26), and an inner-city, Hispanic Community Organization (N = 30). Knowledge of stories about grandparents or great-grandparents was a robust predictor of lower sexual risk-taking in the STD Clinic sample. This relationship persisted, but only at the trend level in the Community Organization sample. In both the total sample and the STD subsample, the number of categories of extended family members with whom a respondent was in at least monthly contact was correlated with less sexual risk-taking. Given the fundamental importance of the family system as the primary social unit, these findings argue for further family theory-based research and for its potential application in the development of health prevention and intervention. Implications for practice and future research are discussed.