Involving family members in substance use disorder treatment can enhance patient outcomes
Substance use disorder (SUD) is complex and often difficult to treat. The benefit of involving significant others, such as partners, family, and close friends, in treatment to support recovery has long been recognized but less well implemented over time. This study summarizes findings from clinical trials that include significant other involvement and demonstrates its effectiveness when combined with individual therapy.
WHAT PROBLEM DOES THIS STUDY ADDRESS?
The benefit of including significant others in treatment for SUD has been recognized by clinicians for decades, and more recently supported by clinical researchers as well. Several therapeutic frameworks and specific treatments exist that provide structured intervention to significant others as a means of improving recovery outcomes for patients with SUD. Uptake of these empirically supported interventions that integrate significant others, however, has been slow. In order to inform and improve best practices for individuals with SUD, the current study summarizes the findings from 16 separate clinical trials to provide updated and aggregated information on the effectiveness of significant other involvement in SUD treatment.
HOW WAS THIS STUDY CONDUCTED?
For this study, the authors conducted a systematic review and meta-analysis of randomized controlled trials comparing individual therapy for SUD with significant other involvement vs. individual therapy for SUD without significant other involvement.
The initial article search for this study included 4,901 articles retrieved from the PsycINFO database. After excluding ineligible articles, the researchers examined study outcomes and intervention and participant characteristics from across 16 included studies. These 16 studies included 77 treatment outcomes and a combined total of 2,115 participants. The authors did not exclude articles based on age, which included studies of patients younger than 18. Once reviewed, the authors performed a meta-analysis. This involved combining the results of each trial reviewed to derive an overall summary estimate of the effectiveness of the various interventions involving significant others, relative to individual therapy without significant other involvement, across studies.
The researchers were interested in studies comparing behavioral (sometimes called psychosocial) therapies that included significant other involvement vs. active individual therapy comparisons without significant other involvement. Interventions with significant other involvement were diverse and included couples-focused, family-focused, and broader Community Reinforcement Approach treatments.
The active individual treatment comparison conditions varied but included cognitive-behavioral therapy (CBT), motivational enhancement therapy (MET), 12-step facilitation, and “other” individual therapy approaches. Additional inclusion criteria specified that participants had a SUD. The authors excluded studies that used non-clinical samples, patients with severe psychiatric disorders (i.e., schizophrenia), or studies that compared significant other involvement with group-based therapy, or where the significant other was engaged in treatment (e.g., to motivate their loved one to seek treatment) but not the individual with the SUD was not. Studies were also excluded from review if the study researchers did not randomize participants to treatment conditions or offer their treatment in a face-to-face therapy format. Also excluded were studies conducted by an identified investigator whose work in the area has been deemed suspect and unreliable.
Participants included 2,115 individuals from 16 separate trials. The majority of participants were male (65.2%) and the mean age of participants was 22.7 years (SD = 13.47, Median = 28.2), and the range of mean ages reported across studies was 15.36-45.5 years.
- Multidimensional Family Therapy:
This is considered to be an integrated, comprehensive family-based approach for youth and their family. The focus of this intervention is to reduce problem behaviors, including substance use and social-emotional contributors to problem behavior.
- Functional Family Therapy:
This intervention approach places strong emphasis on the family dynamic and focuses on improving family communication and relationships as a catalyst for behavior change, especially for youth and adolescents. This intervention is also designed to improve the individual’s motivation for change.
- Behavioral Couples Therapy:
The goal of this intervention is to improve couples’ relationship quality, which can be significantly impacted by addiction, and bolster social support for recovery. This is accomplished by improving communication and recovery skills.
- Community Reinforcement Approaches:
This is a psychosocial intervention for individuals with SUDs, including adolescents, and family members, to support and bolster motivation for treatment and change. This approach is also designed to examine the drivers of substance use, help individuals identify more adaptive methods of getting their needs met without substances (e.g., communication skills, relapse prevention skills, urge management, occupational assistance), and strongly reinforcing this positive behavior change.
WHAT DID THIS STUDY FIND?
Compared to individual therapies alone, which have been shown to be effective by themselves, treatments that integrated significant others were associated with even better substance use outcomes (e.g., frequency, quantity of use) and reductions in substance-related problems. Specifically, the researchers estimated that this equated to a 6% reduction in substance use overall compared to individual therapy without significant other involvement, which translates into 2 fewer drinking days per month or 3 fewer drinking weeks per year when examining alcohol consumption, specifically, for example.
The researchers found that the magnitude of such benefits were consistent across intervention types, duration of treatments tested, and participants’ ages, genders, types of substances used, baseline substance use severity. The researchers also found that, while the benefits of significant other involvement were greatest immediately after treatment ended, this benefit persisted for up to 18 months post-treatment.
Half of the studies evaluated involved primary caregivers (parents), 31.3% involved romantic partners (25% had a couples therapy focus), and 18.8% involved a mix of individuals (e.g., children, siblings, parents, spouses).
The largest proportion of studies used cognitive-behavioral therapy-based treatments (37.5%) for the comparison individual therapy; 18.8% were motivational enhancement treatment-focused, 12.5% were 12-step focused, and 31.3% were classified as “other.” The researchers did not find differences between the different interventions tested, or regarding the type of significant other included in the treatment.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
Empirically-supported treatments such as cognitive-behavioral therapies and motivational enhancement therapy have been shown to improve substance use outcomes. These researchers found that compared to empirically supported individual therapies like these, involvement of significant others in these treatments was associated with improvements over and above individual therapy without significant other involvement. Further work aimed at promoting the implementation and maintenance of significant other involvement in care could also be of added value to individuals with SUD. Also, understanding for which patients, in particular, the involvement of significant others might be especially helpful, as well as the type of significant other (e.g., parent, partner, friend), and the degree of emotional closeness to, and/or the frequency of contact with, the significant other, all would be helpful to know.
Given the chronic nature of substance use disorder for many individuals, interventions that integrate significant others into treatment might improve care by bolstering the support needed for recovery, improve relationships, and potentially increase accountability and for patients. The researchers in this study were unable to evaluate whether these were the exact reasons for the superior treatment outcomes observed and additional research is needed to evaluate these and other possible causes, which is an important direction for future research. It is important to note that the researchers did not restrict studies based on patients’ age, and that average age (mean = 22.7 years old, SD = 13.47) across studies suggests that patients were remarkably young overall. These results might generalize more readily to adolescents and young adults than older adults.
- This study focuses on individually-delivered SUD interventions only, which excludes comparisons to common group-based or other combination treatments that are not exclusively individually-based or psychosocial in nature.
- The current review includes articles retrieved from one data base (PsycINFO), which might have missed studies indexed in other data bases (e.g., PubMed, CINAHL).
- A strength of this review is the combination of treatment outcomes from multiple studies to get an overall estimate of effectiveness. On the other hand, this method also might limit the ability to examine individual differences in treatment response within the studies they included. For example, the effectiveness results of a particular study could be driven by a few participants who achieved total abstinence, even if many or most of the other participants continued hazardous substance use. This level of within-study variability is not accounted for directly in the current study.
- The methods of the studies included and the analysis itself did not allow for examination of causal mechanisms – meaning how exactly the treatments produced better outcomes – such as improved relationship quality, enhanced accountability or support, etc., potentially leading to improved drinking.
- In all likelihood, included studies would have involved individuals only who had a significant other who was willing to participate in the treatment. Because many patients in SUD treatment do not always have a significant other who is willing to participate in such treatment, implementation of these beneficial protocols will be restricted to patients who have a willing significant other. This might also be impacted by age, and the average age of participants across studies was young (22.7 years old).
- For individuals and families seeking recovery: This study found that treatments that incorporate significant others in treatment are associated with improved treatment outcomes for individuals with substance use disorder. These results, which are consistent with prior work conducted in hospital-based settings, were similar across the different types of intervention tested or significant other involved (e.g., child, parent, spouse). Although more research is needed, and results might differ among older individuals (average age of patients across studies was about 23), these results speak to the power of involving supportive individuals in substance use disorder treatment. In addition, there are several other helpful treatments or supports for significant others. For example, Community Reinforcement and Family Training (CRAFT) helps friends and family develop strategies to support their loved ones struggling with substance use and facilitate their participation in treatment when their addicted loved one is not motivated to enter care.
- For treatment professionals and treatment systems: Compared to empirically-supported individual therapy alone, integrating significant others in treatment was found to produce significantly better treatment outcomes. While these results reflect outcomes from outpatient treatment, similar findings have been observed in hospital-based settings. Further, the outcomes of the current study were unrelated to the type of significant other involved and appeared to add value to treatment regardless of the individual treatment approach used (e.g., cognitive-behavioral therapies, motivational enhancement therapy, Community Reinforcement Approach). At the same time, selection of significant others should still be considered carefully, as some significant others might be more helpful and supportive than others. For administrators and systems, inclusion of significant others in treatment could improve patient outcomes and potentially reduce the likelihood of treatment interference and future relapse. With respect to feasibility, the average difference in the number of sessions required for significant other-involved treatment vs. individually-based comparison treatments was 1.58 sessions, with the largest proportion of studies showing no difference. Other approaches that might be useful to patients and families, which were excluded in this study, include those designed for loved ones specifically. For example, Community Reinforcement and Family Training (CRAFT) helps friends and family develop strategies to motivate and support their loved ones struggling with substance use.
- For scientists: Results of this study suggest that integration of significant others in empirically-supported substance use disorder treatment, relative to individual therapy alone, was associated with a significant improvement in post treatment outcomes that persisted up to 18 months. The magnitude of this effect was small (Cohen’s d = .24) but consistent from post treatment though 18-month follow ups (when available). Study implications should be interpreted in light of study limitations, including the possibility of missing articles indexed in other databases (e.g., PubMed) and within study variability obscured by meta-analysis. Information regarding treatment moderators (e.g. patient characteristics, type of significant other, living in the same residence vs not, etc) and mechanisms of significant other involvement (e.g., enhanced support, accountability) would be helpful to gather and investigate in future investigations. In addition, many substance use disorder treatment centers rely on group therapy approaches, which the current study excluded from analysis. Additional work that is inclusive of these approaches could be of added value, and research that clearly identifies and overcomes barriers to implementation and sustainability of significant other involvement in SUD treatment.
- For policy makers: Involving significant others in empirically-supported individual therapy was found to be associated with superior outcomes for patients with substance use disorder. While the findings of this study offer novel insight into the efficacy of this treatment approach, the benefit of significant other involvement in treatment has long-been recognized. However, barriers to further examination and implementation in real-world settings will continue to undermine dissemination. Policy and decision makers could work with treatment programs and systems to identify and address barriers to implementation and dissemination of interventions involving significant others. These efforts could include increasing funding for training in significant other involvement (including training of the significant others themselves to increase efficacy, effective support, and decrease burnout), and research funding support for implementation and dissemination research. In summary, enhanced support and advocacy of methods that include significant others in empirically-supported individual therapy may lead to further improvements with respect to efficacy, effectiveness, and implementation, and ultimately improve patient care.
Ariss, T., & Fairbairn, C. E. (2020). The effect of significant other involvement in treatment for substance use disorders: A meta-analysis. Journal of Consulting and Clinical Psychology, 88(6), 526–540. doi: 10.1037/ccp0000495