Disrupting Standard Mode: A big picture story of family inclusion in substance use services


We hear a lot about patient-centred care in substance use services, but what about family-centred care? Family members are important sources of support for those accessing substance use services. However, family inclusion is not always regular or customary practice within substance use systems and services. In the midst of an unprecedented public health overdose emergency, families are vital first responders who can provide life-saving first aid and are key resources and facilitators in accessing and using substance use services.

With this in mind, Island Health and CARBC partnered to explore family involvement in out-patient substance use treatment services across youth, adult and senior’s programs. The purpose of this research project was to understand, from the perspective of Island Health service providers, the current landscape of family inclusion and what might be possibilities for increasing practitioner and organizational capacity to facilitate responsive family inclusion in substance use treatment services.

What do we mean by family and why is family inclusion important? We found that providers had a broad definition of family. Family was considered to be anyone in a person’s circle of care who contributed love, connection and closeness. Examples of family members were many and included biological relations and chosen relations such as friends, partners, neighbours, and in some cases pets. Family inclusion was described as being a necessary means of reducing consequences of substance use throughout generations, while fostering wellness for the individual accessing services and the broader family system. Families were recognized as being integral sources of support and safety for people involved with substances and vital resources beyond immediate, time-limited formal interventions.

What gets in the way of family inclusion? While we heard service providers emphasizing the importance of family inclusion, in reality working within the health care system meant operating in ‘standard mode.’ Standard mode included dominant structural values privileging individualized and predominantly biomedical service philosophies that often left families out of the picture. In spite of this, service providers described ways of disrupting standard mode and working towards family inclusion. They talked about trying to make time to support families and increasing availability by way of telephone and/or in-person connection. Providers emphasized the importance of offering compassion and presence while maintaining openness to the potentials of expanding the scope of services to involved family members.

How might family inclusion become a regular and customary practice? In order to understand how to change standard mode, we asked research participants to describe their “preferred story.”  They expressed the importance of sparking a broad societal, organization and programmatic culture shift towards family inclusion. Such a shift would include emphasizing the effects of substance use on families and the importance of mitigating ongoing intergenerational ripples of substance use impacts in families affected by substance use. An overarching culture shift would require openness and access to relational, strengths-based and capacity-focused ways of knowing and understanding substance use and working with families affected by substance use.

Read the full report to learn more about recommendations and future directions for increasing family involvement in substance use service.

For further information on this project contact Stephanie McCune at stephanie.mccune@viha.ca or Bernadette Pauly at bpauly@carbc.ca

Stephanie McCune, Manager, Practice Support Program, Island Health

Bernie Pauly, Scientist, Centre for Addictions Research of BC

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC.

Does forced drug treatment actually work?

A judge's gavel

Note: We are pleased to announce CARBC scientist Dr. Karen Urbanoski’s appointment as the Canada Research Chair in Substance Use, Addictions and Health Services Research. This blog post offers a look at some of her research on treatment services in Canada.

Why can’t we just make people go to addiction treatment? This is a question some may be asking in light of recent overdose deaths and other drug-related problems in Victoria. Is forcing people to get help an effective response to the problems caused by addiction? It turns out the evidence is murky—and the research may not even be asking the right questions.

Compulsory addiction treatment does exist in Canada in a number of different forms. People can be formally mandated to a treatment program as an alternative to going to jail or as a condition of parole or probation. People can also be compelled to get help in order to keep their jobs, their children, their social assistance benefits, and so on. Where the data are available in Canada, the statistics show that around 1 in 5 people attending services for addiction are required to be there.

Advocates of compulsory treatment argue that providing services and supports for addiction is more humane, economical, and effective than putting people in jail, firing them, or letting them hit “rock bottom.” These arguments have (quite reasonably) led to a large number of studies aimed at determining whether or not forcing someone to attend treatment “works.” After decades of research, why is this still such a controversial topic?

At this point, it has become apparent that the right question is not whether or not mandated treatment works, but under what circumstances might it work and how? And under what circumstances does it become yet another negative experience with the system, leading to further marginalization and drug-related harms? Here’s why.

The majority of studies have focused on mandates from the legal system (e.g., through the courts). Findings differ across studies, but most show that people who are court-mandated seem to do just as well in treatment as others. However, people who are court-mandated tend to be different from those who are not. Specifically, they tend to be younger and less severely addicted. Comparing groups of people who are different to begin with, finding that they differ (or not) at the end of a study, and chalking that finding up to treatment is not good science.

Another important issue is that personal motivation and other life circumstances play a role in recovery, and this is true whether or not the person is required to be there. Many people who are court-mandated report low motivation to attend treatment, but not all. Many of those who are not court-mandated report low motivation and would not describe themselves as “voluntary.”  Comparing people who do and do not have a court mandate is opportunistic research, but it misses the point if we are interested in knowing whether addiction services are effective when they are forced versus voluntary.

Current policies on compulsory treatment implicitly assume that people who do not initially want to be there will “come around” with time. However, this has never actually been studied. If the point of compulsory treatment is to help people make steps toward recovery, then this is exactly the kind of research that needs to be conducted. We need to figure out the best ways to support and increase people’s motivation and their capacity for decision-making.

Of course it is preferable (and likely more effective) if we can help someone early on, before their problems get really bad. But it is not at all clear that the people who are being diverted from the legal system to addiction treatment are ones who are most in need, or the ones who will end up being most in need down the road. If we aren’t careful, there is ample opportunity for inequities to arise in terms of who is even offered the choice of going to treatment. There is some evidence that this may already be happening. A recent review of Canada’s Drug Treatment Courts found that the majority of those diverted from prison via the program are middle-aged white men. This means women, youth, and indigenous peoples—among the prime target groups of the program—are not being served.

There is no doubt that some people mandated to treatment have been helped. But it is far from a panacea. Even with a variety of strategies in place to compel people into programs, the most severely affected people are still falling through the cracks.

The bottom line is that no society will ever treat its way out of addiction. Yes, addiction treatment can help people. A continuum of services should be accessible to everyone.  At the same time, the impacts of poverty, homelessness, colonialism, racism, and mental illness are not solved by a short stint in a treatment program. Such complex problems will require systemic policy changes that extend far beyond what addiction services are able to provide.

Dr Karen Urbanoski

Author: Dr Karen Urbanoski, Centre for Addictions Research of BC

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC.