Intervention style

In this section:

We consider different kinds of intervention style and how they can be integrated to form a coherent and effective service. We evaluated five broad categories of intervention:

  • Universal and community awareness raising;
  • Individual;
  • Parenting support;
  • Child focussed;
  • Whole family therapeutic approach.

Most services used more than one of these approaches in combination with one another.

First steps

There is good evidence for some interventions which can be used by services aiming to reduce the impact of parental alcohol misuse on children. Much of this evidence is generalised from other aspects of drug treatment or family interventions and has not been evaluated in the most rigorous ways when applied to alcohol hidden harm. The findings of our evaluation point to some key questions about the range of intervention styles used by the projects.

Ask yourself:

  • Do you have evidence and experience which supports your approach to reducing alcohol hidden harm? If not, where can you access the evidence?
  • Do you have, or can you develop the capacity to work with more than one generation within the same family, whether parent, grandparent, carer or sibling and child or young person? Can you offer support to parents who are misusing alcohol or who have lived with or are still living with a partner who misuses alcohol?
  • If your intervention is focused specifically on children, do you have a strong and willing partner agency who can offer support to adults (whether they misuse alcohol, or are living with the consequences of another’s alcohol misuse)?
  • Can you work closely with the universal services commonly accessed by your client group e.g. schools, GPs?
  • Is the intervention you propose aimed at changing health and wellbeing outcomes for children even if your primary client is an adult?
  • Do you have a range of strategies for engaging with adults who misuse alcohol?
  • Is your service flexible enough to adapt to emerging issues and needs for clients once they have begun to engage with the service? (Flexibility may be needed with respect to family members you work with, location, other agencies and or specific aspect of the intervention).
  • Do you plan to work with clients over a period of six or more months? Are you able to extend the period according to client needs? Can your clients return for further support and advice at a later stage?

If the answer to any of these questions is no, you may need to re-think your intervention styles as the experience of the five alcohol hidden harm projects funded by Comic Relief demonstrated the value of all these elements.

While each of the intervention styles listed above can be used independently of one another the most effective services employed more than one kind of intervention in their work with families. Broadly speaking the most effective alcohol hidden harm services funded by Comic Relief were:

  • Child centred (i.e. the needs of the child or children came first);
  • Whole family oriented (worked with more than one member of the family including the child if over 5 years old );
  • Therapeutic (i.e. were not solely respite or leisure focussed);
  • Evidence/experience based;
  • Long term (engaged with clients over a minimum of 5-6 months, sometimes for much longer/more than one cycle);
  • Flexible (adapted to the expressed and felt needs of the clients);
  • Involved universal services, especially schools,

These interventions often included specific features such as motivational interviewing, play therapy, parenting support groups, and one to one work with children and with adults to address the impact of their drinking on their children.

Effective services also developed ways to raise awareness of alcohol hidden harm among those agencies most likely to come into contact with children on a day to day basis, especially schools. Evidence from children for the evaluation report demonstrated repeatedly the vital role of schools, and particularly of primary school staff, in identifying parental alcohol misuse and providing support for children affected by parental alcohol misuse.

Look again at your response to the sections on Agreeing Outcomes, Needs Assessment and Service Qualities in this toolkit. What outcomes do you want to achieve and for whom? Do you know and understand the needs of the children and adults with whom you will be working? To what extent have clients been involved in defining their own outcomes? (See the IRISS guide on Leading for Outcomes: parental substance misuse). Do your practitioners have the experience and skills to deliver the kinds of interventions you believe are needed? Do you have resources to engage with and support family members for a sustained period of time and for them to re-engage with the service after a gap? Now take a closer look at the different intervention styles (below). What can you offer which is most likely to make a difference to children whose parents misuse alcohol?

Universal and community awareness raising

Universal interventions are usually only weakly effective on their own. They do contribute to raising concerns about an issue, in this case the impact of parental alcohol misuse on children. However, this is rarely enough to make any significant change for children in the long run. Indeed, what may happen is that a community may become aware of the issue but be unable to tackle the the consequences because there is no service available to address the child’s needs.
What we found from the five alcohol hidden harm services funded by Comic Relief, was that once awareness was raised – and universal providers knew there was a reliable local service – there was a real readiness to refer parents and children to the services. In some cases these referrals came directly to the service from some unexpected people: a Police Community Support Officer, an extended schools officer and a teenage child of a drinking parent. In some cases the awareness raising was a clear objective for the service.

Case study: Increasing awareness and referrals

A London based family alcohol service wanted to raise the awareness in/ among schools and children’s centres of the impact of parental alcohol misuse on children. They trained a large number of workers in several locations which increased their referrals from these agencies. In addition they worked alongside partners to ensure reducing alcohol hidden harm became a strategic priority for other agencies in the borough. As a result of this they were invited by the healthy schools team to develop some classroom activities to be used with children at school. Referrals to their therapeutic service increased as a result.
In others it was something which evolved alongside the service.

Case study: Increasing the 'offer'

An alcohol hidden harm service was finding it difficult to work with families in parts of the area with poor transport links to their base. One solution was to offer therapeutic play therapy to children at school. While this approach was unfamiliar to the schools they readily agreed to provide space and time so that the children could be supported. Once schools saw the benefits of the approach they began to make direct referrals to the service for children in similar circumstances. A service level agreement was drafted to help the schools understand the role of the therapist, how safeguarding issues would be managed and the need for the sessions not to be disturbed. One of the challenges of this approach is the need for ongoing training. Schools and children’s centres can have a high turnover of staff, so expertise can gradually be lost.

Individual (adult focussed)

Most of the services funded by Comic Relief offered some form of individual support for adults. The level of support varied greatly from intensive therapeutic interventions such as counselling to regular but less intensive mentoring, advice and guidance on stopping drinking. Some services also offered practical help to meet specific needs, for example arranging child care while a mother attended court to give evidence against her violent husband, and arranging for a faulty cooker to be replaced.

Adults valued one to one support which relied on a high level of trust between the worker and the service user. For some adult service users this relationship was the first where they felt able to be open about their alcohol use. One to one work should be delivered by suitably qualified practitioners who receive a high level of clinical and managerial supervision. Where one to one support is intensive there is a risk that some adults can become over-dependent on their worker, who should not be ‘contactable at any time’. For examples of one to one psycho social and other interventions intended to help adults change their behaviour or develop resilience to cope with adverse circumstances see Alcohol Concern’s Embrace: Knowledge Set 3: Parents and Carers

Parenting Support

Several of the services offered parenting support, sometimes in the form of groups and sometimes on a one to one basis. There is good evidence that children benefit from group based parenting programmes for adults, especially the 3-10 year olds. The Economic and Social Research Council (ESRC) has published a ‘nugget’ summing up the evidence for the effectiveness of parenting programmes and identifying some of the more successful programmes available. The nugget also lists some useful organisations which support parenting work.

According to the ESRC nugget (Gibbs et al, 2003) parental alcohol misuse is one of a number of risk factors for behavioural problems in children. The evidence from four of the Comic Relief alcohol hidden harm services suggested that parents observed improvements in relationships with their children as a result of the services they received.

Case study: Simple changes

A group of parents accessing a range of services at one agency described attending a parenting course which taught very simple techniques including: getting down to children’s eye level when speaking to them, giving them a warning before you act, counting ‘1, 2,3’ when you ask them to do something, spending positive time together as a family, eating a meal together and use of ‘time out’. These parents had been amazed at how making simple changes and establishing some routines had made a very big difference to their ability to communicate with their children in a positive way.

Child focussed

All the services we evaluated were set up to address the needs of children whose parents misused alcohol. Only one of the services offered support only to children. The service was specifically aimed at children who were already known to other partner agencies and whose parents misused alcohol. In some cases the parents did not know that the children were receiving support because of alcohol hidden harm and the service did not offer any support for adults. In every case where the child was receiving a service without the parent’s or carer’s knowledge, the child was judged to be Gillick or Fraser competent (click here for further details of the Gillick Guidelines and Fraser competencies. The children were very vulnerable and received a high level of intensive support from a well-qualified practitioner. Some work was carried out in schools but this was not consistent and was affected by spending cuts. At the end of the funding the workers acknowledged that they had not achieved as much as they would have liked, because they had not been able to work with the parents.

Case study: Focus on children

An agency with experience of running drug services for children set up an alcohol hidden harm service. The service ran group sessions and offered one to one therapeutic interventions with the children. The groups were small and retention was difficult, but the attendance at one to one sessions was good. The children reported that they learned a lot about the way their parents’ alcohol use impacted on their family life, that it was not their fault and that they should not feel responsible for caring for their parent or siblings. In a very few cases we observed that the strategies gained by the child also benefited the parent and the relationship with the parent improved. Children were safer because they were more able to name adults in the wider family and community who could help them.

The Children’s Society has developed a toolbox for practitioners working with children affected by parental drug and alcohol use: ‘Ask about me’. The aim was to highlight the needs of the children of adult clients and to help practitioners devise better ways to help them. It includes a dvd in which children themselves describe the impact of their parents’ behaviour on their lives and emotional well being.

Whole family therapeutic approach

Parental alcohol misuse is a complex issue, often with roots in the adult’s early lives. Family life is also complex and the interactions between family members, where alcohol is not an issue, can also be fraught with difficulty. It is not surprising then, that whole family approaches, with a focus on therapy, have been successful in helping children whose parents misuse alcohol.

Case study: Involving Mum

A mother, who had misused drugs and alcohol over many years, sought help from a service because her 5 year old child had begun to self harm. She acknowledged that she had been unable to bond with her child because of her drug misuse, and although she no longer used drugs her continuing dependence on alcohol meant she was sometimes unpredictable in her parenting. She received counselling which helped her to stop drinking and her son also began a course of play therapy. When she was ready, Mum began to sit in on some play therapy sessions, learning how to use play to help her child express his emotions (filial play). At home she continued to try the strategies used in the play therapy sessions, with support from the therapist. Over time the child stopped self harming. His Mum said that the support she had helped her to become ‘more like a Mum and not just a carer’.

Key to whole family approaches is the co-ordination of support as a family unit, as in the example above. An alternative model was observed where an adult worker supported parents and a child worker supported children by visiting them at school. The risks associated with this model are that adults and children can remain dependent on their respective workers for support, rather than moving forward to improved relationships within the family or beyond.

We could extend the argument for whole family approaches to whole community support. To be truly resilient, a child needs a resilient community, able to respond to their needs promptly and appropriately. This brings us back to the points raised at the beginning of this section and Section 8– the vital role of universal services in being able to recognise and respond to the needs of children where parental alcohol misuse is a problem.

If you are setting up a service aimed at improving outcomes for children whose parents misuse alcohol, you should consider how to combine the intervention styles described above into holistic family based service, offering support to other practitioners, parents, carers and children.

Effective interventions

Finding evidence for specific interventions which have been shown to be effective can be complex. Research evidence tends to be reported in academic journals and may not be presented in the most accessible format for busy practitioners. You may not always find exactly what you are looking for: you may wonder if an intervention developed for use with adults is appropriate for children, or if an intervention which has worked for illegal drug users can be useful for those who misuse alcohol. Nevertheless to assume there is nothing to be learned from such sources would be a mistake. A number of voluntary sector organisations provide advice and guidance or summaries of research evidence which are relevant to alcohol hidden harm services. Visit the Skills Hub developed for the Skills Consortium for interventions for drug and alcohol users. See the Table below for some suggestions about other sources of advice and guidance for working with families:

Organisations
Adfam Many of the resources are focused towards adults but the website includes a lot of useful information related to families (some related to children); and importantly, non-misusing members of the family.
Alcohol Concern Training and other resources. Includes reports from the Embrace project which looked at the relationship between alcohol misuse and domestic violence.
STARS National Initiative (Children’s Society) Resources, publications etc. for a range of workers working with children and families where substance misuse is an issue.
Information
NSPCC NSPCC hosts two free services which workers can sign up to for information
CASPAR
Inform - Inform has a clear child protection focus but not exclusively so. Can signpost to academic publications.
DS Daily Produced by Drugscope. This is a good free daily news service you can sign up to for information about drugs and alcohol in the popular and academic press.
DDN (Drink and Drug News) Weekly free magazine for the Drug and Alcohol field available in hard copy and from the website
Findings Good online resource for accessing details of published research, and commentaries and summaries for practitioner with a user friendly search facility. For example a search of psychosocial interventions for young people/family members yielded 9 articles published since 2001
Project Cork A US based resource for accessing academic publications in drug and alcohol specialisms.
Services
Action on Addiction (M-PACT) M-PACT (Moving Parents and Children Together) is based on the Strengthening Families approach developed in the USA. A small scale evaluation study suggests that families benefited from the approach.
Addaction (Breaking the Cycle) Breaking the Cycle employs a range of approaches, as recommended by the findings of our evaluation, including parenting support, systemic family therapy and involvement of universal services.
Bristol Drugs Project One of the five Comic Relief funded alcohol hidden harm projects. As part of their service they used trained volunteers as mentors for young people and to help run youth groups for children whose parents misuse alcohol.
HertSpeak, Hertfordshire One of the five Comic Relief funded alcohol hidden harm projects. HertSpeak worked intensively with children and their parents/carers over a long periods, using a range of interventions based on the experience developed by CoreKids (part of the Westminster Drugs Project). One of the key features of their approach was play therapy.
CASA, Islington One of the five Comic Relief funded projects. They focussed their work on developing the awareness and skills of universal services which came into regular contact with children such as Family Centres and schools
Turning Point Base Camp offers opportunities for young people to talk about the problems of growing up with a parent who misuses alcohol. Support can be one to one or in groups.
Phoenix Futures Best known for its residential services, Phoenix Futures also offers community based support for families where parental alcohol misuse is a problem.
Specific interventions
Option 2 Option 2 is designed helps families in crisis because of substance misuse
Strengthening Families A number of organisations have adopted – and adapted -the original Strengthening Families programme which works with adults and children separately at first and then together to prevent substance misuse and other risk behaviours in children and young people. Additional link http://www.mystrongfamily.org/
Systemic family therapy Systemic family therapy (SFT) seeks practical solutions to family based problems without analysing the root cause (psychotherapy). The University of the East of London (UEL) hosts a database of references to help those interested in SFT.
Motivational interviewing Motivational interviewing has developed as an approach to helping people identify for themselves the steps to change in their lives. ‘Motivational interviewing: preparing people for change’ By W.R. Miller and S. Rollnick is the key text on this approach which was developed based on clinical experience of worker with people who were dependent on alcohol. Brief motivational interviewing has been found to be effective with young people in some circumstances.
Play therapy The Play Therapy association describe a range of interventions which can help children with emotional and behavioural problems including filial therapy

Overview

Different kinds of interventions can contribute to positive outcomes for families where parental alcohol misuse is causing harm to children. The way services use these different interventions contributes to the overall effectiveness of the services. The most effective services used sound evidence to identify and experience to adapt the interventions to suit their clients.

Tools