Social Behaviour &
Network Therapy
Dr Ed Day
WORKSHOP 27th APRIL 2011
UNIVERSITY OF BIRMINGHAM
Overview
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Background
Theoretical basis
Principles and skills
Structure and content
Case examples
Practical skills
Social Behaviour and Network
Therapy
• A Manualised time limited intervention
consisting of 8 sessions
• Based on the principle that social behaviour,
social interaction and network support for
change play a central part in the resolution
of addiction problems
Family Interventions: Three Broad
Categories
• interventions that work with family members to
promote the entry and engagement of drug and/or
alcohol users into treatment
• the joint involvement of family members and the
relatives using drugs and/or alcohol in the treatment
of the user
• interventions aimed to respond to the needs of family
members affected by drug and alcohol problems in
their own right
Table 1 : Working with family members to promote the engagement of substance users into
treatment or influence the user’s substance related behaviour (Based on Orford et al, 2005)
Approaches
Description
Unilateral Family Therapy
(UFT)
Thomas et al, 1987;
Thomas and Ager, 1993.
Partners of relatives with alcohol problems are trained to act as a ‘rehabilitative
influence’. Three stages: preparation, intervention to reduce drinking or help the
drinker enter treatment, and maintenance of gains.
Pressures to Change
(PCT) (Australia)
Barber and Crisp, 1995;
Barber and Gilbertson,
1996.
Community Reinforcement
and Family Training
(CRAFT) Miller et al, 1999;
Sisson and Azrin, 1986;
Meyers et al, 1999.
Designed for spouses of relatives with alcohol problems. Aims to create change in
the behaviour of those concerned in order to achieve treatment entry for the
relative. By focusing on: education; discussion of family member’s response to
drinking situations; setting up activities incompatible to drinking; and preparing the
family member to confront the relative and request him/her to seek help.
Uses the principles of the Community Reinforcement Approach (Hunt and Azrin,
1973) that focus on the influence of the family, social and vocational aspects in
reinforcing abstinence and assisting substance related behaviour change.
Cooperative counselling.
Yates, 1988 (UK).
Aims to develop a co-ordinated strategy for change working with anyone
concerned enough to take positive action in response to another’s alcohol
problem.
‘Intervention’ (or
‘benevolent confrontation’)
Johnson, 1986; Leipman,
1993.
Social networks of concerned family members and friends are trained to stage a
confrontation, during which attempts are made to reduce ‘denial’ about ‘alcoholism’
and engage the relative in treatment.
A Relational Intervention
Sequence for Engagement
(ARISE)
Garrett et al, 1998, 1999.
A development of ‘Intervention’ that places less emphasis on confrontation and
more on support for family member and relative prior to, during and after treatment
entry. A series of strategies are used to respond to calls from concerned others
aiming to mobilise family members and social networks to assist the problem
substance user’s treatment engagement.
Table 2: Joint involvement of family members and substance misusing relatives in treatment (Based
on Orford et al, 2005)
Approaches
Description
Family therapy for drug abuse
Stanton, Todd et al, 1982; Szapocznik et al, 1988;
McLellan et al, 1993; Bernal et al, 1997.
Family therapy: structural-strategic, Bowen type or
contextual.
Behavioral couples therapy
O’Farrell et al, 1995, 1992, 1993, 1998; O’Farrell
and Murphy, 1995.
Combinations of couples treatment in individual couple
and group formats. Has been applied to both alcohol
and other substance problems.
Network therapy
Galanter, 1993, 1999.
Used alongside individual therapy for the problem
substance user, NT uses an active approach to engage
members of the substance user’s social network in the
treatment process.
Social Behaviour and Network Therapy (SBNT)
(UK) Copello et al, 2002; UKATT Research Team,
2005.
Aims to help a substance user identify potentially
supportive family members or friends and to enlist them
in providing support for change, where possible
engaging them in sessions. Areas covered include:
communication, coping, social support, relapse
prevention and joint activities.
Table 3: Interventions aimed to respond to the needs of family members affected
by drug and alcohol problems in their own right (Based on Orford et al, 2005)
Approaches
Description
A psycho-educational
approach
Dittrich and Trapold, 1984;
Dittrich, 1993.
Based on understanding of ‘alcoholism’ as a ‘family disease’, attempts to: increase
understanding of alcoholism and family interaction; identify and decrease
‘enabling’ behaviours; increase self-esteem; decrease depression and anxiety.
Organised in three phases: educational, experiential (in which assertive responses
are practised), and goal setting and planning.
Al-Anon Family
Groups/Families
Anonymous Gorman and
Rooney, 1979; Miller et al,
1999; Humphreys, 2004.
Mutual-help groups for family members, meeting separately from, but affiliated to
mutual-help organisations for problem drinking or drug taking relatives.
Supported counselling
versus stress
management versus
alcohol focused couples
therapy
Halford et al, 2001.
Three forms of help for women partners of men with alcohol problems Each 15
sessions of one hour aiming to: reduce risk of violence; assist the family member
to choose whether to remain in the relationship; and to help her enact a decision
to leave or alternatively to improve coping and empower her to influence the
partner’s drinking. Based, respectively, on education and non-directive counselling
(Rogers, 1991); reducing the stressful impact of the problem for the family member
and help to influence the partner’s drinking (Sisson and Azrin, 1986).
Parent coping skills
training McGillicuddy et al,
2001.
Behavioural Exchange
Systems Training (BEST)
(Australia) Toumbourou et
al, 1997, 2001.
Counselling for partners in
their own right (UK)
Howells, 1996; Howells
and Orford, 2004.
Copello et al, 2000 a,b;
Copello et al, 2005.
Primary Care Family
Intervention
Based on a behavioural-analytic model of skill training (Goldfried and D’Zurilla,
1969). Eight weekly two-hour sessions to teach ‘more effective’ coping skills in
responding to their adolescents’ substance use. Uses group discussion and role
play around a standard set of frequently encountered situations.
An 8-week group programme for parents of drug using adolescents: first four
weeks focusing on improving parents’ well-being; later weeks aiming to increase
assertive parenting responses.
Counselling, mostly delivered by trained volunteers, for partners (mostly wives) of
relatives with drinking problems, as part of specialised, secondary care services.
Emphasized stress experienced by partners and discussion of ways of coping.
Based on the Stress-Coping-Support Strain model. Includes 5 steps: (i) giving the
family member the opportunity to talk about the problem; (ii) providing relevant
information; (iii) exploring how the family member responds to their relative’s
substance misuse; (iv) exploring and enhancing social support; and (v) discussing
the possibilities for onward referral for further specialist help.
The developing evidence of SBNT
• UKATT
• Implementation with drug users
• Including Family Members project
Social Behaviour and Network
Therapy
• Developing clients natural environment
• Creating conditions to support change
beyond contact with service
• Has the potential to help other people
affected and concerned by the addiction
problem
• Manual based but flexible
Origins
• Need to develop an intervention focused on
the social environment
• Ellis (1998) Network Support Therapy with
alcohol users
• Copello et al. (2002) Social Behaviour and
Network Therapy in UKATT
Copello, A., Orford, J., Hodgson, R. Tober, G
and Barrett, C. on behalf of the UKATT
Research Team (2002)
Social Behaviour and Network Therapy:
Key Principles and Early Experiences
Addictive Behaviors,
Vol. 27, 345-366
Percent Days abstinent
Ukatt
– United Kingdom Alcohol Treatment Trial: BMJ, 2005,
331, 541-544 & 544-548
Drinks per drinking day
Ukatt
– United Kingdom Alcohol Treatment Trial: BMJ, 2005,
331, 541-544 & 544-548
Interventions
‘Mesa Grande’ Miller and Wilbourne (2002)
Top 8 out of 46 treatments with 3 or more
studies included:
Social Skills Training
CommunityReinforcement Approach
Behavioural Marital Therapy
‘Attention to the person’s social context and
support system is prominent among several
of the most supported approaches’. (p. 276)
Theoretical and
research basis
• Project MATCH evidence
• Evidence from Social treatments for
Substance-use problems
• Research on the experiences of family
members e.g. the stress–coping model
(Orford et al, 1998)
Theoretical and
research basis
• SBNT = elements of:
– Relapse Prevention (Marlatt and
Gordon, 1985 )
– Community reinforcement approach
(e.g. Meyers et al, 1996)
– Network Therapy (Galanter, 1999)
– Family Member Intervention (Copello
et al, 2000)
SBNT: OVERALL AIM
• To mobilise and/or develop
positive social support for a
change in drinking or drug use
HOW?
• Through a series of sessions focused on a
range of relevant topics, the therapist aims
to develop a supportive team of concerned
others that will not only offer support
during therapy but beyond the treatment
period
• Homework tasks and role play are key
components of the therapy
Philosophy of Treatment
• Social context crucial in substance-using
behaviour
• Development and consolidation of “social
network for change”
• Maximise support for positive change, minimise
support for continuing substance use
• Every person in the room is receiving a service
• “Focal person” and “Network members”
• Thinking network
• The therapist as an active agent of change
• The therapist as a task-orientated team leader
(cf. family therapist orientated towards insight)
User of alcohol/Focal Client
Worker/Therapist
Families and other
important people/Network
Members
Social Behaviour and Network
Therapy – Therapist tasks
POSITIVE SUPPORT
LEADER
ACTIVE AGENT
NETWORK FOCUS
Social Behaviour and Network
Therapy – Therapist tasks
…and be able to manage
and work with conflict
NETWORK MEMBERS
• Need to be readily available
• Offer positive support but be firm if
required
• Not have an alcohol or drug problem
• Agree with the drinkng goal
• Agree to continue to meet
• Be prepared to continue to work beyond the
therapy period
The Treatment Structure
• Phase I : Session 1
Identifying the social network
• Phase II : Sessions 2 - 7
Combination of core topics and elective
topics - building positive support for
change
• Phase III : Final session
Termination and planning for the future
Social Behaviour and Network
Therapy – Key Components 3 Cs
Communication
Coping
Creating a social environment
that supports change
SBNT can be applied
• with people with readily available networks
• with people with networks where there has
been conflict and relationships are strained
• with those who are isolated
• with those concerned even in the absence of
the person with the drinking problem
Other important issues
• Confidentiality
• Where treatment takes place
• Dealing with the risk of violence
Id e n t if y
s o c ia l
n et w o rk
Ph a se I
NM
p resen t ,
s u p p o r t iv e
NM
p resen t ,
c o n f lic t
P r o b le m s
e n g a g in g
NM ’s
FP
is o la t e d
D e a l w it h
c o n f lic t
focus on
p o s it iv e
P h a s e II
C o n s o lid a t e
n et w o rk
su p p o rt f o r
c h a n g in g
W o r k w it h
FP t o
en g ag e
NM ’s
W o r k w it h
FP t o
b u ild
s o c ia l
n et w o rk
P h a s e III
Pre p a ra t io n
for the
f u t u re
The first meeting
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Welcome those attending
Communicate the philosophy of the treatment
Communicate the format of future sessions
Discuss, if necessary, the treatment goal
Discuss the treatment goal with network members and attempt
to reach an agreement
Conduct a review of the focal person’s current social network
Make a decision about who to invite and how to approach them
Communicate that anyone from the network can continue to
attend all treatment sessions, even if others decide to drop out
End session by giving positive feedback
Client’s Name:
Name:
Date:
My Social Network
2
2
3
2
3
4
4
5
5
6
9
7
8
4
5
6
9
3
8
6
9
7
8
7
Client’s Name:
Name:
SHEET 1
Date:
2
2
3
2
3
4
7
5
5
6
8
4
4
5
9
3
6
6
9
8
7
9
8
7
My Social Network
2. Relationship
1=partner
2=immediate family
(parent, sibling)
3=extended family
4=friend
5=from work
6=self-help/treatment
7=other
6. In past 6 months,
how would you
describe this person’s
drug use?
5=uses a lot
4=uses a moderate
amount
3=uses a little
2=non-user
1=did use, now drugfree
3. In past 6 months,
how often have you
been in contact?
4. In past 6 months,
how important has this
person been to you?
5. In past 6months, hoe
supportive of you has
this person been?
7=daily
6=3-6 times/week
5=once or twice/week
4=every other week
3=about once/month
2=less than monthly
1=once in past 6 months
6=extremely important
5=very important
4=important
3=somewhat important
2=not very important
1=not at all important
6=extremely supportive
5=very supportive
4=supportive
3=somewhat
supportive
2=not very supportive
1=not at all supportive
7. In past 6 months,
how often has this
person used drugs?
7=daily
6=3-6 times/week
5=once or twice/week
4=every other week
3=about once/month
2=less than monthly
1=once
0=not at all
8. How has this person
reacted to your drug
use?
5=encouraged it
4=accepted it
3=neutral
2=did not accept it
1=left, or made you
leave, when you were
using
9. How has this person
felt about you coming
to treatment?
6=strongly supportive
5=supports it
4=neutral
3=mixed
2=opposes it
1=strongly opposes it
The IPDA/Social Network
Diagram
•
The Important People Drug & Alcohol (IPDA) Inventory is a research
instrument that measures
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–
–
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•
•
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size of a person’s social network (i.e. number of people they have contact with)
the substance use patterns of their social network
the level of general and substance-specific support (or discouragement) they get from
their network members
It normally takes the form of a grid, but here we have combined it with the
‘Network Diagram’ used by SBNT therapists in the first session to draw out a
picture of the client’s social contacts
The aim is to ‘kill 2 birds with 1 stone’ by completing the research assessment
as you draw out the network diagram
The network member’s name is written in one of the 12 ovals (2 x 6 per sheet),
and each of the 8 questions is answered
The answers to the 8 questions are printed out on a separate sheet, and could
be given to the client to help them answer the questions
Conducting a Review of the Client’s Social Network
• Who
– Family
• Immediate
• Extended
–
–
–
–
–
Friends
Friends of friends
Acquaintances
Work Colleagues
Professionals
• Techniques to broaden
the network
– Who have you
seen/spoken to in the
last week? (day-byday)
– People you knew
‘before drugs’
– Who is in your phone?
– If I asked your
mum/partner/brother,
who would they add to
the diagram?
Inviting Potential Network Members
• Agree on the most appropriate person to invite with
client
• Rehearse the invitation process with the client
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–
–
–
when and how will they contact them?
what will they say?
how will they ‘sell’ the treatment?
be clear when the next session is
• Offer active support to invite the network member
– phoning them in the session
– helping to write a letter
– text reminders
Core topics
• Communication
• Coping
• Enhancing social support networks
• Developing a network-based relapse
management plan
Elective Topics
• Basic education on drugs/alcohol
• Increasing pleasant activities
• Employment
• Minimising support for drug/alcohol use
Meeting Format
• Part 1: review of progress [10-15 mins]
• Part 2: new material [30 mins]
• Part 3: tasks for the next week [10 mins]
Communication
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•
•
•
Welcome new network members and explain their role
Review inter-session change
Explain the importance of effective communication
Explore the communication skills necessary to invite potential
network members to a meeting
–
–
–
–
–
re-establish contact by telephone
composing a letter to a potential network member
starting conversations
receiving criticism
feeling talk and listening skills
• Explore ways in which the network members can communicate
effectively to support the focal person’s substance use goals
• End session by giving positive feedback
Clearly express what
you want
Tell the other person
why you want it
Use “I” statements when
expressing your needs
Avoid using “you” statements when
expressing your needs
Make good eye contact
Keep your facial expression & gestures
consistent with your message
Speak loudly and firmly, but
without hostility
Reply promptly, letting the person
know you are sure of yourself
Balance the negative
with the positive
“I know you have tried really hard to be supportive of my
problems in the past, but I feel like you have been on my
case all the time recently”
Acknowledge the other
person’s feelings
“I know you don’t like going out on your own, but it would
be better for me not to drink at the moment”
Try to be as specific as
possible
How useful was this map and discussion?
Not useful…1-2-3-4-5-6-7-8-9-10…Very useful
Comments:
Client Name:
Keyworker:
Date: /
/
Coping
• Welcome new network members and explain their role
• Review inter-session change
• Discuss the concept of coping and the ways different
people cope
• Discuss the advantages and disadvantages of current and
past ways of coping with the focal person’s substance
use
• Agree a strategy or policy for helping the focal person’s
efforts to change
• End session by giving positive feedback
ENGAGED
TOLERANT
WITHDRAWN
Active interaction
with the substance
user, trying to deal
with the problem
Removes negative
consequences for the
user
Increasing distance
from drug user
Example
Watching his/her every
move, checking up on
him/her
Give him/her money even if
you knew it would be spent
on drugs
Avoid him/her as much as
possible because of drug use
Advantage
Makes me feel I am doing
something positive
Avoids arguments
Stops me getting too
involved – better for my
health
Disadvantage
Very stressful and user
he/she doesn’t like it
Feel I am being taken
advantage of
I feel I am rejecting him/her
Types of Coping
There is no ‘right’ way to
cope
How useful was this map and discussion?
Not Useful 1–2–3–4–5–6–7–8–9–10 Very Useful
Comments:
Strategy 2
Strategy 3
Disadvantage
Advantage
Strategy 1
How useful was this map and discussion?
Not Useful 1–2–3–4–5–6–7–8–9–10 Very Useful
Comments:
How Do I Cope?
Enhancing social support
• Welcome new network members and explain their
role
• Review inter-session change
• Talk about and identify who is and who is not
supportive, and match them to different categories
• Discuss different types of support
• Discuss the factors to be considered when
developing a social network
• End session by giving positive feedback
Think
Network
Planning
Sessions in
Advance
Therapist as
Task Oriented
Team Leader
SBNT
KEY SKILLS
Focus on
Positive
Support
Therapist as
Active Agent
of Change