This paper offers a conceptual overview of a neglected field. Evidence is presented to suggest that, globally, addiction is sufficiently stressful to cause pain and suffering to a large but uncounted number of adult affected family members (AFMs), possibly in the region of 100 million worldwide. A non-pathological stress-strain-coping-support model of the experience of AFMs is presented. The model is based on research in a number of different sociocultural groups in Mexico, England, Australia and Italy and aims to be sensitive to the circumstances of AFMs in low and middle income countries and in minority ethnic and indigenous groups as well to those of majorities in wealthier nations. It highlights the social and economic stressors of many kinds which AFMs face, their lack of information and social support, dilemmas about how to cope, and resulting high risk for ill-health. The public sector and personal costs are likely to be high. Attention is drawn to the relative lack of forms of help designed for AFMs in their own right. A 5-Step form of help aiming to fill that gap is briefly described. Family members affected by addiction have for too long been a group without a collective voice; research and action using the model and method described can make a contribution to changing that state of affairs.

This article is based upon the collective findings of a number of studies conducted in a number of countries during the past 20 years. Female partners and mothers are the family members who have been most represented in the study samples, but the latter also included sizeable numbers of male partners, fathers, sisters, brothers and adult sons and daughters. Citing examples taken from the studies, the article describes some of the most prominent elements of the stressful experience of living with a relative who is drinking or taking drugs excessively, notably: the relationship with a relative becoming disagreeable and sometimes aggressive; conflict over money and possessions; the experience of uncertainty; worry about the relative; and home and family life being threatened. The reasons why family members may put up with substance misuse are described, and the ways in which family members may either withdraw and gain independence or stand up to substance misuse, as alternative ways of coping, are outlined. Examples of the strain experienced by family members are given. The kinds of social support valued by family members are explained, as is the finding that good quality social support for family members is often lacking. The article concludes by offering an integrated view highlighting the disempowered position in which family members usually find themselves and the importance of good social support for family members in their coping efforts. Although the picture is coloured by factors such as sociocultural group and the ages and genders of family members and their relatives, we believe the core experience for affected family members is a universal one.

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.

The family plays a key part in both preventing and intervening with substance use and misuse, both through inducing risk, and/or encouraging and promoting protection and resilience. This review examines a number of family processes and structures that have been associated with young people commencing substance use and later misuse, and concludes that there is significant evidence for family involvement in young people's taking up, and later misusing, substances. Given this family involvement, the review explores and appraises interventions aimed at using the family to prevent substance use and misuse amongst young people. The review concludes that there is a dearth of methodologically highly sound research in this area, but the research that has been conducted does suggest strongly that the family can have a central role in preventing substance use and later misuse amongst young people.

This chapter outlines the stress-strain-coping-support (SSCS) model which underpins the whole programme of work described in this supplement. The need for such a model is explained: previous models of substance misuse and the family have attributed dysfunction or deficiency to families or family members. In contrast, the SSCS model assumes that having a close relative with a substance misuse problem constitutes a form of stressful life circumstances, often long-standing, which puts affected family members at risk of experiencing strain in the form of physical and/or psychological ill-health. Coping and social support are the two other central building blocks of the model. Affected family members are viewed as ordinary people faced with the task of coping with such stressful life circumstances. It is an assumption of the model that, difficult though the coping task is, family members need not be powerless in maintaining their own health and helping their relatives. Good quality social support, in the form of emotional support, good information, and material help, is an invaluable resource for affected family members, supporting their coping efforts and contributing positively to their health. The 5-Step Method, to be described later in the supplement, is based on the SSCS model. It can be seen as a way of increasing the positive social support available from professional sources.

A set of standard measures is available for helping to assess the needs of concerned and affected family members, derived from an explicit model of the family in relation to excessive drinking, drug taking or gambling. It may have a role to play in correcting the current neglect of the needs of such family members, estimated to be in the region of nearly a million adults in Britain alone.

We outline the huge literature on the potentially negative impact on children of growing up with a parent who has an alcohol or drug problem, the risk factors that can exacerbate this effect, and resilience and the protective factors that can reduce it. Clear ways that practitioners can intervene to reduce risk and to increase resilience are discussed. All practitioners have a responsibility to work in holistic ways if damage to children and families is to be avoided, and we summarise the key common skills needed to work with individuals (children as well as adults) and families. The differences between a resilience and a deficit approach are outlined.

All the women had problematic lives, affected by a multitude of factors, and raised a number of serious concerns that related to health and social care. This has implications for practice and service provision, as demonstrated by the data from GPs and health visitors, in, for example, the provision of advice and information (and in different languages), training, improved communication and inter-agency working, in this area (where the research was conducted) and elsewhere in England. More research is needed to further explore the needs of women from minority ethnic groups, taking issues of, for example, cultural specificity and urbanity/rurality into account. Further research also needs to investigate ways of offering help and support to this patient group.