“Better family lives”: experiences of a whole family case management approach for parental alcohol misuse

ABSTRACT The Family Support Project is a whole family case management approach based on the principles of Acceptance and Commitment Therapy (ACT) and developed for families affected by parental alcohol misuse. Using thematic analysis of interviews and clinical notes, this study explored the outcomes and factors that influenced change in families. Parents misusing alcohol became aware of the impact of their drinking on family, were motivated to change, adopt new positive behaviors, and spent time positively interacting with their family. Such programs that build trust, employ a flexible whole family approach, and draw on values-based work using ACT, merit further research.

Parental alcohol misuse (PAM) refers to a spectrum of problem drinking, such as binge drinking, hazardous drinking and alcohol dependency, by adults that have parental responsibility for children (Parliamentary Office of Science and Technology, 2018).The latest Global Burden of Disease Study estimates that, in 2016, alcohol use was the leading risk factor for death and disability amongst 15-49-year-olds (Griswold et al., 2018).In England, in 2014, 189,119 children lived with at least one alcohol-dependent adult (Pryce et al., 2017).
PAM negatively impacts on the health of the child.A large UK study of data between 1988 and 2004 showed that maternal alcohol misuse was significantly associated with child injury (OR 2.33, 95% CI 1.13 to 4.82, p < .05;Baker et al., 2015).PAM is also associated with increased acute or chronic care needs (Balsa & French, 2012) and impacts the psychological health of the child (Malone et al., 2002(Malone et al., , 2010;;Rossow et al., 1999).Children of parents that report parental alcohol and/or drug misuse are at increased risk of adolescent substance misuse and regular alcohol use, compared to children of parents who do not report misuse, where alcohol use was four times as likely (OR = 3.83, 95% = 1.65-8.89,p <.01) (Keeley et al., 2015).

Programs that tackle parental alcohol and drug misuse
A few recent reviews suggest that integrated interventions that include a wider set of factors, can be more effective in reducing parental substance misuse than addressing drug use alone (McGovern et al., 2018(McGovern et al., , 2021;;Usher et al., 2015).A recent Cochrane review included 22 unique studies to assess the effectiveness of psychosocial interventions in reducing parental substance use (McGovern et al., 2021).The review compared substance uses outcomes against three main types of interventions: those targeting parenting skills and family relationships, those targeting substance use, and those combining both into an integrated intervention.They found that integrated interventions, including both parenting and drug use reduction elements, were more effective than either alone; whilst interventions that included children in intervention sessions with parents led to poorer drinking outcomes.It was unclear which aspects of the interventions influenced successful outcomes, however.In a realist review of family-based interventions for children of substance misusing parents, effective intervention programs commonly targeted disadvantaged community areas, were family focussed (e.g., involve children, parenting, and family skills training components), and lasted longer than 10 weeks (Usher et al., 2015).Despite the need for family level interventions for PAM, Taylor et al. (2006) described difficulties in gaining access to families experiencing PAM due to shame, fear of negative attitudes from professionals, concerns about children being taken away, and a lack of confidence in the treatment being offered, making PAM a hidden problem (Galligan & Comiskey, 2019).
Overall, the evidence on interventions that reduce the impact of PAM is limited.Furthermore, these studies tend to focus on substance misuse and child protection outcomes, and neglect to consider a broader range of positive changes related to recovery.Some argue that `recovery' should be conceptualized as more than a reduction in alcohol use, involving improvements in physical, emotional, spiritual, relational, and occupational health (White & Kurtz, 2006).

The family support project (UK)
The Family Support Project (FSP) was funded by Public Health England and Portsmouth City Council, to support service innovation for families in Portsmouth, England where PAM is considered a problem.The program was developed through public consultation at a stakeholder workshop held on the 14th of December 2018 and attended by stakeholders working in the local health and social care system.Following consultation, a logic model was developed outlining the overall program, what it set out to achieve and how change could be measured.The overall program goal, determined within the local stakeholder workshop, was to improve the lives of families impacted by parental alcohol misuse (F-PAM) in Portsmouth, whilst focusing on a broader range of outcomes rather than solely drinking reduction or abstinence.
The FSP family workers were recruited from a range of relevant backgrounds including alcohol and drug services, social work, counseling, homelessness or housing, mental health services, schools, and lived experience of alcohol problems.The FSP started recruiting families in February 2019, offering a 12-week intervention.Referral routes into the service were via statutory alcohol and drug services, children's social care, early help, and, occasionally, via schools.Families also self-referred after hearing about the service on the media or through a community service.Each family was assigned an FSP family worker who undertook an assessment of their values, strengths, and needs.This was named the whole family case management approach.
At the start of the program development, FSP family workers were trained to deliver Acceptance and Commitment Training (Hayes et al., 1999), Motivational Interviewing (Miller & Rollnick, 2012), and parental conflict resolution.Drawing on these resources, the intervention was organized in response to the needs of the presenting families.The approach they took was theoretically consistent with ACT, while integrating learning from the other models.Two tools from the ACT approach, the Valued Living Questionnaire and the ACT Matrix, provided a structure to the intervention.ACT has been shown to be a promising intervention for adults with substance misuse and alcohol problems (Byrne et al., 2019;Hayes & Levin, 2012;Meyer et al., 2018;Petersen & Zettle, 2009;Thekiso et al., 2015), as well as for children, adolescents, and families (Coyne et al., 2011).
The Valued Living Questionnaire (VLQ) is an ACT tool that formed part of the intervention at assessment and at review sessions after 12 weeks (Wilson et al., 2010).The VLQ consists of 10 living domains: parenting, work, partner/intimate relations, learning and education, other family relationships, recreation, friends, community, physical health, personal development/spirituality.Family members were asked to rate the 10 living domains for importance and for the energy/time they gave to this aspect of their life (out of 10).By highlighting any discrepancy between what was considered important to the family and their reality, the VLQ was used to aid goal setting in line with family priorities and as a tool to motivate a change in drinking (Miller et al., 2016).Practitioners also used the ACT Matrix -a tool used to facilitate the development of psychological flexibility (Polk et al., 2016).Using the Matrix, practitioners are able to initiate a process that increases an individual's awareness of the divergence of their behavior from their chosen values, and to promote insight into the role of experiential avoidance in driving unhelpful behaviors such as drinking excessively.Participants are guided to become aware of the unwanted thoughts, feelings, and sensations that trigger their avoidant behavior, and to develop the skills to distance from thoughts, and become more accepting of their feelings.Through this process, they learn that they can choose to act in line with chosen values, rather than be driven by experiential avoidance.
The aim of this study was to gain insight into the experiences of the FSP from the perspective of families and FSP family workers.Specifically, we wanted to first identify aspects of the Project that were considered to have supported change, and secondly to describe the outcomes related to these.

Study design
This study used qualitative methods, drawing on data collected during semi-structured interviews and from written materials recorded in clinical notes.A thematic analysis of interviews with families, and FSP family workers, aimed to highlight key aspects related to the experiences of the FSP program, from the perspective of the family and FSP worker.The VLQ in the client records included clients written descriptions of behavioral changes made during the intervention, which were coded and summarized to identify common aspects of behavioral outcomes, as described by the parents misusing alcohol (PMAs).The qualitative research has been reported using the 32-item CORE-Q checklist, which is a tool to facilitate explicit and comprehensive reporting of interviews (Tong et al., 2007); we aimed to report on all applicable checklist items.The protocol and all associated documents (e.g., information sheets, consent forms) were submitted to the University of Southampton Ethics and Research Governance Board (ERGO) and approved on the 14th October 2019 (ID: 49,531).

Recruiting participants for family interviews
Convenience sampling was used to recruit interview participants.The criteria for family interviews included (i) families that have completed at least two sessions with their FSP family worker and (ii) families where at least one parent and one child were engaged.Families who met these criteria and engaged in the project between November 2019 and May 2020 were informed about the study by their family workers (provided a Participant Information Sheet (PIS)), and permission was obtained for an identified family member to be contacted by the researcher.The family could choose which members to take part.Children under seven years old were invited to be present during the interview but did not participate (Eggenberger & Nelms, 2007).All FSP workers were invited by e-mail to take part in the study, and provided PIS describing what would be involved, for example, making it clear participation was voluntary.

Qualitative interviews
Interviews took place between November 2019 and May 2020, in a community family hub, in the family home, or over the phone depending on the preference of the participant.The interviews were semi-structured and lasted up to 60 minutes.Ahead of the interview, participants had the opportunity to discuss the research to ensure the information was understood.Informed consent was obtained in written or verbal form depending on the format of the interview.Children between 7 and 16 years old were formally consented by their parents and were interviewed with a parent present.The questions were guided by a topic guide adapted from a prior study on the experiences of alcohol-dependent adults of a novel service (Dorey et al., 2021).Interviews were carried out by LD, who has worked in the alcohol field as a psychiatric nurse, therapist, and academic researcher.Participants were informed that she had experience in the field.

Qualitative data analysis
The interviews were audio-recorded, transcribed, and analyzed (by LD) in NVivo version 12 using the thematic analysis approach of Braun andClarke (2013, 2019).Thematic Analysis allows a data driven complete coding approach to be adopted, to capture experiences of participants from their perspective.Themes were developed from across the codes drawing on a pragmatic and contextual philosophy to highlight where `actions' influence existence (Goldkuhl, 2004) from the perspective of the stakeholders, with attention to context.Family interviews were coded and developed into themes separately from family worker interviews.Related themes for family workers and families are presented under overarching theme headings (Braun & Clarke, 2019).Alongside the VLQ questionnaire, behavior changes were described as free text by PMAs at program review sessions (after 12 weeks of the intervention).These were coded using the domains of the VLQ as a framework and the content summarized.

Routine data
Routine data were collected from the start of the project in order to provide useful quantitative contextual information about the service (see next section), and to provide a summary of participant characteristics for those completing the VLQ (see, Table 1).Consent to share anonymized routine data for the purpose of the study was recorded by the FSP workers at assessment, and a data sharing agreement was in place.

Results
A brief quantitative description of families engaged in the project, between February 2019 and March 2020, is included here to provide context for the qualitative findings with the subgroups who were interviewed and the subgroup who completed the VLQ for the study.Sixty-one families engaged with the FSP during this period (including 57 PMAs) (15 additional families withheld consent for their data to be reported, and 12 families were referred but did not engage).The intervention was initially intended to last 12 weeks, but in the majority of cases the intervention was extended with a mean length of intervention of 21.65 weeks for completed cases (n = 19; data collected June 2020).Children were directly involved in the intervention for approximately 30% of total families.Both parents were involved in the intervention for 26% of total families, whereas only one adult family member took part in the intervention amongst 11.5% of total families.Other families were still receiving the intervention at data collection (n = 38) or had dropped out of treatment before completion (n = 7).

Qualitative interview findings
Table 1 shows the characteristics of the seven families (ten family members) taking part in the interviews.Twelve families were identified by practitioners as willing to be contacted by researchers; recruitment of these families was impacted by COVID19 lockdown in March 2020.Seven families took part in the interviews including seven PMAs (four were female, and three males), two partners and one child.Six FSP family workers took part in the interviews and were all female.Table 2 shows a summary of the themes and example quotes.

Overarching theme 1: building trust through understanding led to opening up Subtheme 1. Families: 'comfortable to open up'
All of the participants commented on the positive relationship with the FSP family worker and linked this relationship to being able to open up.The concept of trust was central to these descriptions and allowed the person to open up honestly.
Several participants described a sense of non-judgment as being an important factor in developing trust; 'I didn't ever feel like I was being judged.' (Family 1; PMA) Another aspect of non-judgment was not feeling labeled: 'they weren't labeling me as an alcoholic.'(Family 2; PMA) The experience of being understood was also linked to non-judgment, for example, through the worker recognition of how personal history had contributed to current circumstance.

Subtheme 2. Family workers: 'gaining trust'
Most participants emphasized the importance of building up a relationship with the families, Once you gain that trust and build that relationship with clients, the clients are more willing to open up and be honest about the situation.(Worker 2) The same worker went on to explain how some individuals they work with can see professionals as their opponents, or 'the other side,' and that 'a positive relationship closes the gap between us and them.' (Worker 2) With some families, relationship building could take time, and would be the focus of the first few sessions.Understanding the family history, trauma and the impact on the family was part of a non-judgmental approach, which could be a significant factor to the process of developing trust.
All the workers spoke about the difficulty in gaining permission from parents to work with children.In some cases, it was possible to gain access to working with the children once trust was established or once the impact on the children was recognized.
In summary, building trust was seen as a key process that developed over time.Families and FSP workers felt that understanding how family histories/traumas had contributed to current family problems was important in relieving their sense of being judged.This level of trust and understanding were factors enabling family members to open up honestly, so that the real needs of families could be addressed.Workers also highlighted difficulty in gaining permission to work with children and that trust could play a role in gaining permission.
Overarching theme 2: working flexibly, whole families changed Subtheme 1. Families: 'She's helped my whole family' When the whole family is supported to understand the changes taking place this was beneficial, which enabled them to move forward together.In some situations, family members were seen together, for example, to improve understanding and communication between family members: 'We can say things we probably wouldn't say to each other without somebody being here.'(Family 5, PMA) At times seeing family members separately was also Practitioners highlighted how working with more than one family member could encourage systemic change: 'the best change is when everyone is involved.'(Worker 5) Practitioners described how they worked flexibly with different family members.Even if one family member did not engage in the intervention formally, being in the family home provided opportunities to keep family members informed: 'they are still milling around the house, they might pop in' (Worker 3) Families and workers valued the flexible approach to working with different family members, seeing individuals, pairs, and groups of family members.Both groups highlighted the benefits of involving more family members, opening up opportunities for families to change as a whole; for example, understanding what was changing, and why changes were happening.

Overarching theme 3: waking up to the impact of drinking on family life Subtheme 1. Families 'A massive eye opener.'
Participants all felt that the children were a priority in their lives: my kids are the main thing (Family 7; PMA).However, families also described the emotional stress on the children as they anticipated or witnessed their parent drinking: 'what mood is mummy going to be in?' (Family 2; PMA) or 'mum's acting weird' (Family 3; child).For older children, exposure to long-term parental drinking was perceived as a concern and, in some cases, had eroded the relationship between the parent and child.Discipline could also be affected; 'I've lost the authority.'(Family 4; PMA) Five of the families described the impact of parental drinking on the quality and time spent interacting with the children, for example: 'he wouldn't make the effort, he didn't spend the time that he needed.'(Family 5;partner) Several of the PMA participants explained how the intervention had contributed toward facing up to the impact of drinking on the children and how this led to change.This could be a challenging uncomfortable experience.The Values focused part of the assessment was often described as means to support PMAs to become aware of their priorities and, through deliberate focus or repetition, this increased awareness of their personal and family values.Some participants identified the focus on their personal values as motivational, by helping them to see the conflict between their family values and the impact of drinking.

Subtheme 2. Family workers: 'a platform for change.'
Family workers reported that PMAs had made changes to their drinking, which were preceded by shifts in awareness around the impact of their drinking.One way that parents came to recognize their impact was when the child opened up to the parent.A shift in awareness was seen to be facilitated when the work shone a light on the conflict between the impact of drinking and meeting the child's needs and their own positive parenting values.
`In summary, some PMA participants described waking up to the impact of their drinking on their children during sessions with their family worker, and that this was a strong motivator for change.As the PMA reflected on their parenting values this increased their awareness of the divergence between their drinking and their values through, for example, an understanding of how drinking interfered with the value of quality time spent with children.Practitioners described facilitating and witnessing these shifts in awareness and motivation.

Overarching theme 4: the ACT model
Subtheme 1 Families: 'I'm more aware of my behavior now.' Several participants described being able to identify the behaviors that take them toward and away from what is important (as identified in values and matrix work).Other participants described being able to identify unwanted thoughts and feelings that, they recognized, could drive habitual unhelpful behaviors.The below example demonstrates how the participant learned how to recognize unwanted feelings and the associated urges to buy alcohol, and how to work with these internal experiences through acceptance of uncomfortable feelings.
Saying [to myself], I'm allowed to feel a bit crappy today, but that doesn't mean that I can [drink].What's going to make me feel better, [drink] or just to sit with those feelings?(Family 2; PMA) Three participants expressed their appreciation of the support they were given to take active steps to cut down on their drinking, rather than simply being told to stop drinking, for example: 'It wasn 't just,"don't do this," and they'd disappear.' (Family 1;PMA) Work with children was often described by parents as work on expressing feelings and coping strategies.The one child interviewed described this work: We write down our emotions a lot, it's helped when we write down how we're feeling, and when we're feeling -what's happening, and what we do when it's happening, so we can cope a bit better.(Family 3; child)

Subtheme 2. Family Workers: 'Weaving it all together [using the ACT model].'
All the family workers spoke positively about using the ACT model, describing it as central to their approach.One of the participants articulated her view about the importance of having a central model, while also using a range of different models to inform the work.This participant explained how the structured parental conflict program which formed part of the worker's training, did not really fit comfortably into the FSP program and it was more helpful to weave together strands of the approach with aspects of the ACT model.
Weaving it all together has felt more natural and useful than having a separate intervention about the relationship . . . .Because the ACT model lends itself to any kinds of behaviour, the relationship stuff sometimes emerges . . . .it's about the behaviour being helpful or unhelpful or useful or un-useful, which is good to use.(Worker 1) All the family workers highlighted the impact of the values focus of the ACT-based approach.They found that this could be contrasted with the families' prior experiences of services, where the focus might be on drinking or a more directive approach.
ACT, I think it's a really good way for individuals to make their own goals instead Using the ACT Matrix model, PMA family members were taught to differentiate between behavior toward values, and behavior that takes them away.This awareness could open up the possibility to make better decisions and was seen as empowering; then you can make a choice (Worker5.)Another key aspect of the ACT model was the normalization of thoughts about drinking.They witnessed the PMAs learning to recognize and talk about thoughts associated with drinking, without needing to act on these thoughts.
Interventions with children and teenagers allowed them to speak about their experiences, accept and express their feelings, and to develop new ways of coping with feelings.In summary, the ACT model was seen as guiding the focus of the intervention toward the families' own priorities.PMAs became more aware of thinking, feelings, and behaviors and learnt to accept thoughts about drinking when they were normalized.Children and teenagers were reported to have learnt to accept and express feelings and new coping strategies.This was seen as an empowering approach by families and practitioners, allowing families to make positive changes.

Descriptions of behavior change recorded at review meetings
Table 3 shows the characteristics of those PMAs who completed the descriptions of behavioral change, guided by the domains of the VLQ, at review meetings after 12 or more weeks of the intervention (n = 20; collected between 15 th April 2019-December 2019).The majority of PMAs were young adults, female, living with their children, in regular  Identification Test (The AUDIT is a screening tool that indicates low, increasing, and higher risk drinking, and a score of 20 or more suggests likely dependence (Reinert & Allen, 2002).
employment and in stable accommodation.A high proportion of the PMAs indicated likely alcohol dependency (82%) in their AUDIT score and had mental health concerns (54%) which were being treated (81%), usually in primary care.The analysis of the PMAs (n = 20) descriptions of behavior changes at review meetings provided insight into the nature of changes made and the impact on family life.(Table 4 provides examples of new actions described by participants for each of the 10 VLQ domains.)In the domain of health, participants frequently described cutting down or stopping drinking altogether, and that this change improved their physical and mental health.Other new behaviors in the health domain involved increasing exercise or working on nutrition and engaging with medical help.The category of spiritual/personal development was used to describe other aspects of their personal recovery journey, such as

Discussion
This study explored the experiences of workers delivering, and families receiving, a program designed to meet the needs of families impacted by PAM.PMA participants had alcohol problems at the more severe end of the spectrum, and commonly also experienced coexisting mental health issues.The themes highlighted the importance of non-judgmental understanding in building trust with families, the potential benefits of taking a flexible whole family approach, the process by which families recognized the impact of drinking on children, and the acceptability of applying the ACT model to facilitate whole family change.
The descriptions of behavior change related to the VLQ helped to further describe the outcomes relevant to these families.As commonly recognized in the literature, our findings show that the impact of PAM on families can be a hidden problem (Galligan & Comiskey, 2019).The findings from this study contribute to our understanding on how to overcome such barriers to engagement.Typically building trust through a non-judgmental approach was essential for engaging families; for some families this was facilitated by understanding the family history and how trauma contributed to their experienced difficulties.This corresponds with a large body of research on the use of a non-judgmental empathic, rather than a confrontational, approach in the addictions field (Davidson & White, 2007).The intervention goes further than the practice of non-judgment to actively recognize the impact of trauma and family histories on clients and families, and this depth of understanding was important in the context of families that often felt judged or stigmatized.The importance of trauma informed work for women with addictions has been highlighted by Covington (2008); due to the high prevalence of related violence and abuse it is not enough to focus treatment solely on the addiction as has been the dominant model.
The Cochrane review (McGovern et al., 2021) found integrated parenting and substance misuse intervention as more effective; but did not advocate seeing children and PMA together.By taking a whole family approach families developed a better understanding of one another, were able to change together, and support each other's changes.Through the flexible implementation of the whole family approach, members were seen together or separately according to need, and children were often seen separately for part of the intervention; this sensitivity to the needs of different family members at different times may be an important aspect of the FSP intervention, potentially impacting effectiveness.
The ACT approach with families experiencing PAM can be seen as acceptable to practitioners and families, and merits further research.The focus on values work alongside highlighting the impact of drinking on children helped develop discrepancy and motivation to change, an approach informed by Motivational Interviewing.There was evidence, in both family worker and family descriptions, that key elements of the ACT model were being delivered and were contributing to change.These new skills engendered a greater understanding on how to manage the children and teenagers' experiences in the family and their feelings, the PMA's alcohol problems and coexisting mental health issues, interpersonal issues between family members, as well as being able to take steps toward `better family lives'.
Outcomes in studies of interventions for parental substance misuse have included alcohol and drug misuse, completion of treatment, and the number of children entering care (McGovern et al., 2018(McGovern et al., , 2021)).While these outcomes are important consequences of interventions for these populations, they do not capture the broader nature of change conceptualized in this paper as 'better family lives.'The VLQ domains offered a tool which quantitatively captured broad categories of change in 10 living domains; furthermore, the qualitative analysis of VLQ data showed that there were more precise areas of behavior change that were common across the families.Future studies in this field could seek to capture these positive changes by adapting the VLQ or developing a bespoke outcome tool.
There were some limitations to this study.Firstly, because of the Covid-19 pandemic and lockdown activities, we were able to undertake fewer family interviews than planned.Specifically, it would have strengthened the evaluation to have more interviews with children.We also sought to recruit families where children engaged; an understanding of the perspective of families where children did not engage would have been helpful in hindsight, as well as the experiences of families who dropped out of treatment.Data collection was, however, sufficient to identify themes from families and family workers that were largely in concordance with identifying the valued aspects of the program, and complimentary in providing different perspectives.

Conclusion
Despite the recognized harms, there are significant challenges to engaging families impacted by PAM.This paper has highlighted the benefits of developing a separate service to social services and mainstream alcohol services to tackle PAM, by employing a flexible 'whole family approach' that draws on values-based work through the ACT model to support 'better family lives.' Families were asked open questions about their experiences of the service, what had changed for them and what aspects of the program contributed to these changes: e.g., (a) What has changed for you as a family since starting the program?(b) How have the lives of your children changed?(c) What or who do you consider was helpful in supporting changes.Probe for examples of specific situations.Family workers were asked about their experiences of engaging families and delivering the intervention: e.g., (a) What changes did you observe in the families you worked with?(b) What helped positive change and what barriers were there in your view?
of being told what to do, because I think historically social care told clients what to do, and it wasn't necessarily what they wanted.(Worker 2) live with the client Some of the children live with the PMA None of the children live with the PMA misusing alcohol; VLQ = Valued Living Questionnaire; AUDIT = Alcohol Use Disorders

Table 1 .
Characteristics of families interviewed.

Table 2 .
Examples of quotes from families and practitioners by overarching theme.For example, children were often seen separately for part of a session to help create a context where they could open up: 'I know that the children wouldn't want to talk too much in front of me.'(Family 3, PMA)In another example, the partner of the PMA benefitted from a session on her own: 'someone is listening, and I can see a noticeable change [in my wife].'(Family1; PMA)

Table 4 .
Examples of coding and PMAs descriptions of change based on the 10 domains of the VLQ.increased self-awareness, or reading about relevant issues.Parents also described spending more quality time with the children and other family members, enjoying activities together, communicating better, and managing boundaries positively.Some unhealthy relationships were ended or distanced from.Changes in the domains of work, recreation, and learning were more varied and less frequently described.