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Overview of Total Family Intervention
Dr. Dawn-Elise Snipes

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– Learn what intervention is
– Identify who typically does an intervention and for what reasons
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What is an Intervention
– Interventions are approaches (as in SBIRT (screening, brief intervention and referral for treatment) or meetings designed to facilitate entry into treatment by a person with an addiction or mental health issue who is not yet in the Action phase of change
– Interventions are based on motivational interviewing approaches
– Feedback
– Responsibility
– Advice
– Menu of Options
– Empathy
– Self-Efficacy
Who Does Interventions
– Doctors
– Counselors/Social Workers
– Family Members / Friends
Total Family Intervention
– When a family lives with a person with addiction or mental illness, thoughts, behaviors and relationships are influenced by the problem and also influence the problem.
– Total Family Intervention (TFI) recognizes the impact of addiction or mental illness on not only the identified patient, but also the entire family system.
– Total Family Interventions loosely defines family as those significant others who are most prominent in the individual's life and relies on the agreement of all family members to participate not only in the intervention, but also the treatment process.
The Family Impact
– Think about a person with an addiction.
– What are some of the most common problem behaviors?
– In what ways does the family possibly support, encourage or maintain the behaviors?
– How is supporting, encouraging or maintaining the problem behaviors in the identified patient easier or more rewarding than maintaining healthy boundaries?
– How are family members influenced by the addictive behaviors such as denial, blaming, avoiding, justifying and gaslighting?
– In what ways do the dysfunctional behaviors from the addicted family system impact each family members other social relationships, mental and physical health?

The Family Impact
– Think about a person with a mental illness.
– What are some of the most common problem behaviors?
– In what ways does the family possibly support, encourage or maintain the behaviors?
– How is supporting, encouraging or maintaining the problem behaviors in the identified patient easier or more rewarding than maintaining healthy boundaries?
– How are family members influenced by the problem behaviors?
– In what ways do the dysfunctional behaviors from the family system impact each family members other social relationships, mental and physical health?

The Need for Family Treatment
– When identified patients begin the recovery process they need support and to learn new ways of acting, reacting and interacting.
– The family system, which has been organized around dysfunctional patterns may not know how to react unless the family also participates in treatment.
– While other intervention approaches focus primarily on getting help for the identified patient, TFI recognizes that improvements will be short lived if the family does not also engage in the recovery process. Further, by addressing the whole system, the identified patient often feels less attacked.
– The steps in a TFI follow the standard steps of most interventions with the obvious difference that each person in the process, not just the patient, is asked to recognize their need for Physical, Affective, Cognitive, Emotional, and Relational recovery.
Initial Contact
– When family members reach out they are often desperate. They feel like they have tried everything. They are terrified for their loved one.
– They have a myriad of emotions from love to anger, guilt, fear and hope. If they are calling, they still have hope that something can be done.
– Appoint the interventionist as the primary contact for the team
– Identify who will be on the team
– It is vital that the main people involved in the person's life are willing to join the identified patient in the recovery process. If only a few people join the recovery process, then the person with the addiction can split family members and continue the problem behaviors.
Second Contact
– Educate them about
– What an intervention is
– What will be required of them in the process (including personal counseling and support)
– What the possible outcomes are
– What types of treatment and resources are available to help them
– What the next step might be.
Second Contact
– Hope and Informed Consent
– Develop hope that an intervention can help them move in the right direction by having them envision what life will look like when the person is in recovery.
– Provide information about the success of interventions as well as the success of different types of treatment.
– Educate about risk factors they can reduce and the protective factors they can enhance to support their loved one.
Second Contact
– Motivate them to commit to the process and take the next step in setting up the intervention. All PACER sources of motivation:
– Physical sources of motivation (how it will protect the health of their loved one and reduce their stress related physical symptoms)
– Affective sources of motivation (how the intervention will ultimately lead to improved happiness and reduced distress)
– Cognitive sources of motivation (how this makes sense because they have tried everything else and the person is in danger)
– Environmental sources of motivation (how it will make their household less stressful)
– Relational sources of motivation (how the intervention may improve relationships among family members as they support each other and how it may help the person with the addiction take necessary steps to improve their relationships with their children and others).
Second Contact
– During this first face to face meeting, the interventionist also gathers information about the stage of readiness for change of the identified patient as well as each person on the intervention team. This will enable the interventionist to choose the most appropriate tools to enhance motivation and facilitate change.
– Precontemplation: I do not have a problem. Other people need to change, but not me.
– Contemplation: Maybe I have a little bit of a problem or might be contributing to the problem, but my behaviors are not having a significant negative impact.
– Preparation/Determination: I realize that I have a problem or am contributing to the problem and am considering what I might need to do to address it and getting ready to make a change.
– Action: I realize that I have a problem or am contributing to the problem, and if I do not make some changes, things will not improve. I have decided to take the following steps to address the issue.

Readiness for Change Assessment

– To be completed by each person on the intervention team.
– 1= Disagree
– 2=There is some truth to it
– 3=It is mostly true
– 4= I agree completely

Second Contact
– Ideally everyone on the team will be in the action phase of readiness for change prior to the initial intervention. It will be important to continually reinforce the notion that recovery is possible and identified changes will improve their health, energy and happiness.
– In some cases, because of the threat of overdose or suicidality or because it is impossible to find a time in which the identified patient is sober or mentally stable it may be necessary to help the TFI team pursue involuntary commitment.
– There are currently 37 U.S. states (and the District of Columbia) that allow some form of involuntary commitment for addiction treatment.
– Nearly every state has laws for involuntary commitment for mental health issues.
– The process, requirements, and how long a person can be committed will vary by each state. Once the identified patient has been stabilized, the TFI can take place. It is recommended that it occur prior to the individual's discharge from the hospital, so the timing of the commitment must be aligned with the readiness of the TFI team. NOTE: Involuntary commitment has significant consequences for the relationship between the identified patient and the family, so should not be entered into lightly.

3rd-6th Contact (Planning)
– During the preparation phase, it is vital to help the family see how the behaviors of the identified patient have impacted them as well as the identified patient physically, affectively, cognitively, environmentally and relationally (PACER), and how their behaviors have impacted the identified patient.
– It will be important for everyone to start taking care of their physical health through
– Proper nutrition, adequate sleep, and management of any health conditions
– Learn or enhance their stress management skills
– Deal with anger, grief, guilt and anxiety issues surrounding the patient's situation
– Begin giving themselves permission to be happy every day
– Evaluate their relationships and enhance boundaries and communication where necessary.

3rd-6th Contact (Planning)
– Learn about the addiction or mental health issue and the extent to which the addiction or mental health issue is impacting the person physically, emotionally, cognitively, and interpersonally
– Screen for any addiction or mental health issues in the identified patient as well as the people on the TFI planning team.
– This is vital to ensure identification of the most appropriate treatment placements as well as to ensure the safety of all involved, including the identified patient.
3rd-6th Contact (Planning)
– Explore
– The impact of the identified patient's behaviors on the family
– How they impact the identified patient
– Behavioral changes they will need to make to support the recovery process
– Changes or issues they will need to address for their own health and mental health and how they will do that (i.e. seeing a counselor)
– What is maintaining the behaviors for the identified patient.

3rd-6th Contact (Planning)
– Develop a unified message
– That change needs to happen
– The types of changes expected
– What support is available for change related behaviors
– The consequences for refusal to accept treatment. These may include the identified patient having to move out, being cut off from further financial support and/or not being able to see children when under the influence etc.

3rd-6th Contact (Planning)
– Explore prior attempts to get the person into treatment and what happened
– Find an appropriate initial placement which will be able to admit the person the day of the intervention.
– Ensure the family is versed on FMLA, insurance benefits, options for childcare if needed, someone to watch pets, someone who will be willing to make sure bills get paid while the person is in treatment etc.

3rd-6th Contact (Planning)
– Write personal narratives
– Letter template:
– I love/care about you, and truly believe that it is possible for you to get better.
– Acknowledge the patient's fears about entering treatment (it won't work, we cannot afford it…), but we have all come together and identified some workable options.
– Why is it important that the patient make these changes now?
– How does it make you feel to see the patient struggling?
– How does the patient's behavior impact you in general?

3rd-6th Contact (Planning)
– Write personal narratives
– Letter template cont…
– Give 3 specific examples of things the person has done that let you know the person has a problem and how they have impacted you.
– When did it happen?
– What specifically happened?
– How did it impact you physically (insomnia, high blood pressure, stomach pain, physical injury, worsening of chronic illness…)
– How did it impact you emotionally? (anger, fear, embarrassment, shame, depression, helplessness)
– How did it impact other people (your children, other people who are not represented on the team)
– I recognize that we all have to make some changes in this process.
– Identify what you have committed to doing for your own recovery.

3rd-6th Contact (Planning)
– Rehearse the intervention process
– Anticipate the person's objections and have calm, rational responses prepared for each reason the person with the addiction or mental health issue may give to avoid treatment or responsibility for behavior.
– It is helpful if, as an interventionist, you keep a running list of objections people have to treatment
– Even though the entire family has participated in the process until now, it is often suggested that the person be confronted at first by just one individual with or without the interventionist present
– If that fails, or it seems the family has already tried that then a group intervention is often the next step

The Intervention
– During the Intervention (whether it is 1:1 or a Group)
– Ensure the person with the addiction or mental health issue is not under the influence at the time of the intervention
– Present the messages with love, respect, support and concern
– Set ground rules that prohibit name-calling or angry or accusing statements and insist on objective presentation of the facts using “I” statements.
– Stay on track during the intervention. Remember that the person with the addiction will likely feel very threatened. Make sure team members are prepared to remain calm in the face of the person's accusations, hurt or anger, which is often meant to deflect or derail the conversation.

The Intervention
– During the Intervention (whether it is 1:1 or a Group)
– Express concern and presents treatment/recovery options using the FRAMES method
– Ask for an immediate decision. Don't give the person time to think about whether to accept the treatment offer as that will just allow the person time to continue denying a problem, go into hiding or on a dangerous binge.

The Intervention
– It is recommended that the interventionist have a licensed therapist or the person's physician as part of the team in the event the person goes into crisis during the process. For cost containment reasons, this professional may only need to be present if a phase 2 intervention meeting is required.
– TFI best practices require the participation of a licensed medical or mental health professional if the person has a history of depression, suicidality, physically aggressive outbursts, or is so physically vulnerable (i.e. continued use could imminently result in death) that someone with advanced training is needed to intervene.

Follow Up
– Follow up. After the intervention, it is recommended for the someone (either an interventionist, coach or clinician) to have brief (30 minute) follow up meetings with the family on a weekly basis for 12 weeks to review:
– If the patient accepted treatment, follow up focuses on adapting to all of the new changes.
– If the patient refused treatment, follow-up often focuses on maintaining the united message and preventing further splitting and destruction of the family.
– How everyone is managing to adhere to the recovery plan regardless of whether the patient chooses to begin the recovery process, changing patterns of everyday living to make it easier to avoid destructive behavior, seeking counseling and recovery support for themselves and knowing what to do if relapse occurs are essential for every team member not just the patient.
– Any challenges that are occurring etc.

– All together, a well constructed intervention will take between 15 and 25 hours from initial contact to termination
– The interventionist needs to be aware of not only addiction but also mental and physical health issues which may need to be addressed and could complicate the intervention or treatment process.