Supporting adults bereaved through substance use with the 5-Step Method intervention

The aim of the study was to pilot a brief structured intervention (based on an existing evidence-based model, the 5-Step Method) for adults bereaved through substance use. In so doing, the project brings together two areas of work; namely, developing evidence-based support for families affected by a loved one’s substance misuse in their own right, and research on the experiences and needs of adults bereaved through substance use.

The project aimed to explore:

1. The feasibility of recruiting and training practitioners to use the adapted intervention.
2. The feasibility of whether the intervention could be delivered in a substance misuse treatment service.
3. What practitioners and family members thought of the adapted intervention.

Following a developmental workshop (prior to the award of this grant), the 5-Step Method was adapted for bereavement (Figure 1).

Figure 1: Adapted 5-Step Method: the Five Steps

The project reported here subsequently established a new service, the Family Bereavement Support Service, at a substance misuse treatment organisation based in the Midlands, and the adapted intervention was tested. Qualitative research supported the pilot study and involved semi-structured interviews with family members and practitioners, all of whom gave informed consent. The data were analysed deductively using thematic analysis aligned with the areas of feasibility that the study aimed to explore.

1. Eleven practitioners were recruited from five Aquarius services and trained to use the adapted intervention.
2. Six practitioners remained engaged in the project, four of whom used the intervention with six family members. All had prior experience with using the original 5-Step Method, and some in working with bereaved families.
3. Thirteen interviews were completed with four family members and nine practitioners.
4. The family members were all female, mainly mothers, mainly White British, and aged in their 50s or their 70s. The deaths of their loved ones occurred between 2016-2018; loved ones were mainly male and aged under 40. The deaths involved alcohol or heroin (polydrug use in one case) and the causes of death were associated with (alcohol) liver failure, overdose, or suicide.

Qualitative analysis concentrated on the following three broad themes.

Preparation - covering training, setting up a new service and supervision.

• Interviewees were generally positive about the new service that was established, and with the training, resources and supervision that supported it. However, the new service was affected by wider pressures across the organisation, and by a potentially cautious approach to advertising the new service and generating referrals.
  • “the clients who have received this service have been very fortunate indeed, not just with the model but with the staff they’ve had supporting them” (practitioner)
    

Delivery – covering the delivery of the adapted intervention, and what family members and practitioners thought of the intervention.

• The adapted intervention could be delivered, with flexibility particularly important to be responsive to the constantly changing nature of grief and the impact of traumatic deaths. All the practitioners who used the intervention immersed themselves in the work and all gained from their involvement with the project in a range of ways.
• The intervention seemed to benefit family members in a range of ways that align with the steps of the intervention and the underlying theoretical model. Overall, the family members were hugely appreciative of the support that they had received, and talked about feeling stronger and more hopeful about the future.
  • “it just makes me know I can do this, I can carry on with my life and I will...I can’t give up....[worker] reiterates ‘you’re doing fantastic, you’re stronger than you think’, it gives you the oomph to think you will do this.....I don’t know how to put it in words....gives me confidence, makes me feel positive, [worker] makes me feel that after this terrible tragedy that I’m strong enough and I can carry on” (family member)

Sustainability

• There was consensus that supporting those bereaved by substance use was a gap, that specialist support delivered by skilled practitioners was needed, and that Aquarius was well placed to offer specialist support to adults bereaved through substance use as an extension to the other support that it offers to affected family members.
  • “there was nothing like this available for me....there was nowhere for me to go with this at all....how wonderful it would have been to have had that kind of support, how much I would have welcomed it.....someone to talk to, someone to listen who understood this particular kind of bereavement which is very very different....[this 5-Step support] it was for someone like me all those years ago” (practitioner)
• Interviewees suggested what was needed to maintain the Family Bereavement Support Service, and highlighted that they thought its continuation was feasible. The following elements were identified:
  • Clear referral pathways within and external to Aquarius.
  • Protected time for the work and support from managers.
  • Specialist clinical supervision including peer support.
  • More staff trained to use the adapted 5-Step Method intervention.
  • Financial investment.
  • Part of a broader ‘offer’ to family members.
  • Good links with other services in the community.

The findings suggest that it has been possible to:

1. Adapt the 5-Step Method for adults bereaved by substance use.
2. Recruit and train a group of practitioners to use the intervention.
3. Establish a new service, the Family Bereavement Support Service, across Aquarius with supporting procedures for engaging and monitoring work with clients, including monthly clinical supervision.
4. Recruit family members to the new Family Bereavement Support Service.
5. Deliver the adapted 5-Step Method intervention with family members recruited to the new service.
6. Collect data on the views of practitioners and family members.

The implication from this is that the evidence-based 5-Step Method intervention can be applied to adults bereaved through substance use. However, this was a small pilot, and the supporting evidence, while encouraging, is limited and qualitative. Further research is certainly needed.

Nevertheless, the pilot study has demonstrated a range of positive impacts in the short-term. As a result, Aquarius has demonstrated its commitment to undertaking a number of activities to ensure that the Family Bereavement Support Service (centred on the adapted 5-Step Method but also developing a broader service to its clients) can be maintained and can rise to the challenges presented by austerity and other pressures on service delivery and commissioning. It is hoped that the longer-term impact from this project will be an increase in much needed support for adults bereaved through substance use.

While alcohol- and drug-related deaths across the United Kingdom are of continued concern, insufficient attention is given to the vast numbers of those who are bereaved, often traumatically and often following years of stress and strain associated with the impact of a loved one’s substance misuse, by such deaths. There is evidence that this is a very particular bereavement and one which requires a specific type of response. However, there appears to be very limited evidence-based support for this group of bereaved adults. This pilot study, although small in scale, has demonstrated the potential for an adapted version of an existing intervention to offer much needed support, and for this support to be part of a substance misuse treatment service. It is the sincere hope of all those involved with this project that this pilot study is a springboard for prioritising the needs of those bereaved through substance use and developing and evaluating vital interventions and services for them.