Whole Family Approach: rapid review of literature

Key Findings

Conceptual overview

• There is limited conceptual clarity in terms of a definition of a whole family approach (WFA) and the literature uses a number of different terms to refer to these interventions.
• WFA interventions are characterised by an adherence to a core set of principles. These include: working collaboratively with families as a unit and as individuals to identify their collective and respective needs; providing timely and flexible support; taking a holistic approach by considering substance use within its wider context and addressing associated needs; reinforcing existing relationships and making use of individual strengths; addressing stigma and other barriers to services.
• How families are defined and understood is central to the successful implementation of WFA interventions. The has been a general shift in our understanding of family structures from primarily defined according to biological ties, to a wider more socially constructed concept which includes individuals not directly related. In order to successfully achieve a WFA's aim of supporting the family as a whole as well as its individual members, a clear definition of family is needed which captures the reality and complexity of all family structures.
• The wider context in which substance use occurs and its driving factors (e.g. poverty, trauma) needs to be considered and addressed when providing support to individuals and families affected by substance use.

Examples of best practice

• Involving all members of families affected by substance use in the design and delivery of WFA interventions (co-design) is associated with positive outcomes. Research highlights variance in how families and practitioners identify and prioritise needs. Effective interventions are those that acknowledge and differentiate between the individual needs of different family members and the collective needs of the family unit, and tailors support to the family as a whole as well as to individual members of the family (e.g. parents or children).
• Long term, consistent and timely support and good therapeutic relationships are associated with an increased likelihood of positive outcomes. The interventions reviewed operated between a few weeks to a year, and service users reported the general need for longer term support and for interventions to be implemented early in order to be preventative, rather than when families have reached a crisis point. A flexible approach was reported to be required to accommodate the specific needs of service users and reduce barriers to access (e.g. flexible appointment times, communication by phone, being available out-of-hours).
• WFA interventions that adopt a holistic approach to substance use, acknowledging and responding to the range of needs experienced by families are associated with positive outcomes. This may be by providing practical support for non-substance use specific needs (e.g. parenting support, navigating access to other services) in addition to substance use specific support. There is evidence for improved substance use outcomes (e.g. reduced substance use, increased take-up of and retention of use treatment); increased resilience; improved communication and stronger relationships; reduced isolation; reduced incidence of negative emotions; improved educational outcomes for children.
• Peer support within WFA interventions, e.g. engaging in peer discussions, has a positive effect on substance use outcomes as well as across other domains (e.g. reduced isolation, improved communication, increased understanding of the impact of substance use on other family members) and receives positive feedback from people with lived experience.
• Outreach workers can contribute to reducing barriers to access and promote engagement with support and treatment services. Families report that having someone making the complex procedures of formal child protection understandable to them and giving them the confidence and skills to advocate for themselves is important.

Workforce Implications

• Challenging negative attitudes and stigma towards people who use substances in the workforce is essential to addressing barriers to engagement. Suggestions for doing so include involving practitioners with lived experience and increasing awareness of drivers and contextual factors of substance use.
• There is a need for specific skills training to transition from individual-based to family-orientated practice; improve communication with service users; for trauma-informed practice; and to increase practitioners' understanding of the psychological dimensions of their work. The potential benefits of this in promoting workforce wellbeing and reduce turnover are noted.
• Inter-agency collaboration is needed when adopting a WFA. Suggested effective practices include clear pathways to referral/access; the appointment of a lead professional; the adoption of clear protocols for case-management and information sharing across agencies; regular inter-agency meetings. This may require structural and ideological change within services.