Innovation summary

Millions of family members all over the world are affected by addictive behaviors (alcohol, drugs, gambling) of a relative. Given the stressful impact this can have on affected family members (AFMs: parents, spouses, children, or other relatives of an addicted individual), AFMs experience high levels of physical and mental health symptoms, with knock-on effects on AFMs’ finances, work performance, parenting ability, and overall functioning.

Using an evidence-based intervention such as the UK-developed ‘5-Step Method’ could help AFMs to reduce their symptoms and improve their coping methods. The 5-Step Method empowers individuals by:

  • exploring concerns

  • providing relevant information

  • building coping responses

  • developing greater social support

  • exploring further needs

The present innovation aims to contextually adapt the 5-Step Method to be acceptable, safe, and feasible to deliver to AFMs in Goa, India.

The project also innovates delivery by recruiting low-cost human resources, Lay Health Workers (LHWs), and training them to deliver the intervention in community-based settings, which are accessible and appropriate to the local context.

Impact summary

  • To date, 44 affected family members (AFMs) were referred to the programme (33 (75%) by gatekeepers, 11 (25%) self-referred)

  • Of these, 18 entered treatment and 16 completed treatment (all five sessions)

  • Qualitative interviews, process indicators, and clinical outcomes are currently being evaluated 

What used to happen before was that whenever he (drinking relative) said something I would retaliate and thus the arguments would escalate. Then Reshma (counsellor) helped me learn how to deal with such situations. I also managed to convince him to get treatment (for drinking problems) and his drinking reduced gradually as well.
--Affected Family Member


Innovation details

As AFMs are not a group that wield collective power for social change, they have remained under-recognised and underserved by health policymakers. The SAFE package of care is a contextually adapted version of the 5-Step Method (an evidence-based intervention being used in a number of developed countries (UK, Italy etc.) and showing significant positive effects) to be delivered by lay health workers (LHW) for AFMs in Goa, India. 

The SAFE package of care has been developed through a systematic process which involved:

  1. Adaptation of the 5-Step Method to make it contextually appropriate
  2. Development of a training, supervision and competence assessment system for the LHWs
  3. Demonstration that the adapted 5-Step Method is acceptable to AFMs
  4. Demonstration that the adapted 5-Step Method is feasible and safe to be delivered by LHWs
  5. Providing preliminary evidence that the adapted 5-Step Method leads to improved psychosocial outcomes in AFMs.

Key drivers

Strong collaborative links

Sangath, the organization involved in implementing this project, has strong collaborative links with the Directorates of Health Services and of Women & Child Development, along with various other formal community-based organizations.

Combined team experience

The primary investigators of the SAFE project and Sangath have extensive experience of conducting structured formative work and developing complex interventions within the field of addictions in the context of global mental health.

Community engagement with the program

From the start of the project, community gatekeepers (e.g. self-help group members) began expressing the need for an intervention such as SAFE, and readily accepted the program as they perceived it to address an unmet need in the lives of AFMs.

Rigorous and systematic methodologies

The entire cycle of the formative research phase was planned with iterative, scientifically sound processes.



Community integration for recruitment

In the initial phase we had difficulty identifying and recruiting AFMs as it is generally a hidden problem and our counsellors were not fully integrated into the community. This was solved by engaging with gatekeepers embedded in the community (e.g. community health workers, village council members, self help group members). These gatekeepers were able to access AFMs in the community and recruitment rates rose drastically.

Reluctance of AFMs to accept support

Many participants initially found it difficult to bring the focus to themselves as needing care, and instead emphasized that if the drinker quit drinking, there would be no problems faced in the family. This was overcome by adjusting the content of the counselling, and by integrating the programme with another programme focused on home detoxification and counselling for those with alcohol use disorders, thus allowing the AFM to access help for their drinking relative.

Domestic violence

A large number of participants reported being victims of verbal and/or physical abuse, which was challenging for the counsellors as there are very few existing resources in the study setting to help survivors of domestic violence. We therefore focused on building this capacity in the SAFE skills training, and provided AFMs with information on existing local resources (e.g. NGOs working with survivors of domestic violence) for further support.


In many instances, AFMs preferred not sharing with the addicted family member that they were participating in the program. This required the counsellor to be extremely flexible in their delivery and engagement strategies (e.g. self-help handbooks would be used in sessions instead of sessions at the AFM’s home).



The evidence generated from the SAFE formative research project led to the development of the next phase, a pilot Randomised Controlled Trial. In the second phase, 100 participants will be recruited and randomised to receive either the 5-Step Method or Enhanced Usual Care (an information leaflet).

The preliminary effectiveness of the 5-Step Method will be assessed at 3 months, by primary outcome measures (Coping Questionnaire, Symptom Rating Test, and Alcohol, Drugs and the Family Social Support Scale), and a secondary measure (Family Member Impact Questionnaire). Feasibility and acceptability of the 5-Step Method will be assessed with a range of process indicators and qualitative interviews.



Evaluation methods

The intervention was evaluated through a mixed methods research study, using a before-after treatment cohort. Methods included:

Qualitative interviews

These included in-depth interviews and focus group discussions with the participants in the project, lay counsellors, supervisors, and community gatekeepers. The focus of these interviews was:

  • Understanding attitudes towards an intervention aimed at AFMs as opposed to the addicted relative

  • clarifying what makes such an intervention acceptable;

  • the acceptability and usefulness of the current steps within the 5-Step Method, and potential changes

Process indicators

These included number of AFMs: referred, approached, eligible, consented, refusals and reasons for refusals, entering treatment, completing treatment, and dropouts

Competence and quality indicators

The competencies of lay counsellors were determined through ratings of structured role plays, audio-tapes and observation of treatment sessions

Clinical outcomes

A preliminary estimate of effectiveness was determined by changes in scores on the: Symptom Rating Test (primary outcome), Coping Questionnaire, Alcohol Drugs and the Family Social Support Scale, and Family Member Impact (all secondary outcomes)

Cost of implementation

No cost-related data available

Impact details

44 affected family members (AFMs) were referred to the programme [33 (75%) by gatekeepers and 11 (25%) self referred].

We were able to approach 36 (81.8%) AFM for assessment of eligibility, and completed eligibility assessment of 25 (69.4%) AFMs.

Of these, 22 (88%) AFMs were eligible for inclusion in the case series. 21 (95.5%) consented to receive the intervention and 18 entered treatment. 16 (88.8%) completed the treatment (all five sessions).

We completed outcome assessments in 17 (80.9%) of the 21 who consented to receive the intervention.

These numbers indicate that it is possible to identify AFMs through gatekeeper/self referral, and recruit most of them through a systematic process of eligibility assessment. The low refusal of participation (4.5%) and reasonable treatment completion rate indicate the good acceptability of the intervention.

Some of the areas in which the innovation is expected to influence the mental health scenario is:

Clinical impact

The SAFE project places priority on the needs of AFMs. Some of the positive outcomes arising from this include capacity building of lay health workers, increased case detection, better delivery of and/or referral for mental health care, improved service provision, and better help-seeking behaviors of AFMs. The systematic methodology to adapt the 5-Step Method will result in a contextually appropriate intervention manual to be utilized for capacity-building efforts. On an individual level, if the project has a similar impact in India to that in high-income countries, a large majority of AFMs that receive the intervention will show significantly improved symptom levels and coping strategies. By changing the ways that AFMs act towards their addicted relatives, we also anticipate that the behavior of some of these relatives will also improve.

Societal and economic impact

The project is expected to produce socioeconomic impact at a broader level due to the improved health of individuals  and families, including better wellbeing, functioning and productivity, and a higher likelihood of contributing to the economic wellbeing of society. Cost-savings will also be made to patients, employers, and society. From a health systems perspective, the task-sharing approach is cost-effective by integrating a minimally trained workforce (at a low cost) into primary care.

Impact on policy and funding

The current national mental health policy is envisaged to inform efforts to bridge the huge treatment gap for mental disorders through programmes that are yet to be successfully implemented. The project meets a number of priorities stated in the policy, including universal access to mental health services, support for family members, adequate training of human resources, use of non-specialist health workers to increase access to treatment, and quality research to inform mental health services.

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