The Swanswell Recovery Model. Evaluation Report

Transcription

1 The Swanswell Recovery Model Evaluation Report

2 Acknowledgements We d like to thank the Swanswell Substance Misuse Workers and service users from both the Recovery and Control Groups for their participation in The Swanswell Recovery Model pilot. Thanks are also extended to Chris Robinson as project executive, Renée Fisher as project manager and Sarah Brighton and Nikki Sanger-Farrell as project leads, for their contributions to the development of the project. We d also like to acknowledge the support of the Swanswell marketing team for their assistance in the realisation of the model. Without the effort of those mentioned, and numerous others who also contributed, the completion of the project would not have been possible. 2

3 Who is Swanswell? You probably know someone affected by alcohol or drugs. Most people do. It doesn t have to be this way. Britain is far too accepting of the problems associated with alcohol or drug misuse. Swanswell is a national charity that helps people change and be happy. We believe in a society free from problem alcohol and drug use. We ve developed the innovative and costeffective Swanswell Recovery Model which helps people on their journey towards recovery and makes a big difference to people s lives. We ve achieved amazing results so take a look. We re on the look out for partners to help more people change and be happy so why not get in touch? You can call us on % of our clients said their happiness improved with Swanswell 3

4 Executive summary 4 This report evaluates the results of a sixmonth programme, run by Swanswell, which piloted The Swanswell Recovery Model of drug treatment. Drug addiction treatment in the UK is changing. Typically the emphasis has been on reducing the harms associated with drug use by maintaining individuals in treatment, often on substitute medications. However this has led to some people becoming stuck on their treatment journey without fully realising their recovery goals and aspirations. The recovery agenda aims to get more people completing treatment successfully and staying drug free. It advocates an holistic approach to supporting individuals with substance misuse problems, and emphasises the role of the community in supporting an individual to achieve their recovery objectives. The Swanswell Recovery Model is a groundbreaking treatment programme developed on the back of a research project (Swanswell, 2011) 1 which: looked at existing studies about recovery in the substance misuse and mental health fields examined qualitative evidence from existing Swanswell service users brought together the evidence of what works in recovery to produce a structured treatment programme The results of our initial pilot are extremely positive, and provide a sound case for further work. The pilot saw us analyse results from two comparative groups. Both groups had similar demographics and were comprised of Swanswell service users who had been engaged with our service for varying periods of time. The first group, the Recovery Group, used The

5 Executive summary Swanswell Recovery Model as an intervention with service users. The second group, the Control Group, used existing practices with service users. At the end of the six-month pilot we found: an astonishing 168% increase in service users accessing inpatient or community detox programmes (compared to a 0% increase in the Control Group) twice as many service users on The Swanswell Recovery Model programme reduced their methadone maintenance prescriptions compared with those in the Control Group twice as many service users on The Swanswell Recovery Model programme reduced their dose levels of substitute prescriptions compared with those in the Control Group service users on The Swanswell Recovery Model programme showed significant positive behaviour changes in terms of their overall health and wellbeing, as measured by Treatment Outcome Profile (TOPs) data (increased on average by 50% compared with 16.5% for the Control Group) These findings suggest that The Swanswell Recovery Model shows noticeable promise as a method of helping people move away from maintenance prescriptions to become drug free. Looking at individual caseloads, in both groups, % positive change (as measured by service users who either detoxed or reduced their substitute medications dosages) varied according to practitioner, ranging from: 31-82% for service users engaged in The Swanswell Recovery Model programme (average 54% positive change) 5-53% for the Control Group (average 27% positive change) This reveals some variations in the effectiveness of the model between practitioners from within the Recovery Group. Substance Misuse Workers peer support sessions, supervisions and observations of practice revealed several variables that determined these fluctuations. These included differences in service users recovery capital between Substance Misuse Workers caseloads, varying experience and support of GP prescribers involved in the pilot and how enthusiastic Substance Misuse Workers were about using the model. Two Substance Misuse Workers from the Recovery Group worked with General Practitioners with Special Interest (GPwSI) who tended to prescribe for service users with 5

6 Executive summary 6 complex needs and whose recovery capital was typically low. Whilst there weren t as many incidents of detoxes and positive closures associated with these caseloads, using The Swanswell Recovery Model had a positive effect upon those service users making changes to their personal circumstances (as illustrated in the case studies found further on in this report). Similarly, there was a range of prescribing experience amongst the shared care GPs from the Recovery Group. Some had little confidence in managing community detoxes, and so this inevitably impacted upon the numbers completed in those surgeries. As part of our evaluation, Substance Misuse Workers from the Recovery Group were asked to rate their enthusiasm for using the model at the beginning and end of the six-month pilot. The average rating of enthusiasm on a scale of 0 to 10 rose from 5.4 at the beginning of the pilot to an average rating of 9.1 at the end. All Substance Misuse Workers in the Recovery Group noted an increase in their enthusiasm for using The Swanswell Recovery Model, as they gained experience of using it. The National Treatment Agency (NTA) acknowledges this as the biggest challenge faced by services in embedding recovery; that a workforce are signed up to, and enthusiastic about delivering recovery-orientated treatment. The figures from the initial pilot clearly demonstrate that, even in a relatively short timeframe, impressive results can be achieved. As a result we intend to run an extended pilot (using larger sample groups), with a view to rolling out the method to as many service users as we can. The extended pilot will see The Swanswell Recovery Model delivered to all Swanswell service users receiving drug treatment across three geographical locations. This will achieve a statistically significant sample group at evaluation. For the bigger picture, we d like to see the model being used by other agencies and organisations too. If funding is available, we d like to run a fully evaluated trial in partnership with other agencies.

7 Background Drug treatment services in the UK are changing. Since its formation in 2001, much of the drug treatment overseen by the NTA has focused on reducing the harms associated with drug use and increasing numbers staying in effective treatment. While the NTA has achieved positive results, it acknowledges there s still much to do to support individuals to lead fulfilling, meaningful lives. Through the recovery agenda, the drug treatment system and social reintegration services will work more closely together, becoming more focused on improved outcomes. Treatment will orientate toward the promotion of recovery, both for those who are addicted and their families. For people with substance misuse problems, recovery often means being completely drug-free (McDermott, P., 2010) 2. The 2008 Drug Strategy supported this, putting abstinence as the ultimate treatment goal, and calling for a rapid transformation of the treatment system... to make it happen (Home Office, 2008) 3. This has been reinforced by the coalition government s 2010 Drug Strategy, which aims to focus on enabling local communities to support more individuals to become free of their dependence and contribute to society (Home Office, 2010) 4. The NTA is fully on board with these ambitions its latest business plan includes championing abstinence-focused treatment and new clinical protocols as key actions for 2010/2011. It firmly believes that people can achieve recovery, and to make this happen we need a new system that prevents unplanned drift into long-term maintenance prescribing (Drink and Drugs News, 2010) 5. The role of the NTA is due to be incorporated into the new Public Health Service by April Its plans, centred on the challenge of enabling people to make a full recovery from addiction, will be taken forward by the new body. 7

8 Background 8 Maintaining individuals on substitute prescriptions has its critics; the Centre for Social Justice (CSJ) condemns the overinvestment in methadone-based treatment, and calls for a significant expansion in providing abstinence-based services (Drugscope online, 2010) 6. Whilst the CSJ acknowledges that harm minimisation activities such as methadone can help, it says that these should only be a part of an holistic approach that includes pinpointing and fixing the root causes of addiction. Against this background we developed The Swanswell Recovery Model. This model supports behaviour change, and will help move people through their treatment journeys toward positive treatment outcomes. While some people benefit from stabilisation on substitute prescriptions, the goal is to support people to have more say in their recovery and actively encourage social networks to be involved in their journey. We believe that early help and partnership working will enable people to achieve sustained recovery. The Swanswell Recovery Model was developed from existing models used within the mental health field, specifically The Tidal Model (Barker, B. Buchanan-Barker, P., 2005) 7. The mental health field is, in many ways, ahead of our own in promoting recovery as a framework to support behaviour change, and therefore provided a useful evidence-based structure on which to develop our model. Its core assumptions lend themselves well to recovery objectives within the addictions field: Change is a constant ongoing process, with even small changes ultimately having a big effect Focus should centre upon the development of the client s future, not their past

9 Background The experience of distress and imbalance is always private to the client, and these experiences need to be explored safely and holistically The relationship between practitioner and client is collaborative, with change occurring on both sides The Swanswell Recovery Model is radically different from existing interventions, primarily because of the way in which the interventions are delivered. Instead of translating the client s story into the third person and framing it against recognised domains and risk indicators, we encourage the client to tell their story in their own voice. The model is based on the fundamental premise that the client remains entirely in charge of their recovery plan, with ownership and personal responsibility as key themes. It provides practitioners with various interventions to motivate, identify and enable service users to take ownership of their recovery. Service users can re-examine their treatment goals, journeys and recovery plans (focusing on areas of risk and responsibility) and, importantly, remain in charge of their journey. The model provides tools and guidance to support change: Self Assessment My Journey Recovery Plan Personal Toolbox Self-Help Checklist Kick Start Reductions Change Record Daily Happiness Plans The Swanswell Detoxification and Rehabilitation Workbook The Swanswell Detoxification and Rehabilitation Workbook is used alongside The Swanswell Recovery Model, offering a portfolio of interventions around inpatient or community-based detoxification and rehabilitation programmes. Produced by Swanswell, this workbook provides clear, concise guidance and tools to help suitable service users complete their treatment journeys successfully. It gives practitioners confidence to explore detox and aftercare as part of recovery objectives. 9

10 Methodology 10 We conducted a six-month pilot using The Swanswell Recovery Model with a sample of current service users in the Birmingham area. For simplicity, we used two of our existing operational teams to conduct the pilot: Team 1 (the Recovery Group ) practitioners using The Swanswell Recovery Model and The Swanswell Detoxification and Rehabilitation Workbook on a sample of 309 service users Team 2 (the Control Group ) practitioners using existing practices on a sample of 225 service users While the number of service users in each group differed slightly, the demographics were very similar for both groups, comprising a 73/27% male/female split, with around 45% of service users falling into the age bracket. For both groups, the most common substitute medication was methadone, prescribed for more than 67% of service users. Both groups contained a mix of service users who had been in treatment for periods ranging anywhere from less than one year to ten years. All practitioners in the Recovery Group received full training in the delivery of the model. This included an overview of national recovery objectives, Tidal Model principles, self assessment methods, and guidance on using The Swanswell Detoxification and Rehabilitation Workbook. As part of the pilot they took part in regular peer support, observations of practice, and clinical supervision structures. It was anticipated that this would increase competence, develop best practice and embed recovery-orientated systems into our service. The Swanswell Recovery Model was delivered to service users accessing treatment via GP

11 Methodology surgeries, as part of the well developed shared care service in Birmingham. As integral members of the practice teams within shared care, Swanswell Substance Misuse Workers are best placed to respond to clients needs holistically and with multi-disciplinary support. As such the shared care service offered an ideal setting to support the embedding of recoveryorientated practice. Surgeries were notified of practitioners involvement in the pilot, and all shared care GPs were fully briefed on the model. We had initially anticipated some resistance from service users and GPs who might favour ongoing maintenance prescribing, but found that face-to-face discussions about The Swanswell Recovery Model alleviated concerns. In addition, service users were encouraged to include carers and significant others in their journeys as this is an important factor in sustaining and supporting behaviour change. of movement within this group as a knockon effect of the wider debate of the recovery agenda. Over the six-month period we measured effectiveness of the pilot using: Quantitative measures Numbers undergoing detoxes Numbers coming off substitute prescriptions Numbers making reductions to their maintenance prescription doses TOPs data to measure behaviour change for overall psychological and physical wellbeing Qualitative evidence Feedback from practitioners Feedback from service users The Control Group was used throughout the pilot to measure the effectiveness of The Swanswell Recovery Model. The practitioners in this group had not been given access to The Swanswell Recovery Model or The Swanswell Detoxification and Rehabilitation Workbook. However, in line with the current recovery agenda, we did expect to see a modest level 11

12 Results Quantitative Figures 1-4b illustrate a range of significant positive changes in line with a recovery agenda for the Recovery Group in comparison with the Control Group. 180 March No of clients prescribed methadone = 8.5% August = 4% 100 Recovery Group Control Group 12 Figure 1: Number of service users prescribed methadone at pilot start and pilot end. Around twice as many service users in the Recovery Group (by %) had come off methadone by the end of the pilot period.

13 Results Figure 2: Numbers of service users who had ever been referred to detox at the start and by the end of the pilot period. Although initially numbers referred to detox were higher in the Control Group, by the end of the pilot period numbers detoxing in the Recovery Group had increased by a phenomenal 168%, while no change was observed in the Control Group. March 45 = +168% August No of clients referred to detox = 0% 10 Recovery Group Control Group 13

14 Results 40 % clients with reduced methadone/ Buprenorphine dose Recovery Group Control Group Figure 3: Service users who reduced their substitute medication dosages during the pilot period. 38.5% of the Recovery Group reduced their dosages just over twice that of the Control Group (17.5%). 14

15 Results The results also measured positive changes achieved by service users per individual practitioner caseload. Positive change was measured by % of service users who had detoxed or reduced their dosages of substitute medications. In our evaluation we found: an average of 54% achieved positive change in the Recovery Group an average of 27% achieved positive change in the Control Group This suggests that service users from the Recovery Group achieved double the rate of positive changes as those from the Control Group. 15

16 Results Control group Psychological health Quality of life Physical health Average rating (0 20) Start Review Exit Treatment stage Figure 4a: Indications of positive behaviour changes, as measured by average TOPs data. Over the course of the pilot, the Control Group showed increases of 16.7%, 25% and 7.7% respectively for psychological health, quality of life and physical health. 16

17 Results Recovery group Psychological health Quality of life Physical health Average rating (0 20) Start Review Exit Treatment stage Figure 4b: Average TOPs data for the Recovery Group showed increases of 50% for each of the three areas significantly better than the increases achieved within the Control Group. 17

18 Results Qualitative During the pilot service users were invited to complete specific self assessments and worksheets from The Swanswell Recovery Model, telling their stories in their own words, with their workers present. This helped practitioners to review treatment goals and objectives for both existing service users and those entering treatment. This method encouraged service users to remain entirely in charge of their treatment and motivated them to identify treatment goals and pathways to recovery. Feedback received from Substance Misuse Workers from the Recovery Group indicated that these interventions generated useful dialogue with their service users that previous practice would not have, and encouraged their service users to take greater ownership of their treatment. Substance Misuse Workers from the Recovery Group rated an average of 42% increase in their enthusiasm for using the model over the six month pilot. This increase was largely due to their observations of how effective the model was in prompting positive behaviour change with their service users. At the end of the pilot, the Recovery Group workers completed a questionnaire about their experiences of the project. They felt that: The Swanswell Recovery Model offered them a different way of working with their service users it refreshed them as a worker and changed their style of delivery The Swanswell Recovery Model has helped to motivate service users in positive behaviour change it provided greater structure than previous practice while they experienced some initial resistance from service users when introducing The Swanswell Recovery Model, they made good progress to achieve positive changes during the course of the pilot some service users associated the word recovery with abstinence which put barriers in place there was, in general, a willingness to take part from service users GPs aftercare should include more structured daycare, more time with practitioners in sessions, social enterprise, mentors, telephone support and college/work programme 18

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21 Case studies Using the recovery materials and approach can be a powerful instigator of change. David: Re-evaluating his personal circumstances David has been in treatment since 2005 after referral to the shared care service via his GP. A previous intravenous heroin user, during his treatment David had achieved some stability in relation to his drug use. However, it was evident to both David and his Substance Misuse Worker that something else was preventing him from reaching his potential and achieving his recovery goals. Using the interventions contained within The Swanswell Recovery Model, David and his Substance Misuse Worker were able to identify the most significant obstacles to him moving forward. Through a process of self-assessment, David was able to acknowledge his low mood and anxiety as having a significant impact upon his quality of life. This had prevented him from achieving his ambition of getting back into employment. During the pilot David, supported by his Substance Misuse Worker and GP, continued to use The Swanswell Recovery Model interventions to explore his goals and reexamine his attitude toward achieving them. Two months later, David secured work as a labourer for a big, national contractor and was delighted with this achievement. David stated that The Swanswell Recovery Model had really helped him to re-focus on what he wanted, and helped him to identify skills and strategies he d forgotten about. David discovered that he had been trying to ignore his negative emotions, instead of facing up to them. He said of himself before the pilot: I d been letting myself get away with doing nothing and feeling sorry for myself. David continues to engage in drug treatment, is still in employment and his psychological health is now well managed with the support of his GP. 21

22 Case studies Alan: Achieving his recovery objective Alan has been in treatment with Swanswell since He had stopped using illicit substances some time ago but found coming off his methadone prescription was a big challenge. Prior to using The Swanswell Recovery Model interventions, Alan had been attempting to reduce his medication gradually. Alan had many anxieties around reducing his methadone. This meant the reductions had been sporadic and slow, leaving him feeling further de-motivated and lacking in confidence of his ability to become medication free. Using The Swanswell Recovery Model and The Swanswell Detoxification and Rehabilitation Workbook, Alan and his Substance Misuse Worker from the Recovery Group were able to explore different treatment options. Alan was able to explore his anxieties around reducing, and used the interventions in The Swanswell Recovery Model to re-state his recovery goals and increase his confidence to achieve them. A few months later, Alan successfully completed a community detox, supported by his Substance Misuse Worker and GP. To date Alan remains illicit drug and methadone free, and has exited drug treatment after eight years. It s great to be clean. I ve got my old life back again. I have far more energy. I didn t realise being on methadone was like living your life through a fog. My wife is so pleased. The detox was the hardest thing I ve ever done and I couldn t have done it without Swanswell. 22

23 Case studies Claire: Getting life back on track Claire attends regular sessions at a shared care surgery with a Substance Misuse Worker from the Recovery Group. At the start of the pilot, Claire s stability was at risk. She lived with a partner who was abusive, she was estranged from her family and any positive supporting influences and was using illicit substances on a regular basis. Claire s health was also a concern, as she had neglected a chronic physical health condition for some time. Using The Swanswell Recovery Model helped Claire to re-evaluate her situation. With the support of her Substance Misuse Worker, Claire worked through the interventions enabling her to identify her strengths and aspirations and develop personal risk management skills. At the end of the pilot Claire s personal circumstances had improved greatly. Claire developed the confidence to end her relationship and re-establish contact with her mother and son. She began to address her physical health complaints with the support of her GP and found herself able to increase her working hours as a result. To date, Claire has reduced both her prescriptions for methadone and sleeping tablets and is testing negative for illicit substances. I m in a better position now I m enjoying life much more than I was. 23

24 Conclusion 24 The Swanswell Recovery Model was created to support behaviour change for those entering treatment to move towards recovery, avoid long-term maintenance prescribing and to motivate existing service users to reinstate their recovery goals. At the end of our six-month pilot we found: an astonishing 168% increase in service users accessing inpatient or community detox programmes (compared to a 0% increase in the Control Group) service users on The Swanswell Recovery Model programme were twice as likely to come off methadone maintenance prescriptions than those in the Control Group service users on The Swanswell Recovery Model programme were more than twice as likely to reduce their dose levels of substitute medications service users on The Swanswell Recovery Model programme showed significant positive behaviour changes in terms of their overall health and wellbeing (TOPS data increased on average by 50% as compared with 16.5% for the Control Group) % positive change (as measured by service users who either detoxed or reduced their substitute medications dosages) averaged at 54% for the Recovery Group i.e. double the 27% of the Control Group Substance Misuse Workers from the Recovery Group reported an average increase in their enthusiasm for using The Swanswell Recovery Model of 42% over the six month pilot These findings suggest that the radical new approach of The Swanswell Recovery Model shows significant promise as a method of helping people to move away from maintenance prescriptions, become drug free and make positive changes in various aspects of their lives. We recognise that while the project has delivered amazing results in a very short space of time, effecting behaviour change towards recovery can take longer. This is why we now intend to take this further with a larger pilot group, with a view to rolling the method out company-wide in the future. We also see The Swanswell Recovery Model being used by other organisations and agencies too, as part of a fully evaluated trial. Substance Misuse Worker enthusiasm for using The Swanswell Recovery Model increased during the pilot. All Substance Misuse Workers in the Recovery Group noted an increase in

25 Conclusion their enthusiasm for using The Swanswell Recovery Model over six months. As expected, these ratings differed with each worker. It s likely that worker enthusiasm for using the model directly affected its success with service users. We weren t able to collate this data during our initial six-month pilot, but intend to give this particular consideration moving forward. We ll continue to use peer support, direct observation of practice and supervisions to support our Substance Misuse Workers in the delivery of The Swanswell Recovery Model during the extended pilot. We ll also incorporate the use of recovery champions in our teams to further this support and ensure the continued success of The Swanswell Recovery Model with our service users. 25

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27 References 1. Swanswell, The Swanswell Recovery Model, Supporting research. Swanswell. 2. McDermott, P., Centre Stage. Drink and Drug News. 3. Home Office, Drugs: protecting families and communities. The 2008 Drug Strategy. Home Office. 4. Home Office, Drug strategy Reducing demand, restricting supply, building recovery. Home Office. 5. Drink and Drug News, Changing Landscape. Drink and Drug News. 6. Drugscope online, Think tank publishes Green Paper on Criminal Justice and Addiction. Available at org.uk/newsandevents/currentnewspages/csj Green Paper.htm 7. Barker, B. Buchanan-Barker, P., The Tidal Model: A guide for mental health professionals. London and New York: Brunner- Routledge. 27

28 Swanswell, Suite 5, Hilton House, Corporation Street, Rugby, CV21 2DN T F E admin@swanswell.org Swanswell 2012