Models of care for the treatment of adult drug misusers: Update 2005 Stage two consultation questionnaire Please note that some questions in this questionnaire are similar to, or the same as questions in the care planning toolkit consultation questionnaire, which is available at www.nta.nhs.uk Implementation of Models of care (page 8) 1. Have the integrated care pathways, protocols, care planning and care co-ordination arrangements set out in Models of care 2002 been implemented in your area? Fully Partially Not implemented Other (please specify) 2. How will the implementation of Models of care: Update 2005 fit with any ongoing implementation of Models of care 2002? The Update 2005 has the potential to highlight the links between substance misuse and domestic violence and provide a thorough response to these dual issues which feature in the lives of many service users. There is an abundance of information which shows significant overlap between domestic violence and substance misuse. A recent UK study showed that 51% of respondents from domestic violence agencies claimed that either themselves or their partners had used drugs, alcohol and/or prescribed medication in problematic ways in the last five years (Humphreys et al, 2005). Another UK study of 60 women using crack cocaine (Bury et al, 1999) found that 40% reported being regularly physically assaulted by a current partner and 75% being physically assaulted by a current or past partner. A US study involving 360 women across eight substance misuse agencies reported 60% of clients disclosing either current or past domestic violence (Swan et al 2001). It is also important to highlight the differing patterns of drug and alcohol use for both the survivor and the perpetrator. The most commonly cited theory is that women subjected to domestic violence use drugs or alcohol to cope with their abuse (Humphreys et al 2005a). For perpetrators, the use of alcohol and drugs takes place prior to or during the perpetration of their abusive behaviour. Findings from a review of the British Crime Surveys revealed that 44% of domestic violence offenders were under the influence of alcohol and 12% affected by drugs during the domestic violence incidence (Budd 2003). Brookhoff et al (1997) found that family members reported that two thirds of the male perpetrators had used a combination of cocaine and alcohol on the day of the incident. The results of numerous studies overwhelmingly show the need to address more holistically the reasons for problematic drug and alcohol use by service users and provide appropriate and safe responses. 1
3. What do you think the timescales for implementation should be? Commissioning substance misuse services Key differences between Models of care 2002 and Models of care: Update 2005 (pages 11-14) 4. Models of care: Update 2005 proposes that Tier 1 services are not to be seen as the generic services themselves, but rather the range of interventions provided by generic services. This also includes what was previously described as Tier 4b being designated as Tier 1. Do you agree with this revised focus? No Please comment on your response 5. How can Tier 2 interventions, as outlined, play an enhanced role in engagement and retention? By explicitly recognising the scope and variation of organisations and agencies which can be considered Tier 2 agencies: Some domestic violence agencies are already providing interventions to engage people into drug treatment, support people prior to structured treatment, as well as providing a service which will retain people in treatment. They are already screening and assessing for drug problems and referring on to specialised drug treatment services. Some also employ specialised substance misuse workers. They target a priority group of service users providing parallel support in addressing the wider reasons for drug use and making a significant contribution to preventing drug relapse. Those agencies that have not taken on this work have the ability to do so with appropriate funding for training and specialist workers Tier 2 interventions by drug agencies need to better encourage the engagement of women by providing women-only space, appointment times, childcare and varying opening times. Consideration must be given to the enhanced feelings of stigma and shame which women from some black and minority ethnic groups may experience with regard to their drug use and their experiences of abuse. This needs to be borne in mind when considering appropriate engagement with this particular group of women. There are some excellent examples of substance misuse agencies in London boroughs which work effectively with service users from black and minority ethnic groups. Thought should be given as to how this can be enhanced and extended across all London boroughs Agencies must also consider how their interventions may be jeopardised when a service user returns to an abusive partner or family member after each appointment or meeting e.g an abusive partner or family member can encourage drug use and jeopardise any attempts to access treatment. If these wider issues are addressed by appropriately trained staff in Tier 2 interventions, there is a greater chance of improving retention rates for service users who are in abusive relationships. 2
6. How can Tier 2 interventions, as outlined, be a key delivery mechanism for aftercare? For survivors of domestic violence who have left structured treatment, it is essential for their safety, and in order to avoid relapse, that the wider issues of partner and family abuse are addressed. The safety of the service user should be paramount in any aftercare initiatives particularly where they are returning to an abusive relationship. Domestic violence services also have a key role to play in providing aftercare through psychosocial interventions which cater for the variety of survivors needs. For example, survivors may be at different stages of readiness to leave a violent relationship and an aftercare response should be sensitive to this and not place blame on those who choose to stay and/or return to the abuser. For perpetrators, merely addressing drug/alcohol misuse is insufficient to stop their abusive behaviour. Agencies already work to address other offending behaviour therefore domestic violence should be included. The Update specifically mentions emphasis on appropriate community reintegration after treatment. For perpetrators, this should include referral onto an accredited perpetrator programme (see RESPECT www.respect.uk.net). For those perpetrators already in the criminal justice system e.g DIP, there is an ideal environment to enforce attendance on programmes. Drug/alcohol agencies can play a key role in delivering thorough and holistic aftercare if staff are appropriately trained on the issues of domestic violence from the perspective of both the survivor and the perpetrator. This requires knowledge of positive screening and effective responses to disclosures of violence. Such an approach fits into the Update s ethos which calls for Tier 2 interventions to include services for those who are drug free and require aftercare. 7. Given the outlined need for expansion of Tier 4 services, how can the commissioning of Tier 4 services be improved to enhance client journeys through treatment? The Update refers to a range of drug and alcohol residential rehabilitation units to suit the needs of different service users. The Stella Project maintains that for survivors of domestic violence, there needs to be priority access to these rehabilitation units where issues of confidentiality and safety are paramount. Staff at such units must be trained to understand how this particular group of vulnerable women are in danger of being tracked down by their abusive partners. They should also be aware of how drug and alcohol use are coping mechanisms for the abuse experienced. Becker and Duffy (2002) highlight a major gap in service provision in emergency crisis accommodation for women drug users. For the most part, women who enter into residential treatment are unable to bring their children and commonly will be referred to mix-sex units which are particularly unsuitable for women who have experienced abuse at the hands of a male partner (Raine 2001, Barnes et al 2002). Consideration should be given to the fact that mixed group services may contain perpetrators of domestic violence towards others which will be particularly frightening to any survivor. Recognition must be given to the fact that women will be unwilling to undertake a residential programme where their children are left to be looked after by a violent partner or family member, or taken into local care potentially resulting in their loss of permanent residence. The need for women-only units is of crucial importance and issues of childcare should also be considered if we are serious about moving more women into such drug treatment interventions. 3
8. How can the implementation of Models of care: Update 2005 help treatment to be better planned, so as to ensure clients are guaranteed social support and aftercare after leaving residential rehabilitation? A personalised care plan must consider the safety of the service user throughout the four key domains. If a service user is in an abusive relationship, upon completion of residential rehab, she is often sent back to this relationship where her efforts to remain drug free are at risk along with her personal safety. An abuser may sabotage efforts to remain drug free and may feel threatened by the survivor s attempts to control her dependency. Further abuse perpetrated against the survivor will increase the need for her to use substances in order to cope with the abuse. Therefore links with domestic violence agencies must be a central part of a care plan and these links must be ensured prior to leaving rehab. A prerequisite for this level of support and aftercare is that screening and disclosure of domestic violence has taken place previously during the service user s treatment journey. The four tiers (page 14-18) 9. Do you agree with the definitions, interventions, settings, and competencies as set out for each tier in Models of care: Update 2005? No If your answer is no, what changes would you recommend? Improving clients journeys (pages 19-21) 10. Do you find the division of the treatment journey into the component parts (engagement, delivery, completion and maintenance) useful? No Comments on the phases of the treatment journey 11. Are there any specific interventions that need to be commissioned to make the engagement phase of treatment, as outlined, work better? Funding to allow the development of specialist domestic violence and substance misuse workers in Tier 1 and 2 agencies, including include refuges. In particular, specialist refuges for women with problematic substance use should be supported through adequate funding. For those who choose to remain in their 4
home, there is a need for floating support services provided by drug/alcohol agencies. This has proven particularly important in accessing women from black and minority ethnic groups who require interventions which are highly confidential. In general, all drug and alcohol treatment interventions need to engage women by making the service more women friendly (see answer to question 7). Basic training for all domestic violence and substance misuse agencies would also strengthen the ability to engage both women and men into treatment. 12. How can the implementation of Models of care: Update 2005 ensure that service users other physical and mental health needs (e.g. clients with hepatitis C, alcohol problems) are more effectively helped? There is a need for a more explicit emphasis on addressing the underlying causes for the physical and mental health needs of service users. Evidence shows that there is a clear link between domestic violence and mental ill health. Academics and practitioners suggest that experience of past or current abuse including domestic violence is a precursor of, and a clear causal factor in, the development of mental health issues (Barron, 2004). 13. How can the implementation of Models of Care: Update 2005 enable clients, as well as their carers and/or family be better involved throughout the outlined phases of the treatment journey? For service users who are survivors of domestic abuse, agencies need to engage with the perpetrators of their abuse. As mentioned previously, the treatment journey may be in severe danger of jeopardy if a survivor is returning to their partner. It has been reported that when women seek help for their problematic substance use, their partner may become even more abusive (Taylor, 2003). Equally, it has been acknowledged that for service users who are perpetrators of domestic violence, the period of detox and rehab can increase their violence and abuse at home, especially when the emphasis is on abstinence (Baron, 2004). This can be the most dangerous time for the survivor and there is a clear need to engage with her and provide support and assistance through engagement with appropriately trained staff or referral to a domestic violence agency. This emphasis on the safety of the service user and partners of abusers must be made more explicit through the Update. This can become overlooked by treatment agencies where there is a low awareness of domestic violence issues and a lack of appropriately trained staff. 14. How can local treatment systems be better configured to create better exit routes out of treatment and be integrated into primary care and other systems of support? Please also comment on the suggestions on drug service / system redesign. Substance misuse assessment (pages 22-24) 15. Will implementation of Models of care: update 2005 help to ensure effective integration between assessment in the Drugs Intervention Programme (DIP) and non-criminal justice substance misuse assessment? 5
No Please comment The Stella Project welcomes the explicit reference to domestic violence in the risk of significant harm from others in the risk assessment procedures. We would also like to see this explicit reference in the risk of significant harm to others area. If this is not mentioned specifically it is in danger of being overlooked. The Update needs to give clear guidance on appropriate methods of screening and how workers should be skilled in responding effectively to disclosures. The Update suggests that if there are concerns of safety to the service user or others, that Social Services should be involved along with appropriate cross-agency policies and information sharing. There are concerns here about the fear survivors have of Social Services due to inadequate support given regarding experiences of domestic violence. Social Services usually intervene on the basis of child protection issues only. The Update should be more explicit about the need to refer to a domestic violence agency as the first port of call if there are concerns of safety to the service user. Furthermore, the safety of the survivor and her children must be the driving factor in any information sharing protocols. The Stella Project welcomes the approach taken by the Update to promote partnership working within the treatment journey. We would like to see clearer guidance placed on how to work effectively in making referrals and producing working protocols with domestic violence services for both survivors and perpetrators. This guidance has already been produced by the Stella Project and is entitled Domestic Violence, Drugs and Alcohol, Good Practice Guidelines. This can be found online at http://www.gldvp.org.uk/service_providers_and_employers/drugs_and_alcohol_agencies/stella_toolkit/. A hard copy can also be provided on request. Care planning (pages 25-30) 16. Do you agree with the definitions of the care plan and the care planning process? No Please comment on your answer 17. Do you agree with the re-focus of care planning and care co-ordination, as outlined in section 6.2? No Please comment on your answer The Stella Project would also like to see emphasis on the safety of the service user and partners of abusers with reference to harm from others. We welcome the emphasis on enhanced service user involvement in care planning and review. 6
18. How can introducing an initial care plan as outlined, and if required, enhance a client s treatment journey? From the perspective of a survivor of domestic violence, an initial care plan should aim to positively screen for domestic abuse. Staff should be appropriately trained in these skills and know how to act effectively upon disclosure. Women who experience domestic violence and who also abuse substances are often likely to do so as a consequence of their abuse. Studies have shown that survivors of domestic violence are more likely to begin their problematic substance use following their experiences of domestic violence (Humphreys et al, 2005). If these issues are not addressed in a care plan, the client s treatment journey well be less effective. 19. How can the enhanced focus in Models of care: update 2005 on care planning as the integral part of all structured treatment, improve a client s treatment journey? See above 20. Do the diagrams (1&2) help clarify the treatment journey process, and assist better care planning? No Please comment (e.g. if no, how could they be improved?) 21. Do you think the implementation of Models of care: Update 2005 will help to enhance care planning and co-ordination across drug treatment services, criminal justice agencies and groups involved in externally co-ordinated care? No Please comment Yes, if guidance is given as to what constitutes effective screening, assessment, referral and partnership working for service users who are experiencing domestic abuse. See the Stella Project s publication Domestic Violence, Drugs and Alcohol, Good Practice Guidelines. See the care planning toolkit consultation questionnaire for more questions on care planning. Available at www.nta.nhs.uk Integrated care pathways (pages 31-32) 22. How can ICPs (as outlined) incorporate the focus on the client treatment journey and link with the treatment journey diagrams? The Stella Project welcomes the inclusion of ICPs which focus on specific client groups, particularly excluded groups of service users who may have difficulty accessing treatment because they have complex needs and because they are vulnerable. Service users who are experiencing domestic violence fit into this category and it may be necessary that elements of the ICP are delivered by agencies which provide specialist support and advice to domestic violence survivors. This includes services which cater for the 7
different needs of women from black and minority ethnic communities. The ICP needs to focus on the safety of the service user with priority on confidentiality and safe information sharing practices, particularly for women escaping an abusive partner who may need to remain anonymous within the service. For those who remain in an abusive relationship, access to treatment interventions may need to be kept hidden from their partner. These issues developed in an ICP should inform the type of treatment journey experienced by this particular group of service users. From the perspective of a perpetrator of domestic violence, an ICP should seek to address the offending behaviour by working with accredited agencies who work with perpetrators. This may result in a service user entering an accredited perpetrator programme as part of their treatment journey. 23. Should the NTA produce additional guidance on ICPs, local treatment systems and the treatment journey? No Please comment Should feature explicit reference to good practice guidelines when working across the issues of drugs, alcohol and domestic violence. Quality criteria and improvement reviews (pages 35-39) 24. Are the standards for providers and commissioners set out in section 9.5, the appropriate range of standards required for the drug treatment system? Yes No Please comment (e.g. should any further standards be included here)? QCP: reducing harm to drug misusers This should not only focus on harm reduction from drug use but the harm experienced by service users from partners. This may be the cause of their drug use and/or a major factor in their continued drug use. QCP 4: reducing drug related harm to others. Domestic violence should be explicitly mentioned here in order that it does not become overlooked. Drug treatment interventions Substance misuse-related advice and information (page 40) 25. Do you agree with the definition of advice and information? No Please comment 8
26. How can advice and information be commissioned to span interventions in all four tiers, and integrated into care plans, as Models of care: update 2005 recommends? Harm reduction (page 41) 27. Do you agree with the definition of harm reduction? Yes No Please comment This should be broadened to not only focus on harm reduction from the physical use of drugs but the harm experienced by service users from partners which may be the cause of their drug use and/or a major factor in their continued drug use. 28. How can harm reduction be most effectively commissioned and provided, to become an integral part of care planning across the four tiers, as Models of care: update 2005 recommends? 29. How can commissioners and treatment services ensure that all drug users receive a hepatitis B vaccination, as Models of care: update 2005 recommends? 30. How can commissioners and treatment services best engage with families, carers and wider communities to adopt a harm reduction approach, in order to minimise the harm caused by drug use? See answer to question 13 Community prescribing (page 41) 31. Do you agree with the definitions of community prescribing? Yes No Please comment 9
32. How can commissioners and providers ensure that community prescribing interventions work as part of a client s integrated care plan, which also addresses health needs, offending behaviour and social functioning? Structured day programmes (page 43) 33. Do you agree with the definition of structured day programmes (SDPs), and the distinction made between SDPs and day care (see other structured treatment )? Yes No Please comment The definition should include the need for specialist SDPs which cater to the needs of women by providing women-only programmes with childcare provision. It is important that the SDPs address offending behaviour, but it should also be acknowledged that this may be more appropriately done in accredited perpetrator programmes. In certain circumstances this could be completed alongside the SDP. Structured psychosocial interventions (page 44) 34. Do you think the change of name from structured counselling to structured psychosocial interventions and the definition in Models of care: Update 2005, clarifies the intervention? Yes No Please comment It is an opportunity to expand the type of interventions provided for example, there is a need for specialist psychosocial interventions for survivors of domestic violence. It should be acknowledged that domestic violence agencies play a key role in delivering this and funding should recognise this role. 10
Other structured treatment (page 45) 35. Do you agree with the definition of other structured treatment? Yes No Please comment 36. Do you find the examples of interventions useful in helping clarify the definition? Yes No Please comment or suggest other examples if necessary 37. Do you agree with the inclusion of daycare (as distinct from structured day programmes) under other structured treatment? Yes No Please comment 11
Inpatient treatment (page 46) 38. Do you agree with the definition of inpatient treatment? Yes No Please comment 39. Which other interventions should inpatient treatment services also provide as part of a range of treatment interventions, to ensure more effective service provision? Psychosocial interventions which address the domestic violence experienced by service users through one to one work or women-only therapy groups Residential rehabilitation (page 47) 40. Do you agree with the definition of residential rehabilitation? No Please comment The Stella Project welcomes the reflection on the need for residential treatment for specific client groups. We would like to see women only residential units available which are necessary for service users who are escaping domestic violence and for whom residence with male service users is particularly inappropriate. Aftercare (page 47) 41. Do you agree with the definition of aftercare? No Please comment 12
42. Do you agree with the outlined concept of an aftercare plan being drawn up, to ensure that support and reintegration services are in place for a client leaving treatment? No Please comment. We welcome the emphasis on links with appropriate support services being made prior to the service user leaving treatment. This is particularly important for a domestic violence survivor whose safety is placed in danger upon return to a violent partner. Equally for a perpetrator, their partner will be at risk if the violent behaviour is not addressed through the treatment journey and aftercare plan. In both cases ongoing access and support from specialist domestic violence agencies is essential. 43. What types of mutual aid groups could be available to people in aftercare, in addition to 12-step groups? Groups which address other harms related to the drug use such as those provided in domestic violence agencies, specialist sexual assault support agencies, agencies which promote exit strategies for sex workers/prostitutes etc. For perpetrators, referral to an accredited perpetrator group programme. 13
Additional comments Please use this box for any further comments you wish to make either to expand on the areas addressed above or on related issues. Please mark clearly which section of Models of care: Update 2005 your comments relate to. Please also include suggestions for overall improvement of the document and requests for clarification (e.g. terminology), if necessary. Within London, there are major problems in domestic violence survivors accessing appropriate drug/alcohol treatment in the boroughs where they have fled to (upon receiving temporary housing or emergency crisis accommodation). For survivors who arrive to a new borough, there are issues concerning residency and timely access to services. When the survivor is not considered a resident she is ineligible for funding to access drug and alcohol services. However, the nature of domestic violence service provision is that survivors tend to be accessing these services in a borough in which they were not previously a resident. If we are serious about engaging these women into treatment, their eligibility for access must be addressed as a priority. In some cases an immediate access to treatment may be required, for example, a survivor fleeing a partner may also be leaving behind the source of their heroin supply and will be in desperate need to access a methadone programme upon arrival to a new borough. References: Barron, J. (2004) Struggle to Survive: Challenges to Mental Health, Substance Misuse and Domestic Violence, Women s Aid Federation of England: Bristol Becker J. & Duffy, C. (2002) Women Drug Users and Drug Service Provision, London, DPAS Paper 17 Brookhoff, D., O Brien, K., Cook, C., Thompson, T. & Williams, C. (1997) Characteristics of Participants in Domestic Violence, JAMA, 277, 1369-1373 Budd, T. (2003) Alcohol Related Assault: Findings from British Crime Survey, Home Office Research, Development of Statistics Directorate, Online Report, 35/03 Humphreys, C, Thiara, R.K. & Regan (2005) Domestic Violence ad Substance Misuse, Overlapping Issues in Separate Services, Greater London Authority and the Home Office Humphreys, C., Regan, L., River, D. & Thiara, R.K. (2005a) Domestic Violence and Substance Use: Tackling Complexity, British Journal of Social Work, Volume 35 (7), 1-18 Raine, P. (2001) Women s Perspectives on Drugs and Alcohol: The Vicious Circle, Aldershot: Ashgate Swan, S., Farber, S. & Campbell, D. (2001) Violence in the Lives of Women in Substance Abuse Treatment: Service and Policy Implications, report to the New York State Office for the Prevention of Domestic Violence, Rensselear, New York Taylor, H. (2003) Substance Misuse and Domestic Violence Making the Links. An Evauluation of Service Provision in Tower Hamlets, Tower Hamlets Domestic Violence Team: London 14
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Respondent information 1. Name: Karen Bailey 2. Organisation The Stella Project 3. Job title Coordinator 4. Contact details (including phone and email) 1 st Floor, Downstream Building 1 London Bridge London SE1 9BG Tel: 020 7785 3862 Email: karen.bailey@gldvp.org.uk 5. Type of organisation 6. Please indicate if this response is: Community advice and information service Community treatment service Inpatient treatment service Residential rehabilitation service DAT / partnership or equivalent Commissioner Social services Housing / homeless service Head office of voluntary sector organisation NHS Trust Other (please specify) Second tier policy organisation An individual response An organisational response x Thank you for your time. Please return this questionnaire, by 27 January 2006, by email to consultation@nta-nhs.org.uk or by post to Freepost RLSA-HYXA-YZZC, NTA, 8th Floor, Hercules House, Hercules Road, London SE1 7DU. Please mark your response Models of Care Update Consultation Response 16