Describes our 2000-2002 national evaluation of projects supported by the Drug and Alcohol Treatment Fund (DATF) in Wales, detailing two particular projects, the North Wales Community Drug and Alcohol Liaison Midwife position and the Option 2 project in Cardiff. (4,837 words)
As indicated in an earlier chapter, I won the tender to evaluate all projects supported by the Drug and Alcohol Treatment Fund (DATF) in Wales early in the year 2000. The DATF was developed by the National Assembly for Wales (in effect the Welsh Government) in response to the recognised shortage of addiction treatment services, in particular for young people.
Although the funding £1.5 million per annum was initially conceived as being entirely for treatment, it was soon recognised that it must be used for a wider set of activities, including prevention and training. Organisations submitted bids for funding to their respective Drug and Alcohol Action Teams (DAATs)—Bro Taf, Dyfed Powys, Gwent, Morgannwg and North Wales.
The Gwent DAAT co-ordinator, David Jeremiah, was given the responsibility of initiating, developing and organising the DATF, which started on 1 April 2000. Each DAAT was given an annual sum for evaluating, monitoring and supporting projects, of which part was top-sliced to provide funding for a National Evaluation—funding was given to my employer, the University of Wales Swansea (as it was known then)—whilst the remainder was used for local evaluation.
Becky Hancock and I over 20 years later in Llangennith, Gower, 2022.
Local evaluators monitored progress of the projects within their DAAT area, passed relevant information on to the National Evaluation Team, and facilitated meetings between project holders and the National Team. I directed the National Evaluation part-time and had a full-time assistant, one of my former Psychology undergraduate students, Becky Hancock.
Becky and I worked closely with David Jeremiah and we had a fruitful and enjoyable collaboration. We also collaborated with four of the other DAT Co-ordinators—the fifth decided that the DATF did not require an outside evaluator and refused to collaborate. She thought she knew best. David and I decided that we should leave her to her ‘own devices’, as she represented my local area and Becky and I could just work directly with the services and projects. They were all happy doing that.
Programme evaluation has been described as ‘the systematic collection of information about the activities, characteristics, and outcomes of programs to make judgements about the program, improve program effectiveness, and/or inform decisions about future program development’ [1].
The role that Becky and I were to play as the National Evaluation team was multi-faceted. I first invited all DAT Co-ordinators and their local evaluators to attend a one-day conference in Swansea where Professor Michael Williams, an evaluation expert, talked about the various facets of programme evaluations.
Over time, Becky and I, and the relevant local evaluator, visited all the projects in each area, some many times. We described the evaluation process to members of the project (the person hired and normally a senior representative of the organisation) and explained why such a process was necessary. It was important that the local project teams did not feel that they were being tested and did not feel threatened. We tried to encourage a healthy culture for evaluation in the organisation—the mission should be to continually question and gain information about the different elements of the project and the outcomes arising from the intervention.
I emphasised that we wanted to learn from what they were doing, write project profiles where relevant, and publish them to help other organisations learn from their experiences and be able to develop similar projects if required. We wrote a number of profiles which appeared on the early Wired In websites, substancemisuse.net and wiredinitiative.com.
1. Listening and Learning
During our visits, we had discussions with members of staff, heads of organisations and clients accessing the service. The latter often gave invaluable feedback. The range of projects varied greatly, so there was obviously no simple ‘one-fits-all’ measure of outcomes. It was also important to note that David Jeremiah and I considered it important that my team not only evaluate the DATF-funded projects, but also the system(s) within which these projects and services operated.
A number of clients and staff requested that I pass on their feedback about the wider system(s) to the National Evaluation Board and the National Assembly for Wales. This I did, although some of what I had to say was not appreciated by government. It was telling (and rather sad) that my National Evaluation final report, which included criticisms and suggestions to improve the system(s) to help people, was never published by the National Assembly for Wales.
The two years of working on the DATF evaluation gave Becky Hancock and I an initial understanding of what was happening in the addiction treatment field in Wales. I learnt more about the treatment field in the UK as a whole once I started visiting services in England and Scotland. I continued to read as much relevant material about addiction and addiction treatment as I could.
One of the most important things we learnt during the initial evaluation was the need for information and education about good practice to be circulated widely.
This was made all the more necessary given the UK Government’s 1998 drug strategy, which focused on an integrated approach to tackling drug problems involving health, criminal justice, and social service sectors. It was a tremendous challenge for the system to equip staff in all these areas with an understanding of the nature of addiction and how best to help people overcome substance use problems, ensure best practice, and develop approaches that facilitated communication between the sectors. High quality training was essential for the workforce.
It didn’t take us long to discover that this challenge was not being well met. Practitioners, clients and family members told us that they were not getting enough of the right information.
Leading addiction experts told us that whilst we knew a lot about how to help people overcome addiction, little of this information was actually used in practice.
Those practitioners working at the ‘coalface’ told us that the overall system was not working well. As we travelled around, we met many practitioners who knew little about how to help people overcome substance use problems. Training programmes were often inadequate and were one of the first things to be dropped if funding became tight.
The voices of recovering people were just whispers at the time.
2. North Wales Community Drug and Alcohol Liaison Midwife
The problem of poor information flow, and how this problem could be largely overcome—greatly benefitting the system—was well-illustrated in the report by North Wales DATF local evaluator Anni Stonebridge about the North Wales Community Drug and Alcohol Liaison Midwife position that was supported by the DATF.
Prior to this position being developed, expert guidance regarding how to manage pregnant women who had a substance use problem was not readily available in North Wales and many (probably most) other places. The personal prejudices of practitioners towards substance using mothers were more likely to fill in the gaps in their knowledge than the person trying to dig for the best advice.
Many pregnant women with a substance use problem who visited (or wanted to visit) services lived in fear of having their baby taken by the authorities. Child removals occurred in many cases, often for no reason. Some pregnant women were being forced into hasty abstinence by professionals with the best intentions, but little or no evidence-based guidance was available for them to design the best approach for the safety of both mother and child.
Frustrated by the above problems, nurse Jill Timmins, who had periodically worked with pregnant women with a substance use problem, became determined to find funding for a midwifery post that focused on pregnant women with drug and/or alcohol use problems. Jill had initially been inspired by a lecture given in the late 1990s by midwife Faye McCrory on the effects of using alcohol and other drugs in pregnancy. Her subsequent successful funding application to the DATF was the culmination of several years study, thought, and development.
After two-years funding was obtained, Christine Weaver was seconded from a community midwife team in North Wales to be the Community Drug and Alcohol Liaison midwife for the whole of North Wales for two years. Jill and Christine knew that the latter’s job would be challenging, given the geography of North Wales—smaller towns and rural communities—compared to Faye McCrory’s home town of Manchester. The post had five primary aims:
1. To develop and launch a treatment protocol for pregnant women who misuse drugs and alcohol.
2. To educate all professionals about substance misuse in pregnancy.
3. To meet all pregnant women who misused drugs and alcohol to offer advice and support.
4. To liaise with all professionals across North Wales.
5. To develop specialist knowledge ensuring recent research information is provided and used at all times.
Education and awareness-raising activities were used to promote and disseminate an evidence-based Protocol and Guidance document. A Midwifery Steering Group, led by Jill Timmins, had partially completed a draft of this document which Christine went on to complete. The document was informed by a wide-ranging research evidence and by the experience of existing Drug and Alcohol Liaison practitioners in other parts of the UK. The Protocol and Guidance document provided a quotation regarding the expected approach that professionals were to adopt when dealing with this group of pregnant women:
‘It is vital that health and welfare responses to pregnant drug users are both multidisciplinary and multi-agency, with effective collaboration between agencies which take into account the needs of both the mother and the new born. Similarly appropriate support for families and protection of children requires all agencies involved to co-operate and communicate with each other in terms of planning and providing services.’ Institute for the Study of Drug Dependence, 1999.
At the time of Annie’s formal evaluation of the project in the summer of 2001, the document had been made available to all professionals in the majority of primary care settings in North Wales. Direct education through regular lectures and updates had been delivered to approximately 85% of hospital and community midwives. Many health visitors, GPs, consultant obstetricians and paediatricians, social workers, and drug and alcohol workers had also received direct education. Christine also lectured to student midwives and nurses.
The second major element of the project concerned direct clinical support to pregnant women who were misusing drugs and/or alcohol, as well as their health care teams. The process of examining the care needs of clients generally involved a multi-disciplinary planning meeting or review. These could be a one-off meeting or, when complications arose, be more frequent.
The project adopted good practice guidelines detailed by the Standing Conference on Drug Abuse (SCODA) and the Local Government Drug Forum (LGDF), which emphasised collaborative case management and suggested the stages at which it might be important to hold multi-agency planning meetings.
The Planning Team generally consisted of Christine and relevant agency representatives: the community midwife, social worker, health visitor, a representative from the child protection team, a drug and alcohol worker, and consultant or community paediatrician. An opportunity was arranged for the client to meet all the professionals involved in her care at one time. Chris also met each new client at her home to discuss any concerns and inform them they could call her at any time. She provided support to the pregnant women and their community workers as and when needed.
Local evaluator Anni Stonebridge had been monitoring the different elements of the project since it had started. During this time, it was clear that there was strong support for the project from all agencies involved, and that the management and development of the post has been largely smooth and unhindered. Interest was being shown from other parts of Wales and the UK in establishing similar services. As indicated earlier, Anni conducted a formal evaluation of the project in 2001, which involved interviews with staff and clients, as well as Jill and Christine.
In brief, dramatic positive changes occurred for North Wales pregnant mothers who had a substance use problem. The knowledge base of different practitioner groups, and the communication between them, was greatly improved. A process was developed by which information could be shared by the relevant agencies, with the client’s full knowledge, and time spent developing an understanding of the work of other professional groups involved. There was a greater enthusiasm for multi-agency working.
Proper care plans were put in place. Babies of mothers with substance use problems were not routinely taken. Women on methadone were given the option of standard pain relief in labour. Pregnant mothers thought that with the new position there would be less chance of them being exposed to judgemental attitudes by workers. They knew that Christine would act as their advocate.
‘She has been a really good help, you know, making sure that I’ve been treated properly by other hospital people. Sometimes when you’re on heroin they think that you don’t care.’
Chris pointed out to Anni that in her first 18 months, only two of 82 pregnant women failed to turn up to their interview. That was a huge change. Anni emphasised that the midwifery post had been very effective in challenging existing practice when it was obvious that evidence for it is lacking, or previous directions have been superseded by more recent research findings. A couple of the people she spoke to explained how important it was Christine having authority both professionally and academically:
‘I think the fact that she’s been able to go and challenge practice that’s happened traditionally for years with no evidence base and that she’s been strong enough to do that in terms of consultants and senior midwives.’
‘[The] evidence-based stuff…sometimes we used to think, ‘Well that’s what we do, that’s why babies go into special care, because that’s what we do’ and Chris has come and said, ‘Why?’ She helped to sort of make people look at their practices.’
Finally, it should be pointed out that whilst here had been initial concern that the more remote areas such as South Gwynedd would not receive the same consistency of support as other areas geographically closer to Christine’s base in Wrexham, respondents from the former areas strongly stressed that it was to her credit that this fear had not materialised.
It was always a great pleasure to visit Chris and Jill and hear about their work. Their passion and commitment were so evident and it helped fuel our own passion. We could see how disseminating their story, and that of many of the other practitioners whose work was making a positive difference in their area, could help improve the practices of other people around the country and further afield. We therefore published reports on this project and others supported by the DATF on our websites. The dissemination of good practice became an important aim of Wired In over the years.
It was also a great pleasure to work with Anni Stonebridge; Becky and I loved our trips up to North Wales, and Anni always had our visits to various projects well-planned. It was clear that she was highly regarded by all the people we met who knew her. Anni eventually moved to Logie Coldstone in the north-east of Scotland, where she worked for a time for the Aberdeenshire Drug Action Team. She became part of Wired In for a while and I would visit her in Scotland to plot Wired In strategy and develop funding applications.
3. Option 2: A Crisis Intervention Service for Families
Option 2 was a short-term crisis intervention service for families in which parents had substance use problems and there were children at risk of harm. A particular focus of the service was reducing the need for children to be placed on the Child Protection Register or removed to alternative accommodation. Becky and I were particularly interested in this service and the positive impact it was having on families. Some of the principles on which Option 2’s work was based have influenced my thinking over the coming years.
Rhoda Emlyn-Jones—Principal Officer of the Community Alcohol Team, Social Services, Cardiff County Council—had developed the Option 2 approach after finding out about Home Builders—a home- and community-based intensive family preservation services programme in America—and considering various psychological therapies that were known to work. She brought two practitioners over from the States to train the two Option 2 workers. The name Option 2 was decided upon, since it said to social services colleagues: ‘At the point that you are about to remove children, there is another option. Come to us and then we’ll do some intensive work.’
Option 2 worked intensively with families over a four to six week intervention period where the worker was available 24 hours a day, seven days a week. All families had the phone number of their Option 2 worker.
The service aimed to enable parents to learn and practice new problem-solving skills to prevent future crises and lead to a positive change in the way that the families functioned. Goals were established, behavioural changes formulated, and progress towards goals monitored. Work was normally undertaken within the family home and each of the two therapists worked with no more than two families at any one time in order to provide an effective service. Option 2 was a joint initiative of the Community Alcohol Team and Children’s Services of the City and County of Cardiff.
In his interview with Becky, Option 2 worker Mark Hamer explained that referrals came from childcare social workers who were working with families. Parents were made aware that there was a real risk of their children being removed or having their names placed on the Child Protection Register. The allocated social worker continued to have case responsibility during the Option 2 intervention.
During the first few days, Option 2 workers spent a great deal of time with their families learning about, discussing, clarifying, and recording beliefs and values of family members. A key point was to help families identify the changes they wanted to make. Families were in a complete state of crisis at this early stage and an important aim was to give them hope that things could change. This phase led to family’s personal beliefs and values becoming focused, allowing any uncomfortable discrepancies between their beliefs and their behaviours to be discovered.
‘At this stage I feel I am opening some windows and letting some light in—giving people the opportunity, without feeling threatened, to express what it is they are feeling. We are listening, building trust, showing respect, care and concern, accepting people as the real experts on their own situation.’ Mark Hamer
An important task in the first 72 hours was for the family to devise a safety plan. This was an agreement between members of the family about what their immediate risks were, and what resources they could use to combat them.
The worker and family explored and developed the strengths, interests and resources that could be used to solve problems and achieve goals. Throughout this process, which was facilitated by a number of card games and exercises, there was a continual discussion about what changes the family wanted to make.
The family was asked to devise and prioritise a number of clear, realistic and achievable goals that could help them gain a better life. In negotiating the goals, clear behavioural outcomes were set, and the goals themselves set the basis for the skills-based intervention of Option 2. Examples of the goals set included: safer parental substance use; improved communication between partner, parents and/or children; anxiety management; having a cleaner and tidier home; improved parenting skills, such as dealing with problematic behaviour and improving school attendance.
More often that not, overcoming substance use problems were not the first priority. However, Mark emphasised that these problems got dealt with by default.
‘Once you start dealing with the stresses and tensions, life does suddenly start to get a little bit better for people, and their possible future becomes a little bit more real. Then they start to think, “Well what’s the next thing I need to do, and the next thing?” Inevitably, somewhere down the line, the substance use issue gets in there because it’s causing people a lot of problems.’ Mark Hamer
While the worker and family worked together exploring what needed to be done to achieve a family’s goal, it was important that the goals were realistic and within the family’s reach. The partnership explored what new skills were needed to enable that family to move closer to individual goals. The skills-based work included cognitive behavioural strategies for family members with anxiety issues; motivational interviewing; relaxation sessions; using and managing a diary; making referrals to specialist agencies; practical parenting skills; domestic hygiene; behaviour management; crisis management; communication skills and anger management.
Option 2 workers provided practical solutions to stressful situations with the aim of removing some stresses from the family and motivating the family to take action. Workers have found themselves providing such practical interventions as hanging doors, mending bicycles, and laying carpets.
The family put their alternative behaviours in place, which they had never had the opportunity to do, whilst holding a safety net of their safety plan. If things got difficult, the children knew what to do. Behavioural outcomes and progress towards goals were continually monitored. Each Option 2 worker regularly discussed with Rhoda and the other team member progress and issues.
One example provided to us by Mark involved a single mother, who I’ll call Chloe, with two young children. She had previously been using a substantial amount of heroin, but had stopped and was receiving medication from her GP. He had recently cut her methadone dose in half, thinking that this was a good idea, which it wasn’t since it threw her into withdrawal and pain. She panicked and went over to the GP and started shouting at him. The GP’s response was to strike her off his list. Chloe’s social worker was now talking about removing her children because she was climbing the walls and was unable to focus on parenting. This was the situation when Mark received the referral.
Mark managed to find her a new close-by GP and explained to him Chloe’s history and the fact that she couldn’t wait a week for her appointment. The GP arranged for her to get a prescription that day and she started to stabilise. Mark was already modelling assertiveness and communication skills, and teaching Chloe how to express her needs without losing her temper and how to communicate with professionals.
Chloe also had to learn effective parenting skills, particularly as there was no routine in her five-year-old son’s day-to-day life. Moreover, he was mistakenly convinced he was going to be taken away from his mother because she was telling him that they would be moving to a new house. He started asking every day if he was moving that day, and then began packing his bags every morning to take to the new house. There was no new house and he had misinterpreted what was happening. Mark starting working on parent-child communication skills with Chloe. Mark also suggested making changes in sleeping arrangements within the house which improved matters.
Chloe was being messed around by her landlord. The flat flooded regularly because of plumbing problems that were not fixed, and her electrical supply was intermittent. Mark helped her get in contact with a housing project and helped her fill in dozens of application forms. She was moved into a new flat.
Chloe had also been sexually abused as a child. Her social worker arranged for her to see a counsellor, but she was only available at 7.00 at night, a time that was totally unsuitable for obvious reasons. The social worker then organised for Chloe to see another counsellor, who was located miles away in Merthyr Tydfil. Mark then arranged a counsellor for Chloe that suited her needs.
In her statement regarding aspects of her life that she wanted to change, Chloe wrote that she had been abused and misused. People had broken her trust. She knew that some people do this, but she wanted to be better at putting up boundaries and keeping safe, so that she didn’t get ripped off or hurt. She felt bullied by some people, and that others did not give her what was due to her. She felt that others were sometimes in control of her destiny.
Mark helped Chloe set up boundaries and develop communication skills in a way that she could be assertive without being aggressive or emotional.
The aim of the first year of the Option 2 service was to ensure that 75% of families referred to the service remained intact. Impressively, 95% of such families stayed intact.
I mention this project in some detail because it emphasises the importance of various factors that are key in helping individuals and families overcome substance use problems and a variety of other related issues. Firstly, the importance of focusing on a person (or family’s) strengths and assets, rather than the approach adopted by government-based addiction treatment and other services, which focus on weaknesses and deficits. Secondly, to listen to the person with the problem about their needs and desires, and involve them in the decision-making process in helping them move forward to a better future. What outcome do they want and how can we help them achieve their goal? Too often services fail to listen to their clients.
Thirdly, as Mark continually pointed out to us, people with substance use problems have a variety of other problems in their lives, and often these issues have led to or continue to influence the former. Helping people deal with these other issues can often help them address their substance use problem. Sadly, as discussed in the next Chapter, much of the treatment system was focused on getting people onto methadone maintenance programmes without offering other forms of help to people.
‘When you do your social work course you are taught, and it’s drummed into you, that people are the experts of their own situation. It’s like a buzz-word. People are the experts of their own situation. Then, you’ve got this in your head and you go out to do the work of removing the children, taking people to court and all the things that you do, and that gets lost. But, I’ve got that back, you know… You’ve just got to give people the time and the space and the environment to let you know what they know. And they will tell you what they know and they will help themselves.’
‘I think part of my role is about making people feel like a human being again. It’s about looking at the opportunities. I say, “There are real opportunities, you know. You’re not going to be a millionaire, you’re not going to have a great job and live in a wonderful house out in the country and have horses, you know. That isn’t going to happen. But what is going to happen is that you are going to be able to walk out your front door with your head up high, smiling. With happy children and doing the things that you need to do. And be pleased…and be pleased to be going out and be pleased to be coming back home again. You can do that you know, and that’s real.'” Mark Hamer
‘Option 2 has made me become the person that I want to be, not the person I would have become, a druggie, hopeless, lost my kids and everything.’ L, a mother on an Option 2 evaluation form
‘… extremely helpful at putting back the perspective in my family life … helped me to deal positively with the past and get control for the future. It has helped me to view myself and my role as a parent in a much more positive light.’ E, a mother on an Option 2 evaluation form
Option 2 went on to have a strong impact in the community. The work of Rhoda and her team led to the Welsh Government approaching her to help them develop a strategy to integrate all professional groups concerned with health and social problems, with an emphasis on families and reducing the number of children in care, which would help develop a proposed Integration Model, Integrated Family Support Services (IFSS).
Coincidentally, on the day that I am editing this chapter, I posted films of a conversation between Wulf Livingston and Rhoda Emlyn-Jones on the Recovery Voices website that Wulf and I have developed. Since Becky Hancock and I evaluated the Option 2 Service in the early 2000s, Rhoda has completed a great deal of amazing work… and was awarded Welsh Woman of the Year in 2007, and an OBE in 2009 for services to disadvantaged families.
Endnote:
[1] U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. Office of the Director, Office of Strategy and Innovation. Introduction to program evaluation for public health programs: A self-study guide. Atlanta, GA: Centers for Disease Control and Prevention, 2005.
