Substance misuse detox and rehabilitation, a qualitative survey of clients and professionals briefing paper by Stephen Wilkinson & Willm Mistral May 2006
Mental Health R&D Unit
a joint unit of Avon & Wiltshire Mental Health Partnership NHS Trust and University of Bath
Dr Willm Mistral, Research Manager, 01225 38 43 56; W.Mistral@bath.ac.uk
Substance Misuse Detoxification and rehabilitation, A Qualitative Survey of Clients and Professionals
This is a report on an exploratory qualitative research project, in the Wiltshire and Swindon areas during 2005/06, to elicit the experiences and views of clients and staff on Residential Rehabilitation (RR) and In-Patient Detoxification (IPD) for drug and alcohol problems.
· to discover what was seen as most and least useful during rehabilitation and substance misuse detox
· to discover whether pre-placement preparation was seen as beneficial for outcomes.
A steering group, including service users, helped construct a semi-structured questionnaire partly based on prior qualitative research, considering rehabilitation as a process starting and ending in the community. A total of 26 interviews were conducted, 14 clients (10 men and 4 women) and 12 staff and managers of the main drug and alcohol services in the area, including managers of two RR centres. Client interviewees had drug and alcohol problems and all had received help from services prior to admission. Eleven of the 14 clients were abstinent from drugs and/or alcohol at the time of interview, at least six months after discharge. The sample under-represented females and younger drug users and was perhaps biased towards those more favourably disposed towards RR.
Abstinence-based RR was perceived as a minority treatment option by referring agencies, whose main focus is harm reduction and substitute prescribing. Despite proven effectiveness, some staff in some services apparently believe that RR does not work, disapprove of 12 Step treatment philosophy, and believe RR is elitist. Although all staff and managers interviewed were positive about the benefits of RR, some of their views
were influenced by the ability of their own services to provide effective rehabilitation in the community. Prior to admission most clients strongly valued the help they received, but some had distressing experiences as they perceived their agency workers to be unhelpful or, on occasions, obstructive to them going into rehabilitation.
Assessments for RR have improved, with established criteria including: desire for abstinence, failed attempts to stop or control drug or alcohol use, lack of local support, unsafe to detox in the community, and risk assessment. Further mention was made of clients’ need for safety, motivation, clients perhaps needing to relocate away from home, and that RR was a long-term option. Some concerns were expressed about staff assessment skills, possibly resulting in inappropriate referrals or needs for IPD/RR being overlooked.
Good quality care coordination appeared essential to maximise RR/Substance misuse detox effectiveness. Care assessment, planning, coordination and management have all improved in recent years. Arrangements for aftercare need to be considered before admission, taking a comprehensive holistic approach to client needs, including childcare, housing, training and
education, employment, family and relationship concerns. This implies skilled keyworking and effective inter-agency collaboration. Understanding, commitment and continuity on the part of key workers seemed essential for clients and may affect retention in treatment and outcomes. Concern was expressed about the variability of keyworker/ care coordinator involvement. Rural isolation was viewed as making readjustment and access to services more difficult.
Understanding family dynamics was considered essential in helping families cope and to change co-dependency patterns. Little work of this nature takes place in the community and the family work undertaken in RR was considered superior. The involvement of families in care planning was in some instances seen as inadequate, neglecting such basics as childcare arrangements whilst parents were in RR.
Three themes emerged as important in terms of perceived help:
· Quality of relationship with key worker
· Attitudes of key workers towards rehabilitation (particularly to 12-Step programme)
· Practical assistance in dealing with the process of admission.
Clients’ preparation for substance misuse detox and/or rehabilitation varied considerably, in terms of the knowledge and information they received beforehand, their understanding and experience of rehabilitation treatment (such as group work), and practical assistance with the rehabilitation process.
Various recommendations were made by participants:
· More written information from key workers / counsellors about detox / rehabilitation.
o Treatment philosophies practiced by different centers.
o Rules and regulations in RR, what could be expected of a typical day
o Prior information about availability and procedures for funding.
· Prior experience of group work
· As regards 12 Step programmes, prior attendance at local NA/AA meetings (perhaps with key workers, as clients are often highly anxious about going alone)
· Liaison with local NA/AA groups, with members coming in to community services to share their experiences
· Former clients of treatment centers to talk about their experiences of substance misuse detox / RR
All staff interviewed believed good preparation improved RR retention and completion.
· Waiting lists and preparation time were viewed, sometimes inappropriately, as a test of clients’ motivation.
· Educational work; Motivational Interviewing and Cognitive Behaviour Therapy for Relapse Prevention help clients to engage in treatment and prepare for RR.
· Prior supportive group experience seemed beneficial, along with understanding the 12 Step Programme, and need for abstinence
· The Preparation Group in Trowbridge is described as an example of good practice, having a therapeutic as well as educational function.
· Concerns were that group experience in the community was too intense for some; non-attendance rates were high; it was difficult for clients from rural areas to attend.
· Attention needs to be given to transport, childcare and work arrangements for clients to attend a preparation group.
· Most clients valued visiting RR facilities beforehand, though some were unaware that visits often incorporated assessments, and facilities are often difficult for clients to access, owing to their remote locations.
· All agreed current levels of funding for RR were insufficient, and the perceived lack of funding resulted in fewer assessments for RR.
· Funds are inconsistently available across the year, such that waiting times vary
· Waiting times varied from a few days to two years; those offered places within a few days had difficulty making rapid arrangements for children or work. For some, uncertainty and waiting exacerbated their problems and left them at risk
· Structured planning to acquire funding for rehabilitation; a clear idea about availability and the length of time before admittance appeared lacking
· Nonetheless, the system has improved, and the fund manager was praised.
· Clients were highly sceptical of substance misuse detox in general hospitals, particularly with an absence of discharge care plans
· Staff expressed considerable dissatisfaction with detox in A&E in a crisis, or in the few mental health beds, seeing prejudice against substance misusers (especially drugs).
· All the clients were positive about their care experiences during detox in RR
· All participants felt welcomed by RR units and especially valued the ‘buddy’ system to help with induction. There were some concerns about not feeling physically or mentally well enough whilst detoxing to engage in the rehabilitation programme.
Many different Primary and Secondary RR Units were mentioned, mostly positively. Most clients were very complimentary about the care and expertise of RR staff. Some had found the experience life changing, that it had equipped them with an understanding of the nature of their alcohol/drug dependency, and skills and tools to maintain their recovery. One-toone
Counseling, group therapy and other therapeutic activities all helped, but non-specific factors were also seen as essential. The themes that emerged as important were:
· Experience of being with others with similar problems
· Reduced sense of isolation
· Sense of belonging
· Sense of relief
· Feeling of security and ability to be open and honest
· Motivation for help and change.
Maintaining abstinence within a therapeutic community is at the heart of RR. All clients interviewed appeared to have benefited from admission. There were one or two exceptions where clients thought the level of therapeutic involvement was not enough, but these people found the overall experience beneficial.
The 12 Step treatment method predominates, but most units incorporate Motivational Interviewing, Cognitive Behaviour Therapy and Cognitive Analytic Therapy. Skills-based approaches, such as Assertiveness Training and Anger Management, have also been introduced alongside other activities, such as Yoga, which have resulted in more eclectic therapy. According to clients and staff interviewed, going through the Steps of the 12 Step Programme is often the way for RR clients to understand the disease model of addiction, along with their powerlessness should they pick up a drink or a drug.
Counsellors facilitate group sessions, give one-to-one help, and assist with case management. Clients learn to support each other in groups, which have become less confrontational than in the past, but rely on honest feedback and acceptance of individual responsibility for future management of addiction. Some women would have preferred female-only groups. Life Stories are produced recounting the effects of drug or alcohol misuse. Most RRs have a range of activities, which help to develop a more normal lifestyle. Involvement with local NA/AA is a usual part of the programme, and reunions for past clients reinforce the hope of recovery. Literacy problems are an issue, particularly with clients from the Criminal Justice system, and some RRs offer adult literacy assistance.
Key workers remaining involved, and organising support in the community, was deemed of critical importance by clients. Help with deciding whether to go into secondary care was needed, along with the practicalities of placements and funding. Clients who were isolated (notably in rural areas) were regarded as more likely to relapse, and activities such as day centres, voluntary work and education were all helpful in maintaining abstinence. Attendance at AA/NA was the most frequently mentioned form of successful ongoing
support. As a matter of good practice RRs undertake follow-up of former clients. This provides feedback about the effectiveness of the units, and is important for staff morale.
Apart from a minority staff view that Community Rehabilitation (CR) could achieve as much or more than RR, all those interviewed agreed there were many benefits to be gained from RR, with the most useful/helpful aspects as follows:
· A safe place to get well, removal from a risky, harmful environment or individuals
· Talking openly and listening, in groups and one-to-one, with people from outside their local areas, and not having to put on an act
· Working with other people and being treated like a person
· 12-Step programme, particularly Steps 1 and 2. Understanding the disease model of addiction, powerlessness and unmanageability, plus hope of recovery
· Groups, feeling closer to others, getting feedback, support and understanding in a non- judgemental way
· Counselors/key workers, who were understanding, non- judgmental and who provided educational advice and practical assistance
· Quality of support network – on discharge, was seen by some as the most important factor in maintaining recovery. An understanding family.
Further mention was made of the following, mainly by managers and members of staff:
· Information – guides, brochures and videos about RR units and treatment, to help clients (and staff) make informed choices
· Prior Visits to RR – preferably accompanied by key-workers
· Prior Assessments – conducted by the RR Units
· Chance of a Fresh Start – perhaps to develop a new life in a different area
· Change Thought Processes – to learn new ways of thinking and other ways than drugs or alcohol of dealing with stresses
· Other Activities – such as Shiatsu, Yoga, and Acupuncture
Some interviewees could see nothing least useful about RR. Most only had minor concerns, such as activities that were not available when they had been led to expect they would be, compulsory activities (such as aerobics), and visiting restrictions. Most criticism by clients was reserved for what happened before and after RR; their key workers; and absence of support in the community. Most had also found it difficult when other clients in the treatment facilities left prematurely or restarted drinking or using drugs.
The following were specifically mentioned by staff and managers as Least Useful:
· Homesickness – particularly for some younger clients; and those who had children
· Lack of Contact – with families and friends, especially at the beginning of treatment, which was hard for some, particularly with regard to talking to their children
· Telephone Interviews – by some RR Units were seen by some as poor practice, if not followed up by a visit and assessment
· Isolation - when discharged home, having been in a supportive community
· Drop-Outs – a sense of guilt and shame at having failed, also those who tended to blame the RR unit for their discharge
· Unreality – the sense that the RR environment is removed from reality and that although clients may be well whilst in-patients, it is harder on discharge
· Intensity –some clients complained that there was no time to themselves in RR, or if they did seek it they were accused of ‘isolating’.
The following were seen as gaps in services (not necessarily presented in priority order):
· Funding - not enough to meet the need.
· Women – more vulnerable female clients might be preyed upon by predatory males
· Mothers and Babies – improved special provision for mothers needing treatment
· Opportunities for clients to stay in touch with and their families, especially children
· Detox – improved provision of in-patient detox facilities
· Local RR – suggested for the Swindon area
· Learning Disability/Complex /literacy/numeracy needs – noted as presenting difficulties, not just for community staff to find places, but for RR units also.
· Care Coordination – noted to be poor in some instances and at times by some RR Units. Related to this were some staffs’ negative attitudes towards RR
· Sheltered Accommodation – seen as needed in some parts of the area, also the need by some RR Units to have Tertiary stage units
· Training/Work – some improvements for vocational training and work opportunities were seen by community staff as needed in the RR Units.