A New National Care Service: Analysis Update

–  A series of blogs about families and substance use by our Policy and Research Assistant, Rebecca McColl

In February 2022, the Scottish Government published its analysis of responses submitted to the National Care Service Consultation in October 2021, to which Scottish Families responded jointly with Scottish Recovery Consortium. You can view our full response here or read our blog post summarising our response.

The Scottish Government received a total of 1,291 responses from both organisations and individuals. Concerns we raised about the short space of time we had to submit a response and the lack of detail in the proposals were echoed by others who responded. 33% of respondents who used the online portal to submit their responses were dissatisfied with the consultation process. Others agreed with our concerns about the timeframe for the proposals, as the Scottish Government estimated the new National Care Service would be complete by 2026. This is simply too long to wait for vital changes that are needed now.

In relation to Alcohol and Drug Partnerships (ADPs), 85% of respondents felt that ADPs would have the benefits of providing greater coordination of Alcohol and Drug Services and 75% felt that ADPs should be able to provide better outcomes for people accessing care and support. Despite this, it was said that confused leadership and accountability was the main drawback of ADPs. Again, our concerns were also raised by other respondents regarding how the concept of ADPs should work would be beneficial to communities, but often this does not translate into real life. However, it was highlighted that ADPs abilities to respond to local needs and bring together a range of local resources is a strong benefit, something we were concerned may be lost as part of a National Care Service. Three-quarters of respondents said that Alcohol and Drug Partnerships should be incorporated into the proposed Community Health and Social Care Boards (CHSCBs). We had some concerns about this proposal, as it was unclear where ADPs would fit into CHSCBs, if at all, and how this would then impact local areas. There was not enough information included in the consultation for us to take a stance at the time of our response.

Furthermore, eight in ten responses agreed that residential rehabilitation services could be better delivered through national commissioning. Again, it was unclear what this would look like in practice, and we highlighted the need for more local rehabilitation facilities that will support people long-term, and prevent people from being separated from their family and friends.

The Scottish Government quoted our response regarding what else needs to be delivered through national commissioning. We highlighted how challenging it can be for people to access support for both substance use and mental health simultaneously. We would hope that in practice, a National Care Service would allow for greater joint working across services and improve outcomes for people with dual-diagnosis.

“Mental health and substance use support needs to become further integrated. We know it can be extremely difficult for people to access support for both substance use and mental health, and understand the Scottish Government is aiming to achieve integration through a National Care Service.” (Scottish Families Affected by Alcohol and Drugs (SFAD); Scottish Recovery Consortium (SRC)).

Lastly, our emphasis on the need for lived experience throughout was echoed by others who submitted a response and were acknowledged by the Scottish Government. We believe if the National Care Service is to happen successfully, lived experience must be at the heart of the creation process, and stay there.

What happens next?

The Scottish Government has said the consultation and the analysis represent the first phase of engagement for the National Care Service. They say they will continue to engage with us moving forward, putting people with lived experience ‘at the heart’ of their work. Now we need to see a clear roadmap of what the National Care Service will look like, how it intends to implement change, a realistic timeframe for completion and details on how it will be funded. At the moment, there are still more questions than answers

Family Support Around the Word: The Origins of CRAFT

–  A series of blogs about families and substance use by our Policy and Research Assistant, Rebecca McColl

At Scottish Families, CRAFT (Community Reinforcement and Family Training) is a key element of what we do. CRAFT was created by Dr Robert J. Meyers at the University of New Mexico, who first developed the program in 1976. Since then, CRAFT became a dominating method of supporting families across North America and has been used to support families all over the world. Today, CRAFT is used by Scottish Families and many other organisations to support families in Scotland. Recently, some of our team members have worked with CRAFT trainer George Charlton to create the CRAFT Community of Practice, to bring together CRAFT practitioners to support one another. So, how did it all begin?

Dr Meyers himself identifies as a family member, who grew up around his father drinking alcohol. In his 2004 book, Meyers wrote,

“although my mother was blessed by the support and comfort she found in Al-Anon meetings, she was never able to achieve her most cherished goals of getting my father into treatment and getting him to stay sober.” [1]

Witnessing the impact alcohol had on his family, and his mother and father’s relationship, inspired Meyers to seek an alternative approach that actively involved family members and gave families support in their own right. Meyers sought to develop a way for families to effectively communicate with their loved one who was using substances in a more engaging, positive way to improve the relationship between them.

In short, Meyer’s personal experience as a family member led him to believe that families could play an integral part in their loved one’s recovery if they had the right tools. This is where CRAFT comes in. CRAFT aims to teach family members how to have positive interactions with their loved ones, set boundaries and take care of themselves. Research shows that around 64% of families that engage with CRAFT are able to help their loved one access treatment (if they weren’t already). However, the main focus of CRAFT is to help family members improve their own lives, regardless of their loved one’s decisions. CRAFT is delivered in around 6 sessions, each of which focuses on a specific topic.

Some examples of what CRAFT covers are:

  • Understanding your loved one
  • Positive communication
  • Setting boundaries
  • Recognising positive behaviour and how to respond
  • Allowing natural consequences of a loved one’s actions to happen
  • Self-care

Sisson and Azrin conducted the first study into CRAFT which was published in 1986. 12 participants took part, with half receiving CRAFT sessions. The study showed CRAFT was achieving its desired results, as did future studies into the 1990s and early 2000s. Furthermore, studies concluded that CRAFT is effective across all types of relationships (parental, friends, significant others etc.) and across diverse ethnic groups. Since then, Meyers has offered training in 31 out of 50 states in America and 15 other countries worldwide, including the UK. His books are available in 7 languages, exemplifying the global reach of CRAFT.

Before CRAFT: The Community Reinforcement Approach (CRA)

CRAFT has been described as a ‘variant’ of The Community Reinforcement Approach, CRA, which is an intervention based on the belief that a person’s environment, future experiences or events can play a critical role in encouraging or discouraging substance use. [2] The CRA model provided Meyers with the foundations to create CRAFT and adapt the thinking behind CRA to work for families. So, what is CRA?

CRA has a program that can be tailored to an individual’s needs. There are some similarities to CRAFT, such as conducting a ‘functional analysis’, which means to find out about an individual’s behaviours, the reasoning behind them and how they make the individual feel. Other components include ‘behavioural skills training’, which includes communication and problem solving, ‘job skills’, and counselling. CRA was designed to be community orientated and focused on not only the individual’s substance use but on embedding them into the community and making sure they had access and the ability to navigate community resources. Studies showed the CRA program to be working reasonably well, proving a good starting place for the development of CRAFT.

CRAFT Today

CRAFT is now a well-known and trusted program for families across several countries. America, Japan and Sweden, to name a few, all have certified CRAFT practitioners that support family members affected by alcohol and/or drugs. CRAFT has provided family members worldwide with support in their own right and with essential tools to help improve their relationship with their loved one. At Scottish Families, we see first-hand the impact CRAFT can have on family members and the importance of families receiving support.

If you’d like to learn more about CRAFT, you can read our little book of CRAFT, along with other Scottish Families materials, here.

 

[1] Meyers. J.R., and Wolfe, B.L., (2009), ‘Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening’, Simon and Schuster.

[2] Meyers, J.R., Villanueva, M., and Smith, J., (2005), ‘The Community Reinforcement Approach: History and New Directions’, University of New Mexico.

Proposed Right to Addiction Recovery (Scotland) Bill: How We Responded

–  A series of blogs about families and substance use by our Policy and Research Assistant, Rebecca McColl.

The Right to Recovery Bill was launched for consultation by Douglas Ross, MSP for Highlands and Islands (Region) in October 2021. Scottish Families responded to the consultation in January 2022 after discussions with our team and our Family Reference Group (which includes family members impacted by someone else’s substance use).

The reasoning behind the proposed Bill is to “enable people addicted to drugs and/or alcohol to access the necessary addiction treatment they require” by enshrining the right to access “necessary addiction treatment” in Scots law (Right to Recovery Bill, 2021). The Bill proposed a statutory right to a range of treatment options, such as short and long-term residential rehabilitation, community-based rehabilitation and medical assisted treatment. Furthermore, the Bill seeks to prevent individuals from being refused treatment from alcohol and drug services for reasons such as medical or criminal history, and allow for individuals to choose a preferred treatment option “unless it is deemed harmful by a medical professional” (Right to Recovery Bill, 2021). Having carefully considered the Bill, Scottish Families welcomes any discussion to improve treatment, support and recovery in Scotland, however, we shared concerns regarding if the legislation would achieve real change on the ground, and noted there was a stark absence of any mention of rights for families.

How We Responded

We know that individuals and families constantly face barriers and challenges when trying to access services and support, and there are persistent issues around the quality of treatment when accessed. We believe the sentiment and intentions of the Bill align with the experiences of families and individuals across Scotland, however, the decision to propose a legislative right brings a number of concerns.

Firstly, there is a range of policy changes happening in Scotland right now, such as the likely implementation of a National Care Service and developments to Human Rights Legislation. Both have the potential to completely change the landscape in Scotland, and changes to Human Rights Legislation could secure stronger rights regarding access to alcohol and drug treatment than what is currently being proposed by the Right to Recovery Bill.

The language used within the document (such as ‘addiction’ and ‘drug user’) can be stigmatising and may exclude people who may not identify with such terms. We would suggest using ‘people first’ language in order to be respectful and inclusive, which is especially important when proposing change.

It is deeply disappointing that rights for families were completely omitted from the Bill, aside from a brief mention in the foreword. As stated in the national alcohol and drug strategy ‘Rights, Respect and Recovery’ (2018), family members were given the same rights as individuals using alcohol and drugs. Furthermore, the Scottish Government published a new framework, in December 2021, further solidifying the commitment to whole family approaches and family inclusive practice. It must be said that the absence of families in the Right to Recovery Bill ignores this commitment and that families have the right to support in their own right, regardless of the treatment or other status of their loved one. If the Bill is to progress, there is significant room for improvement and a need for clarity throughout, particularly regarding what the Bill could mean for families.

What Would Legislation Mean?

Families tell us constantly that they are often excluded from their loved one’s care and nor are they updated. We understand restrictions around GDPR, however, it is of concern that legislation would only add another barrier for families. We know there are already multiple issues experienced by families whose loved ones also have mental health issues. Change has been needed here for a significantly long time, and it is of concern that adding legal processes to an already complicated situation for families may make matters more difficult.

It is unclear what sort of right the Bill is proposing, how that would be achieved, or what type of action it would allow for. It is difficult to comment on what this would mean for individuals and families when much of what the Bill is proposing is uncertain. The Bill also suggests individuals should be able to choose a preferred treatment option unless deemed harmful by a medical professional. It is unclear what circumstances would give a medical professional the right to deny a treatment option, and the final decision would still be beyond the individual seeking treatment. This proposal would therefore allow for little to no change, and could potentially damage therapeutic relationships by creating a power imbalance. There is no mention of families, causing questions surrounding family involvement in this process and what support families should have in their own right.

We agree that no one in Scotland should be refused treatment when seeking help, no matter their circumstances. We have the right to healthcare, but there is an existing accountability gap. The Bill is specifically proposing the right to a service, as opposed to the right to a desired outcome (for example, highest attainable health). An approach based upon human rights would focus on the quality of services and ensure outcomes were being met. We need a commitment from the Scottish Government and all political parties that the Human Rights Bill, which states that the ‘right to health’ includes those who need access to alcohol and drug services, is adhered to. Although we understand the sentiment behind the Bill, we believe other avenues, such as human rights, would create a more robust pathway to long-lasting cultural change.

What Happens Next?

The Bill is the first step in introducing a Member’s Bill in the Scottish Parliament. The consultation period ended on 12 January 2022, and responses will be analysed prior to a final proposal which will be submitted to the Scottish Parliament by Douglas Ross MSP. The proposal must achieve the support of at least 18 MSPs from at least half of the political parties or groups represented in Parliament. If the Scottish Government does not intend to legislate the Bill, Douglas Ross MSP will then have the right to introduce a Member’s Bill. A Member’s Bill must then pass three stages where it may be amended or rejected. If passed at the end of the process, it becomes an Act. This can be quite a lengthy process, meaning it takes a couple of months to find out the outcome of the proposed Bill. At the time of writing, Scottish Families submitted our full response to the Bill on 12 January 2022 and are awaiting the publication of the final proposal.

Family Support Around the World – Iceland

A series of blogs about families and substance use by our Policy and Research Assistant, Rebecca McColl.

The Planet Youth Model (also known as the Icelandic Model) made local news in Dundee after school pupils at a Dundee high school were chosen to ‘kick-start’ the model in Scotland. Planet Youth started in Iceland in 1999 and has since been adapted and used by over 30 countries around the world. The Planet Youth Model has also been making the news across Scotland, as other areas have begun to get involved. So, what is it? What does it do?

What is Planet Youth?

Planet Youth is a prevention model aimed at improving the lives of young people. It aims to strengthen links between schools and communities and encourage families to spend quality time with their children. The overall aim of the model is to reduce youth substance use, substance use harms, improve mental wellbeing and family connections.

According to the Society for the Study of Addiction, Iceland had high rates of substance use amongst young people in the 1990s, which led to the creation and implementation of Planet Youth (then known in Iceland as the ‘Youth in Iceland Model’). Since then, there has been a significant decrease in substance use shown in data from between 1997 and 2014. Drunkenness decreased from 29.6% to 3.6%, and tobacco use decreased from 17% to 1.6%. This was achieved by the Planet Youth Model using a community-based approach to reduce potential risk factors and increase protective factors.  Essentially, Planet Youth finds out what is happening with young people, then puts plans in place to decrease any negatives (such as substance use) and increase any positives (such as sports and recreational activities).

What’s happening in Scotland?

Since 2019, a multidisciplinary team has been looking at the evidence supporting Planet Youth and how it could be implemented in Dundee. In February 2020, a group from Dundee, including a family member, travelled to Iceland’s capital Reykjavík and spoke to school pupils to hear their experiences of Planet Youth. School pupils are asked to fill in a survey, which then allows Planet Youth to understand youth trends, what risk factors are prevalent and when they change. Pupils said they were honest in the survey as it is completely anonymous, and the results benefit them as they lead to leisure and sports activities that suit them. The video following the group’s journey can be viewed here.

The findings were shared in April 2021 along with the video. Next steps were put in place, with Winning Scotland set to begin Planet Youth surveys in five areas of Scotland (Dundee, Clackmannanshire, West Dunbartonshire, Highland and Argyll and Bute) in September and October 2021 (just last month!). The University of Stirling says that Planet Youth is designed to stop increasing drug-related harms in future generations and is not a ‘sticking plaster’, it is a long-term solution. Inga Dora Sigfusdottir, ICSRA Founder and Scientific Director said Planet Youth is about taking responsibility away from the child and placing responsibility on policymakers to ensure every child can live a happy, healthy life and support parents and families.

How does it work?

The image below from the University of Stirling shows the different factors involved in a young person’s life that impact them.

Image from the University of Stirling

A young person can have a lot to contend with, such as home life (relationships with family), the effect of their peers, schoolwork alongside the school environment and the expectation to be involved in extracurricular activities/leisure time. Each young person’s experience with all these factors can be vastly different. Planet Youth aims to hear from each young person in the community to make sure they have the tools to deal with any difficulties and fill the gaps that young people need.

By doing this, Planet Youth works as a prevention method. As seen in Iceland, when the needs of the community are met, fewer young people engage in alcohol or drug use. A study conducted this year found that people in Scotland were supportive of the implementation of Planet Youth, as long as there was a successful trial period and the program was altered to be more culturally appropriate to Scotland. Watch this space!

What do you think of Iceland’s Planet Youth? Email rebeccamc@sfad.org.uk with any thoughts.

A New National Care Service: Our Response

In August 2021, the Scottish Government set out plans to create a new ‘National Care Service’ following recommendations published in the Independent Review of Adult Social Care (otherwise known as the Feeley Review) in February of the same year. The Feeley Review established that there needed to be ‘revision and redesign’ to improve outcomes for those using the care system. The Review recommended the implementation of a person-centred, human rights-based approach, the responsibility of the delivery of social care support be delegated to Scottish Ministers and that local Integration Joint Boards (IJBs) should become a ‘delivery arm’ to a new NCS.

The scope of the National Care would bring other services outwith the current system of care, such as Children’s Services, Justice Social Work and Alcohol and Drug Services under one umbrella. The Scottish Government opened a consultation on these proposals, which Scottish Families responded to in partnership with Scottish Recovery Consortium (SRC) on November 2, 2021. Our response focused on proposals to include alcohol and drug services within a National Care Service, and was shaped by a co-hosted consultation event, where colleagues from the Scottish Government presented an overview of the National Care Service and its reasoning, then opened the floor to family members and those with lived experience to share their views.

How We Responded

Both Scottish Families and SRC welcomed the idea of a cross-sectional approach, which plans to offer integrated treatment to people accessing social care in Scotland. We know that people who are affected by substance use need support across different care services, such as housing and mental health, as well as alcohol and drug services. However, both organisations had some key concerns.

Firstly, there were concerns about the scale and the timeframe of the consultation. The consultation document was lengthy and proposed serious changes which took time to digest. It was difficult to form a meaningful response in the time given by the Scottish Government.

The Scottish Government is proposing significant structural change, and there are concerns surrounding how services will be managed upon the completion of an NCS, and throughout the transition from the current system. We understand that structural change is needed in some respect but believe cultural change and addressing stigma within services should be a priority.

The Scottish Government has made a point of better valuing the workforce across social care, which we wholeheartedly agree with. We know that frontline staff are often undervalued and can be understaffed. Although unpaid carers were acknowledged in the consultation, little was said about how a National Care Service would support them in caring for a loved one.

Proposals to Include Alcohol and Drug Services

The most relevant part of the consultation for both Scottish Families and SRC was the proposal to include alcohol and drug services with a National Care Service. The Scottish Government asked a series of questions relating to the current delivery of Alcohol and Drug Services through Alcohol and Drug Partnerships (ADPs), the national commissioning of residential rehabilitation services, and what future planning of services should look like.

In short, we feel that outcomes can vary depending on the ADP area. During our consultation event, family members and those with lived experience highlighted that a ‘postcode lottery’ exists, as where you live can often determine the options available and the quality of treatment you receive. If ADPs received adequate improvements and funding, it is possible that services would be better planned and managed. There is the risk that if Alcohol and Drug Services became part of the National Care Service, the local partnership working that ADPs do with voluntary organisations could be lost. Although it must be acknowledged that there are significant drawbacks of ADPs, such as poor outcomes for people who engage with services, access routes to services in the first place, and a lack of input from people with lived experience. There has also been a lack of commitment from ADPs to implement the human-rights, person-centred approach that was published in the Scottish Government Strategy ‘Rights, Respect and Recovery’ in 2018.

However, it is impossible to answer if alcohol and drugs services would be better off within a National Care Service. There are still many unanswered questions regarding this proposal, as to the future of ADPs and how services would be planned and managed. Although greater integration with other services would be welcomed, it is unclear how alcohol and drugs services would fit into the proposed larger Community Health and Social Care Boards.

In relation to proposals around the national commissioning of residential rehab, we also had a mixed response. Those that attended our consultation events spoke of how longer-term rehab stays need to be more widely available and support plans need to be in place for when people return home. If national commissioning would make rehabilitation facilities more accessible, and reduce financial pressure that families experience from private rehabs, this would be welcomed. Concerns were also raised about the lack of local rehabilitation facilities, with most people having to travel far from their families to access treatment. If residential rehab was to be commissioned nationally, it needs to be accessible and funded for anyone who wishes to go.

Lastly, we were asked about what services should be commissioned that may currently be missing. We heard from those at our consultation event that there is a lack of support for people who have alcohol-related brain damage, for example, and their families and that it’s extremely difficult to get support outwith 9am and 5pm. We were also told that greater integration of mental health and Alcohol and Drug Services is much needed. The potential for a 24-hour crisis line is something that families have highlighted for a long time, and we would support the commissioning of such a service. We know that services can be disjointed, under-advertised and often don’t offer the aftercare that people need. Problems with existing services, staff attitudes and stigma need to be addressed, whether alcohol and drug services become a part of the National Care Service.

What Happens Next?

Scottish Families and SRC submitted our joint response to the Scottish Government on 2/11/21. We are keen to be involved with what happens next in the consultation process, along with our other partnered organisations. At the time of writing, we are currently awaiting a response from the Scottish Government as to the outcome of the consultation. For now, you can view our full response below.

National Care Service Consultation (Scottish Families and Scottish Recovery Consortium) – November 2021

Family Support Around the World: Iran

A series of blogs about families and substance use by our Policy and Research Assistant, Rebecca McColl.

In July 2021, researchers Azam Pilevari and Mohammed Zahedi Asl published an article regarding the effectiveness of The Congress 60 Treatment Method (DOI). Congress 60 (C60) is an independent organisation based in Iran and works to reduce substance use and offer individuals and families support in several ways (Research Recovery Institute, 2017).

How does it work?

Congress 60 works as a three-step journey:

  1. An 11-month long pharmacotherapy treatment consisting of opium tincture. Opium tincture is made of air-dried poppy latex and can also contain morphine or codeine (National Cancer Institute, 2021). This treatment is common in Iran as opium use is culturally tolerated (Noroozi et al, 2021).
  2. An individual then focuses on physical, mental, emotional rejuvenation and self-growth.
  3. The ongoing process of understanding the “order and mystery” of the universe (coming to an understanding of what life means, I think?!).

All of these steps are used to reconstruct an individual’s personal identity, relationships and daily lifestyle. Both family members and their loved one have access to individual counselling sessions and a range of psychological, social and recreational activities.

The Facts
  • According to the World Health Organization, the Iran Drug Control Headquarters declared that in 2015 there were 2,808,000 people between 15 and 64 years old that were dependent on illegal drugs.
  • There are around 11.2 million individuals affected by someone else’s substance use in Iran.
  • Evidence in Iran suggests that family involvement can have a positive impact on a loved one entering treatment and can improve treatment results.
  • Little research had previously been done on how changes within the family can impact people who use drugs.
What do the findings do for us?

The research argues that often, family members can act in a ‘hostile way’ when family stability is threatened, or when they are ‘chronically trapped in familiar patterns of interactions.’ Families make attempts to help their loved one who is using substances in a range of ways, including help to end their substance use, which can often go untaken. The researchers argue this cycle is caused by a lack of a whole-family/culture approach in treatment. Rights, Respect and Recovery has highlighted this as an area that needs improvement in Scotland. However, many families are yet to see and experience the implementation of the family-inclusive practice, despite the strategy being published 3 years ago in 2018.

Community Reinforcement and Family Training (CRAFT) used by practitioners at Scottish Families works with family members to improve communication with their loved one who uses substances in order to improve relationships, stability and remove the possibility of ‘hostility’, as described by the researchers. CRAFT has similar principles to the C60 method, as both help family members to be better equipped to control and respond to reoccurring challenges and situations. The success of C60 in Iran shows the importance and impact a whole-family approach can have. Family members engaged with C60 said the programme was life-changing for them, as they now “think about” themselves more, and restarted old hobbies that had been lost whilst supporting their loved one who used drugs. The researchers concluded that C60 gave family members control over their own circumstances and rebuilt positive relationships between the person using drugs and the family members involved in the treatment. Knowledge and research into global whole-family approaches strengthen the need for families’ voices to be heard in their loved one’s treatment.

What are your thoughts on C60? What would you like to see in the next post? Email rebeccamc@sfad.org.uk with any thoughts or comments.

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