Learning About Addiction Treatment, Part 9

In my fourth blog post focusing on what I learnt from the treatment agency BAC O’Connor back in 2004, I focus on treatment outcomes and two short client cases. The first blog in this series can be found here.

In the year prior to our visit, 231 clients accessed the BAC day care programme. A total of 87% of these clients had been involved with the criminal justice system; many, possibly most, were prolific offenders. 90% of the clients were unemployed, whilst 28% were officially classed as homeless. However, the latter percentage was realistically 67%, since 14% were due to be evicted for arrears or ASB (Anti-Social Behaviour), while 25% were staying with friends or relatives on a temporary basis and did not have a permanent home.

Of these 231 clients, two-thirds completed the programme drug-free. This was a very successful outcome, given the ‘challenging’ nature of the clients entering the programme. 52% of the clients attended aftercare on a regular basis. BAC was not in a position to track long-term outcomes at the time of our visit, but they were trying to set up a project to do so.

I was particularly interested in Noreen’s views on client motivation. Over the years, I have frequently heard treatment agency workers say that clients must be ready (be motivated) to access treatment, otherwise treatment will not work. Some agencies ‘cherry pick’ clients, picking out those who they consider are highly motivated to overcome their problem.

Noreen emphasised that BAC O’Connor did not screen clients and adjust their admission criteria to help ensure successful outcomes. They did not believe that clients should jump through hoops to get into the service; they believe that motivation is part of the treatment process. It is up to BAC O’Connor staff to motivate clients into wanting to take the journey towards recovery. If they can’t do that, how are they going to keep the client motivated on their recovery journey?

‘Time and time again professionals elsewhere say, “I want to test their motivation first” or “You’re not ready, it’s not the right time”.’

Noreen also pointed out that some people with a substance use problem come into the Centres thinking, ‘This will be my get out of jail card’. She considers it the job of her staff and herself to change that attitude. These clients are usually not aware of any other way of thinking. They have become so entrenched in the drug and criminal culture that they have never seen people in their environment break that cycle.

“It is our job to change that entrenched behaviour, to motivate clients to change and instil in them the belief they can do it and move on.”

In our evaluation report, we considered the cost-effectiveness of the BAC O’Connor day care programme. A piece of research from 1998 by Edmunds and colleagues that the average problem drug user could be costing the community £25,000 per annum (criminal justice costs, costs to crime victims, benefits), excluding health costs. On the basis of this outdated estimate, and given the core funding that BAC O’Connor received from Social Services, they only needed to keep 15 people away from crime for a year for the service to be ‘cost-effective’. On the evidence we saw, the Centres were probably doing this easily.

Client Profiles:

Louise, age 24 years, was referred by the Stafford Prolific Offenders project. She was unemployed, homeless and a single mother. Her four-year old son was living with her sister.

Louise started using cannabis, solvents and glue when she was 13 years old. She was using heroin when she was 14 and was soon averaging a gram a day. By age 16 years, she was using heroin, cocaine and benzodiazepines. Crack was on the menu at least once a week when she was 21. She bought methadone off the street.

She had served seven prison sentences (street robbery, shoplifting, deception, assault, burglary), the longest being for two years. She was currently on license.

Louise had received 11 in-patient detoxs (with no aftercare) since she was 17 and had been on numerous methadone programmes. She had been on a Drug Treatment Testing Order (DTTO) on methadone, which she breached.

Louise described her family background as ‘Okay, until mum and dad split up’, after which her mother was in various relationships. The men were all physically abusive to Louise. She said she had always been ‘up to no good’. She was expelled from school at 14 years for hitting a teacher, taken into a care home for 8 months when 15, and then into foster care until she was 17 years old. She often got emotional and upset through lack of parental support.

She had regular contact with her son. Her ex-partner was also a drug user, but she had not seen him for 12 months.

Louise completed a 16 weeks programme at the BAC. She relapsed once and worked through this problem. She was due to soon start college to gain an education. She currently visited local schools to advise children of the dangers of drugs. During a one-to-one session in the aftercare programme, Louise divulged that she had been sexual abused. She was currently dealing with the related issues in one-to-one sessions.

Susan, aged 20 years, was referred via a Children and Family social worker. She was a single parent, with two children (girl of three years and boy of one year) in foster care under the Social Services Child Protection Register at the time of admission. The children’s father was a drug user and was in prison. Susan was living with her mother, having been evicted from Council accommodation due to rent arrears and an ASB due to drug use on the premises. She was unemployed.

Susan started with cannabis and amphetamines at the age of 17 years. She began using heroin, crack and street methadone on a regular basis at the age of 19. She was a four-bags-a-day heroin user.

Susan had been shoplifting on a regular basis since she was 19. She had a Class A possession offence and a Probation Order on admittance to BAC. She showed depressive symptoms, delusional thoughts and was experiencing short-term memory problems.

Susan’s relationship with the father of her children had broken down. She described this relationship as centred around drugs, violence and abuse. He was serving his second term in prison.

Child Protection Care proceedings were taking place at the time of Susan’s admission to BAC. The police used their protection powers to remove the children. Susan’s brother, who was also a heavy drug user, was living with her and her mother. The home was used for other people to take drugs. At the time of her admission, Social Services had identified severe neglect in relation to the two children.

Susan was not motivated when she was admitted. She had difficulty relating to the group, did not trust anyone, and saw every professional as her enemy. Her family clearly did not support her rehabilitation and going back to her previous partner on his release from prison was always high on her agenda. She had no social or living skills.

At the time of our visit to BAC, Susan had been drug-free for eight months. She had a new partner who was not a drug user and had her own flat. She was now a peer supporter at BAC.

Susan had turned her life around. She had to work hard on her motivation and trust issues. She became determined to maintain a drug-free lifestyle. On completion of the programme, she began to attend parenting classes and independent living skills courses. The rest followed. On the 5th March 2004, the names of Susan’s children were removed from the Child Protection register. Integration plans to return the children to live with her had begun.