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Drug Treatment and Testing Orders: Evaluation of the Scottish Pilots
CHAPTER FOUR: TREATMENT PROVISION
INTRODUCTION
4.1 This chapter examines the range of treatment services available in the two pilot sites, explores issues associated with treatment provision, discusses perceived gaps in treatment services and considers offenders' views of the treatment and other services received.
TREATMENT PROVIDERS IN THE DTTO PILOTS
4.2 The two pilot sites had different systems of treatment provision, with the Glasgow scheme using existing Glasgow services and Fife setting up in-house treatment providers. The Glasgow DTTO scheme's main treatment providers were the Glasgow Drug Problem Service (GDPS) and Phoenix House, with counselling, groupwork and other additional services provided by addiction workers from Glasgow Addiction Services. Other treatment providers (such as Toby's, a groupwork project supporting methadone users) were used when appropriate and possible. The Fife DTTO scheme used for their treatment provision drug workers from Fife Primary Care Community Drugs Team, a consultant psychiatrist for prescribing, and a specialist counsellor from the voluntary sector.
Glasgow Drug Problem Service (GDPS)
4.3 GDPS was the main treatment provider for methadone substitution on the Glasgow DTTO project. Occasionally an offender's GP would provide the methadone prescription when use of GDPS was not possible. The aim was stabilisation on methadone, with gradual reduction to a drug free status. However, this was unlikely to be completed by the end of the DTTO sentence, at which stage the offender's GP took over the prescription. GDPS also offered detox prescriptions in some cases and carried out the urine drug testing for the DTTO offenders who attended their services.
Phoenix House
4.4 This particular Phoenix House programme was developed specifically for the DTTO project and was not, therefore, intended to be attended by non-DTTO service users. It was primarily a non-resident abstinence-based programme but had latterly changed to allow those on up to 40mls of methadone per day to attend. The programme included group work, social inclusion activities, pre-employment training and counselling. Phoenix House also carried out urine drug testing for those on the programme.
Fife Healthcare Team
4.5 The treatment provision in Fife had been set up in-house with prescribing provided either by the offenders' GP or the consultant psychiatrist. The drug workers offered a comprehensive physical healthcare package and therapeutic counselling. They also undertook urine testing for every offender on a DTTO in Fife. Counselling was also provided by the addiction workers and the specialist counsellor, depending on the type of counselling required.
TREATMENT PROVIDERS' KNOWLEDGE OF DTTOS
4.6 All of the treatment providers were content with the information that they had received about DTTOs at the beginning of the pilot and some indicated that they had undertaken further reading to familiarise themselves with the philosophy and operation of this new order. However some lack of clarity existed among treatment providers with respect to the roles of the different staff members in the Glasgow DTTO scheme. As one treatment provider explained:
"I think that the more information that we could have about all different people, and what all the different people do and why in the DTTO team, I could have done with more information."
4.7 Two of the treatment providers commented that more information needed to be provided to other groups of people, such as the social work area teams and sentencers:
"I would reckon a lot more PR, and sometimes when I hear what goes on in the courts an' when I've been to a couple of court reviews myself, I think the sheriff's needing more education on what these orders are about."
"As time progresses this probably requires educating the sheriffs, they are going to have to be a bit more selective [with referrals]."
However, these concerns did not appear to be reflected by sentencers, nor did it appear that sentencers were making DTTOs in inappropriate cases as a result of their lack of understanding of the disposal. On the contrary, sentencers' use of DTTOs appeared to be very much dependent upon the assessments carried out by and recommendations made by the DTTO team.
4.8 Treatment providers in Glasgow were critical of the amount of information they sometimes received about offenders at the assessment stage, stressing that the more information they had prior to seeing an offender, the easier the assessments were to conduct:
"Sometimes somebody appears and we have nothing and we just have to do it from scratch. So more written information would be better."
"There's been missing … if you are requested to do an assessment at short notice, then you might not get an SER or… their criminal convictions."
A similar view was not expressed in Fife, where the drug workers were satisfied with the information provided at the assessment stage.
TREATMENT PROVIDERS' VIEWS ABOUT THE PURPOSES OF THE DTTO
4.9 The overall view of the treatment providers was that DTTOs were intended to engage people in services to deal with their addiction. Whilst they emphasised the treatment aspect of DTTOs, treatment providers also recognised that the orders were intended to impact positively upon associated offending behaviour:
"To rehabilitate drug users, as an alternative to prison, to treat their drug problem if that's what's leading to their offending, stop it at the root cause of it rather than just imprison them, to break that cycle of re-offending."
"To let somebody attempt to deal with their problems outwith prison… rehabilitation in the community. An extra strand probably to community service and probation, but something that's a bit more pointed in dealing with addiction problems."
4.10 One treatment provider mentioned the potential cost effectiveness of treatment in the community instead of custody:
"I don't particularly think governments are interested in people reducing their drug use, what they're interested in is the crime rates get reduced… it's a lot cheaper as well to keep people in the community and treat them than it is to put them into prisons that are already over-crowded and bursting at the seams."
COMMUNICATION BETWEEN DTTO STAFF AND TREATMENT PROVIDERS
4.11 Informal communication seemed to be an important way of sharing information between DTTO staff and treatment providers in both pilot areas. This was especially so in Fife where the team worked from the same office and informal communication was the preferred medium. However, formal communication also took place when required.
4.12 The Glasgow treatment providers similarly used informal communication, but they also had regular meetings with the DTTO staff and participated in any necessary case review meetings. Formal written information about positive test results and non-attendance were sent by the treatment providers to the DTTO team and court reports were sent each month from the DTTO staff to the treatment providers to provide information about individuals' overall progress. However, the Glasgow treatment providers believed that the frequency and availability of written communication could be better, because they sometimes did not receive all the written information they required:
"We're very good at passing information on to them [DTTO team]… however, it's not reciprocated."
"It could be better and I firmly believe that better communications is key to the whole thing. The difficulty lies with time, basically, more than anything else."
4.13 These problems had been brought to the attention of DTTO staff and had lessened through the duration of the pilot. GDPS were also in the process of developing a dedicated DTTO team which they believed would impact positively on the exchange and processing of information. This might go some way to addressing the occasional tensions that DTTO workers reported as existing between themselves and medical staff involved in the treatment provision. For example, social workers expressed some frustration at communication between the DTTO team and the treatment providers:
"I don't see the clients myself.. you don't really know what exactly was done with that client and how it was done… as a social worker sometimes.. I find it hard to deal with that issue.. because I am used to working with the client myself, and not working with them [the treatment providers] and having to rely on other people for information…it makes my job a bit harder than if I was working with the clients myself."
4.14 Communication with treatment providers in Glasgow was thought by managers to be adequate, taking place via a number of mechanisms including joint meetings. Goodwill was said by managers to exist on both sides, with treatment providers committed to working in partnership with the DTTO scheme. Any difficulties that had been encountered were attributed to the fact that treatment providers were not accustomed to having to provide the level and frequency of information required by a DTTO. This had occasionally resulted in the provision of late reports and test results, though managers suggested that this had improved over time. Moreover, the proposals by GDPS to have dedicated DTTO staff were thought by social work managers to be likely to further improve the efficiency and effectiveness of the service.
4.15 In Fife, the fact that the treatment providers and DTTO staff were in shared premises was thought by managers to expedite access to treatment services. Managers also regarded this arrangement as having promoted a greater mutual understanding of roles and responsibilities among different members of the team and having facilitated communication between different groups of staff at the assessment stage and during an order.
4.16 Most sentencers felt unable to comment on the effectiveness of communication between DTTO and treatment staff. Those who did offer comment believed that communication was very effective, basing their views on contacts with staff or on the information contained in review reports.
MULTI-DISCIPLINARY WORKING
4.17 In Glasgow, daily communication took place between DTTO workers and addiction workers by telephone, personal contact and in writing. Communication centred around the assessment of offenders for orders and the supervision of orders in the event of a DTTO being made. Managers considered the level of communication to be adequate and suggested that any problems that had arisen in this respect had related more to professional cultural differences between addictions and criminal justice social work staff. However DTTO workers suggested that communication difficulties sometime arose because established professional parameters tended to be blurred by a DTTO (for example, social workers were in charge of treatment plans rather than addiction workers).
4.18 While there was cognisance of formal procedures within the DTTO teams, practice relied heavily on informal communication. Contact was typically made by telephone or by fax rather than formal exchange of letters. This was viewed both negatively and positively by addiction workers:
"I would say that communication between DTTO staff is bad, probably on both parts, but it's quite bad at times, most of it's done via telephone."
"I like telephone calls because you often find you're drowning in a sea of paper."
4.19 The addiction workers in Glasgow expressed some concern that they did not supervise the clients on the orders, this having been identified as the role of the social workers:
"We should be the care managers… we are providing treatment….the social workers are quite clearly case managing and care managing.. they're co-ordinating treatment which they shouldnae be."
Instead, addiction workers reported that their role was "to chase them up basically", that is, to respond to instances of non-attendance on the part of offenders on orders.
4.20 Social workers also reported some dissatisfaction with their role within the DTTO. As one social worker explained:
"It's a new role..it's very frustrating because in their particular role I am dependent on getting information from the other treatment providers. My role of working with the client is limited and there is no provision for us to directly work with the clients.. my role is to implement .. the treatment plan into action and once it's done, I kind of take a back seat for two or three weeks, if things progress."
4.21 Contact between DTTO social workers and area team social workers was generally confined to the assessment period and was believed by managers to work well on the whole in view of the existing time constraints. In Glasgow some tensions were said by managers to have arisen when area team social workers had difficulty contacting DTTO staff or the latter were unable to respond with the immediacy that area teams required. Managers attributed this to the small size of the DTTO team and their regular attendance at court. One manager also observed that some friction had been created between area team social workers and DTTO workers because the latter ultimately had the responsibility for deciding whether or not an offender was suitable for a DTTO. This was perceived by some area social workers as undermining their professional capability at the assessment stage. The manager explained that the arrangement had been instituted to maximise the quality and thoroughness of DTTO assessments and would be reviewed at the end of the pilot.
RANGE AND QUALITY OF TREATMENT SERVICES
4.22 Information about the treatment and other services provided to offenders on DTTOs was made available to sentencers in review reports. Sentencers were broadly content with the services offered to offenders on DTTOs, while acknowledging that they had little detailed knowledge of the treatment services available. One sheriff in Fife, however, expressed concern that treatment services were not uniformly available across different geographical areas.
4.23 Social work managers were broadly content with the range and quality of treatment services available, though they similarly noted that the geography of Fife meant that services had to be taken to people in some parts of the authority who would otherwise be unable to access them. Managers in Fife also recognised that the development of services was still in its relative infancy following on from the introduction of the pilot DTTOs.
4.24 In Glasgow the range and quality of services available was also considered to be, on the whole, appropriate though some difficulties had been encountered with some organisations. For example, some agencies had been resistant to provide services for offenders on DTTOs because the orders contained a degree of compulsion and coercion that they perceived to be inconsistent with their treatment philosophy. The cultural divide between addiction services and criminal justice services in Glasgow was thought by managers to have stood in the way of fully effective partnership work. Some agencies were also said to be reluctant to accept offenders on DTTOs without assurances regarding payment, effectively making it more difficult for offenders to access services that they would have access to if they were not subject to orders.
4.25 Social workers suggested that treatment providers had a crucial role to play both in helping offenders become drug free and in helping them deal with the void in their lives that this created:
"By providing them intensive support and linking and filling their .. free time.. help them to structure their time which they were using for offending prior to being on DTTO."
4.26 Whilst the range of services available to offenders on probation orders in Glasgow was similar to the range available to offenders on DTTOs, offenders on DTTOs were said by social work managers to have much faster access to treatment. For example, offenders on DTTOs could be referred directly to GDPS for methadone rather than having to be referred through their GPs and placed on a waiting list for a service. However, waiting times for some programmes were felt to be an issue by the DTTO workers since the most popular treatment programmes were reported as having waiting lists up to three months long. This was felt by addiction workers to compromise the treatment plan of the offender on a DTTO:
"If you've got to wait, to wait two or three months, the notion might have worn off by that point."
"There are the groups around, some of them better than others, and the ones that are, got a reputation, usually it's hard to get people in places on them."
4.27 Although methadone was the main treatment provided in both pilot sites (apart from Phoenix House which was abstinence-based) this was always accompanied by counselling. In Fife, specialist counselling for the DTTO offenders was carried out by a voluntary sector counsellor, with the drugs workers providing therapeutic counselling and addiction workers providing individual counselling. In Glasgow, however, addiction workers from Glasgow Addiction Services provided the individual counselling. One treatment provider commented that some offenders:
"…complain that they feel that the counselling is not helpful. They feel that, some of them feel that the problems they have are so specific or deep rooted or whatever, that they feel that the counsellors they see aren't able to help them with that and they just don't talk about their problems because they're not just going to talk to somebody that they don't feel is qualified to help them… they often say they feel the counselling is not effective or not helpful."
4.28 Overall, however, the treatment providers in both pilot sites spoke very positively about DTTOs, including the operational procedures that had been put in place and their effectiveness for individuals and for society.
PERCEIVED GAPS IN TREATMENT PROVISION
4.29 The services available to offenders on DTTOs were considered by managers to be, in the main, appropriate to their needs. For example, although methadone substitution and counselling was the primary treatment method adopted in Glasgow, this was thought to appropriately reflect the characteristics of drug misuse in the city. One manager commented that at the local level few GPs in Glasgow were prepared to prescribe methadone, while another suggested that tensions sometimes arose between social workers and health workers regarding the termination of prescribed treatment: social workers were, apparently, concerned that if treatment was terminated too soon - before other aspects of the offender's lifestyle had been stabilised - the DTTO might fail as a result. In Glasgow, where a dedicated project existed for female offenders involved in drug misuse, none of the managers identified gaps in provision for women. However services for women were said by a manager not to be well developed in Fife, largely because of the relatively small numbers spread across a wide geographical area.
4.30 DTTO staff in Glasgow identified the main gap in treatment provision for offenders on DTTOs as being the absence of groupwork provision for those on methadone treatment. This was viewed as particularly significant in view of the fact that when offenders were attempting to abstain from illicit drug use "one of the biggest problems that they then face is boredom".
4.31 DTTO staff in Fife echoed the views of managers that there was a general lack of services for drug users:
"I think we provide quite a quality service, I think we get somewhat let down by the broader range of services in Fife. I think I can honestly say that the people in the team try their best and do the best they can with what's available."
4.32 The absence of short-term residential detox facilities was perceived by DTTO staff as constituting a huge gap in services. The other main gap was considered to be services related to dual diagnosis (that is, co-existing drug and mental health problems) but this was identified as a problem for addiction services as a whole, and not just DTTO treatment provision:
"I don't think, well… to my knowledge there isn't really any project that deals with both… then they maybe come into a, a programme like this, and because they become clean the psychiatric problem explodes and we can't deal with that… in a sense we're excluding these people, we're discriminating against them and I think that's unfair."
OFFENDERS' VIEWS ABOUT TREATMENT
4.33 Around half of the offenders indicated at the initial interview that they had not previously received treatment for their drug use, though some had tried to come off drugs on their own and some had tried unsuccessfully to get onto a methadone programme. The latter highlighted the difficulty of accessing a methadone programme via normal channels. In Glasgow, for example, it was said to be difficult to find a GP who would make a referral to GDPS and even if such a referral was made, the waiting list for GDPS meant that several weeks could elapse before the offender received treatment.
4.34 Other offenders described a range of treatments and services they had received in the past, including detox (prison and hospital based detox and 'blind detox'), methadone, drug counselling, rehab and attendance at day centres (which required that those attending were drug free). In most cases the treatments accessed had had at least a short-term effect on drug use, though several of those who had participated in an enforced detox programme reported that they resumed their use of drugs relatively quickly.
4.35 Methadone prescription and counselling was viewed by most offenders as being a necessary step towards becoming drug free. By taking away the 'urge' to use heroin it was also said by offenders to reduce their need to offend to get money to support a habit. All the offenders who were interviewed had been prescribed methadone and were participating in or expecting to participate in individual counselling and/or groupwork. As one respondent explained:
"When you are taking heroin all the time, your total time - from when you open your eyes in the morning 'til you close your eyes at night - is spent on thinking where you can make money, where you're going to get money. DTTO takes all that away from you, you know what I mean? When you get the methadone programme, it takes all that away…The self help groups, and that, is more to give you something to do with your time."
4.36 Offenders on orders did not feel that they had been coerced into participating in treatments or activities that they did not want to take part in. However, some suggested that the treatment available was, for the most part, confined to methadone (with associated counselling) and that opportunities for choice were therefore limited 15. This contrasts with the English DTTO pilots, where residential rehab was provided in around one third of cases and is likely to reflect the level and range of resources available to the Scottish pilots.
4.37 Offenders were generally positive about the treatment and other services they had received since starting their DTTO, though a few offenders expressed some anxiety about taking part in groupwork: as one offender commented, "I have not really spoken to anybody about dope problems".
4.38 Methadone treatment and counselling were the services that offenders had most often received during the first six months of their orders, though some had taken part in groupwork or other activities. One offender reported that his ability to attend for treatment and other services had been restricted by health problems he was experiencing and housing difficulties that he had to resolve.
4.39 With only once exception - an offender who had expected to receive psychiatric treatment and a range of activities to keep him fully occupied - offenders interviewed at the six-month stage in their orders indicated that they were happy with the services they had received. As one respondent explained:
"I think I have come a long way, you know. I have not offended from being on the order so something must be working here."
4.40 All but one of the offenders interviewed shortly after receiving their order believed that their drug use had improved since being given a DTTO and that this was wholly or partly attributable to the treatment they had received. All of the offenders interviewed after six months on an order indicated that they had either stopped offending or that their offending had reduced considerably since they began their DTTO and most attributed this to aspects of their order including the testing, court reviews, methadone treatment, counselling and groupwork. Half of the offenders interviewed at the six-month point in their orders said that through their DTTO they had also received other practical help in relation to issues like housing and employment.
4.41 Four offenders who were interviewed after being on a DTTO for six months identified other treatments or services that they believed would help them stay off drugs including group counselling, Narcotics Anonymous, and rehab. One offender said he was keen to obtain a place in a residential respite facility to ease him off methadone because he understood that coming off methadone was more difficult than coming off heroin itself. Two offenders stressed the importance of having things to do to occupy their time, one of whom was critical of the fact that there were limited services available for people who were still undergoing methadone maintenance or reduction. This same offender said that he would welcome counselling to help him come to terms with feelings of guilt and remorse he was experiencing in connection with his previous offending.
SUMMARY
4.42 Treatment provision in Glasgow was mostly provided by GDPS, Phoenix House and the DTTO addiction workers. DTTO provision in Fife was in-house, with prescribing provided by the offender's GP or a consultant psychiatrist. In both sites, the treatment providers undertook urine testing and provided a range of individual counselling, groupwork and other services.
4.43 Treatment providers felt sufficiently well informed about DTTOs, though those in Glasgow suggested that they were not given enough information about offenders at the assessment stage. Much of the communication between treatment providers and DTTO staff occurred informally and was generally believed to be effective, though treatment providers in Glasgow suggested that the timing and content of written communication could be improved and DTTO staff reported occasional tension arising with respect to communication from treatment providers.
4.44 The co-location of the treatment providers and DTTO staff in Fife appeared to have circumvented the problems that sometimes arose in Glasgow. It also appeared to have prevented the blurring of established professional boundaries between the DTTO social workers and addiction workers.
4.45 Social work managers were broadly content with the range of treatment services available to offenders on DTTOs, though services were not uniformly available in different parts of Fife and some treatment providers in Glasgow had been reluctant to accept offenders as part of a DTTO. However, DTTOs offered offenders more rapid access to treatment services than did existing disposals.
4.46 Available treatment services were considered by managers to be appropriate to offenders' needs, though some gaps in services were identified. These included provision for women (in Fife); groupwork for offenders on methadone treatment (in Glasgow); short-term residential detox facilities; and facilities for drug users with a dual diagnosis.
4.47 Around one half of the offenders interviewed had accessed drug treatment in the past with varying degrees of success. Methadone prescription and counselling, which was the most common treatment offered in the pilots, was viewed by most offenders as a necessary first step to becoming drug free. Offenders did not feel coerced into treatments or activities though opportunities for choice were, in practice, limited. However most offenders reported being happy with the treatment they had received, with some stressing the importance of having access to a range of activities to occupy their time.
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