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Chapter 5: Aberlour Edinburgh Outreach Project:

Process and Outcome Evaluations

This chapter is in three parts. We begin with a description of the aims and the nature of the work undertaken by the Aberlour Edinburgh Outreach Project, before going on to present the results of the process and outcome evaluations.

Part 1: Project description

Project aims and objectives

Working exclusively with families with children under the age of 12, the aim of the project is to reduce the impact of parents' drug use upon their children, It seeks to achieve this by improving parenting skills, by promoting greater stability in relation to the parents' drug use and by helping children build resilience. As far as parenting is concerned, individual goals can include the establishment of appropriate routines for the children, keeping children safe from drugs paraphernalia and trying to instil confidence and enjoyment in the parenting role. Efforts are also made through work with parents and children to improve children's engagement with key services, such as regular school attendance and participation in routine health care programmes. Drug related objectives for individual adults tend to emphasise reduction, stability, lapse prevention and safer management of substance use rather than abstinence.

The project is hosted by Brenda House which is a well-established residential rehabilitation unit for drug using mothers and their children, and part of Aberlour Child Care Trust. It has an Edinburgh-wide catchment area. At the start of the evaluation the project team consisted of a project manager, two project workers and part time administrative support. Social Inclusion Partnership and Sure Start funding supported complementary posts within Aberlour Outreach, including the innovative role of Children's Worker. The re-structuring developed by the end of the study period reflected a more integrated approach to service delivery across Brenda House and the Outreach Project - this included shared overall management.

Client characteristics and recruitment

The project works with families facing complex problems encompassing drug use, childcare issues, low income and housing problems and poor links with health and other services. Clients are mainly mothers or pregnant drug users, although fathers are not excluded, and are of varying ages including teenagers. Most clients have had experience of substantial substance misuse, with poly drug use being common, and many clients are on methadone maintenance programmes. They often suffer from low self-esteem and a lack of confidence as parents, some having experienced poor parenting themselves. Whilst there are similarities with Brenda House clients, the Outreach Project offers support for clients for whom the residential rehabilitation service is not appropriate, such as those not ready to commit to detoxification, male parents, and those with children over 12 years old who would not be admitted with their mother.

Referrals

Referrals to the project are largely from social work and health services (mainly health visitors). Additional referrals come from various drugs services and a relatively small proportion of clients are referred from Brenda House. There is also a small but increasing number of self-referrals.

Caseload and waiting times

Caseloads varied but each worker tended to have around eight adult cases at varying stages and levels of intensity. Following referral, at least half of the cases were seen within four weeks. The time lag reflected initial internal discussion, the gathering of extra information and the practicalities of co-ordinating a visit. When referral levels were high, the project directed families to other services, feeling this was preferable to families waiting for support.

Nature of intervention

The project adopts a person-centred approach. Through an initial process of engagement and assessment, clients are encouraged to define their own needs and take personal responsibility, but within a culture of support. Workers ensure parents acknowledge the impact their substance use is having on their children from an early stage. Ongoing work addresses the defined goals, such as safer substance use and effective engagement with health and other agencies, through a mix of discussion and practical support and advocacy. Parenting skills are also addressed, such as encouraging setting realistic behaviour boundaries and modelling more positive parenting behaviours through work with the parent and child. Workers also participate in child protection case conferences. Workers often have to respond flexibly to new issues as they emerge and cases are reviewed regularly. Whilst working with family members, it should be noted that these interventions do not constitute 'family therapy'.

Contacts with clients can vary from two to three one hourly sessions a week to less intensive fortnightly or monthly contacts as the intervention nears the end. If need be, workers will visit clients outside office hours or at the weekend, for example to establish bedtime routines or getting to school. The project tries to be readily accessible to clients and telephone help or advice is offered, even if their own worker is not available.

Work with school age children is often independent of their parents and mixes focused work and activity based outings. At the Project base, workers use varied worksheets and programmes to help the child explore feelings or gain understanding of parental substance misuse. Outings present alternative opportunities to explore issues and experience of more positive life experiences. Where possible, children are linked into affordable local activities which could continue after the intervention. Much of the work with younger children is with parents as well.

Assessment and care planning

Following a four to six week assessment process, a mutually agreed care plan is devised based on what clients themselves identify as key issues to address. This establishes clear goals and how they will be achieved. Regular case reviews include the client, the worker and a manager. While the project aims to review cases every six to eight weeks, this varies in practice.

Location

Work with adults and pre-school children is largely undertaken in their own homes, although alternative venues are arranged if needed. Workers may also accompany clients to appointments with other agencies. Interactions with school age children are generally outside the home, in the project base or a suitable outing location, such as the park or a café.

Case closure

Casework can last from three months up to a year or more, often with a reduction in input frequency near the end. Closure is negotiated and prepared for in conjunction with the client and a final review is held prior to disengagement. A case will also be closed if a client withdraws from the service.

Part 2: Process evaluation

In the process evaluation we distinguish between those factors which appeared to facilitate the effective operation of the project and those that seemed to impede or limit its effectiveness.

Facilitating factors

Being well embedded in established host and parent agencies

The project has derived considerable benefits from being well embedded organisationally and physically in the host agency, Brenda House, and the parent organisation, Aberlour Child Care Trust, including staff organisation, physical resources and practice development.

Importantly, the project's ability to absorb and cover gaps in staffing and managerial functions facilitated relatively smooth progress. On-going recruitment from Brenda House (either to full-time or seconded posts within the Outreach Project) meant that gaps were covered by individuals with understanding of the complex issues addressed by the project, e.g. the potential impacts of drug and alcohol misuse on families, child development and welfare and family interactions. It would otherwise have been difficult to recruit suitably experienced workers for this relatively new area of combined work, especially to provide short-term cover: "There aren't ready-made workers out there", (Manager). However, the initial recruitment approach adopted by the project, which prioritised staff skills in working with families and children (rather than drugs awareness, which could be more readily acquired) had also been successful.

Links with Brenda House and the dependency sector of the parent organisation also enhanced development of professional practice, both for the project as a whole and for individual workers. The physical and organisational links facilitated sharing of experience and approaches, formally and informally; for example children's workers across Scotland met twice a year in order to learn from each others' experiences. In addition, the parent organisation encouraged reflection on key areas of practice and project development, which might otherwise prove difficult to address in the context of busy and challenging workloads; for example, reviewing the length of time for which meaningful intervention can be sustained (concluding that intervention beyond 12 months is unlikely to achieve significant change), encouraging confidence in and documentation of project achievements, and actively addressing child protection policies. Practice support also included a standard assessment framework across Aberlour and IT support in database development. Finally, there was also an organisational ethos of supporting individual professional development and training, for which staff cover might be difficult to realise in a smaller project.

The location within the Brenda House complex also meant considerable resource benefits in comparison to a more isolated project. For example, play areas could be accessed, which might otherwise have been too costly, and out-of-hours home visits could be monitored by residential staff through telephone check-ins.

In addition, the non-statutory setting was seen to have many benefits, allowing greater flexibility than statutory services can offer together with options to focus resources on longer-term programmes of work rather than crisis interventions. This, and the non-statutory basis of engagement, may have enhanced clients' response and engagement.

Having experienced and committed workers

The project was largely successful in retaining staff, despite managerial disruption and changes in areas of practice. This could be largely explained by considerable personal commitment to the work and to individual clients. In addition, workers felt their own expertise was acknowledged.

"I think one of the good things - when you are stuck in a big statutory organisation you are just are a number. … [Here] it is very much, 'That is your area of expertise. You tell us what is working'." (Project Worker)

This was facilitated by regular staff meetings and development days. Meetings were important because outreach work and the variable hours meant that informal staff contact was infrequent, although staff tried to be in the office at some point on most days to update notes and contact other agencies.

As already discussed, later recruitment largely from the host agency meant that staff were better able "to hit the ground running", although they still had to gain understanding of the differing challenges in working with clients in their own homes. However, there is a potential risk of 'insularity' if not actively recruiting from other agencies.

Client recruitment approaches and referrals

Project workers were proactive in raising awareness of the scope of project work and client characteristics in order to enhance referral numbers and quality. Project leaflets and posters were circulated and workers offered to attend relevant professional groups and departments to further explain their work. Awareness-raising was seen as ongoing because knowledge and understanding of the project tended to be patchy among potential referrers (see B1). In addition, it was important to emphasise the planned and structured nature of the work to address specific client-centred issues and to stress that referrals needed to fit project aims. It was also important to highlight what the project did not offer: for example, that it was not a service to facilitate everyday living or a befriending service.

The project became more rigorous in screening referrals to ensure greater suitability for effective engagement, and had gained greater confidence in refusing and redirecting inappropriate referrals. Workers found that insistence on fully completed referral forms, rather than a brief telephone call, enabled a considered assessment of appropriateness and was also important for child protection and worker safety issues.

"Our referral sheets are quite stringent. It'll not be the first time that someone has phoned and said, 'Oh I've got this child. This is the age of them, mum uses drugs. This is their address. Can you go out and see them?' I say, 'No, sorry, that is not enough information. You need to give me much more than that'." (Project Worker)

Effective engagement

Project workers felt they achieved good levels of engagement with most clients. This was facilitated initially by the quality of initial contacts and assessment stages, as well as rigorous screening of referrals. For example, workers referring clients into the project would be present at the initial Outreach Project visit and help clarify the project input in the context of other services that may be involved. Clear explanations of the work of the project and exploration of whether this fitted the potential clients' expectations and needs were important. Once agreement was reached and the care plan devised, workers persevered in building a productive person-centred relationship which in some cases was felt to take several months to evolve. It was recognised that some clients may have felt a sense of coercion to participate, which could potentially mean ambivalent or tokenistic participation, especially where children were considered to be 'at risk' and participation seen as a route to prevent them being taken into care. However, workers' experience was that actively working with such families could achieve change in some cases, leading them to engage more positively.

Use of assessment tools

Workers use a range of assessment forms and standard scales, although predominantly in the initial stages of care plan development rather than for ongoing review (see B6). The Aberlour assessment framework is used consistently across all projects in the Dependency Sector, and covers issues such as home situation, drug and alcohol behaviours, and children's health, needs and risks, and enables prioritisation of key areas. Following this, workers selected from a number of standard scales, depending on the client situation. Most commonly used were the Aberlour adaptation of the SCODA Risk Assessment scale, which includes greater reference to risks to children, and the Parenting Daily Hassles scale, both favoured for their brevity and utility in prioritizing concerns. Others included the Readiness to Change questionnaire, Chance to Change, and other Department of Health questionnaires.

"We would go in and do our assessment and then from that - say it's parenting, then I would take out the Parenting Hassle Scale to find out what parenting issues they highlight up. … But say I went into a house and there was inappropriate things lying about - medication, needles - I would take in the SCODA Assessment at the next visit because that is more geared towards how safe is your house for your children. It would depend on the circumstance of the family what paperwork I took with me." (Project Worker)

Confidentiality and the development of trust

Project workers had considerable experience in continually balancing the need for maintaining client confidentiality and trust with the need to address child protection and other statutory issues. These issues were always raised straightforwardly at the first meeting in the context of explaining the need for care and support. Clients are asked to sign a confidentiality sheet, confirming understanding of the principles and identifying those professionals that they agree could be informed if the family's situation began to cause concern. Workers were also skilled in overcoming considerable secrecy and hiding of the 'truth' in interactions with clients through the process of building trust.

"They are quite clear that if I was concerned about a child and if there were any child protection issues, then it is my duty to report that. We make that clear from the very start." (Project Worker)

"People will say all the things that they think you want to know when you first meet them but then a couple of months down the line they'll say, 'Well actually …' … That is about building up a relationship and them saying, 'Well, they're not actually here to take my kids away." (Project Worker)

Outreach working

The outreach approach facilitated productive working. Contacts were mainly in clients' own homes, where much of the parenting activities take place and there are potential risk situations for children. At times, workers would support clients in attending other agencies, such as their GP. Specific work with school age children tends to be outside the home, giving greater freedom to explore issues.

"If it's adult clients and I'm working with them on parenting issues, that is easier done in their own space, 'cause obviously that is where they have to carry out the practice. If I'm doing one-to-one work with children I tend to bring them back [to the project base], because we are so well resourced and we have got the playroom and it is somewhere safe that the child feels they can really say what they want to say or work through the issues." (Project Worker)

Work with other agencies

The project placed a high priority on joint working and maintaining contact with other professionals working on individual cases; this mainly consisted of keeping each other up to date on progress and suggesting additional interventions as appropriate. This was seen to be particularly important in the context of complex needs and vulnerable client groups, although developing and maintaining links across localities and through organisational and staffing changes was challenging (see B4). In addition, the project enhanced interagency communication by providing and eliciting written confirmation of decisions at key joint meetings rather than relying on verbal communication. These approaches were reinforced following Aberlour's internal review of child protection and the subsequent development of policy and guidelines.

Workers would also ensure that individual clients knew that services were working together and would communicate informally and at reviews and core groups. The client was helped to understand the varying roles and input of each worker and agency. Respondents reported a tendency at times for parents to try to play one agency off against another, demanding support from one that was similar to the support offered by another, or falsely claiming engagement with another service. These experiences enhanced the importance of joint communication.

"These families that are being referred have complex needs - the families, not just the children - and it is silly to think that the one project or one agency can sort all of that out. So we don't work in isolation and I think being clear with the parents and setting the boundaries right from the onset [is important]." (Project Worker)

In addition to joint working with individual clients, the project also explored possibilities for partnership working and sharing their expertise with relevant agencies, such as potential joint sessions with the Castle Drug Project. However this had not progressed, which was largely attributed to time constraints and staff changes within the project and in other agencies. In order to enhance networking across the city, staff also participated in local forums, such as Edinburgh Women's Services Support Group, and in cross-agency training opportunities.

Individual referrers also recognised and valued the project's multi-agency working, especially where there were child protection plans and meetings.

"If Aberlour are involved [in a core group] they engage very fully in that. And it means that the client and the key workers are sitting down with the client on a very regular basis - monthly to six weekly and discussing what the support is and where we're going from there." (Referring Worker)

Finally, whilst working with other agencies is important, it is noteworthy that the project potentially reduces the number of services needed to support an individual family, as it addresses both parenting and substance misuse.

Limiting factors

The organisational environment in other services

The project development coincided with a period of considerable change and upheaval in services involved in children and families which were main sources of referral, joint working and onward referral. The Edinburgh location made this particularly salient, in light of the O'Brien Report (O'Brien 2003) following the death of the infant Caleb Ness, and the subsequent review and re-organisation of statutory and health services. Key external agencies and staff were working under considerable pressure, with staff changes and shortages. In turn, pressures on other agencies made it difficult to generate referrals, build interpersonal working relationships and develop effective joint working. Changing external structures also contributed to an increasing feeling of distance from the DAAT.

"The whole social work department is topsy-turvy. … I think our position in Edinburgh is weakened because of Edinburgh's overall difficulties in trying to restructure itself and also find its identity again." (Senior Staff)

"With thinking about the Caleb Ness case for example, everybody's just gone into panic mode and kind of been referring everybody and then not been referring anybody. … the work that was being done was just to hold things together - crisis management …. I think that undoubtedly has a knock-on effect." (Project Worker)

In addition, staff felt there were some initial suspicions on the part of some agencies about ownership of work with children and families, although workers demonstrated that their approach complements rather than encroaches upon the work of other agencies. Furthermore, new projects in the non-statutory sector were being developed over the study period which might be perceived to have overlap in provision and potentially cause confusion among referrers.

Other agencies' lack of awareness of children's needs in drug misuse contexts

Outreach Project workers, and other Aberlour workers, felt that the impacts on and needs of children in drug using households tended not to be taken into account by some staff in other agencies. This was in spite of being recognised at policy level, and it sometimes impeded referrals and work with their client groups. Thus the project often found it necessary to undertake an advocacy role in multi-agency working, specifically to ensure that individual children's needs are incorporated in planned programmes for substance misusing parents, and generally to raise awareness of the impact on children. Additionally, it was felt there was an untapped potential to share these acquired skills in raising such issues with parents among other professionals.

"Sometimes I feel I really have to advocate for the child because they set up all these wonderful things for parents and I'm in the background saying. 'And what about the child? That is great you are going to do all this wonderful work with mum and she's going to go here and there of an evening. What is happening with the children when mum is doing all this wonderful stuff?' 'Oh yes we didn't think about that." (Project Worker)

Internal management and staffing issues

There were considerable management changes during periods of the project history which respondents felt at times had had an impact on overall functioning, although to some extent ameliorated by host agency support as discussed above. During the second year, the project manager was in effect outside the case management element of the post for a substantial period. To fill the gap at that time, day-to-day management and case supervision was covered by the manager of Brenda House, who had had experience of an earlier outreach project. This resulted in periods of reduced project management time available, particularly important with children potentially at risk, because the role was shared between Brenda House and the project. Staff commented on implications for accessibility to case supervision and frequency of case reviews, but also on limitations for potential project developments, such as community based parenting groups or more pro-active partnership working. These limitations may also have been observed by potential referrers, and may have contributed to the subsequent decrease in referrals.

"I cannot deny that what had been going on … it's impacted on the number of referrals, it has impacted on the nature of referrals. It has impacted on the relationship [with other agencies]." (Senior Staff)

"There's been all this 'Oh, yeah, we'll do this, we'll do that, do this', but none of it's ever come because we've not had a manager who had the time to do it." (Project Worker)

Subsequently, organisational integration continued across the rehabilitation and outreach services as a planned objective over the study period, with restructuring of the managerial component involving other staff from the two services.

In addition, the project had to cope with periods of reduced staffing levels because of study leave or sickness, which can have a big impact on small projects. Whilst the host agency provided cover to some extent, gaps in management and worker complement, combined with uncertainties regarding funding renewal, resulted in what was described as "a period of basically making do - who was there and who could take on some responsibility" (Senior Staff), before new structures were finalised and a "practice culture" developed.

Geographically dispersed client group

Whilst outreach work contributes to achieving a client-centred approach, the client group was widely dispersed across the city. Thus there was a need to develop links with a range of service networks across a number of localities, for referrals and effective on-going joint working. In addition, staff travel times added to the workload, especially as missed appointments were not unusual, and some workers were dependent on public transport. Worker safety issues were addressed through joint initial visits and telephone check-in mechanisms.

Challenges in maintaining focus

The client group often presented with chronic deep-seated problems and chaotic behaviour, often making it difficult to maintain focus in individual casework and across the project. On the one hand, the focus is on mutually identified individual goals, with an agreed plan of how to achieve them. On the other hand, the likelihood of rapid changes in a family's situation and a tendency to miss appointments mean that at times keeping to planned work is difficult. For example, the client may increase their drug use and be unable to concentrate, or be preoccupied by other issues, such as money shortages. These might present as a short-term crisis requiring immediate response, or a long-term issue which would require a review of the goals. To some extent, workers often did not know what they would find when they arrived for a planned session. In addition, clients' experience of other services, perhaps resource workers or befrienders, might mean they have different expectations of the service.

"If somebody's not had their giro they're not really that bothered about sitting down and answering questionnaires, but they were quite happy that we'd accompany them to the Post Office to sort out their giro … really that's not technically our job, but in emergencies we can do it, you know, if they were having problems, because it's about supporting them, but that's that session gone." (Project Worker)

This meant a continuing balance between maintaining the developed plan of work and providing a flexible service that responded to changing needs. It was therefore important for workers to be clear and confident in their own roles, and, to try and draw the work back to the initial plans - " Because of the nature of the client group … you [can] end up as a worker chasing your tail but not achieving much" (Senior Staff). Confidence and skills to do this were felt to have increased as the project developed, with staff being encouraged to reflect on these issues.

"I always refer back to our agreement that we made at the very beginning. There is a focus and an aim and we can't just keep going willy-nilly. I'll run with it for a few weeks. Everybody goes off track. … But I wouldn't let that be an ongoing thing. I'm quite good at pulling clients back and saying, 'Come on, this is what I'm here to do with you'." (Project Worker)

Demonstrating outcomes

Workers and managers were aware of the need to show progress at both individual and project level, but experienced considerable difficulties in demonstrating outcomes achieved with clients. This was attributed to the project's flexible and person-centred approach, which meant that some of the more subtle positive changes achieved were difficult to measure or demonstrate - e.g. enabling a mother to have fun with her child in the park.

"You can monitor success as someone becoming drug free and that is a great success. But kids whose attendance at school is more regular and their confidence is built up - that is a success. Kids who are actually interacting with their parents that never used to be able to do that - get a story read or getting taken to the park - just things that some kids take for granted. That is a success as well, isn't it?" (Manager)

Workers used a range of assessment tools (see A5), but these were predominantly used in the initial stages of care plan development rather than at regular intervals to routinely assess progress. The mix of tools used, and the varying triggers for reassessment meant that these measures tended not to be of use for wider project monitoring and evaluation. In addition, detailed record keeping could be difficult within the constraints of busy and challenging workloads, although workers themselves felt that they recognised areas of progress in their clients.

"It is those sorts of things that are very difficult for us at the project, 'cause we are not about tracking. We are about doing." (Senior Staff)

The project did however undertake core monitoring procedures. A database of client details was maintained, including monthly updates of information such as numbers of contacts, missed appointments and travel and administration time. Workers also recorded details of contacts in individual case notes. The client's perspectives of the work undertaken were recorded at case closure, and there have also been annual project reviews, seeking comments from service users, referrers and joint-workers.

Lack of client involvement in project development

The project acknowledged a need to incorporate client input into project development, as part of the client-centred ethos, although characteristics of clients' lifestyles make participation difficult. However, clients' perspectives are elicited at the end of individual interventions and in annual project reviews.

Key findings from Aberlour Outreach process evaluation

• The project demonstrated an ability to work with drug misusing adults in a family context, addressing parenting and additional complex issues impacting on family life as well as substance misuse. Working directly with more than one individual in a family as well as the family as a whole was important, especially with children as appropriate.
• Linked with this, the project identified an important advocacy role, highlighting recognition of children's needs with other agencies and workers where these may not have been previously been considered.
• The balance between a flexible, responsive approach and maintaining client focus on individual goals can be difficult in the context of rapid changes in a family's situation. Project staff developed considerable skills in responding to immediate need as well as drawing clients back to the original care plan.

• Effective engagement with clients was important, although this often takes up to a few months. Engagement was facilitated by greater confidence and rigour in referral mechanisms and initial screening to ensure appropriate clients, together with extensive explanations of the project role and exploration of appropriate goals and support.
• The outreach approach was valuable, enabling client-centred contacts where parenting was largely undertaken. However, it presented challenges in terms of maintaining contact with a wide range of agencies. Timetabled meetings were important as workers had less informal contact with each other.
• Similarly, travel times for workers remained an issue, in spite of an urban public transport infrastructure, because of the variety of areas in which clients lived and the project's own peripheral location.
• Working with different agencies was essential for referrals and ongoing work, but meant project working was vulnerable to external pressures on these organisations, such as staff shortages.

• As a small project, this was vulnerable to internal staff and management changes and absences. These were considerably ameliorated through the host agency, with cross-agency filling of short-term and permanent gaps by staff with relevant experience. This was increasingly reinforced by the move to more integrated service delivery.
• Linked with this, the initial recruitment policy of prioritising workers with experience with children and families rather than drug awareness was also felt to be successful in the absence of workers with combined experiences.
• It was difficult to demonstrate change in a standardised way as work with individuals varied. Whilst standard measures were used, this was largely in the initial stages of engagement and establishing goals, rather than as regular assessment. Similarly it was difficult to review areas of practice such as child protection in a demanding work environment. However, the national agency played a part in addressing these issues of monitoring and professional practice.

Part 3: Outcome evaluation

As in the previous 2 chapters, we present our findings on the impact of the project in two sections: 1) an analysis of the adult clients' perceptions of the project and its impact upon their lives and 2) an analysis of the views of the collateral interviewees. The outcome evaluation did not include the project's work with children since this would have involved a range of ethical and practical issues associated with the interviewing of children under the age of 12.

Impact of the intervention on clients' lives: client perceptions

In this section we consider what difference the clients believed their participation in the project had made to their lives, and to those of their children, and in what ways they thought their ability to parent effectively had been improved. The great majority of the clients were very positive in their assessment of Aberlour Outreach and the benefits they had derived from the service. All of them reported that they had found the intervention of the service to be valuable and most of them referred to a number of ways in which they had benefited from their participation in it. Some of the benefits were seen as applying to themselves and some to their children while others, such as improved parenting, were seen as being of benefit to both parties.

Improved parenting

Nearly all of the parents said that their involvement with Aberlour Outreach had made them a better parent. Most of them reported having had difficulties in that regard and help in developing appropriate parenting skills was, according to them, greatly appreciated. This was seen as not only being a very positive development from their children's point of view but as also making parenting a more satisfying and rewarding experience for themselves.

Many of the reported improvements in parenting related to the children's physical and social needs. This included; making sure that the children were properly fed and clothed and that they were kept clean and warm; ensuring that they had appropriate routines and arrangements for meals and sleeping; making sure they had adequate opportunities for play; and ensuring that they attended school regularly. The project worker's intervention could even extend to teaching the parent how to cook simple meals. Several parents also reported that they had changed their approach to the way in which they disciplined their children or set boundaries for them as a result of their contact with Aberlour Outreach. Some of this had to do with the replacement of physical punishment with alternative forms of discipline: '(Project worker) has helped me most by just talkin' an' looking at other ways of dealing wi' stuff. Rather than me just losing the rag and setting aboot them.' However, the advice which the parents received on discipline went beyond the cessation of physical chastisement. According to the clients, they were also offered guidance and instruction on how to implement a non-punitive approach to discipline.

Some of the changes in the clients' parenting skills were about improving the quality of their emotional involvement with their children. For example, sometimes the project worker's support included counselling a mother on how to display affection towards her children. In the following example, the mother had to learn to overcome her own experience of physical contact as being associated with some from of exploitation.

"I suppose stuff like getting showed how tae play wi' the bairns. Being shown how tae put your arms aroond the bairns when you were never loved and shown any affection from your childhood, ken whit ah mean? Or if somebody put their hands on you, it meant they were wanting something fae you, or they were going tae take something fae you. I had tae find a different…the fine line an' that, ken whit a mean? Tae be able tae dae these things. Had tae learn how tae be able tae dae them, know what ah mean?"

Other parents reported becoming more attentive towards their children, spending more time with them and talking to them more often. In other words, they became more involved in their children's lives. Part of the parents' increased attentiveness towards their children involved engaging in various activities with them and taking them out of the house on trips and outings: 'I spend more time with them, doing more activities. I make sure that I'm involved with them more now…doing things. Whether it's going for a drive in the car or taking them to the pictures or doing stuff with them that they like.' It was frequently difficult to distinguish the influence of the project from that of any modification in the parents' drug use in their accounts of these changes. However, it was clear that in some instances both elements were involved with a modified or stabilised drug habit playing a significant part in increasing parents' personal capacity to engage in other activities: 'I get up quicker in the morning. Aye. Definitely. I'm more active…ready to take them out shopping and things like that.'

Improved protection of children

According to the parents, their involvement with Aberlour Outreach had led to a number of changes as far as their children's exposure to illegal drugs, drug paraphernalia and drug use was concerned. Some parents reported that they had taken steps to ensure that their children were less exposed to their own drug use or to that of others. For example, they reported taking greater care to avoid their children being present when they were administering a substance. By the time of the second interview, only one mother said she had taken non-prescribed drugs in the presence of her children in the past 3 months. Although it was more difficult to achieve, some of the parents also said that they attempted to reduce the occasions on which their children saw them under the influence of a drug. The fact that the number saying they had never been under the influence of non-prescribed drugs in front of their children during the previous 3 months doubled from 3 to 6 between the two interviews tends to support their claim to be making progress in this direction. Some parents also claimed that, as a result of their participation in the programme, they were less likely to take their children with them when they went to buy drugs and to have made an effort to reduce their children's exposure to other drug users.

Acting upon the advice of their project worker, the parents also reported taking enhanced precautions to ensure that their drugs and drug-related paraphernalia were inaccessible to their children. The most common strategies for achieving this were to either consign their drugs and related accessories to an elevated position out of the reach of their children or to place them in a locked cupboard. The project staff also supplied the parents with a secure container, a 'sin bin', in which they could deposit their used syringes.

The next two sub-sections discuss two other benefits that parents claimed to have derived from their contact with Aberlour Outreach. These were, 1) help to stabilise their drug use and, 2) the receiving of emotional and psychological support. While these supportive inputs were important in their own right, they were also vital elements in creating a context within which improvements in parenting and the protection of children could develop and thrive.

Help with drug use

Some of the benefits that parents attributed to the project related to their drug use. Parents varied considerably in their current use of drugs. Some continued to be regular users of addictive drugs, some were struggling to control or reduce that use, while others were in receipt of prescribed substitute drugs. A major benefit identified by the parents was the way in which contact with the project had assisted them in either remaining free of illegal drugs or in stabilising or reducing their drug habit. At the time of the second interview, 8 of the 12 interviewees said that, as a result of their participation in the project, the amount of drugs they used had been reduced and 9 said that the stability of their drug use had improved. The following mother describes how the service has enabled her to stabilise her life and carry out some of the essential functions of a parent while continuing to take heroin.

"Ah lost my child through that, so ah had tae get my act together and get him back. My life was a mess. Like I'm not saying it's any better now, but I've got my children. Erm, I still take heroin but I can still like…. I can take heroin and still like, get up in the morning and get my kids seen tae and make their lunch, make their dinner. I can dae all they things."

For clients who were attempting to remain free of certain illegal drugs, being able to call on somebody for support when they felt tempted to use them was seen as being of enormous benefit. Several of them referred to the importance of having ready access to a project worker who had the ability to listen sympathetically and stiffen their resolve to resist temptation.

"Aye, my whole life's changed. I was taking everything, all drugs. And now I'm just sticking to my script. My workers have played a big part in it, by helping me and just advice and help. (Project worker's) been through everything with me. She's always been there to give me support and help when I've needed it."

Finally, in the second interview, 7 clients claimed that the advice and support they had received from the project had enabled them to use drugs more safely.

Emotional and psychological support

A recurrent theme in clients' accounts of the benefits they obtained from the project was the significance for them of the emotional and psychological support they received from their project worker. Having somebody to talk to in confidence about things that were concerning them was greatly appreciated by all of these clients. This support assumed added significance in a context in which individuals frequently had problems of a fairly profound nature and where they often did not have anyone else in whom they could confide and seek advice: 'Somebody coming out to see me, support and that. Ah've liked having somebody tae talk tae, somebody tae ask about things. ...having somebody tae talk tae, ken, that understands.' Sometimes what was required was somebody to whom they could express their frustrations and anger: 'They've helped me when I felt alone or angry or just to get things out.'

An important aspect of the psychological support provided by the project worker was the way in which it reportedly helped to enhance the parent's confidence and self esteem, thereby strengthening their ability to remain drug free and to cope with their children.

"She's actually made me realise a lot of things in my life and made me realise that I'm very low on confidence and she's actually made me realise I can do things, I am clever, I'm just as worthy as anyone else and she's helped me in my confidence."

Some interviewees reported that the development of greater confidence and self-esteem, together with encouragement from their project worker, had enabled them to become more outgoing and sociable and to expand their involvement with other people. This was regarded by those parents as being especially significant given their previous social isolation.

However, it was not just counselling and advice that the project worker provided. Several of the parents praised the breadth of support which the project workers offered with several of them claiming that their worker would do 'anything' or 'everything' for them. This could include various forms of practical support including helping them with housing problems, correspondence or the completion of forms or, even, providing transport. As with the psychological support, the practical inputs which the project workers provided can be seen as part of an attempt to help parents to cope with everyday demands and thereby enhance their ability to look after their children effectively.

Comparison of responses in the two interviews

There were few differences in the benefits identified and in clients' perceptions of the project between the two interviews. Nearly all of the 15 clients had already been in contact with the project for some time prior to the first interview: 8 had been participating for more than a year, 5 for between 3 months and a year and only 2 for one month or less. As a result, considerable changes had already been effected in relation to their parenting and other aspects of their behaviour by the time of our first interview with them. The fairly high level of progress reported at interview 1 therefore tended to be replicated at interview 2 with few signs of additional progress. An exception to this was parents' reports of small improvements between the two interviews in the extent to which their children were exposed to their drug use or to that of other drug users. There were no instances of a client reporting having regressed over the period of the study.

Impact of the intervention on clients' lives: collateral interviews

Collateral interviews were conducted for 11 of the Aberlour Outreach clients: 4 with friends, 3 with mothers, 2 with partners and 2 with social workers. These interviewees broadly endorsed the clients' claims regarding the progress they had made following their participation in the project. However, there were two difficulties associated with these interviews. First, some of the collateral interviewees were, by their own admission, not best placed to comment on certain aspects of the client's life and progress. For example, friends appeared to have greater difficulty than mothers or partners in commenting on the clients' progress in relation to parenting since they were not in a position to observe these routines on a regular basis. Similarly, these interviewees often had a limited perspective on the protection of the children in the home. In addition, interviewees in all categories confessed to not always being aware of emotional changes in the client and, in particular, improvements in self-esteem.

A second issue with some of the collateral interviews was a tendency on the part of some of the interviewees to portray the client in a good light. It was not a matter of them exaggerating improvements and, indeed, they appeared to be more likely to deny knowledge of certain instances of progress. Instead, there appeared to be reluctance on the part of some interviewees to confirm any initial deficit in parenting skills or routines. Four of them denied having observed improvements in parenting or in the children's routines although, in each case, the client herself had reported detailed improvements. The interviewees were especially keen to reject any idea that the client might have neglected her children in any way making comments like, 'she's always looked after her children well' or 'she's never ever neglected the weans'. It is possible that these collateral interviewees might have genuinely believed that the client's parenting abilities had always been adequate and, unlike the client herself, were unaware of any improvements. However, it is equally likely that these interviewees were motivated by a desire to protect the client from accusations of parental incompetence given the sensitivity of the issue and its potential consequences. Some of the interviewees may also have regarded any such admission as reflecting badly upon themselves as partners or grandmothers. That this may be so is suggested by one mother who said that, if she had been aware of any neglect, she 'wouldn't have stood for it'.

Improved parenting

The above discussion notwithstanding, most of the collateral interviewees confirmed that the clients' parenting skills had improved since their involvement with Aberlour Outreach. These improvements included the establishment of settled routines for the children, making sure they were properly fed and clothed, being more patient with them and developing more constructive approaches to discipline.

The clients' relationships with their children were also said to have improved with them being reported as devoting more time and attention to them, taking them out more frequently, spending more time playing with them and conversing with them more often. Most of the interviewees had no doubt that it was the project that had given rise to these improvements.

"Oh ah think they've definitely played a big part in helpin' her. They're helping her like how tae care for the children and they helped a lot wi' her parental skills, how tae manage, how tae make sure the house wis safe and that for the kids, stuff like that."

The interviewees also confirmed the safety precautions adopted by clients to keep drugs and drug related paraphernalia out of the reach of their children. While some of them said that the client had always followed these procedures, others felt they had been improved as a result of the influence of the project. Similarly, some of the interviewees reported that there had been a reduction in the children's exposure to the use of drugs by the client or others in the family home.

Enhanced perceptions of self

The other major area in which the collateral interviewees reported improvements was in the client's emotional health and the way in which she viewed herself. Clients were said to have much more confidence and self-esteem: 'She's got a lot more self-esteem, she takes a lot mair pride in herself and jist generally ah think she's a nicer person. Much nicer, a lot mair confidence.' Again, these improvements were attributed to the client's involvement with Aberlour Outreach: 'Well they've helped her become less depressed, helped her be more confident and outgoing, they've given her hope for the future…..they've let her see that everythin's no' against her.' These psychological changes were, in turn, seen as being central to the improvements the client had been able to make in other areas and, in particular, in relation to their children: 'Jist the whole confidence thing, if ye'd known her before like ye would see that this was the major thing…..once she got more confidence she was able to function much much better.'

Finally, the interviewees overall assessments of the impact of the project upon the life of the client were, in the main, extremely positive. The following extracts give a flavour of their comments.

"They're a great support, ah cannae say enough good things aboot them because ah don't think they jist saved (daughter's) life. They kinda saved mine as well."

"Just everything overall…..ah see such a difference in her, ah really honestly do. Just the whole support thing is what works. As ah say ah've seen massive changes in (daughter)."

"The way they've helped tae turn her around…and ah know it's no' finished, ken ah'm no' that daft….but the way they're helping is magnificent. That's all ah can say really, they're marvellous. Tae me they deserve a medal. For me it's all doon tae the staff 'cos whatever they're doin' or whatever they're sayin' tae her seems tae be takin' affect."

One aspect of the intervention that was mentioned repeatedly by the collateral interviewees was the 'support' which the project provided for the client. By this they meant both the help and guidance the client received during the project worker's regular visits and their ability to call on them for assistance whenever the need arose. According to some of the interviewees, the other important aspect of the support provided was that it was non-judgemental and emotionally supportive in the sense that it sought to avoid saying or doing anything that might undermine the client's confidence or self-esteem while, at the same time, attempting to reinforce a positive sense of self.

Key findings from outcome evaluation

• Participation in the project led to considerable improvements in clients' parenting skills and in their involvement with their children.
• The children's exposure to drugs, drug related paraphernalia and drug taking appeared to be reduced.
• Most parents reported that the project had helped them either to remain drug free or to stabilise or reduce their drug habit.
• Clients' confidence and self-esteem appeared to be enhanced as a result of their participation in the project.
• Clients valued the psychological support and counselling they received from project workers.

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