Addictions Pilot Final Report 2008 – 2009
March 31, 2009 Prepared by: Heather Elliott, BSW, RSW
Executive Summary In June 2008, an Addiction/ Mental Health Counsellor within the heartspace Program at Addiction Services of Thames Valley was recruited for the addiction pilot with Family Networks and Children’s Aid Society of London – Middlesex. In July 2008 the Addiction/ Mental Health Community Counsellor began receiving referrals, and to date a total of 25 referrals have been received. Of the referrals received fourteen have been accepted and completed the screening, intake, and assessment process. One referral was received and accepted to provide support to a mother who was concerned about the impact her expartner’s substance use was having on their son. Eleven of the fourteen clients who have completed assessments are female, and have a family history of substance abuse and mental health concerns. Three males completed the assessment with two of the three reporting no family history of substance abuse or mental health concerns. Results of the assessments indicated that one client has no current or past substance abuse or dependency concerns, one client has a history of alcohol dependency, one client has a history of cannabis abuse, and eleven clients have a history of poly-substance abuse and dependency. Ten of the fourteen clients reported that they have made past attempts to change their substance use, however were not successful with the changes they were making at that time. All of the clients who have completed the assessment have reported that they have found it beneficial to have flexibility around the scheduling and location of their individual appointments. The target to offer four staff training sessions to increase knowledge, skills, and sensitivity for working with individuals who have substance use and/or gambling concerns has been achieved and surpassed. To date, nine training sessions have occurred, and additional two training sessions are scheduled for the next fiscal year. In addition, six community education and information sessions were offered in the North and Northeast London neighbourhoods. Many consultations have occurred with the researcher at Kings University College and the research with Family Networks clients commenced in November. A total of twelve Family Networks clients have been informed of the research and consented to participate. The research with clients at Addiction Services of Thames Valley is scheduled to commence in May 2009.
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Overview of the Addiction Pilot A purchase of service agreement has been agreed upon between, Addiction Services of Thames Valley (ADSTV); Family Networks (FN); and Children’s Aid Society of London – Middlesex (CAS). The contract period is from April 1, 2008 and March 31, 2009. An average of 15 hours per week for the contract period will be purchased from ADSTV. A trained and experienced staff member from the ADSTV team has been seconded to the Family Networks Team to mentor, showcase addiction assessment and treatment planning skills and offer feedback and on the spot training to Family Network Staff. The ADSTV staff will work within the Family Network environment on specific days to be arranged. The ADSTV staff will be accompanied by two managers on occasion who will also deliver training and mentoring as appropriate. The following specific services will be provided to Family Networks by ADSTV staff during the contract period: 1. 2. 3. 4. 5. Peer mentoring of staff to build capacity Addiction assessment and treatment planning Community treatment in individual and group formats Training in addiction and mental health screening (includes Problem Gambling) Training in Best Practice clinical standards
While the pilot was scheduled to commence in April 2008, the ADSTV staff was not recruited and in place until June 16, 2008 and did not start receiving client referrals until July 2008. Addiction Pilot Targets Targets have been established for the pilot in the following four areas: Screening, Assessments, and Treatment Plans – The initial target is to have 25 screens and assessments completed in the community, with treatment plans being developed as appropriate. If this target is easily surpassed, adjustments will be made accordingly. Training Sessions – Four training sessions were to be offered to FN and CAS staff to increase their sensitivity, knowledge, and comfort level to work with individuals who have substance use and/or gambling concerns. Community Information and Education Sessions – Four community information and education sessions will be offered in the North and Northeast London communities. Research – A target of 25 FN clients, and a minimum of 100 clients in the Substance Abuse and heartspace programs at ADSTV has been set for the research project
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connected with the addictions pilot. The purpose of the research is to evaluate the relationship between how assessments are completed and counselling outcomes. Milestones Achieved Addiction Pilot Set-up – The first meeting with ADSTV, FN and CAS to discuss the pilot occurred in May 2008. Following the meeting ADSTV began the recruitment process and seconded an existing staff from ADSTV to fill the position. Technology, in the form of a laptop and blackberry, was purchased and set-up for the position in June 2008. A schedule was created in consultation with the seconded staff, who officially started with the pilot on June 16, 2008. While the target of providing service 15 hours a week did not occur in April, May, and early June, it is important to note that the total target hours of service has been achieved. Referrals Received – The addiction pilot project has set a target of 25 screens, assessments, and treatment plans. To date a total of 25 referrals have been received. Out of the 25 referrals received, 14 have been accepted and have completed an assessment, 1 significant other consultation was accepted and provided with ongoing support, 4 referrals were declined by the clients after the initial referral, 1 referral was declined as the client was already engaged in another program at ADSTV, 3 referrals are pending with FN, 1 referral with withdrawn by Family Networks, and 1 referral was withdrawn by CAS (Figure 1). Referrals received for the addictions pilot have come from CAS, FN, ADSTV, and self-referral with 10 of the referrals being new referrals from CAS, 3 referrals from ADSTV, one self-referral, and the remaining 11 referrals were existing clients of FN who were struggling with substance use concerns (Figure 2). It is important to note that 7 of 11 of the referrals from FN had previously been referred to ADSTV for assessments and treatment however none of the individuals followed through on the past referrals to ADSTV.
Figure 1 - Referrals Received
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Figure 2 - New Referrals vs. Existing Clients
Screening and Assessments – Of the 25 referrals received, 14 individuals have completed the intake, screening, and assessment process. Four referrals were declined after the initial screening process, as the clients indicated that while they would like the support of Family Networks, they were not interested in receiving substance related supports. Of the four clients who declined the referral, two of the clients stated that they changed their mind and no longer wanted substance related supports, one was not home for her intake appointment and did not respond to attempts made to schedule a new intake appointment, and one declined the referral as she feels she has adequately addressed her past substance use concerns. One referral was declined as the client was already engaged in another program at ADSTV, one referral was withdrawn by CAS as the client was no longer working with his partner to have their children returned to his care, one referral was withdrawn by FN as the client was no longer following through and meeting with FN staff, and three referrals are currently pending with FN. All three of the referrals that are pending with FN have been contacted for intake and addiction screening and assessment however none of them have followed through with the Addiction/ Mental Health Community Counsellor. The addictions pilot target of 25 completed assessments was not achieved despite having received 25 referrals. There are many contributing reasons why the target was not achieved. The two main barriers initially identified were a lack of referrals and the waitlist at FN. These barriers were addressed by increased promotion of the addiction services that are now available through the FN program and by the hiring of one additional Neighbourhood Facilitator to address the issue of the waiting list for
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services. Neighbourhood Facilitators provide the overall case management of the families which does limit the number of families each Neighbourhood Facilitator can work with at one time. To further support the role of the Neighbourhood Facilitator and decrease the risk of addiction referrals waiting for services, the Addiction/ Mental Health Community Counsellor had agreed to take on the role of case management with new families who were referred for addiction support until a Neighbourhood Facilitator was available to begin working with the families. Despite taking these steps the target was not reached as additional barriers developed. These barriers included difficulty connecting with clients due to telephone numbers being disconnected, lack of follow through by clients and/ or clients declining the referral, referrals being withdrawn, changes in client’s life circumstances, and a decrease in referrals in March. In January and February 2009 eleven referrals were received (five in January, six in February), however only one referral was received in March and this referral was from ADSTV. If all existing referrals had completed the intake, screening, and assessment process and if the number new referrals remained consistent or increased, the target of 25 assessments would likely have been achieved. To ensure the success of achieving the targets for the 2009 – 2010 fiscal year, it is critical that the ongoing promotion of the addiction services through FN continue.
Table 1 – Monthly Referrals Received
6 5 4 3 2 1 0 Jul‐08 Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ Mar‐ 08 08 08 08 08 09 09 09 Number of Referrals
Training Sessions – The addiction pilot set a target of completing four training sessions that FN and CAS staff could participate in to enhance their sensitivity, knowledge, skills, and confidence level in supporting substance involved individuals. This target has not only been achieved, it has been surpassed. To date a total of nine training sessions have occurred, with another two sessions scheduled for the FN staff. Since June 2008, a total of 12 training sessions have been scheduled. Of the scheduled training sessions, 9 have occurred, 2 have been cancelled by ADSTV, and one has been cancelled by FN. Training topics have included; Addiction Pilot
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Introduction for CAS Supervisors, Best Practices for Working with Substance Involved Individuals, The Evolution of Addictions, Introduction to the Stages of Change, Introduction to Motivational Interviewing, Motivational Interviewing Skills Part II, Addiction Screening and Assessment Tools, and Introduction to Problem Gambling. Community Information and Education Sessions - Six community information and education sessions were scheduled for substance users and families and friends of substance users in the North and Northeast London communities. Research – The research connected with the addictions pilot will be evaluating the relationship between how assessments are completed and counselling outcomes. Many consultations have been completed with the researcher at Kings University College and the policy and procedures for the research study have been developed. The research commenced in November with clients receiving assessments and treatment in connection with FN and to date, twelve FN clients have been informed of the research project and have consented to participate in the research. The research is scheduled to commence with clients in the Substance Abuse and heartspace program at ADSTV beginning in May 2009. Policy Development – Providing addiction assessments and treatment in client’s homes in collaboration with another agency was a new initiative for ADSTV which thereby created the need for policy development. To date, thirty-three policies and procedures have been developed to guide the staff seconded from ADSTV in the role as an Addiction/ Mental Health Community Counsellor. These policies and procedures were designed to supplement the existing policies and procedures at FN. In addition to the need for new policies and procedures, the addictions pilot also resulted in the creation of a new job description outlining the roles and responsibilities of an Addiction/ Mental Health Community Counsellor. Tracking and Information Collection - Tracking sheets have been created using Excel to gather information about client referrals, training for FN and CAS staff, research tools scores, and to track the time of ADSTV staff related to the addictions pilot. The time tracking sheets are used to track the amount of time spent each day, by the Addiction/ Mental Health Community Counsellor, ADSTV Managers, and ADSTV Administrative staff working on tasks related to the addictions pilot. Time is tracked in the following areas: Indirect Client Service, Direct Client Hours Scheduled, Direct Client Hours Occurred, Mentoring, Project Meetings, Staff Meetings, Case Reviews, Research, Workshop Facilitation, Workshop Preparation, Community Meetings, and Other/ Non-client Related Activities. Refer to Appendix One for descriptions/ definitions of each category.
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Through the utilization of the time tracking sheets we are able to identify the amount of time that was spent in each of the above noted areas over the contract period. Of the contracted 780 hours, 334.75 hours were client related, 45.75 hours were spent mentoring FN staff, 84.75 hours were spent in project meetings, FN staff meetings, FN case reviews, and community meetings, 29 hours were spent completed research related tasks and consultations, 106 hours were spent completing preparation and workshop facilitation, and 179.75 hours were other/ non-client related (see Figure 3).
Figure 3 ‐ Time Tracking
In addition to basic client demographic information that is collected, tracking sheets were created to record the following information: referral source, client’s stage of change, assessment outcomes, treatment plan, number of scheduled individual appointments, number of individual appointments that have occurred, group counselling referrals, external/ community referrals, age of substance use onset, trauma history, history of childhood sexual abuse, history of eating disorders, mental health concerns, past attempts to change substance use, family history of substance use, and family history of mental health concerns. Information gathered from clients in these areas is further discussed in the clinical observations section of this report. Client Resources – Resource material has been created and/ or collected from a variety of sources to be used with clients. The materials have been broken down based on the stages of change, to be able to provide clients with the most appropriate information and support for their current situation. For clients who are in the pre-contemplation stage, an individualized education session will be developed for them based on their drug of choice and relevant issues
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that prompted them to connect with the Addiction/ Mental Health Community Counsellor. This is a new approach for ADSTV, where the current practice is that “pre-contemplators” are scheduled for a two hour group information and education session, and are not given the opportunity to meet individually with a counsellor to review their individual situation. While the Addiction/ Mental Health Community Counsellor has not had the opportunity yet to work with “pre-contemplators”, the hope is that by providing an individualized education session, the client will begin to move forward to the contemplation stage of change and be willing to look at ways of changing their substance use. There are a variety of treatment materials that are available for use with the clients based on the client’s identified goals and needs. Clients are given the opportunity to create treatment change plans with the Addiction/ Mental Health Community Counsellor, and through this process identify the areas of their life they would like support enhancing to enable their continued success in their recovery. In addition to the materials that were collected and/ or created by the Addiction/ Mental Health Community Counsellor, a wide range of resource materials have also been purchased to supplement the current resources available. Addiction Training To date a total of nine training sessions have occurred, with another two sessions scheduled for the FN staff. Training was facilitated by the Addiction/ Mental Health Community Counsellor, the heartspace Program Manager, the Problem Gambling Program Manager, and the Executive Director of ADSTV. Over the contract period at total of 24 hours were spent preparing for workshop facilitation, and 82 hours were spent providing workshop facilitation for CAS and FN staff. The following is a breakdown of the training sessions that have already occurred with the FN and CAS staff: CAS Supervisor Training – A one hour information session that was provided for the supervisors within CAS to increase their awareness about the partnership with CAS, FN, and ADSTV. Evolution of Addiction and an Introduction to the Stages of Change – A five hour training session for FN and CAS staff. The Evolution of Addiction focused on increasing awareness about the history of the addiction field and the progress and many changes that have occurred over the years. The Introduction to the Stages of Change was focused on increasing staff knowledge and comfort level to work within the Stages of Change model. The training session had a total of 31 participants, 9 of whom where FN staff, and the remaining 22 were CAS staff (Figure 4).
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Figure 4 - Evolution of Addiction and Introduction to the Stages of Change
An Introduction to Motivational Interviewing – A two and a half hour training session for FN and CAS staff held at the London CAS Oxford Street location. This training session focused on the history and basic principles of motivational interviewing. This training session was offered as a pre-requisite for the Motivational Interviewing Part II training session. A total of 17 staff attended the training session. Of the staff in attendance, 9 were from FN, and 8 were from CAS (Figure 5).
Figure 5 - Introduction to Motivational Interviewing Training
Best Practices for Working With Substance Involved Individuals – This was a thirty minute information session for FN staff reviewing the key concepts and best practice information for supporting substance involved individuals. Best practices for working with substance involved women who are pregnant and/or parenting were also reviewed. This session was exclusively for the FN staff, and there was a total of 11 FN staff present. An Introduction to Problem Gambling – This was a one hour training session that was offered exclusively to the FN staff. During this session, FN staff were taught the
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differences and similarities between substance users and problem gamblers, provided with definitions about gambling, given current gambling statistics, provided with a list of signs and symptoms of problem gambling, and given information on how to screen and discuss potential gambling concerns and referrals with the families they are supported. A total of 9 FN staff were in attendance. Information packages were also left for the FN staff that were unable to attend the training session. Addiction Screening and Assessment Tools – This was a one hour training session that was offered exclusively to the FN staff. During this session, FN staff had the opportunity to review the screening and assessment tools that are currently utilized by the Addiction/ Mental Health Community Counsellor. In addition, the FN staff were informed of upcoming introduction of the GAIN mental health screener that will also be utilized by the Addiction/ Mental Health Community Counsellor. The screening and assessment process was explained and FN staff were encouraged to ask questions and a discussion was facilitated to review how the information collected can further support the work of the FN staff. A total of 12 FN staff were in attendance. Information packages were also left for the FN staff that were unable to attend the training session. Motivational Interviewing Part II – This was a six hour training session that was offered on two separate occasions, once for FN staff, and once for CAS staff. Motivational Interviewing Part II was designed to build on the knowledge and skills taught to staff in the Introduction to Motivational Interviewing training sessions. MI Part II, was a practice based training session, where staff were given multiple opportunities throughout the day to practice the motivational interviewing techniques that were being taught. In total 25 staff participated in the MI Part II training. Of the staff that completed the training 10 were from FN, with the remaining 15 staff being from CAS (Figure 6).
Figure 6 - Motivational Interviewing Part II Training
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In addition to the training sessions that have already occurred, FN staff will be provided with two additional training sessions in 2009. The two remaining training sessions yet to occur are: Harm Reduction Theory and Strategies, and Working with Substance Involved Youth. All FN staff will have the opportunity to participate in these training sessions. To support the formal training provided to FN staff, the Addiction/ Mental Health Community Counsellor has continued to provide mentoring through bi-weekly case reviews and natural opportunities that arise. As the number of addiction referrals has continued to increase there have been more opportunities for mentoring and informal training. FN staff knowledge and skills have been strengthened through the training, mentoring, and increased opportunities to work directly with families who are impacted by substance use. Evaluation of Addiction Training To assist with the evaluation of the training completed, participants were asked to complete pre and post tests for the Evolution of Addiction, Introduction to the Stages of Change, Introduction to Motivational Interviewing, and the Motivational Interviewing Part II training sessions. Participants were given the same list of questions to answer pre and post training with the following three options for their answers: true, false, and I don’t know. While being asked to complete the pre and post tests, the participants were encouraged to circle the “I don’t know” option for questions that they were unsure of the correct answer for and informed that the purpose of the pre and post test was to evaluate the actual training session and information shared vs. their own personal knowledge of the topics. Participants were not asked to record their names on the pre and post tests. Results of the pre and post tests indicate that the majority of participants have grasped the key concepts of each of the training components they have received. In addition to the evaluation forms that were completed by the staff in attendance at the training session, feedback has been provided from supervisors with CAS. While reflecting on the training completed, CAS supervisors were able to apply the Stages of Change theory to their staff with regards to readiness to change. Through application of the stages of change and reflection on the organizational culture at CAS it becomes apparent that individual staff will be at various stages of change which is influenced not only by the individual but also by both the historical and current context of their working environment. For example, during times when there are children dying, either who are in the care of the society or remain in the care of the parents with society involvement, resulting in inquests being conducted, staff are less tolerate of risks and/ or perceived risks. This
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can lead staff to take a more intrusive approach and less relational when working with families. One of the goals of the training which has been completed is to assist staff, especially seasoned staff that have experienced many changes within child protection, to increase their skills and comfort level to take a more strengths based approach when working with families. All people, including the clients served by CAS, FN, and ADSTV, and the staff that support them, will change at the pace that is most comfortable for them. As a result, organizational change can be difficult and takes a great deal of time, even when all people involved believe in the changes that are being made. Ongoing training and open, honest conversation should be utilized to support individual change which can assist to cultivate larger organizational change. Community Information and Education Sessions A total of six community information and education sessions were scheduled and advertised in Northeast and East London. Three sessions were developed for individuals who were concerned about their own substance use and three sessions were developed for family and friends of substance users. Of the six sessions scheduled two occurred, with the remaining four being cancelled due to a lack of registrants. When the sessions were being developed the decision was made to provide food, child care, and assistance with transportation to decrease the number of barriers that could prevent individuals from attending. This information was included on the flyers that were created to promote the information and education sessions. The sessions were promoted by sharing the flyers with existing FN clients, circulating the flyers to CAS, London Housing, and other service providers in Northeast and East London. It is possible that the sessions were not promoted well enough which contributed to lower registration. In future this could be overcome by distributing the flyers to more service providers, clients, and posting the flyers in local community centres and stores that are accessed by individuals in living Northeast and East London. Of the three sessions that were scheduled for substance users a total of two people attended one session (see Table Two). Both individuals reported that they found the session helpful. The first session that was scheduled had two people registered initially however both called and asked to reschedule for a later session. The second session had eight people registered. Two individuals attended, two individuals cancelled due to time conflicts, and four people did not show or call to cancel or reschedule. The two individuals who cancelled did later register for the third session. These were the only two people who registered for the final session that was
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scheduled and unfortunately both individuals cancelled; one no longer wanted to attend, one was called into work on short notice.
Table 2 – Concerned with Own Substance Use
8 7 6 5 4 3 2 1 0 Session One Session Two Session Three Registered Attended Cancelled Did not Show
Table 3 ‐ Concerned with Others Substance Use
12 10 8 6 4 2 0 Session One Session Two Session Three Registered Attended Cancelled Did Not Show
As with the substance users group, there were only two people who attended one of the three sessions that were scheduled for family and friends of substance users (see Table Three). There were four individuals scheduled for the first session however all requested to be rescheduled due to time conflicts. The second session had eleven people registered however only two attended. Of the remaining nine people, four called to reschedule due to time conflicts, and five people did not attend or call to cancel or reschedule. The final session had a total of three people registered. One person cancelled due to needing to provide support to her daughter however requested information be sent to her via mail. The remaining two individuals were the parents of a current FN client and felt that it would be more beneficial to attend when other families would be coming so that they could receive some support from other families experiencing similar issues.
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There are many possible reasons why these sessions were not more successful. Some of the general reasons for both groups could include time of day, day of the week, transportation barriers, location of the sessions, and a lack of notice depending on how and when they received the information. In relation to the substance users groups, low registration and attendance may be related to fear of acknowledging a substance use problem and potential repercussions, lack of motivation to attend the session, stigmas related to substance use, no desire to explore nature of their substance use or frustration with pressure from others to attend. Feedback received from a support worker who had referred individuals to the family and friends sessions indicated that some families did not attend or want to attend due to stigma related to substance use, fear of being blamed for the substance users problems, no desire to increase their understanding of addiction and the impact on the family, concern about confidentiality/ being recognized by others, feeling that they have “done enough” to learn more/ improve the support they provide to substance users in their family, and preference to receive individual support specific to their own situation. Clinical Work and Observations Over the contract period, 42% of the time was spent providing direct and indirect client services. A total of 168 hours were spent providing indirect client services which includes, activities such as writing case notes, preparing progress reports, writing letters of support/ advocacy, consulting with other service providers involved with the client, supervision meetings about clinical work provided, travel to and from client appointments, and recording client appointments. There was 173.5 direct hours scheduled, and of these 166.75 direct hours of service was provided. Direct client service includes individual appointments, phone contact with client, participating in case conferences with client and other service providers, and facilitation of groups for clients. As previously discussed, in addition to basic client demographic information that is collected, the following information is also collected from client’s throughout their assessment: client’s stage of change, assessment outcomes, treatment plan, number of scheduled individual appointments, number of individual appointments that have occurred, group counselling referrals, external/ community referrals, age of substance use onset, trauma history, history of childhood sexual abuse, history of eating disorders, mental health concerns, past attempts to change substance use, family history of substance use, and family history of mental health concerns. This section of the report will review both general demographic information about the FN clients referred to the addiction pilot and information gathered from the above categories.
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Age Range of Referrals – The age of clients referred to the addiction pilot ranges from 13 to 49 years old. Of the fourteen referrals that have been accepted and had assessments completed the age ranges from 21 to 49 years. Male to Female Ratio - Of the referrals received, 17 were female, and 8 were male (Figure 7). Three males have completed the assessment, and 11 females have completed the assessment.
Figure 7 - Gender of Referrals
Stages of Change – Fourteen of the referrals have completed the Stages of Change screening tool. One client has indicated that she was in contemplation, six clients indicated that they were in preparation; three clients indicated that they were in action, three clients are in maintenance, and one client indicated they were in the termination stage of change at the time of intake (Figure 8). Since the time of intake, the individual who was in contemplation has moved into preparation, five of six clients in the preparation stage of change have moved forward into the action stage of change with one remaining in preparation, two of three have moved from action into maintenance with one remaining in action, while the other four clients have remained in the same stage of change at they were in at the point of entry.
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Figure 8 - Stage of Change at Intake
Average age of Onset – Of the fourteen referrals who have completed assessments, the average age of onset of substance use was 14 years. The earliest age reported was 11 years old, with the oldest age of onset reported being 17. History of Trauma – When clients are initially referred to the addiction pilot they complete a series of screening tools related to addictions and mental health. One of the screening tools is called the “Trauma Response Questionnaire”, TRQ, and is used to screen for a history of trauma. Of the fourteen individuals who completed the TRQ and assessment, twelve identified that they have a history of trauma (Figure 9). It is important to note that eleven of twelve individuals were female, and the only two individuals who reported no history of trauma were male. In addition to other forms of trauma the clients have reported, eight out of fourteen clients reported experiencing childhood sexual abuse (Figure 10). Of these individuals, only one identified that she had received past counselling for the abuse, however six of eight reported that they feel the past sexual abuse continues to impact their daily lives presently and is connected to their substance use history.
Figure 9 – Client History of Trauma
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Figure 10 - History of Childhood Sexual Abuse
Mental Health Concerns – Ten of the fourteen clients have reported that they have diagnosed mental health concerns (Figure 11). All ten clients reporting mental health concerns are female and all but one have multiple diagnoses. Eight women report suffering from depression, one women reports a diagnosis of bi-polar disorder, six women report suffering from anxiety disorders, five women have PTSD, and three women are questioning possible ADHD diagnoses (Figure 12). All women reported that they have tried various strategies to cope with their mental health concerns including medication, self-medicating with substance use, individual and group counselling, meditation, and grounding techniques. Two of the three males who completed the assessment identified experiencing some feelings of depression which they attributed to lack of gainful employment; however both were very adamant that they do not have a mental health diagnosis. This finding may identify the need for increased sensitivity and information sharing with male clients when screening for and discussing mental health concerns. This will hopefully help to normalize their concerns and open the door to discuss any mental health concerns they may be struggling with.
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Figure 11 - Clients with Mental Health Diagnoses
Figure 12 - Mental Health Diagnoses
History of Eating Disorders – Three of the fourteen clients have reported past concerns with bulimia and while they have reported they currently are not struggling with bulimia, they have continued to report concerns about their body image and fear of weight gain. Two women have reported that have struggled with anorexia with one of the women reporting that she continues to struggle with anorexia while the other woman reports that she has successfully healed from her past eating disorder. One male client reports that he vomits daily however states that he does not consider this to be an eating disorder as it is not negatively impacting his health. One additional client reported that while she has not had an eating disorder in the past she has used substances to control her weight and decrease the risk of weight gain. All of these
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individuals have reported past sexual abuse prior to the onset of their substance use and eating disorders/ body image concerns. Family History of Substance Use and Mental Health Concerns – Twelve out of fourteen clients reported that they have a family history of substance use and eleven out of fourteen report no family history of mental health concerns. Two clients reported that there was no history of substance use or mental health concerns in their family (Figure 13 and Figure 14). While discussing family history of substance use, clients have expressed their concerns about the potential for their children to develop problematic substance use and have requested information and support about talking with their children about substance use. Two of the client’s have identified that they are aware their teenage children are using substances, and one has requested assistance in connecting her son with support to explore his substance use.
Figure 13 - Family History of Substance Abuse
Figure 14 - Family History of Mental Health Concerns
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External Referrals – Referrals have been provided to six clients for external services. Two referrals were given to clients for counselling at the London Abused Women’s Centre, one referral was provided for community treatment services at Pinewood as the client was relocating and wanted ongoing support, one referral was provided to the Ontario Early Years Centre for a father looking to increase his skills and knowledge in parenting, one referral was provided for a client to receive counselling at the Sexual Assault Centre London, one referral was provided for the PEIC group at Merrymount Children’s Centre, and one referral was provided for a client to receive short-term residential treatment at the House of Sophrosyne. Location of Client Appointments – Each time a client schedules an appointment with the Addiction/ Mental Health Community Counsellor, they are given the opportunity to choose the location of their next appointment. To date, individual client appointments have occurred in the following locations: client’s homes, Tim Hortons (various locations throughout the city), Wendy’s Restaurant, the Beacock Library, Merrymount Children’s Centre, the ADSTV Queens Ave Location, CAS London Oxford Road location, and the London Courthouse. Of the fourteen clients who have completed an assessment, three consistently requested that the appointments occur within their own home due to social anxiety. The remaining clients have been willing to meet with the Addiction/ Mental Health Community Counsellor in other locations throughout London that have been convenient for them. Clients have reported that they determine the location of their next appointment based on things such as other appointments they have on the same day, flexibility around their work schedule, visits with their children, needing to attend court, and presence of other people in their home who they do not what to be present when they meet with the Addiction/ Mental Health Community Counsellor. Feedback from Clients – 100% of the clients who have completed an assessment and accepted a treatment plan have reported that they have found it beneficial to have flexibility around the scheduling of appointments and selection of the location for their appointments. A client satisfaction questionnaire is currently being developed and will be mailed out to clients with a stamped, addressed envelope so that they can anonymously return the completed questionnaire. Unanticipated Findings In addition to the research that is currently being conducted, there were many findings/ outcomes that were expected and these have already been discussed. However, we felt it was important to note some of the unanticipated findings that have come to our attention over the past ten months.
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Neighbours Supporting Neighbours – One of the trends that we have started to see is that neighbours are telling each other about the supports they receive from Family Networks and are encouraging each other to become involved. Neighbours are giving their neighbours referral information for Family Networks and telling them about the addiction supports that are available. One woman identified to the Addiction/ Mental Health Community Counsellor that she would not have sought out support for her substance use concerns at ADSTV due to fears that her son would be removed from her care and that she would be seen by her own clients as she works in the health care field. Being able to receive counselling and support in her home has helped to address her concerns about confidentiality and to educate her about CAS and the supports they have to offer. Family Networks is helping individuals, families, and communities move back towards the philosophy that “it takes a village to raise a child”. Concerns About Gambling – All clients who have completed the screening and assessment process have completed screening for problem gambling. Despite the fact that none of the fourteen clients have identified any concerns with their own gambling, three clients have identified that they have concerns about somebody else’s gambling. These three clients have requested information about problem gambling for their loved ones, and information for themselves so that they can learn more and learn how to be a positive support. In addition, all clients who completed the gambling screen have been open to talking about problem gambling. One client has shared that he does play Texas Hold Em regularly, however identifies that he rarely plays for money. He feels that he is a responsible gambler and has used a weekly family game night as a way of rebuilding his relationship with his extended family. Parents Concerns About Children & Youth Substance Use – Individuals who have been receiving ongoing support from the Addiction/ Mental Health Community Counsellor, especially those with teenagers, have requested information they can share with their children. During their sessions they have shared concerns about their own children developing substance use concerns based on family history, especially if their children are aware of the parents’ struggles with substance use. Parents have requested information they can share with the children about drugs and alcohol and have asked for guidance about how to start the conversations with their children. One of the most consistent fears they have shared with the Addiction/ Mental Health Community Counsellor is that their children will not listen to them because of their own substance use. Parents consistently report that they are fearful they will be perceived as “hypocritical” and they do not have the right to educate their children when they themselves struggle with substance use. They are acutely aware the influence of peers and the changes in the drug culture. All individuals who have completed an assessment have identified that they do not want their children to have the experience
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they have had with drugs and alcohol and identify they want to stop the cycle and pattern of addiction within their family. Families Seeking Support – Despite low attendance at the Family and Friends Community Information and Education sessions that were offered, family members have reached out to the Addiction/ Mental Health Community Counsellor to request support and information to improve the quality of their relationship with substance users in their families. This has occurred through case conferences in which family members have been present and through clients providing their family members with the contact information for the Addiction/ Mental Health Community Counsellor. All family members that the Addiction/ Mental Health Community Counsellor has spoken with have identified that they would like to see more services for the families members, specifically an ongoing support group for the family and friends to discuss how they are feeling, receive support from their peers, and to learn more about how addiction impacts the family and healthy coping strategies they can utilize. Request for Additional Training – As a result of the Stages of Change training and Motivational Interviewing training that was offered at CAS, ADSTV has been approached and requested to provide additional training. While the training that was initially provided was related specifically to working with substance-involved individuals, CAS has requested ADSTV provide training on Motivational Interviewing theory and skills to their staff. ADSTV has agreed to provide the training to their staff and discuss MI as it relates to the world of child protection. Treatment Services – The initial contract with ADSTV was to provide screening, assessments, and develop treatment plans however did not include providing treatment. Due to low referrals, once screening and assessments were completed with clients, when appropriate, they were also offered the option to participate in Community Treatment with the Addiction/ Mental Health Community Counsellor. All clients who were appropriate for community treatment services accepted a treatment plan with the Addiction/ Mental Health Community Counsellor. All treatment plans included participating in individual counselling. For clients who also identified the need for group counselling they were referred to appropriate groups at ADSTV as part of their treatment plans. Clients reported that they found it beneficial to have the ability to receive their individual counselling through the Addiction/ Mental Health Community Counsellor while also being able to participate in group treatment.
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Recommendations and Considerations To ensure continued success of the addiction pilot in the 2009 – 2010 fiscal year realistic targets need to be set. There are several factors that need to be taken into consideration when establishing these targets starting with a reflection on the 2008 – 2009 targets. 2008 – 2009 targets were as follows: Screening, Assessments, and Treatment Plans – The initial target is to have 25 screens and assessments completed in the community, with treatment plans being developed as appropriate. If this target is easily surpassed, adjustments will be made accordingly. Training Sessions – Four training sessions were to be offered to FN and CAS staff to increase their sensitivity, knowledge, and comfort level to work with individuals who have substance use and/or gambling concerns. Community Information and Education Sessions – Four community information and education sessions will be offered in the North and Northeast London communities. Research – A target of 25 FN clients, and a minimum of 100 clients in the Substance Abuse and heartspace programs at ADSTV has been set for the research project connected with the addictions pilot. The purpose of the research is to evaluate the relationship between how assessments are completed and counselling outcomes. Determining targets related to direct client service can only be set once targets in other areas have been established as the time to provide other services will impact the amount of time available to work with clients. Research – No additional targets need to be established in relation to the research as this is ongoing as the research commenced in the 2008 – 2009 fiscal year however the targets were not achieved so it has been carried forward to the 2009 – 2010 fiscal year. Training Sessions – The first question that needs to be asked is will CAS or FN require any additional formal training in the 2009 – 2010 fiscal year? If the answer to this question is yes then another series of questions need to be asked when establishing the target. These questions are: In what areas/ topics does CAS and FN staff require training? Are these the same areas/ topics for both CAS and FN or do the staff at each agency have different needs?
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For any areas/ topics that are the same, can the training to CAS and FN staff be provided jointly? What are the benefits and drawbacks of providing joint training? How long will each training session be scheduled for? When will the training sessions be scheduled? For example, if there is more than one topic to cover, will the training sessions be offered in close proximity to each other or will the training sessions be spread out and offered throughout the year. Who will provide the training, the Addiction/ Mental Health Community Counsellor or a manager from ADSTV or a combination of both? How much preparation time will be required for each training session? What will be the approximate total amount of time the Addiction/ Mental Health Community Counsellor will need preparing and facilitating training for the 2009 – 2010 fiscal year? Determining the total amount of time that would be spent related to training is critical as time spent on training, while a valuable use of time, will directly impact the amount of time available to work with clients. It was already noted that there are two remaining training sessions for the FN staff, Harm Reduction and Working with Substance Involved Youth. These two sessions will be one hour each in duration and will occur during a staff meeting. Each presentation will require approximately one hour in preparation time. This means that a total of approximately two hours will be needed to offer this training as the Addiction/ Mental Health Counsellor is regularly scheduled to attend the staff meetings so no additional time will be needed to offer the training session. Community Education Sessions – Again we need to start by asking the question, should the Community Education Sessions be offered again this year? To determine if they should be offered again we need to evaluate the costs and benefits of the Community Education Sessions and reflect on the sessions that were offered in the 2008 – 2009 fiscal year. In 2008 – 2009 there were a total of six sessions scheduled, each session was scheduled for two hours, with a half an hour scheduled pre and post sessions to allow for set-up and clean-up, for a total of 18 hours being dedicated to offering the training sessions. In addition to the time set aside to offer the training session, there was approximately five hours spent developing the presentations and photocopying the materials for the participants. One must also consider that two of the training sessions
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required child care, one session required one child minder and one session required two child minders. There were not any room rentals fees which was positive. To determine the costs of offering these sessions we need to reflect on and answer the following questions: What was the total time spent by the Addiction/ Mental Health Community Counsellor in preparing for the sessions, advertising the sessions, securing space and child minders, registering people for the sessions, and actually offering the sessions? The cost of child minders vs. the cost of not offering child minding during the sessions and the impact this may have on registration. How much money was spent on food for the sessions? What were the other costs of offering the session? These costs must be looked at in relation to the benefits as well. We must consider if the costs incurred are worth the benefit of the services that were offered to the four individuals who actually attended the sessions. Knowing all four individuals reported that it was a positive experience and they all feel that they gained new information and support we must determining if enhancing the lives of four individuals was worth the costs. If it is determined that it would be beneficial to offer the community education sessions again we need to consider the following: How can advertising of the sessions be improved so that there is increased registration and attendance? What is the best location to be offering these session or does location matter? How can food be offered during the sessions yet be a lower cost than last year? What is the best way to offer child minding services during the sessions or should it be offered at all? Is the time sessions were being offered related to low attendance? If yes, what would be a better time to offer these sessions? Would we offer the same sessions again (one for substance users and one for people concerned about somebody else’s substance use) or should we target different populations? For example, should we offer information sessions to current clients at FN that increase their awareness and knowledge in recovery vs. targeting precontemplative clients?
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How many sessions would be offered over the year if we choose to offer them again? What would be the amount of time the Addiction/ Mental Health Community Counsellor would spend advertising, registering, preparing and offering the sessions and how would this impact client services? We also need to consider if there should be training provided to community professionals working with families in East and Northeast London. Should we offer a two day training session for community professionals were we would offer the Evolution of Addictions, Stages of Change, and Motivational Interviewing both theory and skills training? Again we need to consider the costs vs. benefits of offering this training. If this training is to be offered we need to determine: When and where would the training be offered? Who would facilitate the training the Addiction/ Mental Health Community Counsellor or a manager at ADSTV or both? What would be the advertised cost of the training? Could it be offered at a low cost that would cover the expenses of the training yet still be affordable to increase the potential for registration? Who would coordinate the registration? What would be the maximum number of participants in the training sessions? The final questions to consider before moving on to determining client targets is are there new target areas that we need to set? Once the targets for training and community education sessions have set and it has been determined if there are any other target areas we can then consider the targets for direct client services. Client Services – when determining targets for client services we need to consider what type of services we would like to offer. How many referrals would we like to receive in 2009 – 2010? How many screens and assessments should be completed? Do we want to continue providing treatment as appropriate to clients? Is the focus on increasing the number of new clients or retaining the clients we currently have or a little of both? How will the clients being carried forward from the 2008 – 2009 fiscal year be factored into the targets set for the 2009 – 2010 fiscal year?
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Is there the possibility for group work with clients? What type of group would be offered? How frequently should individual appointments be offered? Some of the general things to consider in relation to client services are: the Addiction/ Mental Health Community Counsellor participates in case conferences which occur every four to six weeks for each family. In addition, there is bi-weekly case reviews which last approximately two and a half hours and monthly staff meetings which last three hours. It is also important to consider indirect time which includes scoring assessment and research tools, preparing case notes, logging activities into catalyst and webtracker, preparing reports and assessment summaries, advocacy and third party contact, and travel to and from appointments/ meetings, especially in the winter months. We also need to consider if we will be providing significant other consultations and if so the target number we would like to offer. One significant other consultation (individual support to a family member concerned about somebody else’s substance use) was provided in the 2008 – 2009 fiscal year. If significant other consultations are to be offered we need to determine: How many individual sessions will they be offered? Should this be limited or flexible? Would the consultations only be available to FN clients or would they be open to anybody living in East or Northeast London? If there is a large request for significant other consultations would it be better to offer a group using the Families CARE materials from CAMH than offer individual appointments? It is apparent that there are many factors to take into consideration when determining new targets for 2009 – 2010. For this to be a successful year in which targets are achieved the above factors need to be carefully reviewed and reflected upon before we can establish the new targets.
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Final Thoughts It has been ten months since the Addiction/ Mental Health Community Counsellor started working with FN. A substantial amount of time has been spent setting up the pilot, getting a referral process in place, developing policies and client materials, and initiating the research component of the pilot. As time has passed by, the number of referrals has continued to increase. However, as with all new initiatives it is anticipated that there is often lower referrals in the early stages which has contributed to the failure to meet the target of 25 completed assessments. The most critical component of this pilot to ensure its ongoing success is to receive client referrals, which speaks to the need for ongoing promotion of the pilot. As with all pilots, evaluation is incredibly important both to ensure the pilot is achieving its targets and to set the stage for new and improved ways of delivering services. While clients have been able to provide their feedback informally about the pilot and the benefits they have experienced, they will be given the opportunity to complete a formal evaluation and client satisfaction questionnaire in the coming month. As the addictions field continues to grow and develop, so does the way the services are delivered. Each day that passes by gives us the opportunity to increase the quality of support and services provided to individuals who are struggling with addiction issues. This pilot allows us to literally “meet clients where they are at” and thereby further reduces barriers for receiving the treatment they need to make and maintain the changes they each identify in their own recovery journeys.
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Case Study – Betty’s Story In July 2008 Betty was referred to Family Networks by the Children’s Aid Society of LondonMiddlesex. Betty was initially contacted by the Addiction/ Mental Health Community Counsellor and agreed to meet to discuss the supports available to her and her family. Intake appointments were scheduled on two separate occasions, however Betty did not show for either appointment. In August 2008, Betty was arrested and charged with assault as a result of an incident that occurred while she was intoxicated. Betty was held in the cells overnight, and as she began to sober up she realized that she was in the one place that she never thought she would be. Getting arrested and taken to jail was the catalyst for Betty’s decision to quit drinking. After being released from jail into her eldest daughter’s custody, she headed to Addiction Services of Thames Valley for walk-in intake, where she completed the intake and assessment group and was given a follow-up appointment to meet with a counsellor individually in November. When the Addiction/ Mental Health Community Counsellor noticed Betty had come to walk-in intake, she gave Betty a call to discuss Family Networks again. Betty agreed that she would like support from Family Networks and scheduled an appointment to complete her assessment. Throughout the assessment, Betty shared her history of binge alcohol use which began at age 13 and was layered with periods of complete abstinence lasting up to four years at a time. Betty noted that she began drinking again in May 2008 and reported it quickly progressed to daily use of alcohol. She reported feeling disappointed in herself and frustrated that despite her daughter being removed from her care, she did not stop drinking until she found herself in “Hotel Exeter Road”. Betty describes the experience of awaking in a cold cell alone, yet surrounded but other women, sobering in many ways. She feels it helped her to look in the mirror to see how her life would progress if she did not quit drinking. Betty started working again and is juggling two part-time jobs. Juggling two part-time jobs would have made it difficult for her to attend traditional counselling offered at ADSTV as she would only get her work schedule one week in advance. Betty identified that the flexibility of being able to schedule her appointments once she has her work schedule has been helpful. She further indicated that it has been beneficial to have flexibility around the location of the appointments so that as needed she could meet with the Addiction/ Mental Health Community Counsellor at the Tim Hortons before or after she finished work. Since October Betty has continued to meet with the Addiction/ Mental Health Community Counsellor on a regular basis. As part of her treatment plan she was referred to the Open Relapse Prevention group at ADSTV which she successfully completed in March 2008. Betty reported that she is very proud of the fact that she not only completed the group but was able
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to attend all ten sessions. In addition to the support she receives from her counsellor and the Open Relapse Prevention group Betty attends AA meetings weekly for ongoing peer support. In January 2008 Betty registered herself and her youngest daughter for guitar lessons as a way of strengthening their relationship. With the support of her Family Networks Neighbourhood Facilitator she was able to connect her daughter with art therapy and a grief support group to help her daughter heal from her father’s death and the separation from her mother since she entered into the care of her grandparents. Betty reports that both the art therapy and the grief group were extremely beneficial for her daughter and opened the door for them to talk about the death of her daughter’s father and the impact it has had on their family. Betty continues to increase her healthy coping skills and recreation and leisure activities. She has been able to focus on her recovery while increasing the quality of the relationship with both her daughters and her extended family. In March 2008 Betty had her daughter returned to her care and celebrated six months sobriety. Betty reviewed her goals and determined in addition to continued sobriety, healthy living, and building her relationship with her children she would like to focus on securing full time employment. Betty is hopeful that full-time employment will give her better financial stability and allow for greater routine and structure with her daughter which will enhance their relationship and her parenting skills. While Betty’s recovery philosophy is “one day at a time”, she reports looking forward to her one year celebration and is hopeful that her daughters and extended family will be able to attend. Betty continues to meet with the Addiction/ Mental Health Community Counsellor although the frequency of appointments has decreased as her confidence in her recovery has increased. Through the support of her Family Networks Neighbourhood Facilitator and the Addiction/ Mental Health Community Counsellor and the hard work she has done, Betty has been able to reach her goal of sustained abstinence and having her daughter returned to her care.
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