National Assembly for Wales / Cynulliad Cenedlaethol Cymru
Health and Social Care Committee / Y Pwyllgor Iechyd a Gofal Cymdeithasol

Inquiry into alcohol and substance misuse / Ymchwiliad i gamddefnyddio alcohol a sylweddau

Evidence from The British Psychological Society – ASM 17 / Tystiolaeth gan Cymdeithas Seicolegol Prydain – ASM 17

British Psychological Society response to the National Assembly for Wales Health Select Committee

Alcohol and substance misuse

About the Society

The British Psychological Society, incorporated by Royal Charter, is the learned and professional body for psychologists in the United Kingdom. We are a registered charity with a total membership of just over 50,000.

Under its Royal Charter, the objective of the British Psychological Society is "to promote the advancement and diffusion of the knowledge of psychology pure and applied and especially to promote the efficiency and usefulness of members by setting up a high standard of professional education and knowledge".  We are committed to providing and disseminating evidence-based expertise and advice, engaging with policy and decision makers, and promoting the highest standards in learning and teaching, professional practice and research.

The British Psychological Society is an examining body granting certificates and diplomas in specialist areas of professional applied psychology.

Publication and Queries

We are content for our response, as well as our name and address, to be made public.  We are also content for the Committee to contact us in the future in relation to this inquiry.  Please direct all queries to:-

Joe Liardet, Policy Advice Administrator (Consultations)

The British Psychological Society, 48 Princess Road East, Leicester, LE1 7DR

Email: XXXXXXXXXXX      Tel: XXXXXXXXX

About this Response

This response was led for the British Psychological Society by:

Dr Pamela Roberts CPsychol, Division of Clinical Psychology

With Contributions from:

Dr Helen Barker CPsychol, Division of Clinical Psychology

Professor Miles Cox CPsychol FBPsS, Division of Clinical Psychology

Dr Lee Hogan CPsychol AFBPsS, Division of Clinical Psychology

Dr Lisa Jones CPsychol, Division of Clinical Psychology

Dr Rosslyn Offord CPsychol, Division of Clinical Psychology

Dr Alyson Smith CPsychol AFBPsS, Division of Clinical Psychology

We hope you find our comments useful.

Mary Clare O’Connell

Chair, Welsh Branch

British Psychological Society response to the National Assembly for Wales Health Select Committee

Alcohol and substance misuse

The impacts of alcohol and substance misuse on people in Wales, including young people and university students; older people; homeless people; and people in police custody or prisons;

Comments:

It is widely accepted that substance misuse causes considerable harm not only to individuals and their social networks but to the wider society. These harms are many and include both physical and mental problems, harms to the well being of families and children as well as harm to the wider community through the crime and antisocial behaviour associated with substance misuse. Recent reports suggest that the economic and social cost of Class A drug use in Wales is estimated to be in the region of £780 million with drug related crime accounting for 90% of this (‘Working Together to Reduce Harm, Welsh Assembly Governments Strategy 2088-2018).

The Welsh National Database for Substance Misuse (WNDSM) was set up in 2005 and provides information regarding referrals to treatment for drug and alcohol problems. In the period of 2011-2012 a total of 31,071 referrals were registered and of these 54% of the referrals identifies alcohol as being the main concern whilst 40% identified drugs and being the main issue. Males accounted for the majority of referrals in both cases and the median age for alcohol referrals was higher than that for drugs. Alcohol and cannabis are the main substances for which young people are referred into treatment (aged 10-19 years) and the rate of underage drinkers, despite a decline, remains one of the highest in Europe and North America. According to the 2011 Welsh Health survey, around 2 out of 5 adults report drinking above the recommended guidelines on at least one day in the past week, including a quarter who report binge drinking (Substance Misuse and treatment services in Wales, National Assembly for Wales, 2013)

The impact of substance misuse can be seen across a variety of domains and populations including mental health services, medical services, older adult services, young people and homeless services. There is also a recognised level of co-morbidity which can occur which has been traditionally difficult to bridge.(A Service Framework to Meet the Needs of People with a Co-occurring Substance Misuse and Mental Health Problem, Welsh Assembly Government 2007).

Research from North Wales suggests that in an inpatient sample of service users undergoing detoxification when screened during admission, 84% of patients were found to be within the clinical range for low mood and 77% were found to be within the clinical range for anxiety. Additionally, 96% of this sample was found to have impaired social functioning as detected by the GHQ 12 (Hogan et al, 2013)

Following the evaluation of two community services in North and Mid Wales information was produced regarding service users with substance misuse and co-occurring mental health problems.

Data from Conwy refrain, a counselling service based in North Wales, suggested that of the 121 service users who attended from assessment, 95% of people reported elevated levels of anxiety with 86% of the total in the moderate or severe range. Further, 85% of people reported symptoms of elevated levels of depression with 51% of the total in the moderate or severe range (Hogan et al, 2014).

HG2G was a group-based service located in Mid Wales  Data from this service suggested that of the clients assessed (n = 321),  88%  were found to have clinical levels of dependency, 94% reported clinical levels of anxiety, 78% reported low mood and 81% reported clinically impaired social functioning. Outcomes including Psychosocial Interventions appeared extremely effective (see Hogan, Elison, Ward & Davies, 2014; Hogan, in preparation).

As part of ‘A Service Framework to Meet the Needs of People with a Co-occurring Substance Misuse and Mental Health Problem’ (Welsh Assembly Government), a joint liaison or collaborative approach was recommended as the preferred model for the delivery of care to people with a co-occurring substance misuse and mental health problem. Via the Care Planning Approach, it was recommended that older people, with special consideration to the use of alcohol and tranquillisers, should be considered within this revised delivery system. The needs of young people, the homeless, ethnic minority groups, women, prisoners and people with a diagnosis of personality disorder were also to be included within this proposal.

Individuals with a dual diagnosis generally experience poorer outcomes with regard to their mental health, and their engagement with services and treatment compliance may also be compromised and or delayed. Conversely, individuals with substance misuse issues risk deterioration of their mental health and the emerging presence of serious mental illness. This may be compounded by the development of physical health problems which may necessitate the use of medical services (Department of Health, 2002) Mental health policy implementation guide: dual diagnosis good practice guide. London).

Given the broad range of mental health disorders – ranging from severe and enduring mental health disorders to milder mental health disorders such as anxiety  in combination with the various types of substances used, assessing which condition is the ‘primary’ and which the ‘secondary’ diagnosis may be challenging and may often present as a barrier to accessing appropriate services.

The long term effects of alcohol on the brain can be both psychological (mental health problems) and physiological (damage to brain tissue). People who drink heavily are particularly vulnerable to developing mental health problems, and alcohol has a role in a number of conditions, including anxiety and depression, psychotic disorders, and suicide. Over a long period of time, however, heavy drinkers may also develop various types of physical brain damage.

It has been suggested that Alcohol Related Brain Damage accounts for 10% of the dementia population and 12.5% of dementias in the under 65’s (Harvey et al, 1998) and whilst evidence of increasing levels of prevalence is suggested, estimates differ widely. Current provision for specialist assessment and rehabilitation of people with Alcohol Related Brain Damage within Wales is very limited. The lack of prevalence rates amongst local populations has meant that opinions about the extent of the problem have been divided across services. To date there are no clear estimates of prevalence of ARBD within South Wales and this has caused a delay in the development of services. Literature does suggest that if a diagnosis of ARBD can be confirmed early and the service user receives medical support and rehabilitative aftercare, that the progress of this disorder can be halted and in many cases reversed. This will have important implications for the development of services for this group as the long term care and support required for a comparatively young population is likely to be costly for the community (All in the Mind 2014).

Within addiction services we are seeing the emergence of younger people being diagnosed with ARBD and locally within Cardiff and Vale this has been noted in individuals under the age of forty (Roberts, 2012 unpublished). However, older people with ARBD often present to Older People’s Mental Health Services with various cognitive changes. Ongoing alcohol use in conjunction with even mild cognitive fluctuations can result in this group of service users presenting as more problematic in terms of management in the community due to relationship breakdowns, public disturbances and unplanned emergency hospital admissions (Wilson, 2013). Once admitted to hospital, it is often difficult to ensure a long lasting discharge back home if they continue to use alcohol there is an increased chance that they become ‘revolving door patients’.

Links have been established between Clinical Psychology services for Addictions and the Memory Team in Cardiff and Vale LHB Trust where clients presenting with alcohol related with memory problems are discussed prior to assessment.  However, there is an awareness that this joint working has to be limited due to limited staff numbers and availability. As such, follow up of these cases can be limited. Discussions are underway within Cardiff and Vale LHB in relation to piloting a rehabilitation unit for people who have cognitive impairment due to alcohol abuse.  However, preferences appear to favour a medically based model, rather than considering models of best practice, in which psychological assessment and therapies would form an integral part of the service.  Concern has been expressed among Clinical Psychologists locally about the quality of neurocognitive assessments that are being advocated and a failure to understand principles of cognitive rehabilitation.

Links between Older Peoples Mental Health Services and Community Drug and Alcohol Teams do not seem to be well established across Wales and whilst older service users with established Korskoff’s are easier for older peoples’ services to manage due to the similarity between this and other dementias, for those individuals who continue to use alcohol, the services are less consistent and many service users often risk losing accommodation which in turn, has implications for an already very stretched homelessness provision.

Another area of increasing concern is the emergence of ‘new highs’. These substances are often referred to as ‘recreational drugs’ and by this term there is an immediate implication of safety and less potent substances. In reality, many have not been tested and there is no information about the long term mental and physical health problems associated with their use. More recently, services have attempted to improve the spread of what knowledge there is via social media outlets and this is potentially an effective way of communicating to the largest using age group which appears to be between 20-34 years (WEDINOS, 2014). Recent changes in the classification of Khat will likely have specific implications for South Wales as currently Cardiff is home to the largest Somali population in the UK and this has been a traditionally used substance within this culture. In 2014 the Advisory Council on the Misuse of Drugs undertook a review of the available scientific evidence on harms relating to Khat and whilst they did not recommend banning the use of this substance it was acknowledged that due to the lack of evidence in relation to its properties and the effects of these, that it should be classified as a Class C drug.

Many of the research studies conducted at Bangor University, North Wales, suggest that hazardous drinking is common among university students (Cox et al, 2014, Shamloo et al, 2010) Moreover, in research studies, which have evaluated the effectiveness of interventions to reduce students’ problematic drinking, they were found to be effective both for reducing alcohol consumption and for bringing about other positive changes in students’ lives (Cox et al, 2014).

The effectiveness of current Welsh Government policies on tackling alcohol and substance misuse and any further action that may be required;

Comments:

There is now overwhelming evidence to support the use of psychosocial interventions for the treatment of substance misuse and co-occurring mild to moderate mental health problems (Dutra et al., 2008; Miller & Wilbourne, 2002).  Indeed, recent policy documents from the Welsh Assembly Government (2011) and the Public Health England (formerly the National Treatment Agency) in collaboration with the Society (Pilling et al., 2010) have provided frameworks that recommend evidence-based psychosocial interventions (NICE, 2011) Their focus on evidence-based interventions is crucial given the continued widespread practice in treatment services of psychosocial approaches that are ineffective (Miller et al., 2006).

It is clear that no one psychological approach is suited to all individuals and the choice of the most suited intervention for an individual is highly complex (Miller & Carroll, 2006).  Providing a choice of approaches is important in terms of successful outcome.  There are a vast array of evidence-based psychosocial treatment approaches aimed at helping people with substance use difficulties (Carpenter & Brooks, 2006), including Motivational Enhancement Therapy (Miller et al., 1995), Motivational Interviewing (Miller & Rollnick, 1991, 2002), Cognitive Therapy (Beck, et al., 1993), Contingency Management (Higgins, Silverman, & Heil, 2007), Community Reinforcement Approaches (Hunt & Azrin, 1973), Behavioural Couples Therapy (Fals-Stewart, et al. 2006), and Family Therapy (Szapocznik Hervis, & Schwartz, 2003)

Welsh Government Policy as set out in the ‘Working Together to Reduce Harm - The Substance Misuse Strategy for Wales 2008-2018’ forms a reasonably inclusive and comprehensive document. The Action Areas included within this document address harm prevention, support for service users to improve their health and maintain recovery, supporting and protecting families and addressing protection within the community and availability of substances.

There is an emphasis upon prevention which addresses both areas of education within schools and support for families where there are issues with substance misuse  In addition there is the promise to focus upon the needs of older students where there may be a development of substance misuse problems with an emphasis on early diagnosis and intervention.

While we acknowledge that services for substance misuse have progressed, there is recognition in this document that there is a need for expanding outreach and other services across Wales. These include addressing treatment outcomes, making services more efficient, improving capacity of services, focusing upon the areas of greatest harm, reducing barriers to treatment access, and reintegrating services users back into the community and engaging service users in the planning and development of services. The aims for these services are that they are made available to all areas across Wales and that there will be an investment in engaging priority and hard to reach groups.

Within this report there is recognition for better service integration and ‘wrap around services’ especially for housing, education training and employment. In addition there is an acknowledgement of the need for action in relation to prescription and OTC medications, steroids and solvents. Improvement in services for young offenders and increased options for adult prisoners are also discussed.

A large section of the policy addresses the reduction of risk of harm to children and adults as a consequence of substance misuse within the family. Closer working between statutory services both in health and Local Authority is emphasised and a multi-agency approach is recommended for identifying and supporting families.

In 2014, the Welsh Assembly annual report was published which looked at the progress made so far in relation to the original aims. This outlines the various ways in which the policy has been implemented across Wales including the potential for legislative change in minimum unit pricing, the publication of guidance for ‘Improving Access to Substance Misuse Treatment for Older people’, publication of guidance aimed at further reducing drug related deaths and the publication of an updated service user involvement framework. It details the conclusion of the Peer Mentoring Scheme and the publication of a document which addresses ‘Improving Access to Substance Misuse Treatment for Veterans’. This report also outlines the investment of over £32 million from the substance misuse action fund to the delivery of harm based services. Built into this report is information about improved waiting times for treatment and evaluation of the impact that the investment is having upon local services.

The capacity and availability of local services across Wales to raise awareness and deal with the impact of the harms associated with alcohol and substance misuse.

Comments:

Despite research findings demonstrating that a number of favourable treatments are available, there is a clear dilemma in implementing such approaches into ‘real-world’ services.  For example, the expertise in these approaches is often unavailable, the training needs to deliver such services can be significant and the implementation of such treatments can be extensive. 

In the PHE/BPS framework, and independently in the Welsh Assembly Government framework, the NICE-recommended psychosocial approaches are classified as either low-intensity or high-intensity interventions.  The distinguishing features between low and high is that the former require far less training, they are typically briefer to deliver, and they are offered to those with less severe problems or as a first step in a treatment journey, whereas the latter are more formal psychological therapies delivered by those with more specialist training and supervision. 

The PHE/BPS framework made a further distinction between their recommended interventions, in that they had interventions specifically for substance misuse and interventions for co-morbid mental health problems.  As outlined above, the evidence is clear that the majority of people who meet the criteria for substance dependence will also meet a diagnostic criterion for a co-morbid mental health disorder (Kessler, 2004).  It is typical that service users will present with some degree of anxiety, depression, or past trauma.

In addition to these established techniques, there is a growing interest in the use of the newer, so-called, “third wave” psychotherapies specifically for the treatment of substance misuse.  There is emerging evidence that these third-wave therapies, which were developed to treat a variety of mental health problems, might be effective in the treatment of people with co-morbid substance misuse problems.  For example, mindfulness-based interventions (Zgierska et al, 2009), Acceptance and Commitment Therapy (Twohig et al, 2007) and Dialectical Behaviour Therapy (Dimeff & Linehan, 2008) have all been used effectively to treat people with substance misuse problems.  Despite research findings demonstrating that a number of favourable treatments are available, there is a clear dilemma in implementing such approaches into ‘real-world’ services.  For example, the expertise in these approaches is often unavailable, the training needs to deliver such services can be significant and the implementation of such treatments can be extensive.

In the PHE/BPS framework, there are two low intensity interventions for drug misuse (i.e., Motivational Interviewing and Contingency Management) and additionally, two low intensity interventions for mental health difficulties (i.e., Guided self-discovery and Behavioural Activation) There is just a single high intensity intervention for drug misuse namely, Behavioural Couples Therapy and a single high intensity approach for mental health difficulties (i.e., cognitive behavioural therapy).  Behavioural Couples Therapy is an approach specifically aimed at those substance misusers who have partners who are able and willing to participate directly in therapy primarily to resolve relationship difficulties and to promote abstinence.

The Welsh assembly framework also recommends the interventions promoted in the PHE/BPS framework.  In the Welsh Assembly framework they describe separate interventions for drug-related and alcohol-related problems. For both alcohol and drug misuse the framework recommends low intensity interventions including Motivational Interviewing and Contingency management. In relation to drug use, they recommend CBT (including Relapse Prevention) and Behavioural Couples Therapy whilst for alcohol use the recommendation is the same but with the addiction of Twelve-step facilitation, Motivational Enhancement Therapy, and Social Behaviour Network Therapy.

It is of note to this review that there are certain omissions in the frameworks from the NICE-recommendations for psychosocial interventions and that there is a lack of clarity in terms of treatment modality.  For instance the PHE/BPS and Welsh Assembly frameworks do not advocate family-based interventions, despite the recommendations from NICE (2011).  NICE additionally recommended Multidimensional Family Therapy, Brief Strategic Family Therapy, and Functional Family Therapy.  In terms of treatment modality, the Welsh Assembly, in particular, advocates individual therapy rather than group-work where structured, formal CBT is delivered.  Researchers, however, have begun to advocate the use of a hybrid MI and CBT-based group programmes due to the efficacy and cost effectiveness of this treatment modality (Sobell et al., 2009).

The simplistic conceptual framework of advocating low intensity and high intensity interventions has some benefits over traditional frameworks, but nevertheless, it continues to have several drawbacks.  First, these high intensity interventions require practitioners to have high-level professional training, which many teams do not routinely possess (Davies, 2007) Secondly, the high intensity intervention of Behavioural Couples Therapy is specific to only a relatively small proportion of service users (i.e., those in a stable relationship and those with a partner who is willing and able to undertake psychological therapy).  In addition, although recognising that Motivational Interviewing is an effective evidenced-based approach, its popularity and delivery within “real-world” services is often unstructured, lacking in specific assessment, devoid of clearly defined treatment plans or goals, and delivered without regular reviews (Forseburg et al., 2010), all of which are recommended within NICE guidelines for psychosocial interventions (NICE, 2007). One issue with the provision of low and high intensity approaches is that it may hinder services ability to adequately provide “stepped-care” approaches and it would appear that these low intensity interventions do not fully utilise the extensive range of practitioner skills available within substance misuse services.

Many of the Cognitive-Behavioural-based interventions can draw on more innovative, third-wave evidence-based approaches.  Group programmes can benefit from greater structure and maintain greater treatment fidelity than can individual approaches.  The group-based approaches can foster a sense of shared “recovery journey” amongst service users, thus equipping them for ongoing recovery within their community groups.

Many structured skills-based approaches can also bridge the gap.  Node-link mapping (Dansereau et al., 1993), for example, draws on CBT-based techniques.  With training, suitably qualified practitioners (i.e., those with professional training in the delivery of client-centred approaches), can deliver elements of Mindfulness-based approaches, DBT skills, and ACT when applied in structured formats.

Whilst there is increasing evidence of investment in third sector agencies there continues to be a marked lack of funding for the provision of services for people with co-occurring mental health problems and despite limited liaison provision, demand continues to outweigh the services’ ability to respond. Where projects have been developed in North Wales which have provided favourable outcomes for this group, recent financial cuts have resulted in a loss of these services.

In Cardiff and Vale almost half (47%) of adults report drinking above the recommended alcohol limits in the previous week, and more than a quarter (28%) report binge drinking (drinking too much alcohol in a short period of time). One in ten teenagers report drinking one or more drinks weekly, and around the same number report having been drunk at least four times in their lifetime. Boys drink slightly more than girls. In those over 65, one-third of men (36%) and nearly one-fifth of women (17%) drink above the recommended limits (S Moore, V Sivarajasingam, M Heikkinen, 2013)

Estimates show that the National Health Service (NHS) in Wales spends about £70 - £85 million per year on treating alcohol related health problems12. Nearly 3000 people attended the Emergency Unit in Cardiff and Vale with an alcohol-related issue in 2010 – 11 and numbers attending are higher at weekends.

There has been a gradual rise in hospital admissions (planned and unplanned) entirely due to alcohol in Wales in the past ten years and across the 22 unitary authority areas of Wales, hospital admissions ‘entirely or partly’ due to alcohol in 2007 – 09 were 3rd highest in Cardiff and 10th highest in the Vale of Glamorgan for males and 5^th highest in Cardiff and 7th highest in the Vale of Glamorgan for women.

Pilot services such as the Cardiff Alcohol Treatment Centre (ATC) aims to provide additional capacity to offset the high volume of acutely intoxicated individuals currently attending University Hospital of Wales Emergency Department and this has successfully diverted patients away from the Emergency Department and was resulted in a significant reduction in alcohol-related attendances, a reduction in ambulance referrals to the Emergency Department and a decrease in ambulance handover times at the Emergency Department

At present the delivery of alcohol screening and brief interventions specifically in Cardiff and Vale Health Board is limited across both primary and secondary care. In primary a number of general practitioners have attended Royal

College of General Practitioners Wales, (RCGP) ‘Alcohol Management in Primary Care’ course. However, with no agreed system of recording any interventions provided, it is not possible to assess the impact of the training. In secondary care:

Training in brief interventions for nursing staff has been offered, however, interventions are not currently routinely recorded.  Despite the development of a one-day training course in Alcohol Brief Interventions to nursing staff since October 2010, releasing staff for training remains a challenge.

Cardiff University Health Board (UHB) currently employs two Hospital Substance Misuse Liaison Nurses, who receive substance misuse referrals from across hospital services. Over a period of four years (2008-2011), there were 1795 referrals of which 82 percent were related to alcohol. Around one fifth of patients referred for alcohol were able to be offered brief advice or an extended brief intervention, (motivational interviewing) but the majority were patients with more severe alcohol issues, who required specialist support.

If these patients could be identified and offered support at an earlier point in their drinking career, for example in primary care, it is though that this could help prevent their health deteriorating further, the impact on families, and the use of hospital resources.

Owing in part of the development of the Substance Misuse Liaison Nurse posts, the identification of services users showing signs of cognitive impairment has increased. Currently there are no specialist facilities available in South Wales to care for the needs of these individuals and there is a significant lack of availability of specialist staff able to assess, diagnose and offer interventions with this population. Currently, within Cardiff and Vale, formal neurocognitive assessment is offered by one Clinical Psychologist within Addictions whilst many of the service users identified are having to wait on sometimes lengthy waiting lists for Neuropsychology services. This is likely to impact on the availability of comprehensive capacity assessments taking place. To date, many of the service users assessed as having ARBD are cared for in care homes in England which remains extremely unsatisfactory for those families who wish to be accommodated in Wales.

There are a number of areas which should be the focus of service development and improvement including holistic rehabilitation for people with alcohol related brain damage (where at present no specific services exist in Wales), a specific care pathway (including a requirement for collaborative working alliances) between mental health and substance misuse services is needed to better serve the needs of individuals with co-occurring mental health and substance misuse problems and a need to address unplanned drop out from substance misuse services. Some of the issues identified (Public Health Wales and Welsh Government 2010) appeared to relate to the need for improvement in service delivery and staff training (e.g. long waiting times, inconvenient opening times, lack of pre-contact treatment, poor staff attitude).

The capacity to manage older people who have an alcohol problem in older adult services is very limited across Wales, with the service already trying to address the needs of a growing population of clients and carers dealing with dementia. Access to CDAT was previously age restricted and although this is no longer the case, it is apparent that their remit is specific to those clients willing and motivated to change. Following financial restrictions and the focus on community based recovery services; there is no Tier 4 residential service available to clients across most of Wales with the exception of those which are provided by generic older adult mental health inpatient services which are often wholly inappropriate to the needs of the client and their family. Clients and families have now to self fund residential rehabilitation where required.

Whilst much work has been completed on the development of third sector services in South Wales there needs to be a continued move towards recovery orientated services and integrated pathways between substance misuse services, through care, aftercare and peer led recovery organisations. In Cardiff and the Vale, the Footsteps to Recovery Programme includes three organisations (Recovery Cymru, Newlink and Solas)  which are working in partnership to provide an integrated, recovery oriented programme of support for individuals who are transitioning from NHS services to the next stage of their recovery journey. This project is still in the early stages, so no outcome data is available yet. If the outcomes of this programme are promising, the move to a system of delivering evidence based psychological and psychosocial interventions by skilled practitioners will need to be fostered with an emphasis upon the training and support needs of those staff delivering the interventions.

Exploration of the Family Drug and Alcohol Court model, currently available in England would also be welcomed in relation to what this could contribute to substance misuse outcomes for families in Wales. Initial findings from the London programme are promising in terms of improvements for families and economic outcomes (E.g. Harwin et al. 2014)

A recognised system for upskilling the substance misuse workforce should be considered. For example, in Scotland STRADA collaboration between Glasgow University and Drugscope) provide a range of university accredited professional development programmes (practice/skills development and academic) for substance misuse practitioners.

Attempts have been made to offer liaison specialists across services where there is a likelihood of co-morbidity, in real terms; joint working between these services remains patchy.  Whilst services for substance misuse have undergone a period of redevelopment to accommodate the ‘peer led’ and third sector agencies, there has been a noticeable period of disinvestment  amongst statutory services generally and Local Authority services in particular. At the same time as new recovery led services are being tendered and are establishing across South Wales, many of the experienced professionals who have in-depth understanding of legislation and clinical procedures relating to addiction are no longer in place and this has resulted in a loss of the ‘seamless move across services’ as limited staff who have a limited knowledge of the service group are left trying to manage cases.

Despite the promise of further training for non addiction staff as highlighted in the strategy, there continues to be a lack of training and expertise amongst professionals within other specialisms about the nature and course of addiction.

Any other comments

The Society has no further comments to make.

References

Alcohol and Its Impact on our Community (2011) Annual Report of the Director of Public Health.

Ant, T., and National Assembly for Wales (2013) Substance misuse and treatment services in Wales. Research Service Briefing, April 2013.

Alcohol Concern (2010) What’s the damage? Negative health consequences of alcohol misuse in Wales, London, Alcohol Concern.?

Carpenter, K. M. & Brooks, A. C. (2006). Psychosocial treatment for substance use disorders:  Guiding principles for promoting behavioural change. Primary Psychiatry, 13(2), 43-50.

Dansereau, D. F., Dees, S. M., Chatham, L. R., & Simpson, D. D. (1993). Mapping new roads to recovery: Cognitive enhancements to counselling. Fort Worth: Texas Christian University, Institute of Behavioral Research.

Davies, R. (2007). Substance Misuse Counselling Workforce Shortages. Welsh Assembly Government.

.Department of Health (2002).  Mental Health Policy Implementation Guide.  Dual Diagnosis Good Practice Guide, London: Department of Health.

Dimeff, L. A. & Linehan, M. M. (2008). Dialectical Behavior Therapy for Substance Abusers. Addiction Science and Clinical Practice, 4(2), 39-48.

Dual Diagnosis Toolkit (2004).  Mental Health and Substance Misuse.  A practical guide for professionals and practitioners. www.rethink.org.uk

Dutra, L., Stathopoulou, G., Basden, S. L., Leyro, T. M., Powers, M. B., & Otto, M. W. (2008). A Meta-analytic review of psychosocial interventions for substance use disorders. American Journal of Psychiatry, 165, 179–187.

Fals-Stewart, W., O’Farrell, T. J., Birchler, G. R., & Gorman, C. (2006). Behavioural Couples Therapy for Drug Abuse and Alcoholism:  A 12 Session Manual (2nd Ed). New York:  Addiction Family Research group.

Forseburg, L., Forseburg, L. G., Lindqvist, H., & Helgason, A. R. (2010). Clinician acquisition and retention of Motivational Interviewing skills:  a two-and-a-half-year exploratory study. Substance Abuse Treatment, Prevention, and Policy, 5(8), 119-120.

Harwin, J., et al., (2014) Introducing the main findings from: Changing lifestyles, keeping children safe: An evaluation of the Family Drug and Alcohol Court in care proceedings. Nuffield Foundation and Brunel University.

Higgins, S. T., Silverman, K., & Heil, S. H. (2007). Contingency management in substance abuse treatment. New York: Guilford Press.

Hogan, L. M. (In preparation). Effectiveness of a group psychosocial intervention (Group PSI) for co-morbid mental health and substance dependence (‘dual diagnosis’): A final outcomes evaluation.

Hogan, L. M., Best, D. & Davies, J. (2012).  The Conwy Refrain Dual Diagnosis Project: An Outcome Evaluation, Unpublished Report.

Hogan, L. M., Elison, S., Ward, J., & Davies, G. (2014). Effectiveness of a group psychosocial intervention (Group PSI) for co-morbid mental health and substance dependence (‘dual diagnosis’): An initial pilot outcomes evaluation, Addiction…

Hogan, L. M., Jabeen, Q., & Rettie, H. (In preparation).  An Audit of 12-month Outcomes at an Inpateint Detoxification Centre.

Hunt, G. M. & Azrin, N. H. (1973). A community reinforcement approach to alcoholism. Behaviour Research and Therapy, 11, 91-104.

Kessler, R. C. (2004). The epidemiology of dual diagnosis. Biological Psychiatry, 56(10), 730-737.

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The validity of a brief depression screen. Journal of General Internal Medicine, 16(9), 606-613.

Liddle, H.A. (2000). Multidimensional Family Therapy for Adolescent Cannabis Users, Cannabis Youth Treatment Series, Volume 5. DHHS Pub. No. 02–3660 Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health

Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.

Mental Health Foundation (2008) Alcohol and mental

Miller, W. R. & Carroll, K. M. (2006). Rethinking substance abuse: what the science shows and what we should do about it (Eds.). New York: Guilford Press.

Miller, W. R. & Rollnick, S. (1991). Motivational Interviewing. New York: Guilford Press.

Miller, W. R. & Rollnick, S. (2002). Motivational Interviewing (2^nd Ed.). New York: Guilford Press.

Miller, W. R., & Wilbourne, P. D., (2002). Mesa Grande: A methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction, 97, 265–277.

Miller, W. R., Wilbourne, P. D., & Hetema, J. E. (2003). What Works? A Summary of Alcohol Treatment Outcome Research. In R. K. Hester & W. R. Miller (Eds.) Handbook of Alcoholism Treatment Approaches: Effective Alternatives (3rd edition) (pp. 13-63). Boston: Allyn and Bacon..

NICE (2007).  Drug Misuse: Psychosocial Interventions. London: National Institute for Health and Clinical Excellence.

NICE (2010).  Alcohol-use disorders: Preventing the development of hazardous and harmful drinking. London: National Institute for Health and Clinical Excellence Public Health Guidance 24.

NICE (2011).  Alcohol-use disorders: Diagnosis, assessment and management of harmful drinking and dependence. London: National Institute for Health and Clinical Excellence Public Health Guidance 115.

Pilling, S., Hesketh, K., & Mitcheson, L. (2010).  Psychosocial interventions for drug misuse: A framework and toolkit for implementing NICE-recommended treatment interventions. National Treatment Agency for Substance Misuse.

Public Health Wales and Welsh Government (2010) Influencing factors and implications of unplanned drop out from substance misuse services in Wales.

Raistrick, D., Bradshaw, J., Tober, G., Weiner, J., Allison, J., & Healy, C. (1994). Development if the Leeds Dependence Questionnaire (LDQ): a questionnaire to measure alcohol and opiate dependence in the context of a treatment evaluation package, Addiction, 83(5), 563-572.

Sobell, L. C., Sobell, M. B., & Agrawal, S. (2009). Randomized controlled trial of a cognitive-behavioral motivational intervention in a group versus individual format for substance use disorders. Psychology of Addictive Behaviors, 23(4), 672–683.

Spitzer, R. L., Kroenke, K., Williams, J. B., & Lowe, B. (2006). A brief measure for assessing general anxiety disorder: GAD-7. Archives of Internal Medicine, 166(10), 1092-1097.

Twohig, M. P., Shoenberger, D., & Hayes, S. C. (2007). A preliminary investigation of Acceptance and Commitment Therapy as a treatment for marijuana dependence in adults. Journal of Applied Behaviour Analysis, 40(4). 619-632.

Welsh Assembly Government (2004). Service Framework for Inpatient Treatment.

Working Together to Reduce Harm – The Substance Misuse Strategy for Wales 2008-2018, Welsh Assembly Government

Substance Misuse Treatment Framework (SMTF) Guidance for Evidence based Psychosocial Interventions in the Treatment of Substance Misuse. Welsh Assembly Government 2011

Zgierska, A., Rabago, D., Chawla, N., Kushner, K., Koehler, R., & Marlatt, A. (2009). Mindfulness meditation for substance use disorders:  A systematic review. Substance Abuse, 30(4), 266-294.

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