Kelli Shackleton, Senior Practitioner and Substance Misuse Worker, and Vicki Ellis, Advanced Practitioner and Team Manager, SWIFT/FDAC, East Sussex
This tenth blog about FDAC focuses on the use of drug and alcohol tests in FDAC. All FDAC specialist teams include substance misuse workers working alongside social work colleagues. The initial parenting assessment, which takes place within two or three weeks of the first hearing in the FDAC court, is carried out jointly by a social worker and a substance misuse worker. The social worker focuses on issues of parenting and the substance misuse worker on the nature of the substance misuse – history, substances misused, and the extent of the problem. The assessment forms the basis for the team formulation and development of the implementation plan, which happens the following week. If the parent signs up to FDAC at the second court hearing, they will have a keyworker from the FDAC team, who may be a social worker or a substance misuse worker. Parents meet their keyworker at least once a week while the case is in proceedings.
The FDAC National Unit (NU) coordinates quarterly meetings for all FDAC substance misuse workers, to provide a forum for discussing issues arising from working in FDAC, which is a very different experience to working within adult treatment services. Issues that arise include being part of a multi-disciplinary team, working within the tight timescales of care proceedings, and the need to focus on the welfare of the child and the child’s timescales rather than solely on the parent/s. Issues relating to testing are also discussed regularly.
Most parents coming into FDAC have a long history of misuse of drugs, or drugs and alcohol combined. A smaller number have a long history of alcohol misuse only. Many parents will have had experience of adult substance misuse treatment services before coming into proceedings and some will be in treatment at the time proceedings start. Some parents will still have chaotic drug use while others may have come some way along the treatment path. FDAC specialist teams work closely with local substance misuse treatment services to support parents to achieve control over their substance misuse.
Regular testing for drugs and alcohol is an important part of the FDAC approach. All FDAC teams are trained to carry out a range of tests, and some teams have the skills to do some of the analysis as well. In addition, over time FDAC judges have developed orders for directions for drug and alcohol tests. These are made at the start of FDAC proceedings and ensure that the costs of the testing will be covered by Legal Aid.
The following description of the role of testing within the FDAC approach, and some of the complexities of testing, is written by the team manager (social worker) and the substance misuse worker in the SWIFT/FDAC team that operates in East Sussex.
‘FDAC, it's like the last-chance-saloon. It was “do you want to be a drug addict, or do you want to be a mother?” So I decided, that's it, I want to be a mum.’
A hair strand test is taken at the start of the FDAC process, as part of understanding the parent’s chemical profile prior to proceedings, as well as to establish a baseline for subsequent evidence. Further hair strand testing, to measure and evidence a parent’s changed behaviour in relation to substance misuse, is taken towards week 18 in the proceedings. This is the point at which the FDAC team carry out a further parenting assessment and make recommendations to the court about whether parents have demonstrated capacity to change within the child’s timescales.
Depending on case specifics and other indicators of use and/or abstinence, it is expected that parents will be tested via oral mouth swab or urine screens once or twice a week. This gives parents an opportunity to provide evidence of their chemical status, including change in their pattern of use. It also ensures that treatment sessions take account of where parents have got to on their recovery journey. In addition, regular testing supports clinical safety management, particularly where substitute prescribing may be in place. As testing forms part of the treatment journey, it is done inhouse by the FDAC team as part of the treatment package.
The FDAC model is one of continuous and iterative assessment, treatment and support. Testing in the FDAC model is not used in isolation – it forms part of FDAC’s holistic therapeutic approach with families, and it supports other forms of evidence that the team present to the court each fortnight.
Alongside weekly keywork sessions, targeted intervention sessions, and fortnightly non-lawyer reviews, testing provides parents with a regular opportunity to demonstrate the change they are achieving. Parents often talk about testing as being a significant motivator for them during their FDAC journey.
The process of regular testing also supports transparency when working with professionals. Parents are encouraged to disclose any use of substances prior to testing and this honesty in proceedings is promoted by the FDAC team as well as the judge. It facilitates the process of change for parents who have previously sought to hide the nature of their substance use because of the fear of repercussion and stigma.
A recovery process often includes lapses and relapses and a parent’s response to these episodes provides critical information when making a prognosis for the future. If parents are able to disclose the nature of their lapse as quickly as possible after the event, despite their feelings of guilt and failure, and if they are willing to undertake drug testing to corroborate their self-reports, these are markers of the cognitive and behavioural change that are needed. This information can then be used in targeted interventions to increase their insight into the events preceding their lapse or relapse (triggers, unhelpful thinking styles) and, more importantly, to identify strategies that can help establish firmer recovery foundations for the future. Some parents find it helpful to ask for an increase in testing over a short period of time, to motivate them when emotional resources are depleted. The aim of the team is always to reduce the extent to which testing is relied upon as an agent of change, and to move from this to a parent’s increased use of internal resilience and effective coping strategies.
Testing is fraught with complexity. Different methods have different detection windows, different cut-off levels, and – arguably – some can be more open than others to adulteration and/or being affected by environmental factors. Moreover, there has been considerable publicity recently about unreliable forensic toxicology results from two laboratories and these are no longer in operation.
Testing is not a marker of abstinence. It is possible that parents can infrequently use low amounts of illicit substances that are either below cut-off detection levels or not within the testing detection windows. It is possible, too, that false positives and false negatives can be present in samples, and some results cannot determine levels or frequency of use accurately. Hair strand test results can sometimes include the presence of substances from a time prior to the testing window, either because the hair has stopped growing in the months before the test (a resting hair phase) or because the rate of growth has been variable. Breathalyser results only reveal alcohol present in the system at the time of testing, not at any other time, and other forms of alcohol testing, including hair strand and blood analysis, only reflect whether there are any biological markers that support chronic excessive alcohol use. The variability of how alcohol is used and the impact this has on the safe care of children is far more complex than simply whether or not levels of use reach what is considered to be a chronic and excessive level.
Testing can also be something of a red herring at times. An over focus on test results can divert attention away from other risky and relevant issues for families, such as domestic abuse or poor mental health.
While there are undoubtedly complexities regarding the use of testing it does have a place within care proceedings where parental alcohol and/or drug misuse feature. In FDAC, testing is used to complement the iterative assessment and intensive intervention process.
Testing should be proportionate. Testing that is too frequent, and doesn’t meet the clinical needs of the case, doesn’t support a therapeutic process and undermines a parent’s belief that change can be seen in other areas of their behaviour. On the other hand, an under focus on testing can lead to gaps in evidence at a later stage.
Testing is a necessary part of gathering information: it helps provides a fuller understanding of the issues underlying the dependence on alcohol and/or other drugs, as well as of the impact this has on parents’ care of their children. It should be viewed as part of a more substantive assessment that takes account of the interplay between other inter- and intra- personal factors.
After all, recovery for our parents is not about providing drug free tests, but about achieving a different way of life. This is about a life of new thought processes, child-centred lifestyles, financial stability, a pro-social social network, better time management, improved family functioning and better ways of dealing with life’s challenges. Change and evidence of change are aspects of the broader context of recovery and, ultimately, the most reliable markers of sustainable recovery are often overwhelmingly evident in the parents and children themselves.