The Alcohol and Other Drugs Aftercare Worker Service: Process evaluation findings
Senior Research Adviser, Research and Analysis Team, Department of Corrections
Senior Evaluator, Litmus
Dr Chelsea Grootveld
Director, AIKO Consultants
Managing Director, AIKO Consultants
Principal Adviser, Psychology and Programmes Team / National Relationship Manager for Drug Treatment Programmes and Aftercare Service Contracts, Department of Corrections
Marianne Bevan joined Corrections in 2014, and has completed a range of projects related to the offending, treatment and management of women in Corrections care. Prior to working at Corrections, she conducted research and implemented projects on gender and security sector reform in Timor-Leste, Togo, Ghana and Liberia. Marianne was the Department’s project manager for the Alcohol and Other Drugs (AOD) Aftercare Worker Service Evaluation.
Anna Thompson is an evaluator with over six years’ experience. Her background is in the not-for-profit sector in research and evaluation and supporting marginalised communities. She’s enthusiastic about using evidence well to support better outcomes.
Liz Smith is the co-founder of Litmus. She has over 20 years’ research and evaluation experience across the health and social sectors, with significant experience working in complex and highly sensitive areas. Liz is driven to work on projects that contribute to change towards a more just and sustainable world.
Dr Chelsea Grootveld (Ngai Tai, Ngāti Porou, Whānau a Apanui, Whakatōhea, Tuhourangi). Chelsea is the director of AIKO Consultants, a research company specialising in kaupapa Māori research design and practice. She is an experienced researcher and evaluator and is passionate about whānau centred and whānau led education, health and wellbeing.
Tīmoti Brown (He Uri Taniwha, Ngāti Ruapani, Ngāti Kahungunu ki Te Wairoa, Rongowhakaata) has extensive policy and advisory experience. Tīmoti is passionate about positively affecting the lives of others and encouraging them to do likewise.
Rebecca Gormley has worked in the criminal justice sector in New Zealand and the United Kingdom for the past 15 years in various policy, service design, social service procurement and contract management positions. She has a Master of Arts in Criminology.
Alcohol and other drug (AOD) addiction is a serious health issue and a significant contributing factor to crime and other social harm in New Zealand. Corrections’ own research indicates that 87 percent of people in New Zealand prisons would have met criteria at some time in their lifetime to date for diagnosis of an AOD disorder, and 47% for a substance use disorder in the last 12 months. In addition, 91% would likely have met at some time in their lifetime to date a diagnosis of a mental disorder, including mood, anxiety, substance and eating disorders.
In 2015, the Department of Corrections (the Department) received $8.62 million over three years from the Justice Sector Fund to develop and deliver a package of AOD treatment and aftercare support services that are responsive to individual needs. Aftercare is a key part of this support package. The service provides maintenance support to people who have completed the Drug Treatment Programme (DTP) or AOD Intensive Treatment Programme (ITP) in prison. The DTP and ITP offer participants the intensive group treatment and recovery opportunities required to manage their AOD use and improve personal (and whānau) health and wellbeing. The service aims to help programme graduates maintain their treatment gains and achieve long-term recovery. The long-term goal is to contribute to reducing re-offending among people who have completed AOD treatment in prison and improving their overall health and wellbeing. The service started in July 2016. As at July 2018, the Department contracts five AOD treatment providers to supply aftercare across 13 prisons.
Following treatment completion, aftercare workers help service users who are remaining in prison as they work towards their release. Aftercare workers provide one-to-one support, facilitate group maintenance sessions, and liaise with case managers. They also help service users develop, improve and adhere to their relapse prevention plans (RPP).
As people transition to community settings, aftercare workers continue to provide individual and group maintenance sessions, and connect people to agencies that can respond to their broader reintegration needs such as benefits and housing. They connect people to the Salvation Army, Alcoholics Anonymous or Narcotics Anonymous. Aftercare workers also help people re-connect with their whānau and other recovery support networks.
Aftercare is available for six to 12 months after the treatment has been completed, depending on each service user’s level of need. This support may be provided exclusively in prison if service users have more than 12 months on their sentence after completing the DTP or ITP.
The Department commissioned an evaluation of the service’s implementation and early outcomes in early 2018. This assessed the extent to which the new service was adequately “bedded in”, and how well the service helped users maintain treatment gains and reduction in AOD use.
Litmus evaluated the service between April and July 2018. Fifty-two stakeholders were interviewed across three regions (Northland, Hawke’s Bay and Auckland). This included interviews with service users (27), aftercare workers (8), and probation officers and case managers (17). A national survey of 17 aftercare workers, 52 case managers and 35 probation officers was also conducted.
Some limitations to the study arose, relating to incomplete administrative data, which reduced the level of insight into service user pathways, and to variations between sites. There was also a low number of survey responses from probation officers, and only a small number of community-based service users were able to be interviewed, which meant that evaluating levels of successful impact in the community was restricted.
Impact of the service on maintaining treatment gains
Stakeholders were very positive about the effect of the aftercare service in the first two years of implementation. Service users, Department staff, and aftercare workers believed the service helped maintain treatment gains, reduce relapses and reliance on AOD, and increase adherence to relapse prevention plans.
Service users thought aftercare worker support was central to maintaining the treatment gains they made in their treatment programmes. In this context treatment gains included the use of recovery strategies to maintain reduced AOD use and prosocial connections to support their ongoing recovery. As one service user observed:
“I would have got re-called by now. Or I wouldn’t have even got out of jail. When I first got into jail, I was always getting in trouble, but I never learned until I got to MIRP [Medium Intensity Rehabilitation Programme]. Then I went for parole, and they asked if I wanted to do the three-month DTU and I haven’t looked back. Being able to talk to people when we’re all moving forward in the same way and if someone has a hiccup, then we can help that person. If I had never had the aftercare, then my hiccups would have just broke out. … It’s a lot of what has kept me out of going back to jail or re-offending.” (Service user)
Although stakeholders believed the service contributed to maintaining treatment gains, further work will be needed to assess this over time. As the service was established just two years ago, the long-term sustainability of these treatment gains is unknown.
Success factors in the design and implementation of the service
Service users, aftercare workers, and Department staff highlighted a number of strengths with the service design and implementation. These ensured the service helped participants maintain their treatment gains.
Continuation of the therapeutic relationship was a strength of the service
Introducing the aftercare worker during or immediately after completing the DTP or ITP was a key success of the service design. This design ensured that service users maintained the therapeutic relationships they developed during treatment. It also provided continuous care across “stress points”, such as transitioning out of the DTP, preparing for release, and reintegrating into the community.
Service users valued meeting the aftercare worker in the DTP because it built relationships and trust. Relationships were particularly strong when the aftercare worker had also worked in the DTP or ITP where service users received treatment. Most service users considered leaving the DTP a stressful time in their recovery. Transferring to other prisons or units was particularly stressful. Service users relied on aftercare support to help them through this period. Early support included meeting one-to-one with aftercare workers and connecting with group support when possible. Most service users established positive relationships with aftercare workers when they enrolled.
“It keeps that sort of good buzz going. That good vibe. If you completely drop your guard, it's a little bit of a let-down after all that support in the DTU for them just to let you go. It would feel like a cold shoulder, just letting you go.” (Service user)
Service users and aftercare workers also described release from prison as a period of risk, with the potential for relapse. Aftercare workers often increased their engagement with service users in the lead up to release. Service users valued help preparing for release, particularly around the risks they might face, and how to manage relapse triggers. They also valued knowing the aftercare worker would be available in the community. The continuity of care boosted a sense of support and trust from service users.
Service users claimed that access to a reliable and consistent support person in prison and in the community helped them avoid relapses and reliance on AOD. The evaluation suggested the early establishment of therapeutic relationships may positively contribute to service outcomes.
Support to practise tools and strategies learned in the AOD treatment
The service helped the men use the tools and strategies learned in the DTP or ITP, including Relapse Prevention Plans. Through this, they were able to prevent relapses and manage risks both in prison and in the community.
Aftercare workers provided group maintenance and one-to-one sessions across the sites. These sessions reinforced the therapeutic lessons from the DTP or ITP. In Auckland Men’s, Auckland Women’s, and Hawke’s Bay prisons, aftercare workers facilitated groups on a weekly or fortnightly basis. Groups varied in size from around four to ten people per group.
Service users found the maintenance groups useful and supportive. Group sessions helped them stay motivated and learn from each other. This was because they shared their experiences in a trusting environment. Service users particularly appreciated group support when they were struggling:
“We'd get together and catch up. It was nice to see familiar people, and we could all have a laugh and stuff ... It's good to have that reboot, hit that switch once a week just to keep that mentality there. It was helpful. (Service user)
Group sessions worked well with ten people (although many were run with fewer). Smaller groups built trust and openness. Consistent membership was also important because they did not want to repeat their story or experiences multiple times. They felt these sessions helped them to cement learning from the DTP, to feel supported, and to expand on individual learning. Aftercare workers used these sessions to challenge and encourage service users to continue their recovery.
The service was designed to support users as they transferred out of prison, however, aftercare worker support in the community varied across the different sites. Delivering community-based aftercare was difficult in several regions because of the time required to arrange it and meet people in the community.
When possible, aftercare workers supported service users in the community through one-to-one meetings or phone calls, group meetings (in some regions), and some engagement with probation officers. Some aftercare workers also referred service users to other AOD support services; however, the evaluation found that accessing community-based AOD support was often difficult.
Stakeholders considered that some community-based programmes were less relevant for service users because they were lower intensity programmes and providers had little knowledge of the impact of prison for service users. Aftercare workers agreed that service users struggled to access community-based support or did not find these services useful. Some service users considered community-based services less valuable because providers lacked understanding of prison experiences (for example, AA meetings). Service users appreciated aftercare because it was tailored to meet their needs.
Overall, most service users believed the service increased their self-confidence and self-efficacy by improving their knowledge and understanding of addiction. This knowledge helped them to prevent relapses and gave them the confidence to maintain their treatment gains. Most considered the aftercare support invaluable to continued learning. They also thought aftercare worker support helped them remember and practise the skills they learned through other programmes.
Kaupapa Māori service delivery and other holistic service models enhanced success
The evaluation found that all aftercare workers worked in a culturally responsive way. All aftercare workers included some practices valued in a kaupapa Māori delivery model. For example, they built trusting face-to-face relationships, strengthened whānau engagement where possible, and used Māori conceptual frameworks such as Te Whare Tapa Whā. Initially only one provider, Te Taiwhenua o Heretaunga, was a kaupapa Māori provider; although since the evaluation was completed, a second kaupapa Māori provider has commenced service delivery.
Service users valued the culturally responsive components of the aftercare. They considered these contributed positively to their health, wellbeing and treatment outcomes. The value of the kaupapa Māori service, as identified by stakeholders, was the ability to work holistically with service users, reconnect them to their culture and whānau, and strengthen their sense of worth. Service users in Hawke’s Bay, particularly Māori, considered the kaupapa Māori service delivery model critical for their success. These service users felt affirmed, respected, and understood. They liked using kaupapa Māori tools to manage their addiction.
“I like it when it’s done in a Māori way, I can adapt to it. If it’s done too much in the way Pākehā do it, I struggle a little.” (Service user)
Most service users believed the service lifted their mana (hīkina te mana) and self-belief. Some aftercare workers nurtured service users’ sense of self and knowledge of their abilities, within the wider whānau context and their AOD history. For example, by supporting service users to identify their whakapapa or acknowledging the impact of whānau history on AOD use. This approach sought to lift the mana of individuals and whānau.
Using practices valued in a kaupapa Māori delivery model also encouraged the strengthening of whānau engagement. Whānau engagement through the service was often limited in prison, and even more so in the community, for a range of reasons. Whānau were sometimes assessed as not prosocial, were not based in the area, or were estranged from the service user. Where whānau were not available or suitable, probation officers or prison staff were often engaged to fill this role.
When whānau engagement occurred, service users valued it highly because it helped them receive the right kind of support on release. It also ensured whānau and other supporters worked with Department staff to prevent relapses. In some cases, aftercare workers helped bridge gaps in whānau understanding of addiction. Whānau engagement often occurred through supported meetings and whānau hui. At these meetings, all stakeholders gathered to discuss what support service users needed and their release conditions.
“[The family hui was] for my family to ask any questions they wanted to ask and for me to say that I was going to be straight up so that if I used I would come straight to them. It was to build trust back up and put the cards on the table. I think it should be compulsory. It was something I set up because I wanted it. Because then when I got out we didn’t have to sit around and have a chat. [Probation officer] was there, my AOD counsellor, [aftercare worker], my two support people and my family. So everyone was on the same page.” (Service user)
Overall, service users valued culturally responsive practices and, together with other stakeholders, believed that such responses contributed positively to achieving the intended outcomes of the service.
Challenges for the service going forward
The evaluation showed the service is progressing well towards achieving its stated outcomes. However, to ensure the service meets its full potential there are areas for improvement in the design and delivery.
Increasing co-ordination across sites
The continuity of care in the service is one its key strengths. It is also logistically challenging and an area to strengthen. As noted above, service users valued having the same aftercare worker throughout their time in the service. This is not always possible, as people often move prisons after completing the DTP/ITP or later on in their prison sentence, and some are released to an area their aftercare worker does not service.
Service users and aftercare workers noted that service users changing location is a challenge as it requires forming new therapeutic relationships. This can be time consuming and difficult for service users.
Good communication between aftercare workers and other Corrections staff (including case managers and probation officers) can help mitigate these risks. Aftercare workers found it useful to receive information about service users from case managers. This information helped them engage with new clients and support service users more effectively and promptly.
When case management staff did not inform aftercare workers in advance of prison transfers, it could lead to delays in service users receiving aftercare support. Aftercare workers considered this had a negative effect on the service users’ ability to maintain treatment gains.
Service users also identified challenges connecting with aftercare workers when they were released to a new region. This was often because they lacked a relationship with the aftercare worker in the new region or they did not know who to contact. These issues were lessened in areas where probation officers knew to advise service users to contact their aftercare worker for support. The service worked best when aftercare workers, case managers and probation officers worked together to support service users.
Increasing uptake in the community and ensuring adequate capacity to deliver
The service was mostly implemented as intended in prisons. However, implementation across the community sites appeared more limited due to aftercare worker capacity, travel times and geographical distances.
Community-based aftercare was difficult in several regions because of the time needed to meet people in community settings. In Auckland and Northland, aftercare workers have significant travel times to reach community locations (such as probation offices). In Auckland, aftercare workers usually phoned service users in the community to limit travel time. In Northland, the aftercare worker travelled across the region to meet service users as well as phoning. Maintenance groups were not offered in either location, as no suitable central location to meet was identified, and travel times were a barrier to attending for aftercare workers and service users.
There were broader issues regarding aftercare worker capacity to deliver the service. Some aftercare workers noted challenges with current caseloads. This was influenced by the logistical challenges mentioned above, but also by the way aftercare workers operated. Aftercare workers’ personal holistic philosophies, and in Hawke’s Bay the kaupapa Māori approach, led to some aftercare workers “going above and beyond” the usual scope of the service, for example, by providing housing or employment support. This reflected the strong relationships between many aftercare workers and service users.
This challenge was compounded by how aftercare workers approached service completion. Despite knowing the intended service duration, aftercare workers were reluctant to exit people until they could manage independently. They noted this may take longer than 12 months. For example, people who completed the DTP and had more than 12 months remaining on their sentence and were not released early, often received the service until after their release from prison. However, the level of engagement decreased until service users began to prepare for release when it increased again.
“We’ve never stuck by those rules to be honest with you. If you’ve got a man in prison for another two years, we can’t just say, right stop, see you later. We’ve just continued with them. I think it’s very important to keep going.” (Aftercare worker)
These aftercare workers stated they continued to enrol new service users, while providing extensive support to those already enrolled. As a result, aftercare workers indicated the service would benefit from additional capacity to deliver services effectively, particularly in the community. One of the key recommendations from the evaluation was that the workload of aftercare workers needs to be more closely monitored in order to develop a better understanding of capacity issues.
Where to from here with the aftercare worker service
Service users value aftercare in supporting their treatment gains. Those who had been released from prison valued aftercare support during the transition and in the community. Department staff also support the service, recognising there are few or no other services providing similar AOD support across prison and community settings.
There are early positive results that suggest the service helps service users to maintain treatment gains, lift mana, and improve their health and wellbeing. However, it is too early to know the effect of the service on re-offending rates, or broader impacts on wellbeing. Also unclear so far is how sustainable the apparent gains prove to be over time.
The service meets an important gap in AOD support for service users. It provides important and unique continuity of care to service users transitioning from the therapeutic context to mainstream prison settings, and from prison to community settings.
The Department is reviewing the aftercare service design, reporting and delivery approach, in response to the evaluation’s recommendations. This ensures the Department is in a strong position to continue offering the type of aftercare support that service users have said they want and need.