Natalie Davies talks to Mike Ward about his work on safeguarding adult reviews and domestic homicide reviews. Senior Consultant at Alcohol Change UK, with over 30 years’ experience in the substance use and mental health fields, Mike shares valuable insight into the concept of ‘change-resistant drinkers’, and why he believes that multi-agency management and assertive outreach are key to working with drinkers with complex needs.

SSA: A large part of your work (including the safeguarding adults review and domestic homicide review) has involved examining cases where the worst has already happened – where there has been serious harm, homicide or death – and working backwards to see what lessons can be learned about working with complex drinkers. If we look at the review about safeguarding vulnerable adults first, I wonder whether you could help our readers understand the definition of vulnerability that you were using there.

Mike Ward: “Yes, in a sense I don’t have to define it because the Care Act does. I mean section 42 of the Care Act determines that people who are at risk of abuse or neglect need to be safeguarded, and within neglect the really important thing for us in the substance misuse field is that neglect incorporates self-neglect. And I think that’s the real difference for us here. Because, there are a huge number of older self-neglecting dependent drinkers who are not getting help. And I think this gives us a real ‘in’ with those people. We’ve got a framework where we can start doing something.”

“We need multi-agency management – bringing together all sorts of agencies around the table. And alongside that, we need an assertive outreach approach to those clients”

Yes, that really stood out to me in your report. You said that self-neglect was not well-understood by practitioners, and that self-neglect combined with alcohol problems was seen as a lifestyle choice rather than a symptom or a cause of other problems. Can you tell me more about what you learned around that?

“Yes. This is not yesterday’s problem; this is a problem that is going on today around the country. There are a number – I hope a diminishing number – of safeguarding professionals who take the view that a self-neglecting dependent drinker is choosing to live like this. But it’s a much more complex picture than that, and there are all sorts of cognitive and physical issues going on for these people that make it hard to move forward. And while the public may see it as a choice, safeguarding professionals shouldn’t see it as a choice. Because it’s not a choice. And we need to challenge that. But more importantly in some ways, if the Care Act is going to operate, then other professionals outside the safeguarding arena need to raise alerts and concerns about these clients. And I think that’s an even bigger problem, that a lot of professionals see these clients and don’t raise concerns about them. And that needs to happen. The hope is that the work that Professor Michael Preston-Shoot and I are doing through a briefing document we’re going to publish next month – and training that we’re running alongside it – is that we are going to raise people’s awareness, and get them doing this.”

You mentioned not enough professionals raising concerns. Is that in part because the drinking problem or the extent of the drinking problem isn’t being recognised?

“No. It’s because people think drinkers are choosing to live like this. These problems are not hidden. These are problems that are visible in plain sight. They’re often ignored in plain sight.”

Could you explain the concept of ‘change-resistant drinkers’ to our readers? Did this come from the Blue Light Project’s work to develop alternative approaches for drinkers who are not in contact with treatment services, but who have complex needs?

“I would be the first to acknowledge that ‘change-resistant drinker’ is not a perfect description. Because sometimes it’s more about them being change-ambivalent; sometimes it’s about barriers to services. But I have to say ‘change-resistant drinker’ has become a flag that’s been useful with these clients. What we are talking about in the Blue Light Project, where the term originated, is those people who are almost certainly dependent on alcohol – probably physically dependent on alcohol – have been offered services in the past, or have been to services in the past, but have either not benefitted from services or have actively resisted going to those services, either by choice or by helplessness.”

“Beyond that, however, what we’re focusing on, is the people that are having the greatest impact on public services. So we’re not just focusing on any drinker who doesn’t want to change. We’re focusing on people who are dependent, not changing, and repeatedly turning up in custody, repeatedly turning up in A&E, the focus of repeated safeguarding alerts, repeated domestic violence incidents. It’s that kind of group of clients. Because, for those clients, if you’re repeatedly having an impact on public services, then I can probably justify some quite resource-intensive interventions.”

You also used the term in the domestic homicide review, which was about cases where someone was killed by an intimate partner, following a history of domestic abuse. Out of a sample of 39 reports, 27 involved alcohol-related harm. Would all of these have been categorised as ‘change-resistant drinkers’?

“Virtually all of those clients were change-resistant in some sense. There was a very small group – probably no more than 7% or 8% who may have had some engagement with services – but it was very small and unsatisfactory engagement.”

You said in the report that the presence of drinking problems can make it more difficult for practitioners to spot domestic abuse, particularly if both people are drinking heavily, in part because of the normalisation of violence within drinking couples.

“The view that we took was that in those cases where you get couples who are fighting a lot, it’s very easy for professionals outside to say ‘that’s them, that’s just the way it is’, and dismiss it – the same as with self-neglect. And as the domestic homicide review shows, even if they are hitting each other, there is still real danger there.”

“We just need a general agenda change in alcohol services to make sure that alcohol services are not driven by the requirement of client motivation, which unfortunately is still happening. There are still services who turn clients away because they are not engaging.”

Was the concept of change-resistant drinkers useful for you in understanding these deaths and how future harm could be prevented in alcohol-related domestic violence cases?

“Yes. In a sense it is the same thing as with the safeguarding adults review. It’s the same as the mental health homicide enquiries. We just need a general agenda change in alcohol services to make sure that alcohol services are not driven by the requirement of client motivation, which unfortunately is still happening. There are still services who turn clients away because they are not engaging. While we can’t expect alcohol services to follow up every client who drops out. If you or I went to an alcohol service as we are, and then failed to come back to an appointment, they could let us wait, because we’re not particularly risky or vulnerable. But if you’ve got one of these clients who is going to turn up in a domestic homicide review or safeguarding review, then alcohol services need to take a different approach. They need to be more actively following them up.”

“I think in all of these cases it highlights the need for two things: multi-agency working; and assertive outreach. These for me are the key approaches to these problems. We need multi-agency management – bringing together all sorts of agencies around the table. And alongside that, we need an assertive outreach approach to those clients.”

“For example, in Northumberland, in Sandwell, in Surrey you can see exactly that approach going on. Every month in Northumberland, I chair a multi-agency group which looks at the most complex dependent drinkers in that area. We develop a joint response across health, police, alcohol services, and adult social care. But in addition, we also have local assertive outreach capacity that can be targeted at those clients. And for me, that’s the most effective response. And similarly in Sandwell in the West Midlands we’ve got exactly the same model. Surrey has been using that model for some time.”

In the domestic homicide report, you talked about evidence-based commissioning at the end. You said that it’s important not to over-rely on interventions that can be measured by randomised controlled trials, and to make sure that we’re not ignoring evidence from things like peer learning and homicide reviews. Can you tell me about it?

“I remember this bit of the report very well, because it’s something that I say all the time. I think it’s really important to understand the difference between health services and social services. Health services are rightly driven by evidence. You need randomised controlled trials to show that if you put this jab in someone’s arm, it’s going to have a positive effect and not kill them. We don’t have that kind of evidence base to support social care interventions.”

“Statutory social care interventions are mainly driven by three things: legislation; court cases; and serious case reviews. In many ways, that is our evidence base. You can’t turn a social care intervention into one thing that is going to work in the same way for everyone, because everyone is so different, and every situation is different, and every intervention they need is different. What I think is most useful to those of us in the substance misuse field are the serious case reviews. They are a very powerful source of evidence for us. And in the social care context are probably going to be more powerful than, for example, randomised controlled trials which will be difficult to carry out in this sector because of the variability of each intervention.”

It’s been a few years since those two reports were published. From your experience, are these types of deaths being prevented? Are we learning from what you found in those reports?

“I think the answer to that is yes, generally. I can’t speak too much about the domestic abuse field, but in the substance misuse field, over the last 6 or 7 years the report of the Blue Light Project has helped to shift services to a recognition that they do need to work with these complex clients who are going to be difficult to engage with traditional services. And you are seeing an uptick in the number of services that are being more assertive in their approach – services that are more engagement focused. They are what a colleague of mine used to call ‘sticky’ services – services that hold onto people, and keep a grip on them.”

Mike Ward is Senior Consultant at Alcohol Change UK, and has worked in the substance misuse and mental health field for over 30 years.

Recommended reading

  • The Blue Light Project: an initiative to develop alternative approaches and care pathways for drinkers who are not in contact with treatment services, but who have complex needs

  • Domestic abuse and change resistant drinkers: preventing and reducing the harm. Learning lessons from Domestic Homicide Reviews

  • Learning from tragedies: an analysis of alcohol-related Safeguarding Adult Reviews

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