an evaluation of the parents under pressure programme (pup

AN EVALUATION OFTHE PARENTS UNDERPRESSURE PROGRAMME(PUP) AT COOLMINEDR JO-HANNA IVERS & PROFESSOR JOE BARRY

SEPTEMBER 2018

“Just connecting with your child. Therewas something being said about that oneday and, I really, really struggled with evenhearing what was being said, and just thebuilding of that bond and even, when shewas showing us the videos. They did

videos and even when she was showing usthat and she was saying to me; Oh lookthe way your daughter is looking at you”, I– I really struggled to actually, accept it.My child loves me…. It was weird now itwas. The amount of emotions that I feltduring the programme, oh my God, it

was unbelievable!”

AN EVALUATION OF THE PARENTS UNDER PRESSURE PROGRAMME (PUP) AT COOLMINE 1

contentsTABLES AND FIGURES 3LIST OF TABLES 3LIST OF FIGURES 3GLOSSARY OF TERMS 4EXECUTIVE SUMMARY 6RESEARCH TEAM 8ACKNOWLEDGEMENTS 8PUP RESEARCH ADVISORY GROUP (RAG) MEMBERS 8CONTEXT OF PUP PROGRAMME AT COOLMINE 9RATIONALE FOR CURRENT REPORT 9LITERATURE 10PARENTAL SUBSTANCE USE AND IRISH POLICY AND TREATMENT RESPONSE 10OVERVIEW OF THE PARENTS UNDER PRESSURE PROGRAMME 10PREVIOUS EVALUATIONS OF PUP PROGRAMME 11METHODOLOGY 13STUDY DESIGN 13AIM AND OBJECTIVES 13

STUDY OBJECTIVES 13DATA COLLECTION 13QUANTITATIVE MEASURES 14QUALITATIVE INTERVIEWS 14PILOTING THE QUALITATIVE INTERVIEWS 14PARTICIPANTS 14FIDELITY CHECK 14ETHICAL APPROVAL 14

QUANTITATIVE FINDINGS 15DESCRIPTIVE STATISTICS 15PRE AND POST INTERVENTIONS ACROSS ALL MEASURES OF PARTICIPANTS 17

THE DEPRESSION, ANXIETY AND STRESS SCALE 17THE MINDFUL PARENTING SCALE 17THE MULTI-DIMENSIONAL SCALE OF PERCEIVED SOCIAL SUPPORT 18THE STRENGTHS AND DIFFICULTIES QUESTIONNAIRE 18SUMMARY OF QUANTITATIVE FINDINGS FROM THE WOMEN IN ASHLEIGH HOUSE 19

QUALITATIVE INTERVIEW FINDINGS 20INTERVIEWS WITH WOMEN IN ASHLEIGH HOUSE 20

PARENTING (BEING PARENTED AND PARENTING) 20GUILT 20GROUP SETTING/PROGRAMME FIT 21BUILDING BELIEF 21IMPORTANCE OF CHILDREN 21ASHLEIGH HOUSE 22CHALLENGE TO CHANGE 22CHALLENGES OF PUP 23EXPECTATIONS 23DIRECT BENEFITS OF PUP 23TRANSFORMATIONAL CHANGE 24KEY LEARNING 24IMPORTANCE OF HAVING CHILDREN RESIDE 25IMPORTANCE OF NOT HAVING CHILDREN RESIDE 25

AN EVALUATION OF THE PARENTS UNDER PRESSURE PROGRAMME (PUP) AT COOLMINE2

SUGGESTED CHANGES TO PUP 26SUMMARY OF QUALITATIVE FINDINGS FROM THE WOMEN IN ASHLEIGH HOUSE 26

INTERVIEWS WITH PUP PRACTITIONERS 27WHAT WORKED? 27WHAT WERE THE CHALLENGES? 28WHAT WOULD YOU LIKE TO DO DIFFERENTLY? 28RECOMMENDATIONS 29SUMMARY OF FINDINGS FROM PUP PRACTITIONERS 29

FINDINGS OF FOCUS GROUPS 30EXPECTATION OF PUP 31CHALLENGES OF PUP 31BENEFITS OF PUP 52COOLMINE LODGE 32REPUTATION 33ACCESSING CHILDREN WHEN IN TREATMENT 33SUGGESTED CHANGES 33SUMMARY OF FOCUS GROUP FINDINGS FROM THE MEN IN COOLMINE LODGE 34

DISCUSSION 35CONCLUSION 35IMPORTANCE OF THIS RESEARCH 36STRENGTHS, LIMITATIONS AND FUTURE DIRECTION OF THE RESEARCH 36

STRENGTHS 36LIMITATIONS 36FUTURE DIRECTION 36

RECOMMENDATIONS 37REFERENCES 38


tABLes & FIGURes LIST OF TABLES Table 1: Demographics and clinical characteristics of women in Ashleigh House P16Table 2: DASS mean score pre and post intervention for women in Ashleigh House P17Table 3: MPQ mean Scale Score pre and post intervention for women in Ashleigh House P17Table 4: Multi- dimensional scale of Perceived Social Support (n=16) P18Table 5: SDQ mean Scale Score pre and post intervention for women in Ashleigh House P19Table 6: Demographics and clinical characteristics of men in Coolmine Lodge P30

LIST OF FIGURES Figure 1: illustrates the difference in DASS scores pre and post-intervention P17Figure 2: illustrates the difference in MPQ scores pre and post-intervention P18Figure 3: illustrates the difference in MSPSS scores pre and post-intervention P18Figure 4: illustrates the difference in SDQ scores pre and post-intervention P19


GLossARY oF teRMs ABSTINENCEIn this report, abstinence refers to the act orpractice of refraining from using illicit drugsor alcohol.

CASE-MANAGEMENTCase-management is the process ofcoordinating the care of a service userthrough a shared care plan and resolving anygaps and blocks that arise.

GETTING CLEAN Getting clean refers to becoming abstinent.

THERAPEUTIC COMMUNITY (TC)The therapeutic community (TC) is anintensive and comprehensive treatmentmodel developed for use with adults that hasbeen modified successfully to treatadolescents with substance use disorders. Thecore goal of TCs has always been to promotea more holistic lifestyle and to identify areasfor change such as negative personalbehaviours-social, psychological, andemotional - that can lead to substance use.Residents make these changes by learningfrom fellow residents, staff members, andother figures of authority1.

PEERIn the Therapeutic Community (TC) model, apeer is an individual who is also engaged inthe treatment programme within thecommunity.

PEER LED In this report the model of treatment, peer ledtreatment refers to the active engagement ofthe peers in their treatment and the treatmentof their peers.

PULL-UPA formalized element of communicationwithin a TC where peers confront each otherwith seemingly problematic behaviour orlapses of awareness.

PuP GROUP FACILITATOR In this report, refers to the PuP GroupFacilitator who is a practitioner trained in thePuP method and who delivers the PuPprogramme in a group format.

PuP PROGRAMME The PuP programme is a 20-week home-based support for parents who are receivingtreatment for substance use.

PuP THERAPIST A PuP therapist is a practitioner trained in thePuP method who delivers the PuP programmeon a one to one basis.

PuP COORDINATOR In this report, refers to the PuP coordinatorwho is a practitioner trained in the PuPmethod who co-ordinates the PuPprogramme at Coolmine. This involves boththe coordination of practitioners andparticipants. In addition all women receivedone to one sessions based on the case-management system.

RECOVERYRecovery is at times used interchangeablywith the term ‘abstinence’; however, recoveryencompasses more than abstaining fromsubstances. As such, recovery is about usersacquiring benefits across a range of areasincluding (but not limited to): health,relationships, well-being, education,employment, and self-care. It is understood to be an on-going process.

SOCIAL WORK INVOLVEMENT In this report, refers to the active and ongoingprocess of Social Work in the care of the childand or parent.

SUBSTANCE USEIn this report, parents were attendingtreatment for substance use, thus they wereengaging in harmful or hazardous use of


psychoactive substances, including alcoholand illicit drugs.

PuP GROUP FACILITATOR In this report, refers to the PuP GroupFacilitator who is a practitioner trained in thePuP method and who delivers the PuPprogramme in a group format.

PuP PROGRAMME The PuP programme is a 20-week home-based support for parents who are receivingtreatment for substance use.

PuP THERAPIST A PuP therapist is a practitioner trained in thePuP method who delivers the PuP programmeon a one to one basis.


EXECUTIVE SUMMARY


Coolmine Therapeutic Community hasopened its Parents under Pressure (PuP)programme to external scrutiny andevaluation. The PuP programme aims toimprove family functioning and childoutcomes by supporting parents who are, orhave been, drug or alcohol dependent.Evaluations of the PuP programme have beencarried out in other countries but never inIreland. This is the first evaluation anywhere ofthe PuP programme in a residential setting.

The current research aimed to investigate thefeasibility and effectiveness of the PuPprogramme being delivered in a group settingin addition to one-to-one sessions at AshleighHouse. A combination of quantitative andqualitative research methods was employed.Twenty-three women took part in theresearch across three waves.

25 women enrolled in the PuP programmeand twenty-three participated in theevaluation. It is noteworthy that no womanleft the PuP programme. The two participantsthat did leave, left the treatment services (onewas prematurely discharged and one self-discharged) rather than the programme.Moreover, a comparison of characteristicsbetween participants retained showed nodemographic or clinical differences.

A series of demographic and clinicalcharacteristics were gathered and analysed.Participants ranged in age from 22 years to44 years of age. The average age were 34years old. The women had complex needsbeyond their drug use; 78% were homeless,73.9% had active social care involvement, 26%had criminal justice issues and 26% reportedhaving a history of psychiatric problems.Twelve of the participants resided in AshleighHouse accompanied by their child. In all casesthis was limited to a single child. All childrenthat resided in Ashleigh House were under theage of five years.

Of the twenty-three, 21 completed a numberof pre and post validated outcome measures.Improvements were found in depression,

stress and anxiety scores after theprogramme. Mindful parenting scoresincreased, and there was a real or perceivedimprovement in children's behaviour. At theend of the programme all women were drugand alcohol free.

All twenty-three took part in the qualitativecomponent of the study. Guilt was a dominanttheme across the interview process. Theprincipal expectation of the participants wasto improve their relationships and access totheir children. As the women progressedthrough the programme, they were visiblybuilding belief in their abilities to parent. Thegroup setting facilitated a sense of solidarity.Through the sharing of experiences, thewomen learned they were not alone. Duringthe evaluation, PuP was being piloted for menat Coolmine Lodge. Thus, ten men took partin a pre and post programme focus groupsand their experience is included.

The men and women experienced challengeswhen participating in the programme.Regardless of whether or not they had accessto their children, the benefits of participatingin the PuP programme were apparent.External agencies such as social services andcriminal justice were familiar with the PuPprogramme and participants received externalvalidation and praise for their participation.All participants emphasised the importance ofaccess during treatment. Most frequently twosuggestions for change were put forth byparticipants; (1) including the children in thesessions and (2) adapting the content toinclude older adult children.

The involvement of a programme coordinatorand group facilitators is essential. PuP shouldbe extended to all fathers. Teenage and youngadult children of participants should beincluded in future programmes. A moreextensive evaluation, with greater numbersand longer follow up, should be carried outwith particular emphasis on communityoutreach and the development of theprogramme to other non TherapeuticCommunity-based treatment settings.


Dr Jo-Hanna Ivers works at the Department ofPublic Health & Primary Care at the Instituteof Population Health, Trinity College Dublin.Jo-Hanna has worked as a researcher in theDepartment of Public Health & Primary Careas part of a broader addiction team since2009. During this time she has completedsome large-scale addiction studies includingthe evaluation of the National DrugRehabilitation Framework. Jo-Hanna hasspecific training and extensive experience in a wide range of research methodologiesincluding qualitative, quantitative,neuroimaging process, behaviouralintervention and outcome evaluation. She haspublished in a number of high-impactinternational peer-reviewed journals and hasextensive experience of addiction treatment.Prior to research, Jo-Hanna worked infrontline addiction services.

Professor Joe Barry, Chair of PopulationHealth Medicine at the Department of PublicHealth & Primary Care at the Institute ofPopulation Health, Trinity College Dublin, hasestablished a drug research group to examinethe impact of substance misuse and addictionon population health. His research expertise inthis field embraces a wide range ofmethodologies relevant to the proposal.These include prevalence studies, behaviouraland attitude studies, cross-sectional surveys,intervention studies, cohort studies and healthoutcome studies, including mortality andsurvival analysis, in addition to policy analysis.He is widely published in international peer-reviewed journals and has extensiveexperience of the public system and public policy.

We would like to extend a very sincere thankyou to all of the service users whoparticipated in this research. Participating inresearch can be demanding, particularly whentrying to complete a treatment programmeand we greatly appreciate the time and effortinvested by everyone involved. In addition,we would really like to thank Professor SharonDawe (Griffith University, Brisbane) who wasalways available to us throughout the courseof the evaluation. A heartfelt thank you is alsoextended to members of the researchadvisory group for their support andfeedback throughout the study.

PUP ReseARcH ADVIsoRY GRoUP (RAG)MeMBeRsThe RAG was made up of the research teamand representatives from the funding agency.The RAG was formed at the outset andremained in place until the final report wasagreed. The group consisted of:

Professor Joe Barry Department of Public Health & Primary

Care, Institute of Population Health, Schoolof Medicine, Trinity College Dublin

Ms Anita Harris Coolmine Therapeutic Community Dr Jo-Hanna Ivers Department of Public Health & Primary

Care, Institute of Population Health, Schoolof Medicine, Trinity College Dublin

Ms Pauline McKeown Coolmine Therapeutic Community

ReseARcH teAM AcKnoWLeDGeMents


Coolmine Therapeutic Community is a drugand alcohol treatment setting providingresidential and community services to bothmen and women seeking to address theiraddiction issues, Coolmine Lodge is aresidential treatment facility for men andAshleigh House is a residential treatmentfacility for women. Both Coolmine Lodge andAshleigh House are collectively known asCoolmine. The residential treatmentprogrammes at Coolmine last approximatelysix months, with a further seven monthintegration and aftercare service.

The primary research site was AshleighHouse. Ashleigh House is unique as it offersthe only mother and child residentialrehabilitation centre in Ireland. Mothers canaccess residential treatment accompanied bytheir children under the age of five. Theprogramme seeks to address the mothers’addiction issues as well as the impact ofparental substance use on babies and youngchildren. Two years ago, Ashleigh Houseintroduced the PuP programme in an effort toimprove child and parental outcomes. Whilstthe PuP programme was originally designedto be delivered as a home basedindividualised intervention, the programme atAshleigh House is delivered in a groupresidential setting and in the TherapeuticCommunity context.

The aim of the current research was toinvestigate the feasibility and effectiveness ofthe PuP programme being delivered in agroup setting in addition to one to onesessions at Ashleigh House. The focus of theresearch was on the women at AshleighHouse. However, during the evaluation periodCoolmine Lodge ran its first PuP programmefor fathers, thus pre and post programmefocus groups were conducted to capture theexperience of these men.

Understanding the differing experiences ofservice users regarding their treatment offersthe best prospects for improving ourunderstanding of their health needs and the opportunities before us to better meetthese needs.

In February 2014 Coolmine carried out aninternal pilot study, which suggested PuP tobe a valuable programme with genuineobserved gains. Nevertheless, this evaluationwas posthoc and examined a single cohort ofwomen who had completed the PuPprogramme at Ashleigh House. Thus,Coolmine concluded that a largerprospective study across a number of waveswith clear study objectives would benecessary to better understand theeffectiveness of the PuP programme.

The research aims to achieve this byconducting an independent evaluation of theImplementation of the Parents under Pressureprogramme (PuP). Evaluation is a systematicmethod for reviewing the experiences of apopulation, leading to agreed priorities andrecommendations regarding resourcereallocation that will improve treatmentservices.

conteXt oF PUP PRoGRAMMe At cooLMIne

RAtIonALe FoR cURRentRePoRt


LIteRAtURe

PARentAL sUBstAnce Use AnD IRIsHPoLIcY AnD tReAtMent ResPonseA number of national2 and international3, 4

studies suggest parental substance use, whilenot always the case, exposes children tohigher risk of physical, psychological,behavioural and emotional problems. TheNational Drug Treatment Reporting System(NDTRS) estimate a total 15% of cases whowere treated for problem drug use (excludingalcohol) for the years 2015 and 2016 wereliving with children. It is likely that the truepercentage is higher as some cases withchildren may, for example be living withparents/families5. More recently in IrelandGalligan & Comiskey (2017), estimates thatalmost 4% of Irish children are affected byparental substance use. Moreover, accordingto the authors, up to 9% of Irish children areliving with problematic parental alcohol use6.As the effects of parental substance use oftengo unnoticed they are increasingly referred toas ‘Hidden Harms’. This, in turn, creates aperpetuating cycle that often includesintergenerational substance use andcontinued high rates of physical,psychological, emotional and behaviouralproblems.

A Hidden Harm National Steering Group wasset up in June 2013. This was led by TUSLA(the child and family agency), the HSENational Social Inclusion Office and HSEMental Health and Drug and Alcohol Services.This group developed a ministerial policysubmission ‘Addressing Hidden Harm:Bridging the gulf between substance misuseand childcare systems, for the attention of thethen Minister of State with responsibility forDrugs, Alex White, TD’ (unpublished)7. Inrecognition of the need to address the hiddenharms associated with parental substanceuse, ‘Hidden Harm’ was included as a themewithin Better Outcomes Brighter Futures: TheNational Policy Framework for Children andYoung People 2014-20208.

Nevertheless, currently in Ireland there hasbeen no accepted integrated treatmentresponse to assist parents attempting toaddress the harms associated with theirsubstance use. Similarly, the National DrugsStrategy (Interim) 2009-20169 andsubsequent Strategy ‘Reducing Harm,Supporting Recovery 2017-202510 set out totarget the child’s needs within the context ofparental drug use. Based on therecommendation of the National DrugsStrategy (Interim) 2009-2016, to target thechild’s need in relation to parental substanceabuse, Coolmine introduced a parentingcomponent, the Parenting under Pressure(PuP) programme, to its already existingresidential programme.

oVeRVIeW oF tHe PARents UnDeRPRessURe PRoGRAMMeThe PuP programme aims to improve familyfunctioning and child outcomes by supportingparents who are or who have been drug oralcohol dependent. The programme combinespsychological principles relating to parenting,child behaviour and parental emotionregulation within a case management model11.The PuP programme is a 20-week home-based support for parents who are receivingtreatment for substance use . ProfessorSharon Dawe and Dr Paul Harnett in Australiaspecifically developed the programme for‘multi-problem high-risk families’ with childrenaged between two and eight years. Theprogramme recognises that parents who arereceiving treatment for substance use quiteoften experience problems across severalareas, such as family life and functioning, childbehaviour problems, mental health difficultiesand loneliness. Thus, the PuP programme issupported by an asset-based model, whichaims to address the complex and multipleproblems specific to these families. The PuPprogramme is a manualised intervention.However, the ‘order and dose’ of the contentof each module is customised to the


individual needs of the family.

Consequently, the programme offers astructured - albeit unsequenced - process oftherapy. The PuP programme is generally runover 20-weeks and aims to enhance parentingskills and develop positive and securerelationships between parents and theirchildren. The programme comprises of 12 coremodules, which begins with a full assessmentand goal setting. Working with the PuPtherapist during assessment allows the parentto identify the further modules to addressspecific needs (view of self as a parent,managing emotions under pressure, healthcheck for your child, connecting with yourchild/mindful play).

The final session of PuP is dedicated toreflecting on the parents’ achievements overthe course of the programme. Sessions areusually confined to two hours. Any necessarysupplementary case-management occursoutside of the PuP sessions.

The programme takes a strengths-basedapproach where the focus is on aspects ofcare that the parents do well in order to buildtheir confidence. PuP therapists work withparents to assist them with theirunderstanding of their child’s developmentwhile focusing and responding to the child’semotional needs and in turn improving themanner in which they interact with their child.A number of other methods are incorporatedinto the delivery of the programme, includingvideo feedback, parent workbook, andmindfulness. Mindfulness is fundamental tothe programme and the proposed method ofchange, supporting parents to recognise andregulate their emotions, while being fully‘present’ during daily interactions with thechild.

PReVIoUs eVALUAtIons oF PUPPRoGRAMMeFollowing the development of the PuPprogramme both Professor Dawe and DrHarnett have been working with students,clinicians and other academics for the pastdecade enhancing and developing anevidence base for the PuP model11. As suchthey have published a number of studies onthe efficacy of PuP 4, 12-14. In the firstrandomised controlled trial (RCT) of the PuPprogramme Dawe & Harnett (2007) foundthat methadone-maintained parents in thePuP treatment arm showed statisticallysignificant improvements across multipledomains of family functioning12 whencompared to a control group. Similarly in alater study with ten families who completedthe PuP programme Harnett & Dawe (2008)found statistically significant improvementbetween the pre- and post-assessmentmeasures of parental and child functioning,parental–child relationships, and socialcontextual measures. However, while themajority of families showed clinicallysignificant improvement, a small proportion ofthe families showed no change ordeteriorated14.

In early 2018 in the UK Harnett et al, (2018)found the PuP programme to be effectivewhen applied to 31 pregnant mothers whoreceived the programme from 18 weeks’gestation until their infants first birthday15. Bythe time that the infant was two months old,the mothers enrolled on the PuP programmehad significantly reduced levels of depression,anxiety and stress, and significantly improvedsocial support, although there was noreported change in drinking patterns.Moreover, two fifths of parents receiving PuPhad improvements in the safeguarding statusof the child, with more flexibility extended tothe parent by the end of the programme15. Inaddition, an economic evaluation of the PuPprogramme in Australia with methadone


maintained parents has demonstrated theprogrammes financial and social benefits.Dalziel et al (2015) concluded that for every100 families receiving the PuP programme,one-fifth would be diverted from the childprotection system. The authors propose thiscould translate to a net saving of £1.7 millionfor every 100 families treated through PuP onthe basis that one in five cases would be nolonger negligent16.

Although the emerging body of evidencesupports positive findings of PuP whenattempting to effect change across multipledomains of family functioning, these studiesalso show that it does not effect change forall parents12. For instance, Dawe & Harnett(2007) found that more than one third offamilies considered ‘high risk’ for child abuseand neglect had no change in risk status atthe end of the study12. Likewise, Harnett et al(2018) found over one quarter of prenatalmothers enrolled on a PuP programme hadjudicial proceedings issued following the birthof their child, while none of the mothers in thecontrol group had a similar outcome.

Nevertheless, the authors highlight thisfinding as positive, proposing that in theseparticular cases the outcome of theassessment and work supported by the PuPprogramme ultimately helped social workersto make improved and timelier judgmentsregarding the placement of these babies,consequently averting additional harm. Morerecently in the UK, the NSPCC conducted anevaluation of the PuP programme3. Thepurpose of the evaluation was to assess theimplementation and impact of the PuPprogramme within the UK context3. Theevaluation findings concluded that substance-using parents who access a parentingprogramme such as PuP tend to havecomplex needs and experience a range ofmultiple adversities. Nonetheless, withsupport from the PuP programme, the

parents displayed changes in both primaryand secondary outcomes assessed3 (with theexception of child social-emotional andbehavioural difficulties).


MetHoDoLoGY

stUDY DesIGnA combination of quantitative and qualitativeresearch methods was used to gather datafrom parents, the PuP Group Facilitator andthe dedicated PuP coordinator.

AIM AnD oBJectIVes The overall aim of the current study was toexamine the effectiveness of the PuPprogramme in the residential TherapeuticCommunity in Ashleigh House.

STUDY OBJECTIVES:Objectives of the research were to review andevaluate:

The feasibility of delivering the Parentsunder Pressure (PuP) programme in agroup format at Ashleigh House.

The effectiveness of the Parents underPressure (PuP) programme in a groupformat at Ashleigh House.

The coordination and delivery of the PuPprogramme strengths-based intervention inAshleigh House.

The development and implementation of anevening PuP structure.

The experiences of the men at CoolmineLodge participating in the Parents underPressure (PuP) programme.

DATA COLLECTIONData collection took place during threeprogramme waves from women attendingAshleigh House for addiction treatment fromSeptember 2017 to June 2018. In addition tothe data collection on the women attendingAshleigh House, a pre and post focus groupfor men attending Coolmine Lodge was alsoincluded between February and June 2018. Data collection comprised two keycomponents;

1. Quantitative measures (a pre and postbattery of PuP validated measures for allwomen).

2. Qualitative Interviews (a pre and postinterview for all women) and Focus group(pre and post programme for men) as wellas interviews with PuP practitioners.

QUANTITATIVE MEASURESAll parents participating in the PuPprogramme at Coolmine women’s residentialprogramme had a battery of validated PuPmeasures administered pre and postprogramme.

Validated measures Include:

Depression Anxiety Stress Scales (DASS) Mindful Parenting Questionnaire (MPQ) The Multi-dimensional Scale of Perceived

Social Support (MSPSS) Strengths and Difficulties Questionnaire

(SDQ)

These scales aim to measure changes in thefollowing:

Affect regulation (DASS) Mindful parenting (MPQ) Perceived social support (MSPSS) Changes in children’s behaviour (SDQ)

These tools work in partnership with thetherapeutic use of video interaction,observation and feedback. Videos of motherswith their infant/child were taken andselected pieces of video were edited and thenshown to the mothers as part of theprogramme. The key to this process is theunderstanding that this is a strength-basedapproach, which emphasizes those aspects ofthe interaction that represent excellentcaregiving rather than illuminating anydeficits. The purpose is to enhance parentalself-efficacy and ensure that parents are clearabout specific parenting elements that needto be changed or enhanced. While videoswere utilised as a therapeutic tool for a smallnumber of the women in Ashleigh House,


video analysis was not part of the currentstudy. Therefore findings from these videosare not reported in the current findings.

QUALITATIVE INTERVIEWS A major strength of qualitative data is the richthematic texture that can arise from this typeof analytic undertaking. The major goal withinthis segment of evaluation is the elaborationof the understanding of the need for andbenefit of the PuP programme thatspecifically addresses the parent and child’sneeds within a supported treatment context.A goal, which is not possible to capture in amethodological format such as aquestionnaire, that is more appropriate withlarger sample sizes.

PILOTING THE QUALITATIVE INTERVIEWS The first wave of the PuP programmequalitative interviews formed the pilot.Following the first wave of interviews, werefined the protocol based on the women’sfeedback. The original protocol included apre-programme interview, a second interviewmidpoint (approximately six weeks) and afinal interview in the week followingprogramme completion. However, the womensuggested that the midpoint interview wastoo much. Thus, following the initial piloting(wave 1) waves 2 and 3 included only a preand post programme interview.

PARTICIPANTS All women who were enrolled on the PuPprogramme at Ashleigh House were invited totake part in the study. A total of 23 womentook part in the qualitative interviews. 21completed the quantitative measures and tenmen from Coolmine Lodge who took part inthe PuP programme participated in a pre andpost programme focus group. In addition,both the PuP Group Facilitator and the PuPCoordinator were interviewed.

FIDELITY CHECK When effective interventions are implementedin real-world conditions, it is essential toevaluate whether or not the programmes areimplemented as intended. Validity forprotocols and accompanying paperwork is akey of the evaluation process. A singletherapist delivered all of the groups, and asingle individual was responsible for thecoordination of the programme. In addition,concurrent with the evaluation process, theCoolmine PuP therapists were completingaccreditation with Professor Sharon Dawe’steam. Professor Dawe is a founder of the PuPprogramme. Thus, fidelity issues wereregularly checked as part of the process andas such fidelity checks were not included inthe current study.

ETHICAL APPROVALThe study received ethical approval from theNational Drug Treatment Centre (NDTC).


QUAntItAtIVe FInDInGs

25 women enrolled on the PuP programme.23 participated in the evaluation. Theattrition rate was low (n=2), and retention ratewas high at 92%. It is noteworthy that nowoman left the PuP programme. The twoparticipants that did leave, left the treatmentservices (one was prematurely dischargedand one self-discharged). Moreover, acomparison of characteristics between thewomen retained showed no demographic orclinical differences. Attempts were made tofollow these two participants up but allattempts were unsuccessful.

DescRIPtIVe stAtIstIcs Descriptive statistics were generated toprovide an overview of the critical variables of change in the evaluation. A battery ofvalidated measures was administered pre andpost intervention. Four measures were takennamely; (i) the Depression, Anxiety and StressScale DASS-21 Scale1 (ii) the MindfulParenting Scale (MP), (iii) TheMultidimensional Scale Perceived SocialSupport and (iv) the Strengths and DifficultiesQuestionnaire. Findings from each of thesemeasures are reported below.

All quantitative analysis was analysed usingSPSS V26 (IBM) and analysis was based onpre and post intervention scores. Descriptivestatistics was generated for each time pointof data collection to provide an overview ofthe key variables in the evaluation. Given thesmall size of the sample, inferential tests werenot conducted for this report.

A total of 21 women completed quantitativemeasures at Time 1 and of these 18 completedquantitative measures at Time 2. Participantsranged in age from 22 years to 44 years ofage. The average age at entry to theprogramme was 34 years. 12 of theparticipants had a child reside with them inAshleigh House. All children were under theage of five years.

Several of the women had complex needsbeyond drug use. More than three-quarterssaid that they were homeless (78%), almosttwo-thirds (61%) reported a family history ofdrug abuse, and more than one quarter(26.1%) reported having a history ofpsychiatric problems and more than one-quarter of the women had criminal justiceissues (26%). Moreover, eleven of the 12women who had their children reside inAshleigh House had active social workinvolvement. At pre and post-intervention, allparticipants were drug and alcohol-free. Morethan half of the participants cite opiates astheir primary problem drug (52.2%) for whichthey are receiving treatment. Table 1summarises the demographic and clinicalprofile of all participants.


Demographic Variable Response categories number and % (n=23)

Age 18-2526-3334-4142-49

4 (17.4%)10 (43.5%)6 (26.1%)3 (13%)

Primary Problem Drug OpiatesAlcoholCocaineCannabis/WeedBenzodiazepineOther

12 (52.2%)6 (26%)1 (4.3%)1(4.3%)3 (13%)0 (0%)

number of children 12345 or more

11 (47.8 %)1 (4.3%)5 (21.7%)5 (21.7%)1 (4.3%)

child/children residing inAshleigh House

Yes No

12 (52.2%)11 (47.8%)

Active social WorkInvolvement

Yes No

17 (73.9 %)6 (26.1%)

criminal Justice Issues Yes No

6 (26%)17 (74%)

Homeless Yes No

18 (78%)5 (22%)

Previously treated forsubstance Abuse

First Time in Treatment 1 previous treatment Episode2 or more Treatment Episodes

7 (30.4%)3 (13%)13 (56.5%)

History of Psychiatric Issues YesNo

6 (26.1)17 (73.9%)

Family History of substanceAbuse

YesNo

14 (61%)9 (39%)

table 1: Demographics and clinical characteristics of women in Ashleigh House


PRe AnD Post InteRVentIons AcRossALL MeAsURes oF PARtIcIPAnts THE DEPRESSION, ANXIETY AND STRESSSCALE Depression, Anxiety and Stress was measuredusing the DASS-21 Scale17. The DASS-21 Scaleis a 21-item self-reported validatedquestionnaire. The scale is divided into threesubscales each containing seven itemsdesigned to measure the negative emotionalstates of depression, anxiety and stress. A total of 21 participants completed the DASSat pre-intervention. Figure 1 illustrates thedifference in scores pre and post-intervention.The data shows that the women at entry levelwere reporting severe levels of bothdepression and anxiety and moderate levelsof stress. It is reasonable to infer that this levelof depression and anxiety could affect theirparenting. At post-intervention, the womenreported notably lower levels of all threenegative emotional states with all three scalesreturning to a reasonable level postprogramme intervention (table 2 and figure 1).

THE MINDFUL PARENTING SCALE The Mindful Parenting Scale18 measures aparent's ability to reflect on their emotionalstate, to manage their emotions and toidentify and respond to their baby/child’semotional state. There are 27 items eachscored on a five-point scale. A score that fallsbetween 2 and 4 indicated that theparticipant has some understanding of theiremotional state and that of their baby/child,but this may not be consistent. The women’sscore was reasonably good. There was animprovement to higher end of score followingthe programme intervention (Table 3 andFigure 2).

DAss scoRe time 1 time 2

Depressionscore 19.3 9.8

Anxietyscore 16.3 8.6

stress score 22.8 13.8

table 2: DAss mean score at pre and postintervention for women in Ashleigh House(n=18)

Figure 1: illustrates the difference in DAssscores pre and post-intervention

Mindful Parentingscale score

time 1 time 2

Mean score 3.1 3.6

table 3: MPQ mean scale score pre and postintervention for women in Ashleigh House(n=18)

25

20

15

10

5

0

Time 1

Depression

Time 2

AnxietyStress


THE MULTI-DIMENSIONAL SCALE OFPERCEIVED SOCIAL SUPPORT The Multi-dimensional Scale of PerceivedSocial Support (MSPSS) measures the levelsof support a parent feels they get from family,friends and significant others. Figure 3illustrates the difference in scores pre andpost-intervention. At pre-intervention,participants scored a mean average of 4.09indicating they receive some support fromfamily, friends and others but this may not beadequate. At post-intervention, there was anincrease in self-reported levels of supportscoring participants reported a mean of 4.9.

THE STRENGTHS AND DIFFICULTIESQUESTIONNAIRE The Strengths and Difficulties Questionnaire(SDQ)19 measures the child’s conduct,emotional and social problems as seen by theparent who completed the form. The TotalSDQ score consists of four sub-scales:Conduct Problems, Emotional, Hyperactivity,and Peer problems. The numbers ofcompleted SDQ’s were lower as thisquestionnaire as it only related to parentswith children between the ages of three andeight years with regular access to theirchildren. Only nine of the 23 parents met thiscriterion and only five completed both timepoints thus, for analysis purposes, data ispresented for these five participants in tables below.

Figure 4 illustrates the difference in scores preand post programme intervention. At pre-intervention, participants (n=5) scored amean of 14 indicating that they perceivedtheir child/children in the borderline range ofproblems that needed to be addressed. Atpost-intervention, participants (n=5) scored amean of 10.8 suggesting there has been adecisive shift in either a) their children’s

Figure 2 illustrates the difference in MPQscores pre and post-intervention

Figure 3 illustrates the difference in MPsssscores pre and post-intervention

Multi-dimensionalscale of Perceivedsocial supportscore

time 1 time 2

Mean score 4.1 4.9

table 4: Multi-dimensional scale ofPerceived social support (n=16)

3.73.63.53.43.33.23.1

32.92.8

Time 1 Time 2

Mindful Parenting Questionnaire

5

4.8

4.6

4.4

4.2

4

3.8

3.6

Support

Time 1 Time 2


behaviour or b) how they perceive theirchild’s behaviour.

sUMMARY oF QUAntItAtIVe FInDInGsFRoM tHe WoMen In AsHLeIGH HoUse 60% of the 23 women were aged under 34 78% of the women were homeless 26% of the women had criminal justice

issues 52% cited opiates as the primary drug of

use, followed by 26% citing alcohol There was a reduction in depression,

anxiety and stress scores post programmeintervention.

There was an increase in mindful parentingscores and perceived social support postprogramme intervention.

There was an improvement in children'sbehaviour or the mothers' perceptionthereof post programme intervention.

the strengths andDifficultiesQuestionnaire(sDQ)

time 1 time 2

Mean score 14 10.8

table 5: sDQ mean scale score pre and postintervention for women in Ashleigh House(n=5)

Figure 4 illustrates the difference sDQ inscores pre and post-intervention

1614121086420

Time 1 Time 2

Strengths and Di!culties


QUALItAtIVe InteRVIeW FInDInGs

InteRVIeWs WItH WoMen In AsHLeIGHHoUse Findings from the qualitative interviewsacross the three waves are presentedcollectively below. All twenty-threeparticipants took part in the qualitativeinterviews. Only one woman refused to takepart in the final interview. However, consent toinclude her previous interview was given. Thequalitative data yielded crucial information onthe women’s experiences of the programme.Several themes emerged from the data. Thesedata are presented and discussed below.

PARENTING (BEING PARENTED ANDPARENTING)Not surprisingly parenting emerged as atheme throughout the interviews. Theexperience of both being a parent and beingparented emerged. In many cases, the womenstruggled for a point of reference for ‘good’parenting.

“…growing up anyways I had no life, mymother and father were, they weren’t amother and father. I was moving aroundthen from foster home to foster homeand living with relations and all that andthen I had a child at 17, still sleeping onthe streets, moving around”

(Participant 2)

“The first week. ‘What do I think I am as aparent? Or what do you think a goodparent should be?’ That was the hardestfor me…I have no clue. No one evershowed me…”(Participant 19)

“It sounds stupid like…but even admittingwhat a good parent was, was so hard forme…I had no examples…”(Participant 22).

“It’s very hard being a mother though, it’sthe hardest thing that I’ve ever had to doand I feel that the two – probably the twohardest things that you can do in life[getting clean and being a parent]…noone shows you, there’s no one way,you’ve just have to get on with it…” (Participant 10).

GUILTGuilt was a dominant theme in the interviewprocess. It was evident that, prior to engagingwith the PuP programme, the women felt thatthey were alone in their guilt.

“...I was beating myself up so much all theway through saying, “God some of youmight have made mistakes but me, I wasjust, like, the [speaker’s emphasis] worst.”and it was, you know, I wasn’t beingdramatic or whatever. I actually didbelieve...” (Participant 1)

“So, I never actually really get time tospend with her [daughter], like youknow? So, that was good to actuallyknow that I can do that and just to givethe – my daughter something, just beforebedtime even so she knows, like youknow. And it’s good for me as well,because I can actually I can [exhales], Ihave a lot of guilt from the past becauselike I didn’t want to, my child was with mebut it’s just she was never, I never gaveher attention” (Participant 17).

“... I got more understanding in meselfand why I was the way I was I supposebut, yeah, it …was – it was hard but I’mglad I done it, yeah…it’s still hard. I stillfeel very guilty and all about all of that,you know what I mean … that’s – that’smy stuff, I need to let that go. But it’s


easy to say that, like, but I’ve learned alot, like, even the relationships part, Ithought that was brilliant. It kind of mademe look at why I go for certain people allthe time…”(Participant 22)

“..they teach you a lot, how to do things,because my child, he's six now and he'shyper, and they teach you, mindfulnesstips and things like that like and, with meI think I feel- when I do see him (son) Ijust have no kind of boundaries with himand thats because I feel guilty over notbeing there all the time... and I'm going tobe finishing here soon enough now so I'mgoing to be with him fulltime again.” (Participant 14).

GROUP SETTING/PROGRAMME FITHowever, despite the negative emotions in thesharing within the group setting, the veil waslifted and the women realised they were notalone. The shared experiences helped thewomen and offered a sense of support.

“At first the shame, you know... I neverthought I would be able to be as honestas I was… stuff I never faced before. Inever told anyone.”(Participant 6).

“The group was great… but it was hardbut the support you get is great…it wasnice to know that I was not the only one,you know like that wasn’t perfect…(Participant 9).

“I didn’t realise until the end that this isnot how it’s done [group format] it wasgrand I think it would be too much onyour own like, specially coming out afterall that…no the group was great, yeah itworked well.” (Participant 11).

Having the one-to-one sessions presented awin-win for the women:

“I love the one-to-ones. Emma is greatthere’s something’s I wouldn’t ask in thegroup you know.. I feel stupid and I feellike…the one-to-ones are good for that.”(Participant 7)

“It’s all going good. I found the PuP really,really good. It’s changed my thinking in alot of ways. I’m still seeing Emma for a lotof the one-to-ones and that’s helpingtoo.” (Participant 13)

BUILDING BELIEFAs the women progressed through theprogramme, they were visibly building beliefin their abilities to parent. The strengths-based approach was critical to thisdevelopment.

“That I’m not such a failure after all… youthink you are really. And just to, like, be agood parent. And be the best I can. Youdon’t have to be this perfect clichémother, like you know what I mean and,like, it’s alright to get things wrongsometimes, you know…” (Participant 14).

“... I just learned about, that, I’m not theonly one, you know. So I always thought Iwas the only one and stressed out to bitsand all saying “How come I’m like this?”with me child ... I don’t know, me childhates me and all I’d be thinking but… hedoesn’t! I just thought I could get nothingright…but I can…I am.” (Participant 5)

IMPORTANCE OF CHILDRENThe importance of children was evidentthroughout the interview process. Holding thechild at the centre of the process pushed the


participants through even the most adverseevents.

“But he’s worth it though. Some – like,during the detox if I hadn’t had him therewould have been times I would have justwalked. I would have been, like, “I can’tdo it, no”. He kind of was the strengththat I needed to keep me here.”(Participant 10 ).

“I have this child and I want to make itright.” (Participant 1)

“I do believe that...he was a gift, I wasstruggling in addiction and then I gotpregnant with him and I thought I have totry and get myself together now.” (Participant 11)

“…I’ve four beautiful kids, and I have [son]in with me. I just wanted a change of life,I was just feeling sick and tired of beingsick and tired every day, I just want forme to benefit, for me kids to have abetter life...” (Participant 15)

ASHLEIGH HOUSEWhile the women recognised that theprogramme at Ashleigh House was tight andthat they needed time to adapt to some ofthe idiosyncrasies, ultimately it was asupportive environment, which was valuedhighly.

“That’s very important for me and thenit’s the support you get from the staffand, you know, support you get fromother women that are in the samesituation as you. So, it’s that support thatyou get and then even with your childrencoming up it’s not, like, watching andwaiting for mistakes or anything like that.It’s a really healthy happy environment

for them as well.” (Participant 6).

“It’s kind of when you’re so used to dodoing your own thing it’s hard to conformin here. The pick-ups and pull-ups system.You can’t say ‘Smoke’, you have to say‘Cigarette’. You can’t, like, you know thedynamics of addiction and, you know,“Maximising”, “You’re minimizing”, so if …that’s just petty things though…I don’tknow. I kind of am – I know I can have mylittle moments about things in here but, Iwould be lost now if I didn’t have thisplace. I don’t know where I would be[emphasizes voice]…” (Participant 10 ).

“It’s a hard programme but, look, it’smeant to be hard, like you know. It’sgoing really well, like, everything is fallingback into place in my life and my kids andeverything, like you know?” (Participant 23).

CHALLENGE TO CHANGEThe majority of women emphasised thestruggle to change. Nevertheless, the value ofthe struggle was acknowledged.

“Just to make sure I went in. I came inand ah I struggled to be honest, I’m notgoing to lie, I struggled to be here. Istruggled to change because it’s not likeme to sit in a place to deal with myfeelings and thoughts, I run from myself. Irun from everything.” (Participant 2).

“…Sometimes I’m struggling – now, evenwhen I’m struggling now I don’t feel likegoing because I want to finish it, I’mnearly finished it, [programme] do youknow what I mean? It’s tough!..”(Participant 9).


“… for me, it’s a struggle, to be honestwith you because it’s that change, thissort of change - learning things in PuP -yeah, I struggle with them but they’relearning me something about me kids…my son, he – he’s getting counselling–and then things about him…And thathelped a lot better to be honest with you,his behaviours, I understand more – I getmore understanding of my child andknow my child better…” (Participant 22)

“… because I think before I was – Icouldn’t even acknowledge the goodthings because I’d say “How dare youthink you’ve done anything right with[son], look at all the things you’ve donewrong.” Whereas that doesn’t actually doanyone any favours…” (Participant 1)

CHALLENGES OF PuP Several elements of the programme posedchallenges for the women. However, therecognition that these challenges werehelping them was evident.

“No. At the start, I used to be crying in itand all, I didn't want to really be going toit. I'd be, like, 'Oh no, we have PuP!'(laughs) I did, that means it's goodbecause you don't want to deal with thatstuff.” (Participant 5)

“I think the one on supports was veryhard, that was very emotional and theone on what kind of parent you are. Ithought that was very hard, you know?But it brought up a lot of stuff for mewhich I – helped me personally workthrough the stuff but I also found that itwas really though.” (Participant 6)

“Hands down this was the mostchallenging thing I had to do… it was theshame feeling those forms out andfeeling that way it was horrible.. I am gladI done it but it was rough!” (Participant 20)

EXPECTATIONSSeveral elements of the programme posedchallenges for the women. However, therecognition that these challenges werehelping them was apparent.

“I’d just love to have a bond back with mydaughter, like, I do – I do have a bondwith her but we’ll say it’s just – I find ithard sometimes just to, you know, even,like, bond with her.” (Participant 17)

“I couldn’t recommend it enough... It’s notjust a parenting course, it’s a lesson forlife.” (Participant 20)

“No, It's been - it's completely different towhat I expected because it's and (reallygood), like, the things (content) that theycover, you know...'brilliant' absolutely.”(Participant 4)

DIRECT BENEFITS of PuP The benefits of the PuP programme to thewomen and their children were immediateand direct.

“…I suppose it’s to do – around me 15 yearold daughter, because I kind of wouldhave felt, at first when I started the [PuP]programme, it was more geared aroundmy younger son but my older daughter,who I would have kind of pushed awaybecause I was afraid of relapsing andstuff like that. And I kind of learned to dothings with her when she’s here, themindfulness, like, if – she likes watching


DVDs so I’ve watched films with her whenshe’s here. So, I’ve been present with her,no distractions; our time. That – that’shuge for me, it’s helped me build back upmy relationship with – with [daughter]and it’s actually really working. I see thebenefits of it already…” (Participant 2)

“I just kind of feel that I’m more aware ofhow I speak to [son] and how Icommunicate with him and that when,like, he’s crying or whining…I wouldn’thave known that really if I hadn’t donethe PuP programme, I know crying, Iwould have known but, like, the hitting[by the child] – I just feel I’m getting toknow his ways more. I’m more mindful aswell when I’m with him and I’m not… theway you can be sitting with your babyand it’s like you’re not really there”(Participant 10).

“…at the start of PuP , when you’re fillingout the forms, and it’s hard, becauseyou’re looking at negative things and, butas you go through, each module, youlearn what you’re after doing well andgood in your children’s lives and howmuch you’ve, I would have a lot of – I’dhave no boundaries with my childrenobviously because – because when I wasin addiction, there was a lot I didn’t doand me mother did and it [PuPprogramme] just shown me, , that eventhough they were with me mother for thelast year everything else that I did beforethat, I [speaker emphasizes] done.”(Participant 4)

TRANSFORMATIONAL CHANGEFor some of the women the programme hadprofound effects on how they viewedthemselves as parents.

“But I do think of myself like that, I do

think “I was damaged so much as a childthat I’ll never be fixable, that I’m toobroken to be fixed.” and I do worry thatwill translate to him, whereas really I cansee both aren’t true. That I’m notdamaged beyond belief and neither is,you know?” (Participant 1).

“Just connecting with your child. Therewas something being said about that oneday and, I really, really struggled witheven hearing what was being said, andjust the building of that bond and even,when she was showing us the videos.They did videos and even when she wasshowing us that and she was saying tome “Oh look the way your daughter islooking at you.” I – I really struggled toactually, like you know, accept it. My childloves me, like, and stuff like that. It wasweird now it was. The amount ofemotions that I felt during theprogramme, oh my God, it wasunbelievable, like!” (Participant 17).

KEY LEARNINGThe learning throughout the process wastransparent and apparent with often the mostsignificant learning coming from affirmation.

“…It was good, now it was over the weeksit was hard, up and down. There wasgood days and I came out feeling positiveand everything, there was other dayswhen I walked out of there, just really,really thinking about things and justriddled with guilt and stuff like that, youknow. But at the end of the day I learnedfrom it that, – if you’re doing things sevenout of ten times, you know, good withyour child, you know, no-one’s a perfectparent I learned from it. So I’m happy toknow, that and – yeah, as long as you –everything’s going well for you seven out


of ten times, you know, that’s kind ofwhat I – one piece I did really, you know,take from it…” (Participant 17).

“I see it all the time in how I – how I talkto him and how I look at him, you know,it’s such a difference. Because I went intoPuP and just wanted to tell everyone howmuch I completely messed up him [son]…that I’d broken him basically. And…he’snot a damaged child, he’s a really ahappy, healthy little boy...” (Participant 1).

“Just knowing that I was doing OK andthat ‘the perfect parent’ doesn’t actuallyexists, really helped me.” (Participant 20).

IMPORTANCE OF HAVING CHILDREN RESIDEThe importance of having their children inresidence was vital for a lot of the women,with the alternative not being an option.

“You know, so – you know, family is soimportant, you know, if I couldn’t come into a place like this I think I’d probably justtake me chances at home or somewhereelse.” (Participant 22).

“I was going to go to [other treatmentcentre] but they didn’t facilitate babiesthere ... so I came here with the baby, like,because it was the only treatment centrethat ...Suitable because they allowbabies…otherwise I could not have come.”(Participant 23).

“My child would probably be in care if Ididn’t – if I couldn’t – I wouldn’t ... Iwouldn’t be coming to treatment if Icouldn’t bring him and out there I cannotstay stable on methadone, I just use.”(Participant 10).

“It was very good, like, because I didn’tactually come in here with her at the startbut, like, I came in and I got her backafter seven weeks, like you know. I had todo my detox and all of that first. So I gother back then and it is – it’s veryimportant, like, it really is because if shewasn’t here my head would be out thedoor.” (Participant 12)

IMPORTANCE OF NOT HAVING CHILDRENRESIDEAt the same time, some of the women sawthe greater benefit of access, rather thanfulltime residence. Allowing them to have thespace to concentrate on their programme,while having access to their children was seenas empowering and the best opportunity tosucceed.

“I started that it was a real heavy kind ofprogramme, some people found – andthey found it very tough going and I thinkstarted, like, doing PuP on the same dayas something else really heavy and toughgoing or whatever. But I didn’t really findthat, you know? I think I would probablyfind it harder, like, if I’d [son] here withme. That, you know, it’s – like, I probablymight find it more difficult to go into aPuP group bringing stuff up from thepast and then kind of have to face, youknow, go and collect from crèche if hewas being difficult or whatever…”(Participant 1).

“But I also – another reason why I pickedCoolmine is because here I’d have the opportunity to do that work, to challengemy behaviours and thinking, but I’d alsobe able to have my kids stay atweekends.” (Participant 2).

“Ashleigh House was recommended to


me because it was a women’s programmeand having that initial support from otherwomen ...You know, to empower you aswell and because I was able – whatattracted me more to it was I was able tohave me children up here at weekends.”(Participant 6).

SUGGESTED CHANGES TO PuP In the main, the women were pleased with thecontent and overall structure of theprogramme. One suggestion that emergedalmost universally was the need to extend theprogramme content to include teenagers andyoung adults.

“I think the – the only important thingthat I see that, that – that touched a littlebit through this course is the importanceof the family being involved in theirrecovery here, you know? Like, my eldestdaughter’s 25 and I would have liked herto be – I know there’s a family supportgroup in Lord Edward Street but I think ifit could be incorporated maybe somehowthere because our families are damagedby our addiction as much as we are, youknow, and they’re on this journey with us.I think it would be a nice idea if therecould be a way of – of some sort of abridge bridging both of us kind of on thejourney.” (Participant 2).

“I think even if they did it for teenagechildren, part of the programme just tofocus on teenage children.” (Participant 6).

“Older children like teenagers and earlyadults…most of mine are grown up and Iwould have liked something for them…likethey said you could use the stuff[programme content] but some of it wastoo young.” (Participant 8).

sUMMARY oF QUALItAtIVe FInDInGsFRoM tHe WoMen In AsHLeIGH HoUse Guilt emerged as an explicit theme,

however, it was also dominant theme acrossthe entire interview process.

As the women progressed through theprogramme, they were visibly buildingbelief in their abilities to parent.

The group setting facilitated a sense ofsolidarity. Through sharing theirexperiences the women learned they werenot alone.

Holding the child at the centre of theprocess was key to the women’s success.

Ashleigh House while tough was perceivedas a supportive environment, which wasvalued highly.

The majority of women undertook theprogramme with the expectation to helpthem enhance their relationship with theirchild.

The women acknowledged the value in thestruggle to change.

The importance of having their children inresidence received mixed responses, forsome it was necessary and for others it wasa challenge.

The majority of women suggested thedevelopment of the PuP programmecontent to include teenagers and youngadults.


InteRVIeWs WItH PUP PRActItIoneRs Two PuP practitioners were interviewed; thePuP Group Facilitator and the PuPCoordinator. The qualitative data yieldedcrucial information on the development anddelivery of the PuP programme at AshleighHouse. Three fundamental questions formedthe discussion (1) What worked? (2) Whatwere the challenges? and (3) What would youlike to do differently?

In addition, practitioners were asked abouttheir recommendations.

WHAT WORKED?The overall feedback from the practitionerswas that the PuP programme was a massivesuccess. The group setting was tough butallowed for a positive shared experience,which was enhanced by the residentialsetting.

“The view of self as parent module isbrilliant although it is one of the toughermodules for participants. This modulechallenges the idea of the perfect parentand opens up conversation on that fact.Here stereotypes in relation to parentingare challenged. People grasp the ideathat there is no such thing as a perfectparent and that it is ok to be goodenough, nobody is perfect all of the time.The importance of love and nurturing isemphasized rather than a focus onmoney and material things to show love.Safety and security is imperative and howone assists their child to develop to theirfull capacity is key." (PuP Group Facilitator).

“I suppose what Coolmine have done iswe’ve tailored – not completely tailored it- but, you know, we’ve introduced thegroups, you know, and that’s been big forus because we’re a group-based

programme. So – but it has worked really,really well.” (PuP Coordinator).

In addition, specific elements of theprogramme were highly successful.

“…Connecting with your child andencouraging good behaviour’ is a reallygood module as many of the women,when they first come in, uponobservation are not connecting, they’renot minding what their child is doing ormay have no interest in, what the child isplaying with. Women often speak abouthow they may not be paying theirchild/children the attention they need astheir minds can be wandering off.Therefore elements on how to be presentwithin this module where extremelyhelpful.” (PuP Group Facilitator).

“One of the things I’ve found has beenpriceless working with the women, hasbeen the video feedback, I got quiteemotional myself reading back over someof their quotes and seeing, when you sayto someone “I’m going to do a video, wewant to look at doing some video work,it’s part of PuP”, you’re met with an awfullot of resistance. So, what I like to do is, –when we do the video – it’s all aboutreassurance and letting them know thatwe’re not going to be showing it toeverybody and who’s going to belooking at it is me. But what I like to do iswhen I give them the feedback, ask themhow they feel before they watch it andthen ask them how they feel after they’vewatched it and every single person we’vedone that with has been so nervous andupset and anxious and then afterwardsthey’re just,– some of the stuff they’vesaid, was absolutely lovely – that they just


didn’t see. And it’s, an eight minute videoand I might show them maybe threeminutes, and I’m showing them reallypositive lovely connections between –whether it’s faces, tones, expressions,whatever it might be, but the amountthat the women get from it ...” (PuPCoordinator).

WHAT WERE THE CHALLENGES?Naturally, the women with limited or noaccess to their children posed challenges tothe applicability of the programme. However,this was combated by their enthusiasm andmotivation to become better parents.

“It’s very, very difficult for the womenwho are getting limited access or maybenone at all. But what I will say, thewillingness [speaker’s emphasis] of thewomen who remain [speaker’s emphasis]in the group and stick with it andcomplete it, even though it brings up somuch emotion. Women can break down... in the group. It’s so difficult for them totalk and explore aspects of parenting thatthey once did well or that they can dowell in the future. But it’s just, reallyencouraging them, to talk about whatthey remember and, bringing it back totheir strengths as a parent whilereflecting on milestones and what theirchildren are reaching. Women usuallyhear reports of how their children aregetting on and it is important toemphasize “Well, you were a part ofthat!” (PuP Group Facilitator)

Managing sensitive issues was at times achallenge within groups but having the one-to-ones to defer to was vital.

“Sometimes managing issues in thegroup setting can be challenging.Different personal issues arise which it is

good for the women to name and try toexpress how they feel about maybedifferent things that happened in theirown childhood or with their own children.Sometimes I’d like to go a bit deeper withthat but think the group isn’t the rightsetting to explore. It is here one-to-onesessions are key.” (PuP Group Facilitator).

Unsurprisingly, coordinating and managingthe training was at times a test.

“…there has been challenges definitely,there’s been challenges I think we have totweak and change things that we feel willwork better in the future. I think one ofthe challenges as the – as the trainees, Isuppose as we’ve had more staff gettrained we’ve had more people accessingthe database so I found that being thecoordinator being a bit of a struggle…sothat’s just something that I’ll need totweak.” (PuP Coordinator).

WHAT WOULD YOU LIKE TO DODIFFERENTLY?The burden of administration was somethingthat practitioners would like to see donedifferently.

“In terms of caseload…The assessmentforms can be difficult, they bring up a lotof emotion for the women. The women, Ifeel, find it difficult, to be honest inanswering. The initial assessment forms,you’re asking them to sit down at one go[one session] and do them all together, Ipersonally don’t think it is a good ideathe assessments are very personal andcan bring up feelings such as guilt orshame. And imagine then if you were tosit participants down in one go andexpect them to do their assessmentforms for their four children, they can get


kind of fed up, frustrated and begin toswitching off. So, I think that the formsshould be spaced out over a period oftime each of the 3 times they are done.”(PuP Group Facilitator).

RECOMMENDATIONSPractitioner recommendations were focusedon developing and enhancing the programme.Neither the group facilitator nor thecoordinator would remove anything from theprogramme.

“I wouldn’t say I’d like to see anythinggone. I’d like to see more – more stuff init in terms of for older children.” (PuP Group Facilitator).

“I suppose a recommendation from –from me to – to the organisation wouldbe that everyone who does PuP to getsome sort of mindfulness training.Because not all of us had hadmindfulness training…I think anyonedoing PuP therapy needs to be able – oranyone who's facilitating the group[speaker's emphasis] needs to be able tohave some confidence in the mindfulnessbecause I think it's such a core part.” (PuP Coordinator).

sUMMARY oF FInDInGs FRoM PUPPRActItIoneRs The overall feedback from the practitioners

was very positive. The content and the format of the

programme were a good fit for Coolmine. Practitioners perceived some element of

administration as burdensome. Managing sensitive topics within the group

format was difficult at times. Both practitioners suggested developing

programme content to include teenagersand older children.


FInDInGs oF FocUs GRoUPs

Two focus groups were conducted with themen from Coolmine Lodge, before and afterparticipating in the PuP programme. Ten menparticipated in the first group, and sixparticipated in the second group. Thisconsultation included the experiences of menat various stages of their treatmentprogramme.

Demographic Variable Response categories number and % (n=10)

Age 18-2526-3334-4142-49

0 (0%)4 (40%)4 (40%)2 (20%)

Primary Problem Drug OpiatesAlcoholCocaineCrack Cocaine Cannabis/WeedBenzodiazepineOther

3 (30%)0 (0%)3 (30%)2 (20%)1 (10%)1 (10%)0

number of children 12345 or more

23400

Access with children Yes No

8 (80%)2 (20%)

Active social WorkInvolvement

Yes No

4 (40%)6 (60%)

criminal Justice Issues Yes No

4 (40%)6 (60%)

Homeless 46

4 (40%)6 (60%)

Previously treated forsubstance Abuse

First Time in Treatment 1 previous treatment Episode2 or more Treatment Episodes

2 (20%)4 (40%)4 (40%)

Family History of substanceAbuse

YesNo

4 (40%)6 (60%)

History of PsychiatricProblems

YesNo

5 (50%)5 (50%)

table 6: Demographics and clinical characteristics of Men in coolmine Lodge


The current group was the first group of menwho had participated in the PuP programmeat Coolmine Lodge. The qualitative datayielded crucial information on the men’sexperiences of the programme. Severalthemes emerged from the data. These dataare presented and discussed below.

EXPECTATION OF PuP The main expectations of the men were toimprove their relationships with their childrenin order to ensure access.

“I’ve three kids meself now; I’ve an olderfella, he’s 27 but I’ve two young boys, tenand six. I just want to get a closer bondwith me kids, like, because I missed outon my 27 year old, so – so I’d like to, youknow, be there all the time for meyounger boys, you know? Been in prisonan awful lot, so I just want to like get thatbond and get a better understanding ofme kids, knowing where they’re at so as Ican talk to them, whatever, you know, sothey understand where I’m coming fromand I understand where they’re comingfrom. Like I get to see them.” (Participant 10)

“I have three kids; a four year old, eightyear old and nine year old….Haven’t seenthem in a few weeks, I’m going throughthe courts system with them, just here tobe a better father, get more trust with mekids, and enjoy the programme, it bringsup some serious stuff - the last time ...”(Participant 2)

“I’ve two kids; a girl of five and a boy,eleven. Just – I just want to have a betterunderstanding about parenting, to behonest, with skills and tools…To build abetter bond with me children, you see, Idon’t have as much parenting with myson, I wasn’t really there for most of the

start of his life so I don’t have – I don’thave as strong a –bond with my son as Ido me daughter. I want to work on myparenting skills when I’m around themand to – to become a better father andget them back into me life.” (Participant 3)

CHALLENGES OF PuP Some components of the programmepresented challenges for the men, inparticular how their behaviours in the pastimpacted their children. However, therecognition that these challenges wouldultimately help them reach their parentalgoals was evident.

“Absolutely – we all think that, like, we’regood parents but until you actually lookinto it and look and see what your actionshave done, like, on your children you startto realise how much of an effect you’vehad on them in a negative way, like, formeself it was going to prison, not beingthere and all that type of stuff. So, it’s –it’s not nice to hear, you know, that yourchildren are hurt because of your actionsbut it’s – it’s better to find out now ratherthan let them grow up and then let themmake mistakes then when you could helpthem as early as possible.” (Participant 1)

“Yeah, touching on things that havehappened in the past. Last week I wastouching on things in role play, you know,that brought up things for me, I found itemotional but I’m dreading it but at thesame time I know it’s helpful for me.That’s the only thing.” (Participant 8)


“It’s hard like…it makes you look at all thestuff you did and you have to face it like…it’s hard.” (Participant 2)

BENEFITS OF PuP The men were quite explicit about the directbenefits of the programme. All of them,regardless of whether they had access, spokeof the benefits that were still apparent.

“It’s in the process now, like, you know.So, it’s only starting with it has just givingme, like, just showing things, like, from –from my childhood and how they’rerelated to my son’s childhood, you know?And just a few tools and things that I gotout of it going forward when I do get mychild, you know? Be a better father andall that, so I enjoyed it.” (Participant 2)

“I got a massive lot from it through this.You know, I got to see my kids yesterday,I was going over and over and I got tomanage my emotions, do you know whatI mean? And their emotions as well, so Ireally – it’s turned a big thing for me now,turned my life right around from oldfather to the new father I am now. Andit’s really, really benefited me, it has.Something I really, really benefited me, it has.” (Participant 1)

“I found it really beneficial, you know. I’vetwo – I’ve two girls and managing them, Ifound it very hard, giving one of themattention do you know what I mean? AndI was able to bring that out and identifythat as well, including role playing stuff aswell, found it really, really good. Also,stepping into their shoes and trying tosee how – what they think as well, certainsituations for my actions as well, youknow? And just being able to relate to

them a lot better now in the day to daythings.” (Participant 3)

“I thought it was brilliant. Like, when Ijoined this course I just wanted to, youknow, to leave, exit the door. I haven’ttough done that and I got more out of it. I got to learn a lot about how mybehaviour or my actions were having aneffect on my child. I learned about heremotions and how she’s feeling when I’mdoing things with her, how I always kindof try and look at things the way she’slooking at it so I can understand and it’s –it’s worked out for the better now for thetwo of us. I have a relationship with medaughter and it’s basically thanks to thisprogramme.” (Participant 9)

COOLMINE LODGEThe men shared their experience of being inat Coolmine Lodge and what why this was soimportant.

“I came in here then and the lads helpedme there and now I have – I have – thedoor’s open for me, you know?”(Participant 2)

“When I came here I’d nothing. I wasbroken and know I have all these lads, thestaff and I’m getting my life back.”(Participant 4)

“It’s nice just to – it’s nice, there’s peoplehere I’d say, more people here withoutanything in their life, or anyone but we allsupport each other.” (Participant 5)

REPUTATIONThe men were familiar with the PuPprogramme and were receiving external


validation for their participation.

“My Social worker, she is delighted I amdoing it [the PuP programme] she keepspraising me [laughs].” (Participant 5)

“I’d say that they will roll big time,because when I was in court with themediator, like, she couldn’t believe that Iwas in it. She has a rake load of peoplethat want to get into it. Some of the –and as well when I was in court the judgeand all, he couldn’t believe I was on it aswell.” (Participant 2)

“I sort of knew about this [PuPprogramme] before I came and I wantedto get my kids back so ye I think that wasa big reason in me coming.” (Participant 6)

ACCESSING CHILDREN WHEN INTREATMENTThe men spoke of the importance ofaccessing during treatment and why this wasoften a deciding factor when coming toCoolmine.

“I made an agreement before I came inwith me family that I would come in andget myself – and do things, like, I couldsee me daughter and get me son backand me family – the kids, basically I’mchanging me life and I need to do it formeself, for her and for me son. So, seeingme daughter is what gets me through atnights, do you know what I mean? It’sreally good form when I’ve seen her. It’sbasically what’s striding me on to dothis.” (Participant 2)“No, 100% that’s why I came here –treatment, and if – this – if our child wasto stay in care and I didn’t have any

opportunity of getting her back, I mean,I’d be roaming the streets. Yeah, I think aswell if – if I was – if I thought I wouldn’tsee my kids here on a weekly basis I don’tthink I would have chose Coolmine tocome to. Look, it’s over five, six months,that’s a big period of time when you’renot seeing them, you know what I mean?I mean the thought of it, I think that’swhat maybe makes the decision to cometo Coolmine, well I’ll see me kids.”(Participant 4).

“If I couldn’t see them [children] I wouldbe gone. It’s too long, six months I need itbut it’s too long without them.”(Participant 5).

SUGGESTED CHANGESWhen asked how the programme could beimproved the men made two suggestions,including having the children in the sessionsand adapting the content to include olderchildren.

“I think something for bigger kids, that’smissing.” (Participant 2).

“What about including the kidsthemselves? That would be a goodtouch.” (Participant 5).

“I’d say – I’m speaking and at the start Iwas thinking is a little session that you’ddo, maybe with your kids.” (Participant 1).


sUMMARY oF FocUs GRoUP FInDInGsFRoM tHe Men In cooLMIne LoDGe The principal expectation of the men was

to improve their relationships with andaccess to their children.

The men experienced some challengeswhen participating in the programme.

Regardless of whether or not they hadaccess to their children, the benefits ofparticipating in the PuP programme wereapparent.

The men shared their experience of beingin Coolmine Lodge and why this was soimportant.

The men were familiar with the PuPprogramme and were receiving externalvalidation for their participation.

The men emphasised the importance ofaccess during treatment.

Two suggestions for change were put forthby the men, (1) including the children in thesessions and (2) adapt the content toinclude older children.


DIscUssIon

The research was concerned with thefeasibility of delivering the PuP programme ina group format, in addition to one to onesessions at Ashleigh House. Based on theexperiences of the women the format of theprogramme was a good fit for AshleighHouse. The fit of the programme at Coolminewas natural and supported by the residentialsetting. The group format was both powerfuland effective. The women could identify withother mothers and knew they were not alonewith feelings of inadequacy and guilt.Moreover, the shared experience within thegroup setting helped alleviate these negativefeelings imparting the sense that they werenot alone. This shared experiences in turnhelped the women and offered a sense ofsupport further facilitating the ethos of theCoolmine peer-driven treatment model.

The focus of the research was on the womenat Ashleigh House, however, during theevaluation period Coolmine Lodge ran its firstPuP programme for fathers, thus pre andpost programme focus groups wereconducted to capture the experience of thesemen. The benefits of the PuP programmeboth for the men and the women wereimmediate and direct. Participants’experience of the programme was incrediblypositive.

The men and the women ultimately had thesame expectations to become the bestparents that they could to improverelationships with their children. Interestinglywhile the challenges of the PuP programmewere quite similar, the men talked about howtheir behaviours had affected their children.However, the women spoke in moreemotionally explicit terms often citing guiltand shame. The importance of havingchildren reside in Ashleigh House during thetreatment programme received mixedresponses from the women. However, both

men and women noted the importance ofaccess during treatment often highlightingthis as the reason for them choosingCoolmine as a treatment provider. Both themen and the women spoke of the supportthat they received throughout their treatmentat Coolmine.

The quality of the relationship built with thePuP coordinator and the group facilitator waskey to a successful application of theprogramme delivery and the reports fromboth men and women emphasise this. Havingthe support of the PuP coordinator gave theopportunity to customise the programme tothe particpants’ specific needs and offered aspace to share experiences that may not havebeen possible in the groups.

The need to develop an integrated treatmentresponse to assist parents attempting toaddress the harms associated with theirsubstance use is a pressing issue. Havingbuilt capacity and mastered the practiceCoolmine are well placed to broaden theimplementation of the PuP programme to thebroader population, which may extend topartner agencies. The outputs of this processcould, in turn, be utilised to showcase work toother potential partners and widen theimplementation scope.

Overwhelmingly all participant groupssuggested the development of theprogramme content to include older children,more specifically teenagers and early adults.The second most commonly cited suggestionwas family focused sessions. Practitionersnoted the opportunity to further developskills that would aid the therapeutic processsuch as mindfulness.

concLUsIonThere was a genuine enthusiasm for theprogramme amongst participants. The


benefits were clear and consistent. Theresidential setting at Ashleigh House offers an eager perspective and supportiveenvironment, which if adequately nurturedwill ensure the continued development of thePuP programme within the residential settingwith the potential to roll-out across similarpartner agencies.

IMPoRtAnce oF tHIs ReseARcH In the main scientific research andprogramme, evaluation have not played asignificant role in influencing the developmentof addiction treatment services nationally1 orinternationally14. The consequence of this islarge disparities in the development,management and monitoring of nationaltreatment systems. The current study seeks torectify this by providing much-neededoutcome data on parents and children inresidential treatment.

By initiating and undertaking evaluationCoolmine are leading their peers byresponding to national policy and furtherdeveloping evidenced based practices. Thecurrent study is aligned with national policyaddressing goals set out in the both NationalDrugs Strategies9, 10 as well as the NationalPolicy Framework for Children and YoungPeople 2014-20208 by taking a responsiveapproach to the treatment of parentalsubstance use.

stRenGtHs, LIMItAtIons AnD FUtUReDIRectIon oF tHe ReseARcHSTRENGTHSThis is the first evaluation of the PuPprogramme in a residential setting globally.Moreover, this is the first study to capture thedelivery of the PuP programme in a groupformat. The research included a mixed-method design, including a number ofvalidated measures, qualitative interviews,and focus groups. The research included the

perspectives of a range of stakeholders:mothers, fathers and practitioners. There is adearth of literature on the experience offathers around parenting when in treatment.Thus, eliciting these views from this cohort isa key strength of the study.

LIMITATIONSNonetheless, the research is not without itslimitations. All data are self-reported andtherefore open to bias. As this is an evaluationof the implementation of a singleorganisation’s implementation of aprogramme, the participant numbers aresmall. The study did not include a follow-upperiod post-programme.

FUtURe DIRectIonThe Therapeutic Community is a uniquesetting with specific characteristics.Therefore, further research is required todetermine the transferability across AddictionServices in Ireland. Future studies shouldinclude a comparison group who receivedtreatment-as-usual with a follow-up period ofat least six months in order to determine theeffectiveness.


1. IMPLeMentAtIon 1.1. For future application of the PuP

programme the continued supports suchas coordination and group facilitation arevital.

1.2. Given the burden of programmeadministration, the development ofprotected ‘PuP time’ for Group Facilitatorsand Therapists will need to be considered.

1.3. Coolmine is strategically placed to leadtheir peers on the development of asystematic programme to improve familyfunctioning and child outcomes forparents attending drug treatment. Withadequate resourcing, Coolmine couldprovide their peers and partner agencieswith the necessary skills and training toadequately address these issues acrossthe various treatment services.

2. PRoGRAMMe DeVeLoPMent 2.1. The PuP programme is child centred and

should further encourage and involvefathers as well as mothers. Following thesuccessful pilot of PuP at Coolmine Lodgethe programme should be rolled out on acontinual basis.

2.2.Given the emphasis on the child within thePuP model, as well as the opportunitiesfor interactive feedback, extending thegroup sessions to include children shouldbe explored.

2.3.Consideration must be given to extendingthe involvement of children, includingteenage and young adult children of drugusers.

3. ReseARcH AnD eVALUAtIon 3.1. If feasible the women and men who took

part in this evaluation should be followedup in six or twelve months.

3.2.3.2. Future evaluations of the PuPprogramme should have greater numbers,and a comparison group, in order toprovide stronger evidence with greaterpower.

RecoMMenDAtIons


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2. Horgan J. Parental Substance Misuse: Addressing its Impact on Children. A Review of theLiterature. Dublin: National Advisory Committee on Drugs. 2011.

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4. Frye S, Dawe S. Interventions for women prisoners and their children in the post‐releaseperiod. Clinical Psychologist. 2008; 12: 99-108.

5. National Drug Treatment Reporting System. Unpublished data, NDTRS 2015/2016. Personalcorrespondance with author 1 (J, Ivers). Dublin: National Drug Treatment Reporting SystemJuly 2018.

6. Galligan K, & Comiskey, C Estimating the number of children of parents who misusesubstances, including alcohol across the communities of the Tallaght Drug and Alcohol TaskForce (TDATF) region. Dublin: Tallaght Drug & Alcohol Task Force. 2017.

7. A Hidden Harm National Steering Group. Addressing Hidden Harm: Bridging the gulfbetween substance misuse and childcare systems. Dublin: Health Service Executive .2013.

8. Hidden Harm was included as theme within Better Outcomes Brighter Futures: The NationalPolicy Framework for Children and Young People 2014-2020. Dublin: Health Service Exective2014.

9. Department of Community, Rural and Gaeltacht Affairs. National Drugs Strategy 2009-2016(Interim). Dublin: Department of Community, Rural and Gaeltacht Affairs. 2009.

10. Department of Health. National Drug Stratergy: Reducing Harm, Supporting Recovery 2017-2025. Dublin: Department of Health. 2017.

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12. Dawe S, Harnett P. Reducing potential for child abuse among methadone-maintainedparents: Results from a randomized controlled trial. Journal of Substance Abuse Treatment2007; 32: 381-90.

13. Dawe S, Harnett PH, Rendalls V, Staiger P. Improving family functioning and child outcome inmethadone maintained families: the Parents Under Pressure programme. Drug and AlcoholReview 2003; 22: 299-307.

14. Harnett PH, Dawe S. Reducing child abuse potential in families identified by social services:Implications for assessment and treatment. Brief Treatment and Crisis Intervention 2008; 8:226.

15. Harnett PH, Barlow J, Coe C, Newbold C, Dawe S. Assessing Capacity to Change in High‐RiskPregnant Women: A Pilot Study. Child Abuse Review 2018; 27: 72-84.

16. Dalziel K, Dawe S, Harnett PH, Segal L. Cost‐Effectiveness Analysis of the Parents underPressure Programme for Methadone‐Maintained Parents. Child Abuse Review 2015; 24: 317-31.

17. Lovibond PF, Lovibond SH. The structure of negative emotional states: Comparison of theDepression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories.Behaviour Research and Therapy 1995; 33: 335-43.

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