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Substance Misuse in the Somali community in the UK: Challenges and Strategies for Family Involvement in Effective Treatment

Written by Toby James for MPRC/Adfam

Executive Summary

1. A number of studies identify prevalent drug misuse in the UK. This drug use extends into BME communities, including the Somali community where there is widespread use of khat. 2. The detrimental impact of drugs on society, families and individuals include increased risks of crime, homelessness, domestic violence and family breakdown. There is some evidence that khat use in the Somali community is having an impact of family relationships, health and crime. 3. A range of factors is likely to increase the risk of substance misuse amongst the Somali community, based on research on the general asylum seeker and refugee community. These include factors such as health, education, crime, employment, housing, environment, the family, past drug use and the role of drug services. 4. There is evidence that some mainstream support services are not reaching or available to BME and Somali communities because of particular cultural barriers. 5. There is a literature on working with BME groups and substance misuse which makes recommendations for good practice such as outreach work, community collaboration and multi-agency working which could usefully assist programmes aimed at the Somali community. 6. There is also a literature on family-orientated drug treatment services which makes recommendations that highlights the utility of programmes such as social network theory. 7. Whitehouse and Coppello (2005) make recommendations for good practice within prison services which may also be useful in guiding the development of services for the Somali community.

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Contents

Introduction The Somali Community in the United Kingdom Drug Use in the Somali Community The consequences of substance misuse in the Somali community Possible Factors Causing Drug Use in the Somali Community Towards a Best practice for BME Communities? Solutions for the BME and Somali Communities Family Orientated Strategies for BME and Somali Communities Family Involvement in Prison Services Conclusions

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1. Introduction

Drug and alcohol misuse is highly prevalent in society (Condon 2003) with recent estimates suggesting that drug use in the UK could be in the region of 161,000 to 266,000 (Frisher 2001). Evidence suggests that substance misuse is linked with crime, homeless and domestic violence. According to Adfam on average three family members are effected by an individual's substance misuse (Kellow & Parker 2006: 3). Thus there is a significant need to address drug and related treatment problems. According to its own initial 1998 drugs strategy, to government strived to provide:

young people from all backgrounds, whatever their culture, gender or race. . . access to appropriate programmes...[and] all problem drug misusers ­ irrespective of age, gender, race and drug with which they have a problem ­ have proper access to support from appropriate services ­ including primary care ­ when needed, providing specific support services for young people, ethnic minorities, women and their babies (Central-Drugs-Coordination-Unit 1998).

Despite this, there is widespread evidence that BME groups are either not receiving or accessing the same level of services as the rest of the population, which this report reviews. Moreover, very little service provision or research has been focussed on the Somali community, in the UK or elsewhere. However there appears to be evidence of a widespread use of the drug khat that has been culturally transmitted from Africa. In 2006 Adfam received a grant to work with substance misusers and families in the Somali community. This report is aimed to review literature in the field with a view to informing best practice for this project. Its ability to make specific recommendations is restricted by the lack of similar schemes. However it is possible to undertake some qualified lesson drawing from: o A literature which focuses on BME groups and substance misuse from a number of sources but notably the Centre for Ethnicity and Health, at the University of Lancaster, and various Home Office reports. o A literature outlining factors that might increase the likelihood substance misuse amongst asylum seekers and refugees noted by GLADA (2004) and McCormick and Walker (2006) o A literature on working with families with substance misuses reviewed by Whitehouse & Copello (Whitehouse 2005). o Particular recommendations of best practice for working with substance misusers and families in the prison services from a comprehensive study by Whitehouse and Copello (2005). Before these are outlined however, this report begins by outlining the history, size and location of the Somali community in the UK. It then moves on to review the literature that assesses the extent of the drug problem in the Somali community and the consequences of this.

The Somali Community in the UK

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`The Invisible community'?

As a report commissioned by The Information Centre About Asylum and Refugees in the UK (ICAR) notes, the Somali Community in the UK has often been referred to as the `invisible community' whose presence is rarely referred to in mainstream society in the UK (2004). A range of papers and reports written by Somali community groups and individuals highlight the extent to which there may be a feeling of marginalisation and social exclusion felt within the community. The ICAR Report cite the example of papers such as Somalis, an invisible community in crisis (Somali Relief Association, 1992), Feeling exclusion? A survey of the Somali community in Lewisham and Somalis in limbo (Ditmars, 1995). The ICAR report's author, Harriot Harris notes how stories about the Somali community rarely feature in the national media:

`A media subgroup of the current Somali Community Meeting (convened in London by Jeremy Corbyn MP) calculated that there had been 741 articles in five of the main newspapers covering the murder of the young Nigerian Damilola Taylor. The killing of a Somali boy, Kayser Osman, merited just 21' (Harris 2004)

Meanwhile evidence that the community feels marginalized is supported by Hopkins who notes that the community has failed to achieve effective representation despite a number of voluntary groups (Hopkins 2006).

History and Development of the Community

The movement of Somali to UK has been fueled by war and conflict with the region for many years. Somalia has been without a central government since 1991. Fighting between warlords, disease and famine has lead to up to 1 million deaths and many hundreds of thousands of people fleeing the country to the UK as refugees (BBCWebsite 2006). However migration from Somalia to the UK has had a longer history than this. Previously though this had been as economic migrants rather than refugees. The establishment of Northern Somaliland as a colony of the British Empire in the nineteenth century allowed migrants to the enter the UK and Somali communities were established in the dockland areas of Cardiff, Liverpool, London, Hull, Bristol and South Sheilds. A second stage of migration also took place after WWII when the post-war boom created opportunities in manufacturing industries. Somali communities quickly became re-established in Sheffield, London and Manchester. Harris comments:

'It was during this time that the present Somali community, chiefly from the Isaaq clan family and Darood subclans from the north, became established in what is now Tower Hamlets, especially in Bow, Wapping, and Poplar' (Harris 2004).

Thus the current Somali community are composed of more than a one recent generation of refugees.

Size of the community today

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There is a lack of (or at least contradictory) knowledge about the size of the Somali Community; no comprehensive national survey has been undertaken. Figures vary wildly depending on how a Somali is defined. The 2001 Census estimated that there was 43,691 Somali's in the UK by including only Somali born residents, not those that might have been born in the UK, but still consider themselves Somali. A study by (Holman 2003) put the figure at closer to 95,000. The ICAR Report concludes that more accurate numerical data is essential. Existing research shows that Somali's are based in London (estimates of around 33,00 to 70,000) with upto 15,000 in the Tower Hamlets. Sizable pockets also exist in Manchester, Liverpool, Birmingham Sheffield and Leicester (Harris 2004). Table 1: Somali communities around the World Country Size of Refugee Population Kenya 155,767 Yemen 80,763 Ethiopia 37,352 UK 33,066 USA 28,693 Djibouti 20,251 Netherlands 15,688 Demark 9,582 South Africa 6,515 Canada 5,545 Source: UNCHR (2002) The size of the community however is considerable. The UNCHR Report in 2002 suggested that the UK had population of Somali's in Europe and fourth largest in the world (see table 1)(UNHCR 2002). According to Home Office figures Somalis accounted for the most asylum applications from any one nationality in 2003, when they made up 10% of those seeking asylum in the UK (HomeOffice 2004). 43,225 Somalians, excluding dependants, applied for asylum between 1995 and 2003. About 16,000 were granted asylum and another 15,000 were given exceptional leave to remain.

3. Drug Use in the Somali Community

Sangster et al (2002) note that drug use is highest in the general population amongst those in their late teens and early 20s (Ramsay 1999). There is also some evidence that use became more widespread in the 1980s and 1990s, but that this might have levelled off by the early 2000's (Deborah Sangster 2002). A number of surveys have suggested that BME groups are less likely than the white population to be involved in drug taking, particularly South-Asian groups (Leitner 1993; Ramsey M 1997). As Fountain (2003) suggests, this has often led policymakers to the conclusion that the use of illicit substances is not widespread in BME communities and less of a problem. There is however a growing literature to suggest otherwise.

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Firstly, again, as Fountain (2003) points out, there is evidence that more serious levels of drug-taking exists in areas where there is higher unemployment and social deprivation (Haw 1985; Peck 1986; Pearson 1987a; Pearson 1987b). BME groups are not only concentrated into areas of inner cities suffering from deprivation but also feature disproportionately amongst those who are unemployed, living in poverty, in the criminal justice arena, detained under the Mental Health Act, in ill health, excluded from school and in care and vulnerable to homelessness. Secondly, there is growing evidence from the literature that drug taking amongst BME groups is on the rise. Fountain sites a number of studies, such as a study of South Asian parents in Crawley interviewed by Bola and Walpole (1999) perceived drug us in their community to be as prevalent as in any other. In addition a series of drug service reviews by the Centre for Ethnicity and Health, University of Central Lancashire, which include interviews with service providers and community members in Calderdale (Bashford et al, 2001), Bury (Prinjha et al, 2001), Bedfordshire (Sheikh et al, 2001), Bolton (Prinjha et al, 2001), Shropshire (Bashford et al, 2000), and Waltham Forest and Redbridge (Sheikh et al, 2002) point to perceptions of the increasing use of a range of drugs - including heroin - in South Asian communities, particularly amongst young men. Similarly, representatives of Black and minority ethnic communities in Greater Manchester interviewed by Chantler et al (1998) reported increases in crack cocaine use by Black Caribbeans (and by white people) and in heroin use by South Asian males. Sangster remarks that crack use is evident in Vietnamese and Somali communities and opiate use was seen to be a big problem in relation to Vietnamese (Sangster et al 2002: 18). Research that focuses on the Somali Community identify the prevalent use of the drug khat (or kat, qat, quat) (Cunningham 1998; Griffiths 1998; Mohammed 2000; Nabuzoka 2000; Fountain 2002) rather than other substances (such as alcohol). Khat is a perennial shrub, traditionally cultivated in Ethiopia, The Yemen and Kenya, where it is often an important cash crop. The leaves and tender young shoots of the plant are chewed for their stimulant properties. Griffiths (1998) sites Carothers on the traditional view of the drug in Africa:

The chewing of this weed induces a happy and mellow friendliness and an increase in intellectual vigour and activity, thought tends to rise to a higher plane, desire for war and women ceases, and conversation tends to concern itself with `the affairs of God' and the accumulation of wealth by peaceful trade (Carothers 1945)

Khat chewing is particularly common in countries where alcohol and other drugs are prohibited on religious grounds and are often important parts of social events and community culture. In Somalia use was traditionally limited to the older male group however since the 1960s usage as spread to women and younger males. Concerns have been raised in Somali regarding its effects on trade and productivity and community violence (Griffiths 1998). Studies are often from non-representative samples but continuously point in the direction of widespread use. A recent report by the National Association for the Care and Resettlement of Offenders (NACRO) assessed the usage in four UK cities by conducting 602 interviews. They found that 39% had used khat at some point in the past, 34% within the last month and 4% on a daily basis (Patel 2005). One study which looked in particular at the Somali Community in London showed that 78% of 6

the sample had used khat in the past, 67% within the last week and 6% on a daily basis (Griffiths P 1997). Both showed higher use amongst men. A further study by Turning Point found similar patterns of use (Point 2004). A recent release from the Home Office provides information on the numbers of the Somali Community in prison (table 2). This gave the total number of Somali's is prison at 343, 330 of which were male. Of these 21 were direct drug offences. However the Home Office figures only record those who are Somali Nationals, i.e. born in the U.K. They therefore do not include those who were born in the UK but ma consider themselves Somali (HomeOffice 2006). Table 2: Somali born prisoners in the UK, August 2006 Less than 6 months 12 months 4 years Life or equal to less than less than 4 less than six months 12 months years life Violence 6 1 11 13 10 against the person Sexual 1 0 3 14 4 Offences Robbery 5 6 37 18 9 Burglary 1 2 6 1 0 Theft and 2 0 3 0 1 Handling Fraud and 3 5 8 0 0 forgery Drug offences 1 1 11 8 0 Offence nor 8 0 7 2 1 recorded Source: Home Office Freedom of Information Release 4662, August 2006

Total 41 22 75 10 6 16 21 18

4. The Consequences of Substance Misuse for the Somali Community

The negatives externalities of widespread substance misuse to the individual and society are well documented and includes links to additional costs to the health service, crime, homelessness, domestic violence and family breakdown. However it is worth noting a) the often-understated consequences of drug use on the family and b) the consequences of khat in particular.

Effects on the Family

Drug misuse can also however have considerable detrimental effects on the family or those who maintain a close relationship with the individual. Adfam calculates that on 7

average three family members are affected by another member's problem drug use. Kellow and Parker cite one study, which examined the impact of a family member's drug taking on close relatives in three different cultural and religious settings. It found that, whether the family was in the UK, Mexico City or rural and urban aboriginal Australia, families tended to cope in similar ways. These involved feelings of guilt and uncertainty. According to the report's authors `The result of these and other uncertainties are that family members commonly develop problems in their own right, often developing high levels of physical and psychological symptoms' (Velleman 2003; Kellow 2006). A study by Whitehouse and Copello showed how the family members of a substance misuser may suffer from theft, domestic violence and a loss of trust in family relationships, shame and stress. Some responses from interviewees included statements such as:

I didn't know what to expect from one day to the next. I was worried when he was out and on edge all the time he was in! I seemed to be forever at the doctor's with one thing or another but I was too ashamed to tell her what was making me feel so bad. Prisoner's Partner From the moment I woke up until I went to sleep again I couldn't think of anything except what was happening to my son and my family. I had to carry on going to work because I needed to earn a living but I was so distracted that, one day, I walked off a roof. I just forgot where I was and it was lucky I wasn't killed! That's what it's like ...it takes over your life. Prisoner's Father/Carer Grandfather (Whitehouse 2005)

Most research however identifies the impact of the drugs on the individual and society rather than the family in particular.

Effects on society and the individual: the case of khat

Several respondents during interviews undertaken by (Patel 2005; TurningPoint 2005) suggested that khat in particular might contribute towards family problems. (Patel 2005) report that 13% of those interviewed felt that they were affected by another person's khat use. When asked for specific problems 23 out of 92 respondents mentioned `family difficulties or breakdown'. A number of respondents to both surveys claimed that users would suffer from mood swings, and the money spent on khat caused problems between partners. According to some respondents of interviews:

... my partner is chewing the khat and he never helps us [with] anything about our family, i.e. looking after children, making shopping and also we have financial problems because he is using all the money to buy the khat (Patel 2005) `On the day that they are chewing they are OK, but on the day after, the opposite ... They don't want to go to their responsibilities to their family. They start fighting and shouting the day after chewing khat.'(TurningPoint 2005)

Thus there is some evidence that khat use may assist family breakdown, but as the ACMD report `it impossible to say that a person's khat use is the cause of family disruption, or just a convenient scapegoat for it (2005). A general assumption amongst policy-makers and practitioners is that crime and drugs are inextricably linked. Bean and Nemitz estimate that about 60% of all

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referrals to treatments providers is from the criminal justice system and that a heroin addict probably commits over 80 serious property crimes per year (Bean 2004). However the direction of the relationship is slightly unclear; as Bean notes does crime lead to drugs or drugs to crime (Bean 2001)? There is less evidence about the relationship between khat and crime. Amongst a small number interviewed by Patel et al (Patel 2005) some reported that violent behaviour had coincided with drug use but that overall the relationship was weak, possibly inverse. Khat is relatively cheap, especially compared to crack and heroin, meaning that it was unlikely to cause people to commit crime to fund addictions. Moreover, some claimed that it discouraged people from offending since it made them relaxed:

When you take khat you cannot do any of those things. It makes you cool and happy and you cannot do something like that.

More systematic research however would be needed to backup these research findings. While the use of khat may be problematic in itself there is evidence that use in the community may lead to the use of other substances. Interviews by Sangster et al (Deborah Sangster 2002) showed concerns that that young Somali men were moving into wider forms of drug use and dealing through supplying khat:

`Khat is a huge problem, Somali women complain about the men in their families taking it. Somali youths are getting mixed up in the drugs trade because of it and get into selling crack and heroin (drug worker, African Caribbean, North)' (Deborah Sangster 2002)

However, contrary to this Patel et al (Patel 2005) found little evidence of a correlation between khat use and the use of other drugs. Some respondents only claimed that they felt that individuals may move to other drugs should khat be prohibited. The ACMD report identified a number of possible health problems for those using khat. Most of these effects had been under researched but included o o o o o o Psychosis Mood effects including sleeplessness, loss of appetite and depression Cardiovascular effects including Acute myocardial infarction Oral cancers Harmful effects during pregnancy and male reproductive health Other medical problems resulting from the use of pesticides in khat production (ACMD 2005)

5. Possible Factors Causing Drug Use in the Somali Community

As mentioned above the use of khat in the Somali community has effectively been culturally transmitted from Somalia as part of the process of migration. However there is a strong literature identifying a number factors that might make refugee and BME communities in general more likely to become involved in substance misuse

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particularly those substances other than khat. These factors are worth noting here sine they might inform best practice procedures to prevent the spread of substance misuse amongst the communities. Drawing on Ross Dawson (Ross Dawson 2003; GLADA 2004) McCormack & Walker (McCormack 2005) identify nine factors that may expose young asylum seekers and refugees to drug misuse: o Health. The Greater London Alcohol and Drugs Alliance (GLADA 2004) suggest that mental health illnesses can lead to a risk for problematic drug use. Some research has found that that refugee and asylum seekers have a greater rates of mental illness such as anxiety disorders, clinical depression and sleeping problems (Ager 2002). Possible causes of these include postmigration factors or stress caused by the violence and poverty witnessed before migration (Meisler 1996). Moreover, McCormack and Walker note particular problems experienced by refugee and asylum communities receiving help through the NHS and support services (McCormack 2005). o Education. Integration into the education system is argued to decrease the risk of problematic substance misuse (Stronski 2000), notably since it alleviates boredom and broadens employment chances (Dennis 2002). McCormack and Walker note particular problems with the placement of members of the communities into schools and availability of education after the age of 16 (McCormack 2005). o Crime. As mentioned, the relationship between crime and drug misuse is well documented, however there is little evidence to suggest that asylum seekers are more involved in crime than the rest of the UK population (McCormack 2005). o Employment. Employment is seen as a means to enable individuals to integrate into the community. Sangster et al (2002) found that khat use and experimentation with other drugs increased among Somali men who were unemployed. o Housing. A strong literature reflects the relationship between homelessness and drug misuse. McCormack and Walker note problems with the suitability of housing and the policy to house asylum seekers outside of London (2005). This may contribute towards eventual homelessness as individuals seek to move back to the capital to reintegrate into communities without suitable accommodation and therefore drug use. o Family. The family can act as supportive mechanism to protect the individual against the risk of drug misuse (see below). o Previous and Current Drug Use. There is evidence that once asylum seekers move into a country, they may adopt local drug taking practices (MacDonald 2002). Also communities may bring particular conventions with them such as khat or the use of drugs in soldiers from Sierra Leone o Environment. A number of studies highlight the relationship between social exclusion and drug misuse (Parker 1998). o Drug Services. The limited availability, lack of knowledge or stigma associated with drugs meant that a wide range of communities are not receiving treatment (See below).

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Barriers accessing Drug Services for Somali communities

The final factor identified by McCormack & Walker (2005) is noteworthy of further attention. Indeed there is considerable evidence that BME groups are not receiving or accessing services that are available to the wider population. Sangster argues that this may be due to historical reasons. In the mid-1980s drug services were developed to focus on the epidemics of heroin and the way in which injecting created risks of HIV transmission. Thus the needs of white males dominated services since they tended to dominate this category of drug use (2002: 20). A number of particular problems have been identified with existing service provision by Sangster (2002) and Fountain (2003). Sangster (2002:21) finds a feeling amongst the communities that the image of services were such that they would discourage participation from the BME since they were essentially seen for `whites'. One drug worker commented that:

It's very important to have black workers, it's a way people identify with somebody. They [black workers] said to me `when you enter a room you're conscious all the time whether you're going to have a good or a bad experience, especially when you go to some sort of like authoritarian structure...so you're looking around for key signals to let you know if this place is okay. If you see a picture of something related to black culture, it makes you feel a little easier. But if you're going to a place that has no signals whatsoever it makes you put your guard up' (Sangster et al 2002: 21).

Secondly, there is some literature which claims that the historic focus of many services on opiate-injecting has been accompanied by an underdevelopment of services focusing on cannabis and stimulant (Cripps 1997; Bottomly 1999). The effect of this has been to marginalize support for drugs that are more widely prevalent in BME communities, Sangster et al claim (2002: 22). In particular through focus group interviews Sangster found little evidence that services were engaging with Yemeni and Somali communities and their use of khat. Members of Somali community groups were critical of research that claimed that the drug was unproblematic. Thirdly, Sangster et al (2002) claim that in their consultations with community groups there were criticisms that drug services were not meeting the diverse needs of the community. One of these was language. This supports Johnson and Caroll (Johnson 1995) who found that little information was available in languages other than English. Thus Awaih (Awiah undated) for example reports how local drugs services in one region could not assist the Turkish community unless they spoke English, and Bashford et al (Bashford J 2000) reported how in some situations children might have to translate to their mothers. As a result, some research highlights the utility of translators. While availability of information in a wider range on languages may have become more common since this research took place, language nonetheless may represent a problem in providing local drugs services. A lack of understanding of BME cultures is also shown as a problem in some research. Some research documents that some potential service users would not seek treatment since they thought that their cultural needs would not be understood or had experienced or anticipated racism (Adebowale V 1992; Khan 1999). Often users

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would not seek help because of the shame that it might bring on the community or because it would result in a loss of pride in the individual and family (Gooden 1999). A key problem is also the feelings of shame and stigma that members of BME communities may attach to drug taking and fear that may therefore become attached to their family. As one respondent to Sangster et al claimed:

If you come from somewhere foreign to do better and it's actually gone worse it's a disgrace. If your child turns out to be a criminal who takes drugs...it's a burden sharing your disgrace so you'd rather shut the door on it and keep it to yourself (Drug worker, African Caribbean, London). (Sangster et al 2002: 23)

Sangster et al also report:

`The Somali community group in LSL [Lewisham, Southwark and Lambeth] felt that it was difficult for Somali drug users to seek help because of the particularly stigmatised nature of drug use in this community which was seen to reflect the influence of Islam and a general cultural emphasis on discipline and responsibility.' (Sangster et al 2002: 23)

These findings are substantiated amongst a wider literature. One key problem identified in the literature is either a lack of awareness or reaction of denial in some BME communities about the extent and nature of the drug problem (Perera 1998; Dhillon 2002). These reactions can mean that drug services are difficult to coordinate (Prinjha 2001), but if a co-operative relationship is sought and found significant progress can be made (Passi 1999). There is also evidence that BME communities were unaware of drug services or even if potential users were aware of their availability were unlikely to use them and perhaps thought them "only for `junkies'" (Gilman 1993; Khan 1999). Fountain et al (2003) also point to research showing that members of BME communities fear that confidentially might be breached with drug services. For example respondents from South Asian committees suggest that a visit to GP or drug agency may be discovered via gossip networks and bring disrepute upon the family (Khan 1999). Related to this, some refugees or asylum seekers may mistrust officials, fearful that their immigration status may be questioned and therefore avoid treatment services (Sheikh 2001).

6. Towards Best practice for Substance Misuse Strategies in BME communities

Having identified the concerns about drug misuse in the Somali community and claims that those within it may not be receiving/accessing suitable support services, this report now considers some possible features of best practice to solve drug misuse. Of course, a number of strategies exist. These include targeting supply and a range of techniques focussing on the individual. This literature review instead focuses on strategies that involve the family since there is evidence that this can be an effective resource in assisting the substance misuser (Whitehouse 2005) and that the family is itself in need of support during the process of supporting a substance misuser.

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A - Solutions for the BME and Somali Communities

Models of `best practice' for working with BME communities (and certainly Somali communities in particular) and substance misuse are thin on the ground. A number of key studies however make some important recommendations, notably Fountain et al (Fountain 2003) who wrote a literature review on service provision to BME communities, funded by the National Treatment Agency (NTA), and Sangster et al 2002. A debate exists about the extent to which individual services should be provided for BME groups or these groups should be encouraged to integrate into mainstream services. One of the arguments against the provision of specialist services is that it enables mainstream services to continue without consideration for marginal groups, and discourages broader social integration (see Fountain et al 2003: 38). Sangster et al (2002) however identify seven recommendations for a cultural competence community service, which they claim are interdependent. These could usefully inform practice within either specialised or mainstream services. Table 2: Recommendations for culturally competent services 1. Cultural ownership and leadership; 2. Symbols of accessibility; 3. Familiarity with, and ability to meet, the distinct needs of communities 4. Holistic, therapeutic and social interventions 5. Diversification of services 6. Black and minority ethnic workers, and 7. Community attachment/ownership and capacity building Source Sangster et al (2002: 26) Firstly, they call for a greater sense of cultural ownership and leadership. By this they call for an avoidance of `tokenism' and short-termism in service provision. Instead the needs of BME groups should be engrained into organisational structure with longer-term strategies. Secondly, services need to effectively `marketed' with symbols of accessibility so that community members are encouraged to participate with the services. Given that one of the key problems is that members of BME communities have difficulties accessing services, Fountain (Fountain 2003) identifies a growing literature which emphasises the importance of using effective publicity. This could be through a range of mechanisms such as radio and TV, videos, audio tapes, dramas, road shows and music events. Fountain et al note how the literature recommends promoting antidiscriminatory images of staff and facilities, images of the target group of users, and reinforce the message that drug services do not exist only for white people. Some literature also suggests that drugs should be publicised as a mainstream religious issue rather than a secular issue to maximise the appeal to religious communities. Thirdly, services need to be aware of the norms, history, codes of conduct and other cultural practices of the client group. An awareness of the religious practice of an 13

individual can help in the treatment programme. As one drugs worker remarked in their study:

Somewhere like Tower Hamlets have a large Bengali community...The young person is talking about the issues he or she may have with their religion, vis a vis their drug use, and what they want to hear is a re-enforcement of the need for them to remain in step with their cultural dimension. But instead what they get is language that suggests they don't need to worry about that ...`I don't want you telling me it's cool to not practice, to not pray five times a day. That's not what I want to hear' and that's what they feel they're getting (Drug worker, African Caribbean, London). (Sangster 2002: 28)

Services should also be able to expect and deal with issues of shame. One interviewee from the Somali community claimed that drugs services should not be readily visible as such so that clients can access them confidentially (p.29). It is in response to these problems that a number have suggested the development of GPbased drug services, on the basis that GPs have respect from some Black and minority ethnic communities and there is no stigma attached to visiting them. GP based drug services are suggested particularly as a method of attracting those women whose movements are restricted by their culture (Fountain et al 2003:38). Fourth, a variety of methods should be provided to form a holistic approach to treatment. These should not just be based on medication but also talk treatment and holistic therapies such as acupuncture, and the development of support services and advocacy for housing, employment etc. The research by GLADA (2004) and McCormick and Walker (2006) on factors causing substance misuse reinforces this Fifth, a diverse range of services should be provided that do not focus on a limited range of drugs. Interventions that focus on injecting should not be provided at the expense of other services. Where services focus on injecting, BME groups should be encouraged. Sixth, employing members from BME communities can have positive advantages provided that they are not employed in a tokenised way. Fountain et al (2003) also report that there is evidence that employing staff from the same ethnic group as their potential clients could have some benefits. However literature also suggests that rather than having a worker of one ethnicity for a particular ethnic group, teams should have many workers of different ethnicities working with all ethnic groups. There may even be evidence that workers from the same ethnic group may be less likely to sympathise with the service user for religious reasons (Khan 1999). Within smaller communities, members of the same group may compromise confidentiality through `gossip networks' (Gooden 1999). Finally, Sangster et al (2002) report the importance of services being based, and of, the community, in order for them to accepted and utilises. Fountain (2003) argues that `one of the most significant ways forward in terms of the development of drug services for Black and minority groups is via the communities themselves'(Fountain 2003). They argue that a model of `collaboration' and `partnership' rather than just `involvement' can build community capacity and pass on new skills and powers to deal with issues such as drug misuse. In order to do this, drug services need to obtain the confidence of and trust of the targeted service users (Chaudry MA 1997; Hothi A 1999). They do warn against some potential problems with community involvement programmes however in that once decisions have been set aside to be made 14

collaboratively, some groups may come into conflict. For example one case study shows how a local project became `a thorn in the side' of local drugs commissioners (Dhillon 2001). Likewise, some writers suggest that community projects are only likely to influence policy-outcomes if there are sympathisers amongst elite policy makers (Foreman 1996). Fountain et al (2003) make some additional recommendations. She points to how many commentators point out the importance of outreach work with communities to access BME communities and convince them of the need for drug services (NWLHPU/GMLCA 1987; Awiah undated). Outreach work not only raises the awareness of services, but also enables greater needs assessment by service providers as they come into contact with the community (Deborah Sangster 2002). One successful example of outreach projects include attempts to increase the participation rate amongst the South Asian communities in Bradford. Patel (Patel 2000) highlights how the scheme achieved a dramatic increase in participation from very few to several hundred per year. Fountain et al (2003) point out that a key recommendation made by a number of writers is multi-agency working. By working with community organisations and local health promotion initiatives treatment services can enable resources to be shared and avoid duplication. Multi-agency working can combine the specialist skills and knowledge of each partner organisation. Moreover, they can gain community support amongst those that may otherwise be `hard to reach' (Gilman 1993; Johnson 1995; Project 1995; Gooden 1999; Awiah undated). For example the Southall Community Drugs Education Project was set up in 1999 with support from DAT, Health Promotion service, the then Home Office Drug Prevention Advisory Service (DPAS) and the University of Central Lancashire. This project sought to work to raise awareness amongst families, young people and communities from South Asian communities in Southall about the problems of substance misuse. The scheme was recommended as good practice by the NHSS support materials on drug education (Drug-and-Alcohol-Action-Programme 2006). Fountain et al (2003) site three examples of good practice: o The Southall Community Drug Education Project which worked with families, young people, professionals, business leaders and voluntary and religious groups in South Asian communities in Southall (Drug-and-AlcoholAction-Programme 2006). o The Making Things Equal project worked with the South Asian community in Lancashire to develop a network of trained community interactors to raise awreness of substance misuse issues (Deborah Sangster 2002). o The Black and Minority Ethnic Community Drugs Misuse Needs Assessment Pilot which was a Department of Heath funded project involving 47 projects of 25 different ethnic groups. Members of communities were recruited, trained and supported to conduct drugs needs assessment within the community. The aim was to enable service provision planning as well as capacity building in the community.

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B - Family Orientated Strategies for BME and Somali Communities

Having reviewed potentially useful strategies to enable focussed support on BME communities, this paper now considers the role of the family in treatment programmes. Traditionally drug misuse treatment has focussed on the individual. However a range of specific treatments have developed within service providers and academic literature recognising a) the beneficial effects that the family can have on the individual's treatment outcomes and b) a recognition of the adverse effects upon the family themselves.

Adolescents

Kellow and Parker (Kellow 2006) note how the existing literature has been largely based upon the relationship between the family and adolescents. In adolescents, they highlight how research shows how factors such as strong parental-child relationships, supervision of and positive disciplining of children; anti-drug misuse attitudes held by parents; family support of and advocacy on behalf of their children, can all alter the risk of adolescent drug misuse (Winters 1999; Vakalahi 2001; Liddle 2004). They point to specific schemes which have been initiated based on this knowledge base. A Strengthening Families programme, for example, uses behavioural and cognitive family training in courses of 14 sessions with parents and children aged 610. These courses, which originated in the USA, see substance abuse as one of many forms of anti-social behavioural activities that can be `corrected' through schemes such as family meals, activities, transport and childcare facilities. Assessing the impact of the scheme, the US National Institute on Drug Abuse found that the programme did generate some positive outcomes, but Kellow and Parker note that, given the cost of the scheme, further research is needed to verify the cost effectiveness compared to other forms of intervention (NIDA 1997).

Family involvement in Adult Treatment

A number of researchers also point towards the importance of family relationships for the treatment outcomes of adults. Kellow and Parker (2006) pinpoint literature which highlights that the reactions of family members will influence the chances of recovery for the service user. If family members withdraw contact from the person using substances, then the prospects of recovery decrease, the risk to the family increases and there develops the likelihood of a family relationships being destroyed (Usher 2005) . A range of methods have therefore been developed to integrate families into the treatment process (for a full review see (Whitehouse 2005)). One key approach is family therapy. There are an enormous range of different types of therapy such as `The family disease approach', `Family systems models' `the behavioural approach', and `the social network approach', (Fals-Stewart 2003). The latter, which has become particularly influential in Britain, seeks to enlist a number of family members and

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friends to provide ongoing support for the substance user and to promote behavioural change. Members of the network are viewed as part of the therapy process, although are not the expressed targets of the process. Instead the aim is abstinence and the development of a drug free lifestyle. The network helps to establish a more accurate usage history from the substance user, exert greater social pressure on the substance user through the network and increase positive social support before and after treatment (Galanter 1999). The UK Alcohol Adult Treatment Trial argue that social network involvement `can play a central part in the resolution of addiction problems' (Copello 2005). Ghodse argues that `the support offered by the group is particularly helpful at the very difficult time when parents begin to detach themselves from the problems of their drug-abusing child.' (Ghodse 2002: 217). This may play a useful role within Somali communities. Applications of the approach may vary. Kellow and Parker (2006: 11) cite one scheme in which opiate-addicted patients were asked to bring in a `drug-free significant other' to assist them to create a drug free social network. The scheme was developed to help users overcome the problem that, after the success of treatment, they may not have any drug free social networks (Kidorf 2005). A further variation of family therapy is multi-family therapy in which a number of families from the substance user are treated together. This strategy, according to Ghodse, has the advantage that it allows family members to share experiences and emotions and are therefore more able to provide support to the substance user as well as themselves. They also learn more about their own family by observing others (Ghodse 2002). Kellow and Parker (2006:12) also note that families of substance misuse may be involved in `continuing care' schemes at home. Home visitation interventions allow professionals to assess needs in the clients `real world setting' that may provide a more accurate picture of need. It also engages the client in the `real world' and allows those around them to form part of the treatment process and create an environment that can help them avoid relapse. Gruber et al note that home visits can be expensive but that it encourages those to engage with the process who might not have otherwise have done so because of childcare and transportation issues (Gruber 2004).

Problems

However, research on involving families in the treatment programme highlight a number of problems or issues to be considered in the design and delivery of services. Ghodse notes how family members may actually play a role in encouraging or reinforcing the drug taking, albeit unconsciously (Ghodse 2002). Family members may not also wish to participate in treatment programmes since they may feel, for example, that this involvement is an acceptance of blame for the problem. This may serve to alienate the substance user further from their family. Likewise, in the significant other programme identified by Kellow and Parker (2006: 11), they remark that not all drug users will have a drug free significant other and that this may dishearten the individual and cause them to leave the treatment programme.

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In some cases, the involvement of a partner or a family member may not be appropriate. If the family or individual has suffered abuse, violence or extreme instability, this can have negative repercussions on the treatment process. One example of this would include co-dependent couples. One piece of research in the USA highlights how a drug user is disproportionately more likely to form a relationship with another drug user. Once this relationship is established, the couple often fall into the same pattern of use, reinforcing habits. These relationships can therefore be resistant to change (Cavacuiti 2004). While there is some qualified evidence that involving the family into the treatment process may be beneficial to the substance user, the focus of most programmes is purely on the substance misuser and not the family. As Fals-Stewart et al note of social network therapy:

`The network (i.e. supportive family members and concerned significant others) is considered an important resource, both to the substance user in his or her attempt to achieve and maintain abstinence and to the service provider helping the substance user achieve this objective' (FalsStewart 2003)

Thus, there is little, if any, focus on the family themselves who may suffer as part of the process (Soyez 2005). One study revealed that while there is little research into the needs of the family during this process. They reported that `the diverse needs of all family members are not so well documented, especially those of wide kin such as grandparents but also of siblings' (Bancroft 2005)

C - Family Involvement in Prison Services

Kellow and Parker (2006: 16) note that drug use is much higher amongst those arrested and the prison population than the general population. For example findings from the Home Office suggest that 69% of arrestees tested positive for one or more illegal drugs, and 36% tested positive for two or more such substances. 38% of arrestees tested positive for opiates (including heroin) or cocaine (including crack) (Bennet 2004). Research also pinpoints the disproportionate chances of those leaving prison relapsing. This heightens the importance of effective schemes working with families and substance users in prisons Whitehouse and Copello (2005) undertook a fundamental review of procedures to assist families in UK prisons involving consultations in four geographical regions with families, prisoners, prison staff and community based agencies. A number of interviewees from families claimed that they suffered from a lack of information about support and were unaware of how to access services. Many faced a number of significant problems such as caring for the prisoners children without much assistance (p19). Moreover, members of BME communities found difficulties accessing services due to issues such as language and gender. Even those services which specialised in BME groups encountered difficulties, as one worker claimed:

We specialise in providing substance related support services for families from minority ethnic communities. However, despite having a multi national staff team, with a wide variety of cultural backgrounds and languages, we still find it hard to cater for the needs of minority ethnic communities as a whole. Community Support Agency (p.22)

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There is some evidence of problems with the level of services provided to substance misusers in the criminal justice system and their families. Whitehouse and Copello provide evidence that families and substance users often feel unhappy with the services provided. Notably problems are identified with language and gender problems making it difficult to engage with BME communities (Whitehouse and Copello 2005). Based on their findings, Whitehouse and Copello make a number of recommendations for good practice of service provision in prisons: o o o o o Training and information for prisoners, staff and family members Support groups Workshops and telephone support for visitors Semi-theraupeutic family therapy Telephone support, workshops and referral services (Whitehouse 2005)

Conclusion and Recommendations

This report has outlined research which assesses the prevalence of drug use amongst the Somali community in the UK. While research is patchy and incomplete a number of writers raise concerns about the effects that this is having within the community, both to individuals and families, and society more broadly. There are many factors that may affect the risks of substance use for an individual in the Somali community, and any effective scheme should consider each of these. This report however highlights that the family can be a key resource in family substance misuse. A range of good practices are identified that may be appropriate for the Somali community, in and out of prison. However the family is not just a resource and requires support services of its own. This latter point has generally been understated by research.

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