SurvivorScotland National Strategy for Survivors of Childhood Abuse

Lessons from the Alaskan Family Wellness Warriors Initiative -18 and 19 February 2014

Conference Report July 2014

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The Scottish Government
St Andrew’s House
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Produced for The Scottish Government by APS Group Scotland, 21 Tennant Street, Edinburgh EH6 5NA
DPPAS30407 (07/14)

Published by The Scottish Government, July 2014

Introduction

We have a proud heritage in Scotland, a heritage which includes:

a unique cultural and historic identity through geography, language, dialect, music, storytelling and the arts

a unique history which we still celebrate today

responsibility for our own education, health care and social care

a diverse multi-cultural society with a range of faiths and beliefs

This heritage reflects aspects of the Alaskan native culture and is why we considered it might be possible to learn lessons from their health and social care system and more particularly, their model of support for survivors of domestic abuse, child abuse and child neglect, the Family Wellness Warriors Initiative (FWWI). We are not suggesting that the FWWI will provide all the answers we need for Scotland, but we believe that consideration of successful approaches from communities with cultural similarities might help to identify what we need to do to achieve our shared aspiration of eliminating childhood abuse and neglect. FWWI provides one such model.

Background

The World Health Organisation Report of 2002 indicated that child abuse was a global problem. Available data at that time suggested that around 20% of women and 5 to 10 % of men had suffered sexual abuse as children. Many more children had also been subjected to psychological or emotional abuse as well as neglect. The report indicated that, apart from physical injuries, child maltreatment was associated with a number of consequences. For example, alcohol and drug abuse, cognitive impairment, development delays and risk-taking factors. Many of these problems, in turn, increased the likelihood of several major adult forms of illness and disease.

In Scotland, over recent years, we have addressed support for survivors through the National Strategy for Survivors of Child Abuse, SurvivorScotland. Through the Strategy we have raised awareness, developed training and provided funding for services for survivors. It is nine years since the launch of the SurvivorScotland strategy and, in recognising what has been achieved, we felt it important to consider what still needs to be done.

Both the Nuka model of care and FWWI are world renowned initiatives. Over recent years officials from NHS Scotland and the Scottish Government have engaged with Southcentral Foundation to learn more from these models.

The "Nuka System of Care" is a healthcare system created, managed, and owned by Alaskan Native people to achieve physical, mental, emotional and spiritual wellness. It is an innovative, relationship based, customer-driven system of health care which has been in place for over twenty five years.

FWWI is Southcentral Foundation's state-wide education and training program designed to address domestic violence, child sexual abuse and child neglect. It aims to encourage wellness in each of these areas in the individual, the family, and the community. The overarching aim is to eliminate domestic violence, child sexual abuse and child neglect within a generation.

As the Scottish Government is committed to a person centred approach to health and social care, we felt it appropriate to engage with both the people who deliver our services and, crucially, with those who use those services. The overall purpose of this engagement was to consider whether a model of support for survivors of childhood abuse, similar to FWWI, might be appropriate for Scotland.

Executive Summary

This report summarises the outcomes of a two day conference to consider how we might 'learn lessons from the Alaskan Family Wellness Warriors Initiative' on informing views on the future development of services for survivors of childhood abuse in Scotland.

The issues for adult survivors of childhood abuse are often seen as mental health and trauma but also include addictions and other physical health issues. Better outcomes are being achieved for survivors through services funded by SurvivorScotland but there is much more that can be done.

The first day focused on setting the scene around the ongoing challenge of improving health in Scotland. This included recognising the longstanding poor health issues and persistent health inequalities of Scotland, and the desire to address those inequalities, particularly for adult survivors of childhood abuse. We also heard about two models of addressing the effects of abuse: CEDAR (Children Experiencing Domestic Abuse Recovery) – an approach adopted from Canada which addresses the effects of domestic abuse for children and mothers and the FWWI, a Native Alaskan model which deals with domestic abuse, child sexual abuse and child neglect. The objective of this was to consider the background to how the models were introduced, what engagement and support were required, what the barriers were and what worked well.

The second day provided an opportunity to take on board some of the lessons from the previous day and to consider how we might address these in taking forward proposals for future improvements in the delivery of services in Scotland. Some of the main points to emerge are highlighted below.

The importance of political influence and leadership.

A cultural change on ownership. Individuals and wider communities need to take on, and benefit from, more responsibility for their own wellbeing.

The importance of engaging with the community in its entirety, using feedback from such engagement to inform service delivery and to contribute towards the development of an evidence base.

A mapping of existing services is required, particularly identifying areas where there was already a good model of partnership working.

Following the discussions and feedback of the two days we propose not to attempt to adopt the FWWI as it is delivered in Alaska but instead to look to adapt its innovative features for use in Scotland, utilising existing expertise and services.

Conference - Day 1

The aims of the first day were:

To share and learn lessons from community-based programmes such as the Family Wellness Warriors Initiative

To consider how we provide services for adult survivors of childhood abuse in the future

The conference heard from a number of speakers who were invited to provide a picture of the services in Scotland at present, the wider context that these services operate in, and provide examples of current work being undertaken to improve these services in the future.

Michael Matheson MSP, Minister for Public Health opened the conference, highlighting the Scottish Government's commitment to support survivors of childhood abuse through the SurvivorScotland Strategy. The Scottish Government's aims are to put people at the centre of their care, as seen in the FWWI and Nuka healthcare system. He underlined the significance of the integration of Health and Social Care in Scotland as a key part of achieving a person-centred approach. He recognised that there were a variety of innovative services for survivors in Scotland but that there was always more that could be done and that Scotland is willing to learn from and share good practice the world over.

Following Mr Matheson's overview of the Scottish Government's work, Dr Andrew Fraser, Director of Public Health Science, NHS Scotland, provided a wider context of some of the challenges that face Scotland's public health, including a range of issues for survivors of abuse. Dr Fraser stressed the need to look at the whole picture of abuse, including domestic and childhood abuse; neglect; associated health inequalities as well as contributory cultural factors like consumption of and attitudes towards drugs and alcohol. Within this context consideration was then given to how services for adult survivors of childhood abuse could look in the future. Examples of this included the FWWI, the CEDAR Project and the Violence Reduction Unit's work with gangs, mentoring programmes, and work in prisons. A key component of all these programmes was their engagement with communities, families and individuals.

Our main aims for the day were to share and learn lessons from community-based programmes and to consider how services are provided in the future. Leading up to the conference, we had a short consultation on FWWI with some of our stakeholders who highlighted the desire for community-based programmes and their engagement with communities. The CEDAR project is one such model originating from Canada, which had been successfully implemented and further adapted in Scotland.

Heather Coady, the National Co-ordinator described factors which were important in introducing the CEDAR model in Scotland and which would be equally important in developing a model of support for survivors of childhood abuse. These included an action research approach; multi-agency learning and integration; the need for multiagency buy-in, for example, statutory services, NHS, Police, head teachers, Women's Aid and voluntary organisations. A key component of this work was maintaining a person-centred approach throughout service design and delivery. Heather's experiences of adapting a model from outwith the UK, with its own distinct social, civic, political and geographical environments, and overcoming these differences to make CEDAR viable in Scotland, helped to provide an example of how a model similar to FWWI could be adapted for Scotland.

The conference went on to hear what lessons could be learned from community-based programmes outside Scotland. Katherine Gottlieb the President and CEO of Southcentral Foundation and Steve Tierney, Michelle Tierney and Kevin Gottlieb spoke about FWWI and the Nuka model of health and social care. FWWI harnesses the power of story to break the silence associated with abuse and aims to initiate a safe, healing journey through drawing upon cultural strengths that can be used to address the spiritual, emotional, mental, and physical effects of abuse. Underpinning FWWI is the Nuka model, a healthcare system that has been transformed in its entirety, with shared responsibility, commitment to quality and family wellness at its core. Shared responsibility comes through people taking responsibility for their own wellness as customer owners. Employees and volunteers also commit to the idea of customer owners and undergo core concepts training which is designed around the concept of wellness:

Work together in relationship to learn and grow

Encourage understanding

Listen with an open mind

Laugh and enjoy humour throughout the day

Notice the dignity and value of ourselves and others

Engage others with compassion

Share our stories and our hearts

Strive to honor and respect ourselves and others

The experiences and work of Southcentral Foundation provided attendees with an insight into an alternative view of healthcare provision and how the principles and approach of such a system can inform wider services, including services for adult survivors of childhood abuse. Paul Gray, Director General Health and Social Care, Scottish Government and Chief Executive NHS Scotland echoed some of these sentiments. He praised the courage of survivors who came forward to talk about andshare their experiences. He highlighted the importance of talking to each other and recognised the need to learn from other successful models, recognising that services must be for and about people.

Plenary

A number of points emerged during the presentations and were put to the panel, made up of the speakers of the day:

People need to accept responsibility for their own health and wellbeing

Survivors need to be involved in making key decisions rather than decisions being made for them

The concept of customer owners was something that people liked but felt that there was a long way to go before there was customer ownership in Scotland

There is a need to recognise that men and boys also suffer from abuse including domestic abuse and should have a model of support like CEDAR or FWWI. Any model of support needs to be about the whole family, recognising men and same sex relationships

It is possible to address difficulties in rural areas. We have already started this in Scotland through telecare which the Nuka model also recognises as a key element of its health and social care delivery

Professionals need to be prepared to let go, to embrace change. While they are experts in their own fields, it is the people who are the experts in their own lives. Change is needed to enable them to break the silence

Child protection is important in helping to identify and prevent abuse

There needs to be support for transition from children's services to adult services. There also needs to be additional support for adults in transition from one service to another

Conference - Day 2

The aims of the workshops on day two of the conference were:

To consider how preventative approaches like the Family Wellness Warriors Initiative would be suitable for Scotland

To identify interested parties who might wish to develop the thinking further

To identify interest in piloting a model developed for Scotland

A number of themes emerged which cut across all the workshops and, as such, this report addresses those themes rather than the individual workshop topics of Awareness Raising and Community Engagement, Development of a Potential Model for Scotland and Care and Support. This still allowed us to address the aims for the day as well as the overall aim of considering whether a model of support for survivors of childhood and domestic abuse, similar to FWWI, might be appropriate for Scotland. It has also enabled us to identify some key points for Community Engagement and considering a model for Scotland.

Community Engagement

Political Leadership

It was clear from the presentations on the FWWI and CEDAR project that the involvement of communities as well as political and civil leadership is important in taking such programmes forward. The groups considered where this support and leadership would be needed for a programme of support in Scotland. If a model was developed on a local basis then support could be sought from the community, with local authority councillors and relevant MSPs and MPs. However, a national model for Scotland would require commitment from the Scottish Government, with political leadership being sought on a cross party basis to ensure future support.

Ownership

A starting point for a model for Scotland should be for the community to recognise and accept that there are problems. Some of the groups felt that the scale of domestic abuse, childhood abuse and neglect was still denied or not considered a high priority. A lack of statistical data also meant that it was not reflected in local police plans or community plans. The key was to consider how we make this a community ownership issue in Scotland.

Asking communities for their views would be the first step. The community could then work together to identify issues surrounding abuse and consider what action and funding was required to meet these needs. The next step would be to let government, local and national, know what was required and for government to actively engage with the community. Some people felt that public funds should be ring fenced, while others felt that funding might have to be addressed as part of the overall resourcing available. Any issues and decision making around funding should involve the community in question.

One of the challenges identified was the ability to turn the vision of a Scottish model into reality. That vision had to be positive, a model of wellness rather than a model dealing with abuse, ensuring it would be clear and accessible. The concept of customer owners was interesting as it emphasised that the relationship between service providers and service users should be based on equality i.e. a service delivered with people not a service done to people. This would help to build up trust and resilience in communities.

Some people highlighted the need to mitigate resistance to change within a community. For other recent changes and interventions, community champions had been identified to lead, mediate and mobilise the community. This would be important in taking forward any new model.

Engagement

Engagement would be required at both a national and local level, to join up the communities within Scotland and the community of Scotland as a whole. This would require engagement beyond current survivor organisations and networks.

In addition to the question of where engagement needs to take place, the question of how to engage was raised. Smaller events might help to get more people from the community involved. Attendance at larger organised events can often be poor because some people find it difficult to express their views in such environments. This could, in part, be overcome through engaging with people in existing groups in which they felt comfortable to express their views. Further methods of engagement could also be carried out through media campaigns and social media.

Further work would be required on how to engage with people who were not in a group or who no longer felt part of a community. Many people who had been harmed felt isolated without any interaction with family, friends or neighbours. This feeling of isolation could often be more acute in rural and remote areas and as such, different approaches would be required for villages, towns and cities. Methods of engagement would need to take account of diversity and equality. Separate engagement might be required with men's and women's groups as well as faith groups for example.

Engagement with public sector organisations could be done at a national level with the NHS and local authorities and at a local level with GPs as well as health and community centres. To address child protection, it would be important to link into and engage with the National Public Awareness Advisory Group which sits under the Scottish Child Protection Committee Chairs Forum, and at a local level all Child Protection Committees have a reference/public group as a sub group. It was also felt that religious and faith organisations should be consulted in addition to the third sector at a national and local level. Many of these organisations work directly with survivors on a local basis.

Community Engagement – Key Points

The importance of political influence and leadership.

A cultural change on ownership is required. Individuals and wider communities need to take more responsibility for their own wellbeing.

The importance of engaging with the community in its entirety, using feedback from such engagement to inform service delivery and to contribute towards the development of an evidence base.

Scottish Model

Existing Services

There would be a number of challenges to directly applying the Alaskan model for use in Scotland without adaptation, for example, differences in population sizes and cultural identities. Before a Scottish model could be seriously considered it was suggested that historic attitudes and ways of working between agencies, organisations and institutions related to survivors, needed to be addressed. Some people felt that many current services are risk averse. Any new approach would need to address this, to accept that things might not work first time as well as to be more ready and willing in dealing with situations where things go wrong. At the moment, the top-down approach of national and local government to service provision and funding has significant influence on service design and delivery. The result of this can be that services are inhibited in their scope and levels of innovation. This risk is something that would need to be addressed.

The Nuka healthcare system and the FWWI represent a highly integrated model of health and social care that a number of group members felt would be difficult to replicate in Scotland. However, many felt that a more integrated model of care would be desirable and something worth pursuing.

An integrated system of care would include an awareness of services available, something that a number of people felt that they already possessed. However, many others felt that they were working in isolation, particularly in rural areas. They did not always know what other services were available in their area, to enable a wider choice of services supporting clients. A greater awareness of services could help identify any overlap in service provision. A fully integrated approach would need to include the public sector, noting the potential of training for GPs and other frontline workers and the value of education and training to understand and connect both the physical and mental health effects of abuse.

It would be important to recognise the makeup and diversity within communities in identifying what would be required. There is a difference in access to services in rural areas where it is more difficult to co-locate these services than in urban areas. It would also be important to factor in the needs, for example, of ethnic minorities where a culturally informed approach to bringing services and representatives of the communities together would need to be considered.

As a first step it was felt that there should be a mapping of existing services; health, social care and the third sector. Doing this could enable organisations to work together better, share skills and knowledge and identify the best person and/or organisation to address the needs of the survivor. It would also build towards an evidence base for the development of any future Scottish model.

Alternative models

Given the landscape and diversity of Scotland some people thought that a single existing model would not work and that a number of different approaches would be required.

The groups felt that there was a need to look at a range of models from Scotland and abroad, beyond the FWWI. Some suggestions were:

The Caledonian System – an integrated approach to address men's domestic abuse and to improve the lives of women, children and men

Systemic Family Therapy

CEDAR

Existing models in the voluntary sector

While many felt the FWWI was an excellent business model others felt that, although they had heard a lot about its aims and outcomes, it would be helpful to know more about how these aims and outcomes were achieved. The FWWI's emphasis on breaking the silence on abuse and on preventing future abuse was welcomed. Yet, it was felt that it was unlikely that an existing, unmodified model could be fit for purpose in Scotland and that work to adapt any potential model would be required. In addition to learning from best practice of alternative models, it was suggested that much could be learned and shared from other policy areas as part of a wider strategy to tackling domestic violence, childhood abuse and childhood neglect.

Person Centred Approach

The groups felt that there should not be a ready-made agenda or model but instead, survivors should be asked what they need. It was felt that a bottom-up approach is needed, addressing the needs of the individual and having the individual inform the design and delivery of the support, not the other way around.

A number of group members felt that statutory services in health and social care did not take care of the whole 'you', that there was often a lack of communication and little consistency in delivery of care. For example, some indicated that they felt lost in bureaucracy when they had reported abuse to their GP. As a result, they felt that a range of professionals became involved in their lives, when it would have been preferable to work intensively with one organisation or professional who could provide long-term support as required. There were also concerns about the number of times information would be shared amongst organisations and professionals. To address these concerns it would be helpful if a range of services e.g. health, housing, advocacy and rights support and police could be located in one place. This could further encourage partnership working, opportunities to share information and easier access to services.

Funding

Third sector organisations highlighted the barrier of funding for existing services. That is, it was often difficult to identify the funding streams available, funds were allocated for a, often short, set period of time and the priorities often changed. The restrictions and boundaries of funding streams, often target driven, could also inhibit the scope and collaborative potential of organisations. It was felt that project managers and skilled staff were dedicating too much of their time developing plans, applications and reports instead of supporting survivors.

Some people felt that we should look at what could be done with existing funding rather than rely on additional funding. Addressing things now that would also be important in the future, making sure that the right services were in place, services that survivors helped to identify rather than those chosen for them. For example, investing in prevention and person-centred support could reduce the necessity to access Primary Care services.

Faith

The FWWI model is a faith-based model, although its origins were not faith-based. For some, such a model was an issue as many survivors had been abused by church representatives and had felt let down by the church.

Others took a different view where they felt that engaging with religious leaders could be a means of gaining access to otherwise insular communities. It was acknowledged that faith did not necessarily mean religion. It is still possible to have a personal faith or cultural belief without that being associated with a particular religion, and that this should be taken in to account when considering any model for Scotland.

Language

Language was considered to be important in both understanding existing models and developing any future model, as it frames and informs wider discussion. A number of people felt that the language used in the FWWI did not speak to them and their values. For example, it appeared that there was an imbalance of power and control being handed to men (warriors) as the message about Princess Warriors did not come out clearly in the presentation. The language of the model did not make it clear that this was about the whole family and not just about men.

The groups highlighted the importance of addressing the stigma attached to abuse and neglect. People often felt they were labelled by professionals and related services, and that they were treated as a community problem. A number of people liked the language of the FWWI which spoke of those who have been harmed rather than victims or survivors, and those who have harmed or caused harm rather than offenders or perpetrators. This helped to reduce some of the perceived barriers, stigmas and labels associated with these terms. Such a change in the language used would be important for the families of those who had caused harm, as they can be associated with the same stigma.

People were clear that the development of any new model should have a positive message, with the positive role models featured in the FWWI and CEDAR project providing key examples of this. The model should seek to reframe the discourse and focus on wellness rather than abuse. It should be about achieving goals rather than problems and aim to remove not reinforce negative stereotypes and stigmas. All language used in the development of a Scottish model should be clear, meaningful and free from jargon.

Legislation

The groups felt that new legislation was not required to take this work forward. Instead, it was felt that better use can and should be made of existing legislation. For example, Self-directed Support legislation (SDS) provides people with increased choice and control over their assessed social care needs. SDS focuses on the outcomes of the individual, placing them at the table when any support plans for their care are being made. In part, the aim of this is to address the imbalance of power between the professional and the individual, giving the individual a bigger role and say over their care.

Moreover, health and social care integration in Scotland aims to ensure people are supported to live well at home or in their community for as much time as they can. This approach stems from the Christie Commission Report (2011) on the future delivery of public services which said: ". . . effective services must be designed with and for people and communities – not delivered 'top down' for administrative convenience". It was strongly felt that this approach should apply equally to the services that survivors are seeking.

Scottish Model – Key Points

A mapping of existing services is required, particularly identifying areas where there was already a good model of partnership working.

Important to consider other models as well as FWWI.

An inclusive approach is important to the development of any Scottish model. Ensuring that wider communities are involved throughout the model's development rather than statutory services exclusively leading the way.

The importance of collaborative working at the level of individuals. There was a view that there is a tendency to focus on professionals working with professionals, organisations working with organisations and little discussion about working with individuals and service users.

It was felt by some that a consistency in service provision and advice for service users can be problematic when there are various organisations offering duplication of services for survivors with their own approaches. This lack of consistency was said to be exacerbated due to organisations competing for the same funding, leading to the possibility of a non-collaborative approach between organisations.

Plenary

Some of the questions identified had already been addressed during the workshops. The key points from the discussions have been outlined below:

Plenary – Key points

Identifying the needs of any model should involve the whole community. This means finding ways of engaging people who do not normally identify themselves as part of a community and those who are socially isolated.

Service providers and service users have to be prepared to take shared responsibility for and ownership of change.

Any new model should be complementary to or part of existing services. This could mean a re-alignment of existing services but not a replacement of them.

Support would be required for service users and providers before and during their engagement with any new approach and continuing care should be in place following this experience.

Education is important in raising awareness and tackling stigma.

Outcomes need to be measured to demonstrate success and highlight where things have not worked or where further work is required.

Evaluation Feedback

The feedback from the event highlighted a desire for further information about the FWWI. While the aims and objectives were clear, further details of how they were achieved would have been helpful. The workshops were mainly considered to be productive and thought provoking. Other points from the feedback were:

"Inspiring"

FWWI/NUKA model is appealing and is something Scotland should and could strive for

More questions than answers

The speakers and their presentations were regarded as very 'real', 'engaging' and 'genuine'.

"Fabulous speakers, so sincere, real people, not at all corporate!"

Re workshops: good to focus on the discussions and thoughts of day one i.e. good to build from day one

Realised the significance of "story" – valuable and thought provoking

Quantitative Data

Fifty six evaluation forms were submitted. All indicated that they had more knowledge of the Nuka system of healthcare and the FWWI and most wished to hear about and participate in any future developments.

Q: 1. Did you have any knowledge of the Nuka Model of health care and Family Wellness Warriors Initiative before the conference?

Q: 2. Has the conference improved your knowledge of the Nuka Model of health care and Family Wellness Warriors Initiative?

Q:3. How interesting did you find the presentations?

Q:4. If you attended day 2 of the conference please give us your views on the workshops?

Next Steps

We are grateful to all our speakers, to those who chose to share their personal experiences with us and to everyone who participated in the Conference. It was a valuable opportunity for us to hear from our stakeholders, including survivors themselves, on how they see services at the moment and what they would like to see differently in the future. We have tried to reflect that in this report and recognise that there is much more for us to do.

We also had the chance to hear about other models of care, particularly FWWI and CEDAR, and to learn from their experiences on what did and did not work, the levels of engagement and support that helped to achieve their outcomes and the recognition that there are often risks associated with any new way of delivering services.

The National Strategy for Survivors of Child Abuse has now been in place for nine years. Over the next year we propose to review the Strategy to consider what has been achieved since its launch in 2005 and to consider what still has to done. As part of that we will look at other models of care, including some of those that were identified as part of our discussions at the Conference.

Our aim is to have a revised Strategy that reflects where we are now and identifies clearly what actions are required and the timescale for those actions. We cannot do that on our own so, bearing in mind the clearest message from the Conference about community engagement, we will be seeking the support of all our stakeholders in the development of that Strategy. We would like anyone who has views and ideas to share with us to have the opportunity to have their say. We hope to let you know of our plans in the next few months.