Provision of creative arts interventions in UK drug and alcohol services: A cross-sectional study

motivational states, and the neural systems that regulate these processes. He is also interested in the role that impulsivity-related personality traits play in decision-making and risk-taking, particularly in the context of substance use and gambling. Abstract Background: The provision of nonpharmacological interventions in UK drug and alcohol treatment services varies from service to service. This cross-sectional study explores the types of interventions that are available for people seeking treatment for substance use dependence within UK drug and alcohol services in the context of nonpharmacological treatment provision. Method: A structured questionnaire was distributed to 762 UK drug and alcohol treatment services. Results: A total of 93 drug and alcohol treatment services are included in the analysis. Key worker support 84.94 per cent and talking therapies 83.87 per cent are the most reported nonpharmacological interventions. Access to creative art provision as therapy or as an activity is reported by 51.61 per cent of included services. Conclusion: Nonpharmacological interventions are currently an integral treatment for people who use substances. The services providing creative art interventions report a positive impact on motivation for recovery and improvement in recovery rates when included in treatment programmes.


1 Background
The acceptability of pharmacological interventions in the drug and alcohol United Kingdom (UK) services has been long established (Rosenberg et al., 2002) and has perpetuated as a strategy to primarily reduce crime, by keeping people who use drugs (PWUD) away from illicit street use. This widely evidenced strategy is dependent on self-reported substance use, which has become the focus for treating substance misuse in the UK and is directed toward harm reduction rather than targeted at assisting the progression towards improving recovery (Reed et al., 2015;Perry et al., 2015). Nevertheless, pharmacological treatment remains an important part of service delivery for the holistic recovery journey.
In addition to the existing national treatment services provision a number of recovery groups exist offering nonpharmacological interventions which are helpful in reducing recidivism in the criminal justice system relating to drug crimes (Perry et al., 2016).
A recently published UK government review led by Dame Carol Black has put recovery at the core of the drug and alcohol treatment programmes and recognizes more resources are required to secure a better rate of recovery whilst in treatment (Black, 2020).
This cross-sectional study investigates the types of creative arts interventions within the context of nonpharmacological treatment services provided by UK drug and alcohol services.
It focuses on creative arts interventions and inquires about the perceived effectiveness by those providing the services, as well as the evaluation methods being employed to determine their level of effectiveness. To the best of our knowledge, no previous studies in the UK have addressed these questions.

Research approach and methodology
This study aims to investigate the nonpharmacological provision in UK drug and alcohol treatment services with particular interest in the use of creative arts interventions. An exploratory quantitative research method was selected, using an online delivered questionnaire, to establish the extent to which nonpharmacological treatments are provided within UK drug and alcohol services. The STROBE cross-sectional reporting guidelines were used as a checklist to report this original research study (Von Elm et al., 2014). The Qualtrics Core XM system was selected as most appropriate for this study to deliver and monitor the questionnaire distribution and data collection.

Drug and Alcohol Service Questionnaire (DASQ)
In recognition of the pressure UK drug and alcohol services are under, such as reduced funding and increases in service user numbers and wishing to keep the participant time required to a minimum, a short questionnaire was developed. The first question related to participant consent and a further 10 questions, sought to address the research aims. Three questions focussed on the service information and the range of services provided. The following five questions were specifically related to creative arts provision. It was intended that the questionnaire would take no more than 15 minutes to complete.

Drug and alcohol service providers
This study required a full list of the UK drug and alcohol treatment services, so they could be contacted with an invitation to participate in this study. A list of UK drug and alcohol treatment services was compiled and stored in a Microsoft Excel Spreadsheet. The list was sourced from various places in the public domain and, when completed, further work was required to ensure as many treatment services as possible had their contact details, including an email address to which an invitation to participate would be sent. The compilation of the list was time intensive and by February 2020 the full list was available.

Questionnaire distribution
Following beta testing of the questionnaire, a randomized 10 per cent test of the full list took place on 26 March 2020, to see how the delivery system operated. This was successful and upon receipt of a fully completed response, the remaining 90 per cent were distributed on 31 March 2020 to the UK drug and alcohol treatment service organisations. During the data collection period, which was 100 days from 26 March 2020, several reminders were sent to those who had not yet started the survey. The survey was designed in such a way that participants were able to partially complete it and later return to the same link to complete it.

Results
The descriptive results of this study relate to the pre-COVID provision of nonpharmacological interventions within UK drug and alcohol treatment services. As services coped with COVID-19-related lockdowns, some of the nonpharmacological interventions were not possible in person until all restrictions had been lifted. The distribution and data collection period coincided with the first COVID-19 lockdown in the UK. Whilst the treatment services had to quickly revise their service delivery provision, the questionnaire asked for answers related to their operation prior to social distancing and lockdown rules.
The compiled list of UK drug and alcohol treatment services included 1,160 named services.
After the removal of duplicate contact details and missing contact information, the invitation to complete the questionnaire was distributed to 762 UK treatment service providers as shown in Figure 1. During the study period, two reminder emails were sent to those services who had not yet completed the questionnaire. A further email was sent to those that had completed their questionnaire as a way of thanking them for their participation. Close to the end of the study period, a final email was sent to services who had not yet started the questionnaire to  (n=1150) Less (n=10) unable to find contact details encourage them to participate in the study. The study data collection period was closed for analysis on 3 rd July 2020 which represented the 100 th day the survey had been available for completion. At the end of this day, there were 119 completed responses recorded in the Qualtrics system.

Drug and Alcohol Services list compilation
The completed records were checked for any anomalies. Three records were found that required deletion. One of these had been created by a member of Qualtrics support staff incorrectly and added to the completed records. The additional record was downloaded before deletion on 13 July 2020. Another two records were deleted on 14 July 2020 as they had subsequently been retaken as a new record using the retake link feature and the original records were obsolete. A summary of the number of responses is included in Figure 2 for clarity.

Types of treatments offered
The results shown in Table 1 show that nonpharmacological interventions are employed by 97.84 per cent (n=91) of the 93 included drug and alcohol services and are divided into 4 main categories as shown in Figure 3. Respondents could indicate that more than one type of intervention was provided at each service. Key worker support is the leading nonpharmacological support; this role is typically provided in drug and alcohol treatment where each service user has an allocated staff member whom 8 the service user would see frequently maybe weekly or fortnightly. Whilst this is labelled as nonpharmacological, it is often the key workers that also provide the prescription alongside the psychosocial aspects of the role in services that offer medication.

Creative arts subdivisions
The provision of creative arts is of particular interest, and this was the focus of five questions of the study questionnaire. Respondents were asked to check those creative arts interventions that were provided by their service from a provided list and add any others in a text box.
Respondents could indicate that more than one creative arts intervention was provided at each service. The main included creative arts activities are shown in Figure 4. In the study, these were divided into music therapy and music activities. There were n=8 services which provide music therapy that also provided music activities.

Methods of evaluation of creative arts interventions and recording of the results
Most services include an evaluation of the creative arts interventions and record the outcome. Table 2 shows the types of evaluation that services use, with the most frequent method (87 per cent) being verbal feedback.

Creative arts provision in included UK drug and alcohol services
Missing data 1 2.08 Supporting the evaluation process is the recording of the information. As shown in Table 3, 66.67 per cent of included services analyse the results in an evaluation report, and 41.66 per cent incorporate the feedback into the individual service users' record.

Qualification level of creative arts interventions providers
The provision of the nonpharmacological interventions was met by people with different levels of qualification, as shown in Table 4. The questionnaire was able to identify that 62.5 per cent of services had people who were experienced in the field of facilitating creative arts interventions. A lower proportion (47.91 per cent) of services were found to have professionally qualified staff providing the creative arts interventions. Some services had a combination of qualification level and experience in the field. An interest in the arts 24 50 None of the above 4 8.33 Missing information 4 8.33

Effectiveness of Creative arts interventions
Informal views on effectiveness are reported in the answers to questions nine and ten of the questionnaire. It gives an indication as to why these interventions are seen to be useful or not by the provider organisations. Although it is not formally evidenced by the recipients of the activities, it can give a useful indication as to whether this could be an area of further interest for future research. The results of these two questions are reported via a Likert scale and presented in Tables 5 and 6. When asked whether creative arts provide motivation for recovery 68.75 per cent (n=33) of participants replied yes. Furthermore, 56.25 per cent (n=27) believe that service user access to creative arts improves recovery rates. To assess whether the number of different creative arts interventions provided by each service is correlated with the level of recovery motivation and recovery rates, as rated by the service providers, a Pearson correlation coefficient was calculated. The results indicated a positive significant correlation between the number of types of creative arts interventions offered and better rates of recovery motivation, r (44) =.33, p =.031. On the contrary, the Pearson correlation coefficient between the number of types of creative arts interventions offered and improved recovery rates was not significant, r (44) =.16, p =.315.

Discussion
This study establishes an overview of the nonpharmacological service provision within UK drug and alcohol services, and in particular the provision of creative arts interventions.

Summary of results
The participant response rate of 23.9 per cent to the invitation represents 176 organisations that started the questionnaire, 7 did not consent and 54 were excluded because they did not

Study limitations
There are some limitations in this study, primarily related to the COVID-19 pandemic that coincided with the beginning of the data collection period. Although 23 per cent of the 762 invited services started the study, only 15 per cent can be included in the results due to missing data, because contributors did not complete the questionnaire. As a result, caution should be maintained when generalising the results of this study to the total UK drug and alcohol treatment service provision.

Implications for service practice
When designing a drug and alcohol treatment service, providers can look to include the more frequently used nonpharmacological interventions to enhance the user experience in aiding recovery. The results of this study indicate that nonpharmacological interventions are already a core part of the drug and alcohol treatment provision. Whilst the extent to which they are used varies from service to service, their value is recognised through several evaluation procedures. Services intent on providing a holistic recovery service are likely to want to include creative arts activities and therapies in their provision if funding and staffing levels permit. The results of this study once disseminated will encourage services to consider their ongoing provision and evaluation of creative arts among their nonpharmacological intervention provision. It may be important to continue the nonpharmacological interventions such as creative arts beyond the delivery of prescription substitutes to establish lasting behavioural changes, highlighting the need for further evidence-based studies.

Future research needs
There is a paucity of research into the effectiveness of nonpharmacological interventions for treating addiction recovery, and even less information on the use and effectiveness of creative arts interventions for this sector. This is, therefore, a key area for future research with more high-quality study design approaches, to collate sufficient evidence for service providers to be able to be awarded the finance required to adequately make these types of services more widely available to their service users. As there may not be more money available, it is clear that a strategy needs to be developed based on evidence to recommend the most effective elements of existing provision.

Conclusion and implications
This research adds to the understanding of the provision of the creative arts interventions available within the UK drug and alcohol treatment services. It shows where creative arts are provided that the professional staff within the drug and alcohol services consider these interventions a valuable part of their service provision in aiding recovery for people with substance use dependence.