Dr. Oliver Aldridge Edinburgh, Midlothian & East Lothian DTTO Service Wraparound Services Dr. Oliver Aldridge Edinburgh, Midlothian & East Lothian DTTO Service

Plan Wraparound Care Outline the DTTO service Is a large, Multidisciplinary Team the way forward? Creating the right environment for recovery – Apples and Barrels Conclusions

Wraparound Care Substitute prescription in and of itself does not usually constitute adequate drug treatment Corollary: In those people who need a substitute prescription, inadequate/poor quality substitute prescribing may render “wraparound care” ineffective

Edinburgh, Midlothian & East Lothian DTTO Service A partnership between Health (NHS Lothian) and Criminal Justice Social Work All healthcare workers are employed by NHS Lothian and seconded to the service. Each client of the service has their own, named Nurse, Resource Worker and Social Worker

Admin Staff Initial Contact Deal with Enquiries Deal with Distress and Anger Positively Promoting the Service and the Service Users

Clinical Team Oversee All Prescriptions Provide Physical, Mental, Sexual healthcare Advice Methadone Education Motivational Work Drug Testing & Monitoring (e.g. Christo)

Resource Workers Negotiate with Benefit Agencies Assist with Accommodation Problems Help with Literacy and Numeracy Problems Advice on Education, Training and Work Opportunities

Social Workers Deal with Problems of Attendance and Behaviour Work Directly with the Court Provide Reports Address Child Care Issues

Courts/Solicitors Positive affirmation of progress Help with navigating through legal difficulties

What We Do Together Home Visits Reviews Case Discussions Team Meetings

Group Work Relapse Prevention Overdose Education Relaxation Group Cookery Group And Coming Shortly !!! The Football Group The Walking Group The Womens Group

Large Multidisciplinary Teams – The way forward? Sometimes!! Not for everyone and may be counterproductive Too much intervention for some peoples’ needs May discourage smaller teams from providing a service Need a range of interventions available in each area.

Creating the right environment Apples and Barrels

Individualism Emphasised by the major systems we work in: Medical Judicial Political Religious Cultural

Power of Individualism

Social Psychology Emphasises the power of the situation to affect/determine peoples’ behaviour Stanford Prison Experiments Stanley Milgram’s Pain Experiments Individual behaviour may be predicted by knowing the situation while having little or no knowledge about the person

Abu Ghraib Were the abuses that happened there due to a few “bad apples” in an otherwise “good barrel”? Or Were the abuses almost inevitable given the environment (barrel) that was created?

Substance Misuse Treatment Different clinics may have different success rates Research indicates that this is less due to a variation in the client group than due to variations in the conditions under which the clinic runs. Should we be paying more attention to the barrel?

Ingredients Buying the same ingredients as Gordon Ramsay won’t necessarily result in a meal worthy of a Michelin star chef Strength “on paper” doesn’t always equal good results All Blacks at the World Cup

How to ensure a poor outcome! Not necessarily an exhaustive list!!

Substitute Prescribing For those that need it: Create as many steps as possible to “test motivation” before issuing a script Prescribe as small a dose as possible Set an arbitrary, upper limit to any prescription Impose detoxification after a set time period Detoxification as punishment e.g. for not paying for an appointment (USA)

Depersonalisation Strip people of their identity as individuals Use non-name identifiers wherever possible Define peoples’ identity by a label: Junkies Offenders Service Users Substance Misusers

Us vs Them Staff are OK, clients are not Allow staff to be late for an appointment, clients are to be breached/discharged for lateness Definitely do not consider any Service User Input Lack of staff accountability

Humiliation Tell people that you are there to help them get “clean” i.e. they’re dirty at the moment Tell people that their drug tests are “dirty” Persistently reinforce the negative aspects of their lives Repeatedly confront with the negative consequences of their past actions

Samuel Taylor Coleridge 1772 – 1834 …The stimulus of shame, like other powerful medicines, if administered in too large a dose, becomes a deadly narcotic poison.

Arbitrary Decision Making Create a set of rules (preferable fairly random) Enforce them randomly so that neither staff nor clients know what the outcome of any behaviour will be.

Staff Attempt to demoralise staff Short term contracts e.g. 3 months Pay as little as possible Combine previous factors to ensure a pressurised clinic environment Create a culture of blame Lack of supervision

Environment Make no attempt to improve the physical environment of the clinic Have lots of “Do Not” notices on display Make it difficult for people to have any privacy when interacting with staff

Team of the Future Needs to consider the environment that it creates More important than the individual skills Corollary If individual skills are lacking or are not evidence based then may have house built on sand

What sort of environment? One in which the average client has the best chance of doing well Some clients will do well no matter what the environment Those that are struggling need additional, individualised input

Issues Many of the staff qualities are not contained in “job descriptions” Need to encourage people to want to work in substance misuse for the right reasons Need to discourage those who see an opportunity to wield power, lack accountability, main attraction is office hours working.

Downside of Substance Misuse Easy to stigmatise clients – there will always be a substantial body of public opinion on one’s side, no matter how draconian one is. Easy to label someone who is struggling as being “not motivated” or a “waster”, rather than looking at the way the clinic functions

Conclusion The “Barrel” is, usually, more important than the “Apple” Sometimes the pressures of the systems that we work in make it hard to design and maintain a “good barrel” We can all contribute to a “good barrel” in whichever service we work in. Avoid being the “silent majority”.

Conclusions Need good quality, evidence based interventions Delivered by a team that is appropriate for the needs of the client group A conscious effort needs to be made to focus on the environment created in the clinic For those clients who are struggling, extra, individual attention needs to be focussed on them. Need to be careful not to create a feeling that no good quality treatment is possible without a full size MDT

Further Reading The Lucifer Effect by Philip Zimbardo Published by Rider & Co. March 2007 The analogy of Apples and Barrels was taken from “The Lucifer Effect”