The Blue Light Project: Responding to Change-Resistant, High-Risk Drinkers

1. The Blue Light Project: Responding to high risk and dependent drinkers who are change resistant Homeless Link July 2019

2. Section 1 • Introduction

3. Rochdale Male 1 • Male 1 was vulnerable through his chronic addiction to alcohol, self harm and to a far lesser degree his joblessness. Appropriate referrals were made to addiction and medical services. He had a stubborn resistance to engaging with them, preferring it seems to continue his drinking unabated... Services cannot be effective unless the client wants to change; Male 1 did not….

4. A familiar theme • If a client is in denial there is little we can do to help them.” Alcohol worker

5. Why does this matter? • Training needs analyses with Tier 1 workers in Birmingham, Surrey and Wandsworth have highlighted that the issue that the workers most want training on is not identification or one to one intervention but “how to work with difficult to engage drinkers”.

6. Why does this matter? • In tackling alcohol’s impact on health, violence or anti-social behaviour, the drinkers tier 1 workers and, society generally, most need to target are often people who are not ready to change.

7. Client needs • A motivation focused approach fails a very large, needy and risky group of clients

8. The treatment gap • Public Health England has suggested that at least 75% of dependent drinkers are not engaged with services. • This is a very large group of needs to ignore.

9. The treatment gap

10. The local burden • E.g. • In a borough of 200,000 there will be at least 250 Blue Light clients who cost at least £12m per year. • This is a very conservative estimate.

11. Case Study - Mr D • 54 year old man • Fire setter • Confused but deemed to have capacity • Possible frontal lobe damage • Wheel chair bound • Multiple health problems inc COPD

12. Case Study - Mr D • In 3 months: • 28 ED attendances • 124 Calls to EMAS • 8 inpatient admissions (15 days) • Arrested 8 times for shoplifting • Cost health services £138,000 in 12 months (inc £13,000 EMAS/ £12,000 Fire). This does not include Police costs

13. Angela Wrightson

15. In 3 years, over 1000 recorded direct contacts with mental health and alcohol services, ambulance, hospital. • 472 reported incidents to the police.

16. Why does this matter? • A motivation focused approach perpetuates the exclusion of the already most socially excluded clients. • Such an approach fails to provide the support non-specialist services actually want. • Ultimately it fails the alcohol field because services do not get the investment the actual need requires.

17. Lack of guidance This picture is extreme: there are examples of good practice locally and nationally but: • There is no national guidance • No consistency. • Too many services that do use the “not interested in change” defence. • Too many non-specialists who believe nothing can be done without motivation.

19. Basic message • We should not write off people who do not want to change their drinking. • There are things you can do to make a difference.

20. Section 2 • The hinge on which this turns: • What do we do with someone like Howard?

21. Howard SAR 2018

22. Howard SAR 2018 • Housing: Howard had been given ample opportunities to address his situation, made more difficult by his failure to moderate his use of alcohol.

23. Howard SAR 2018 • SMS received a referral from Adult Safeguarding on 21st April within which it was noted that Howard had no fixed abode. Howard was assessed on 7th May 2015. The records have noted undiagnosed mild depression, anxiety and heart problems. He was assessed as having decision-making capacity. An appointment was arranged for 3rd June which Howard did not attend. A further appointment was sent by text message by SMS for 13th July and the Adult Safeguarding team notified that he would be discharged if the appointment was not kept.

24. Howard SAR 2018 • There is evidence that agencies closed down their involvement with Howard, often because of his non-engagement, without multi-agency discussions to consider the impact of such decisions on case management.

25. The hinge around which all this turns • What do we do with clients who won’t engage with us as we require? • What do we do with clients who tell us to F*** off? • What do we do with someone who tells his abusers are his “mates”? • The challenge of engaging these clients is the hinge around which these cases turn?.

26. Session 3 • What can we do?

27. Drug and Alcohol Treatment Act 2007 which came in to force in September 2012. • Unfortunately this only applies in New South Wales

28. The New South Wales, Australian experience of involuntary treatment. Here is Glenys Dore talking to their experience http://www.youtube.com/watch?v=DA_3uou6nyQ&index=2&list=PLSEhy70YpU5tZyaoHxz5UTuOUyJokMdFD

29. Criteria under 2007 Act • Severe dependence (tolerance, withdrawals, loss of capacity to make a decision); AND • At risk of serious harm (e.g. physical or psychological, bleeding varices, end stage liver failure, bilirubin >500, children or other dependents in their care; AND • Likely to benefit from treatment but refuses; AND • No less restrictive treatment available.

30. Typical client • 59 year old man • Calling emergency services when intoxicated, crying, physical pain, threatening suicide • 114 ED presentations (56 in past 6 months) • Severe alcohol problem • Living in squalor • “Heart sink” patient

31. Outcomes on ACE-R 2005 • Addenbrokes Cognitive Examination • Score out of 100 – 82/100 = dementia • Mean score of detained patients in Australian unit at arrival was 82 one was as low as 69. • By week 4 risen to 92/100 – the normal range.

32. Evidence of effectiveness - Australia Of 40 detained alcohol patients: • 10% died • 25% relapsed • 60% were abstinent (18) or had improved • 5% not known.

33. Other countries • Holland • Sweden • USA • Canada • Switzerland • France • Germany • New Zealand

34. Powers Containment Powers For Substance Misusers • Mental Health Act – 1983 and beyond • Mental Capacity Act • The new Anti-Social Behaviour powers • ATR – Alcohol Treatment Requirement / Probation Orders with Conditions of Treatment • ASB community trigger

35. Mental Health Act 1983 section 1.3 • “Nothing (in this Act)…shall be construed as implying that a person may be dealt with under this Act as suffering from mental disorder, or from any form of mental disorder described in this section, by reason only of promiscuity or other immoral conduct, sexual deviancy or dependence on alcohol or drugs.”

36. The 2007 Mental Health Act • Amended this, substituting the following wording: “Dependence on alcohol or drugs is not considered to be a disorder or disability of the mind for the purposes of subsection (2) above.”

37. Government guidance on the Mental Health Act • 25. The use of alcohol or drugs is not, by itself, regarded clinically as a disorder or disability of the mind (although the effects of such use may be). However, dependence on alcohol and drugs is regarded as a mental disorder. • 26. The effect of the exclusion inserted by this section is that no action can be taken under the 1983 Act in relation to people simply because they are dependent on alcohol or drugs (including opiates, psycho-stimulants or some solvents), even though in other contexts their dependence would be considered clinically to be a mental disorder.

38. Government guidance on the application of the Mental Health Act • 27. It does not mean that such people are excluded entirely from the scope of the 1983 Act. A person who is dependent on alcohol or drugs may also suffer from another disorder which warrants action under the 1983 Act (including a disorder which arises out of their dependence or use of alcohol and drugs or which is related to it). Nor does it mean that people may never be treated without consent under the 1983 Act for alcohol or drug dependence. Like treatment for any other condition which is not itself a mental disorder, treatment for dependence may be given under the 1983 Act if it forms part of treatment for a condition which is a mental disorder for the purposes of the 1983 Act

39. The Government’s 2015 Mental Health Act Code of Practice • 2.12 The Act does not exclude other disorders or disabilities of the mind related to the use of alcohol or drugs. These disorders – eg withdrawal state with delirium or associated psychotic disorder, acute intoxication, organic mental disorders associated with prolonged abuse of drugs or alcohol – remain mental disorders for the purposes of the Act. • 2.13 Medical treatment for mental disorder under the Act (including treatment with consent) can include measures to address alcohol or drug dependence if that is an appropriate part of treating the mental disorder which is the primary focus of the treatment.”

40. The Mental Capacity Act

41. Carol- Mental capacity • Among professionals the understanding of mental capacity and how to assess it is not robust, which impacts upon professionals responding effectively to cases which are complex, limiting the risk assessment and professional response

42. Examples of impairment Examples of an impairment or disturbance in the functioning of the mind or brain may include the following: • conditions associated with some forms of mental illness • dementia • significant learning disabilities • the long-term effects of brain damage • physical or medical conditions that cause confusion, drowsiness or loss of consciousness • delirium • concussion following a head injury, and • the symptoms of alcohol or drug use.

43. …a person who lacks capacity to make a decision for themselves at a certain time may be able to make that decision at a later date. This may be because… they are unconscious or barely conscious whether due to an accident or being under anaesthetic or their ability to make a decision may be affected by the influence of alcohol or drugs.

44. Fluctuating capacity

45. Carol (AW) - Executive capacity • …the concept of “executive capacity” is relevant where the individual has addictive or compulsive behaviours. This is explored by Preston Shoot and Braye et al. This highlights the importance of considering the individual’s ability to put a decision into effect (executive capacity) in addition to their ability to make a decision (decisional capacity). Therefore, for an individual such as Carol the assessment of mental capacity is unlikely to be as straightforward as a simple yes or no. (ref. 3.6.10)

46. Final thoughts • It is easy to allow people “to die with their rights on”. • Sometimes we need to “deny autonomy to create autonomy”.

47. High level approaches • Understand barriers to change • What works - Assertive outreach • What works – Multi-agency groups

48. Session 5 • Barriers to change

49. Assess………………. • At the outset the most important question is not • “why does this person drink?” but rather • “why doesn’t this person stop drinking?”

50. Understanding barriers to change The perfect storm of physical conditions • Depression • Is there evidence of alcohol related brain injury • Physical health problems e.g. fatigue due to liver disease • Confusional states e.g. liver disease, pancreatitis and urinary tract infections • Sleep disorders • Nutrition • Foetal Alcohol Syndrome • …and they are dependent.