Wraparound Services

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

2. 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

3. 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

4. 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

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

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

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

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

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

10. What We Do Together • Home Visits • Reviews • Case Discussions • Team Meetings

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

12. 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.

13. Creating the right environment Apples and Barrels

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

15. Power of Individualism

16. 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

17. 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?

18. 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?

19. 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

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

21. 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)

22. 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

23. 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

24. 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

25. 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.

26. 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.

27. 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

28. 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

29. 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

30. 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

31. 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.

32. 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

33. 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”.

34. 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

35. 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”