Download Wraparound Services

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
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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
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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
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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”