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