Presentation on theme: "Dr. Oliver Aldridge Edinburgh, Midlothian & East Lothian DTTO Service"— Presentation transcript:
1 Dr. Oliver Aldridge Edinburgh, Midlothian & East Lothian DTTO Service Wraparound ServicesDr. Oliver AldridgeEdinburgh, 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 BarrelsConclusions
3 Wraparound CareSubstitute prescription in and of itself does not usually constitute adequate drug treatmentCorollary: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 WorkAll 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 AngerPositively Promoting the Service and the Service Users
6 Clinical Team Oversee All Prescriptions Provide Physical, Mental, Sexual healthcare AdviceMethadone EducationMotivational WorkDrug Testing & Monitoring (e.g. Christo)
7 Resource Workers Negotiate with Benefit Agencies Assist with Accommodation ProblemsHelp with Literacy and Numeracy ProblemsAdvice on Education, Training and Work Opportunities
8 Social Workers Deal with Problems of Attendance and Behaviour Work Directly with the CourtProvide ReportsAddress Child Care Issues
9 Courts/Solicitors Positive affirmation of progress Help with navigating through legal difficulties
10 What We Do TogetherHome VisitsReviewsCase DiscussionsTeam Meetings
11 Group Work Relapse Prevention Overdose Education Relaxation Group Cookery GroupAnd Coming Shortly !!!The Football GroupThe Walking GroupThe Womens Group
12 Large Multidisciplinary Teams – The way forward? Sometimes!!Not for everyone and may be counterproductiveToo much intervention for some peoples’ needsMay discourage smaller teams from providing a serviceNeed 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 JudicialPoliticalReligiousCultural
16 Social PsychologyEmphasises the power of the situation to affect/determine peoples’ behaviourStanford Prison ExperimentsStanley Milgram’s Pain ExperimentsIndividual behaviour may be predicted by knowing the situation while having little or no knowledge about the person
17 Abu GhraibWere the abuses that happened there due to a few “bad apples” in an otherwise “good barrel”?OrWere the abuses almost inevitable given the environment (barrel) that was created?
18 Substance Misuse Treatment Different clinics may have different success ratesResearch 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 IngredientsBuying the same ingredients as Gordon Ramsay won’t necessarily result in a meal worthy of a Michelin star chefStrength “on paper” doesn’t always equal good resultsAll 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 scriptPrescribe as small a dose as possibleSet an arbitrary, upper limit to any prescriptionImpose detoxification after a set time periodDetoxification 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 possibleDefine peoples’ identity by a label:JunkiesOffendersService UsersSubstance 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 latenessDefinitely do not consider any Service User InputLack of staff accountability
24 HumiliationTell people that you are there to help them get “clean” i.e. they’re dirty at the momentTell people that their drug tests are “dirty”Persistently reinforce the negative aspects of their livesRepeatedly 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 possibleCombine previous factors to ensure a pressurised clinic environmentCreate a culture of blameLack of supervision
28 EnvironmentMake no attempt to improve the physical environment of the clinicHave lots of “Do Not” notices on displayMake 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 skillsCorollaryIf 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 wellSome clients will do well no matter what the environmentThose that are struggling need additional, individualised input
31 IssuesMany of the staff qualities are not contained in “job descriptions”Need to encourage people to want to work in substance misuse for the right reasonsNeed 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 groupA conscious effort needs to be made to focus on the environment created in the clinicFor 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 ReadingThe Lucifer Effect by Philip Zimbardo Published by Rider & Co. March 2007The analogy of Apples and Barrels was taken from “The Lucifer Effect”