Wraparound ServicesWraparound Services

Dr. Oliver AldridgeDr. Oliver Aldridge

Edinburgh, Midlothian & East Edinburgh, Midlothian & East Lothian DTTO ServiceLothian DTTO Service

PlanPlan

Wraparound CareWraparound Care Outline the DTTO serviceOutline the DTTO service Is a large, Multidisciplinary Team the way Is a large, Multidisciplinary Team the way

forward?forward? Creating the right environment for recovery Creating the right environment for recovery

– Apples and Barrels– Apples and Barrels ConclusionsConclusions

Wraparound CareWraparound Care

Substitute prescription in and of itself does Substitute prescription in and of itself does not usually constitute adequate drug not usually constitute adequate drug treatmenttreatment

Corollary:Corollary: In those people who need a substitute In those people who need a substitute

prescription, inadequate/poor quality prescription, inadequate/poor quality substitute prescribing may render substitute prescribing may render “wraparound care” ineffective“wraparound care” ineffective

Edinburgh, Midlothian & East Edinburgh, Midlothian & East Lothian DTTO ServiceLothian DTTO Service

A partnership between Health (NHS A partnership between Health (NHS Lothian) and Criminal Justice Social WorkLothian) and Criminal Justice Social Work

All healthcare workers are employed by All healthcare workers are employed by NHS Lothian and seconded to the service.NHS Lothian and seconded to the service.

Each client of the service has their own, Each client of the service has their own, named Nurse, Resource Worker and Social named Nurse, Resource Worker and Social WorkerWorker

Admin StaffAdmin Staff

Initial ContactInitial Contact

Deal with EnquiriesDeal with Enquiries

Deal with Distress and AngerDeal with Distress and Anger

Positively Promoting the Service and Positively Promoting the Service and the Service Usersthe Service Users

Clinical TeamClinical Team Oversee All PrescriptionsOversee All Prescriptions

Provide Physical, Mental, Sexual healthcare Provide Physical, Mental, Sexual healthcare AdviceAdvice

Methadone EducationMethadone Education

Motivational WorkMotivational Work

Drug Testing & Monitoring (e.g. Christo)Drug Testing & Monitoring (e.g. Christo)

Resource WorkersResource Workers Negotiate with Benefit AgenciesNegotiate with Benefit Agencies

Assist with Accommodation ProblemsAssist with Accommodation Problems

Help with Literacy and Numeracy Help with Literacy and Numeracy ProblemsProblems

Advice on Education, Training and Advice on Education, Training and Work OpportunitiesWork Opportunities

Social WorkersSocial Workers

Deal with Problems of Attendance and Deal with Problems of Attendance and BehaviourBehaviour

Work Directly with the CourtWork Directly with the Court

Provide ReportsProvide Reports

Address Child Care IssuesAddress Child Care Issues

Courts/SolicitorsCourts/Solicitors

Positive affirmation of progressPositive affirmation of progress Help with navigating through legal difficultiesHelp with navigating through legal difficulties

What We Do TogetherWhat We Do Together

Home VisitsHome Visits

ReviewsReviews

Case DiscussionsCase Discussions

Team MeetingsTeam Meetings

Group WorkGroup Work

Relapse PreventionRelapse Prevention Overdose EducationOverdose Education Relaxation GroupRelaxation Group Cookery GroupCookery Group And Coming Shortly !!!And Coming Shortly !!! The Football GroupThe Football Group The Walking GroupThe Walking Group The Womens GroupThe Womens Group

Large Multidisciplinary Teams – The Large Multidisciplinary Teams – The way forward?way forward?

Sometimes!!Sometimes!! Not for everyone and may be Not for everyone and may be

counterproductivecounterproductive Too much intervention for some peoples’ Too much intervention for some peoples’

needsneeds May discourage smaller teams from May discourage smaller teams from

providing a serviceproviding a service Need a range of interventions available in Need a range of interventions available in

each area.each area.

Creating the right environmentCreating the right environment

Apples and BarrelsApples and Barrels

IndividualismIndividualism

Emphasised by the major systems we work Emphasised by the major systems we work in:in:

MedicalMedical JudicialJudicial PoliticalPolitical ReligiousReligious CulturalCultural

Power of IndividualismPower of Individualism

Social PsychologySocial Psychology

Emphasises the power of the situation to Emphasises the power of the situation to affect/determine peoples’ behaviouraffect/determine peoples’ behaviour

Stanford Prison ExperimentsStanford Prison Experiments Stanley Milgram’s Pain ExperimentsStanley Milgram’s Pain Experiments Individual behaviour may be predicted by Individual behaviour may be predicted by

knowing the situation while having little or no knowing the situation while having little or no knowledge about the personknowledge about the person

Abu GhraibAbu Ghraib

Were the abuses that happened there due Were the abuses that happened there due to a few “bad apples” in an otherwise “good to a few “bad apples” in an otherwise “good barrel”?barrel”?

OrOr Were the abuses almost inevitable given the Were the abuses almost inevitable given the

environment (barrel) that was created?environment (barrel) that was created?

Substance Misuse TreatmentSubstance Misuse Treatment

Different clinics may have different success Different clinics may have different success ratesrates

Research indicates that this is less due to a Research indicates that this is less due to a variation in the client group than due to variation in the client group than due to variations in the conditions under which the variations in the conditions under which the clinic runs.clinic runs.

Should we be paying more attention to the Should we be paying more attention to the barrel?barrel?

IngredientsIngredients

Buying the same ingredients as Gordon Buying the same ingredients as Gordon Ramsay won’t necessarily result in a meal Ramsay won’t necessarily result in a meal worthy of a Michelin star chefworthy of a Michelin star chef

Strength “on paper” doesn’t always equal Strength “on paper” doesn’t always equal good resultsgood results

All Blacks at the World CupAll Blacks at the World Cup

How to ensure a poor How to ensure a poor outcome!outcome!

Not necessarily an exhaustive Not necessarily an exhaustive list!!list!!

Substitute PrescribingSubstitute Prescribing

For those that need it:For those that need it: Create as many steps as possible to “test Create as many steps as possible to “test

motivation” before issuing a scriptmotivation” before issuing a script Prescribe as small a dose as possiblePrescribe as small a dose as possible Set an arbitrary, upper limit to any prescriptionSet an arbitrary, upper limit to any prescription Impose detoxification after a set time periodImpose detoxification after a set time period Detoxification as punishment e.g. for not paying Detoxification as punishment e.g. for not paying

for an appointment (USA)for an appointment (USA)

DepersonalisationDepersonalisation

Strip people of their identity as individualsStrip people of their identity as individuals Use non-name identifiers wherever possibleUse non-name identifiers wherever possible Define peoples’ identity by a label: Define peoples’ identity by a label: JunkiesJunkies OffendersOffenders Service UsersService Users Substance MisusersSubstance Misusers

Us vs ThemUs vs Them

Staff are OK, clients are notStaff are OK, clients are not Allow staff to be late for an appointment, Allow staff to be late for an appointment,

clients are to be breached/discharged for clients are to be breached/discharged for latenesslateness

Definitely do not consider any Service User Definitely do not consider any Service User Input Input

Lack of staff accountabilityLack of staff accountability

HumiliationHumiliation

Tell people that you are there to help them Tell people that you are there to help them get “clean” i.e. they’re dirty at the momentget “clean” i.e. they’re dirty at the moment

Tell people that their drug tests are “dirty”Tell people that their drug tests are “dirty” Persistently reinforce the negative aspects Persistently reinforce the negative aspects

of their livesof their lives Repeatedly confront with the negative Repeatedly confront with the negative

consequences of their past actionsconsequences of their past actions

Samuel Taylor ColeridgeSamuel Taylor Coleridge

1772 – 18341772 – 1834 ……The stimulus of shame, like other The stimulus of shame, like other

powerful medicines, if administered in too powerful medicines, if administered in too large a dose, becomes a deadly narcotic large a dose, becomes a deadly narcotic poison.poison.

Arbitrary Decision MakingArbitrary Decision Making

Create a set of rules (preferable fairly Create a set of rules (preferable fairly random)random)

Enforce them randomly so that neither staff Enforce them randomly so that neither staff nor clients know what the outcome of any nor clients know what the outcome of any behaviour will be.behaviour will be.

StaffStaff

Attempt to demoralise staffAttempt to demoralise staff Short term contracts e.g. 3 monthsShort term contracts e.g. 3 months Pay as little as possiblePay as little as possible Combine previous factors to ensure a Combine previous factors to ensure a

pressurised clinic environmentpressurised clinic environment Create a culture of blameCreate a culture of blame Lack of supervisionLack of supervision

EnvironmentEnvironment

Make no attempt to improve the physical Make no attempt to improve the physical environment of the clinicenvironment of the clinic

Have lots of “Do Not” notices on displayHave lots of “Do Not” notices on display Make it difficult for people to have any Make it difficult for people to have any

privacy when interacting with staffprivacy when interacting with staff

Team of the FutureTeam of the Future

Needs to consider the environment that it Needs to consider the environment that it createscreates

More important than the individual skillsMore important than the individual skills CorollaryCorollary If individual skills are lacking or are not If individual skills are lacking or are not

evidence based then may have house built evidence based then may have house built on sandon sand

What sort of environment?What sort of environment?

One in which the average client has the best One in which the average client has the best chance of doing wellchance of doing well

Some clients will do well no matter what the Some clients will do well no matter what the environmentenvironment

Those that are struggling need additional, Those that are struggling need additional, individualised inputindividualised input

IssuesIssues

Many of the staff qualities are not contained Many of the staff qualities are not contained in “job descriptions”in “job descriptions”

Need to encourage people to want to work Need to encourage people to want to work in substance misuse for the right reasonsin substance misuse for the right reasons

Need to discourage those who see an Need to discourage those who see an opportunity to wield power, lack opportunity to wield power, lack accountability, main attraction is office hours accountability, main attraction is office hours working.working.

Downside of Substance MisuseDownside of Substance Misuse

Easy to stigmatise clients – there will always Easy to stigmatise clients – there will always be a substantial body of public opinion on be a substantial body of public opinion on one’s side, no matter how draconian one is.one’s side, no matter how draconian one is.

Easy to label someone who is struggling as Easy to label someone who is struggling as being “not motivated” or a “waster”, rather being “not motivated” or a “waster”, rather than looking at the way the clinic functionsthan looking at the way the clinic functions

ConclusionConclusion

The “Barrel” is, usually, more important than The “Barrel” is, usually, more important than the “Apple”the “Apple”

Sometimes the pressures of the systems Sometimes the pressures of the systems that we work in make it hard to design and that we work in make it hard to design and maintain a “good barrel”maintain a “good barrel”

We can all contribute to a “good barrel” in We can all contribute to a “good barrel” in whichever service we work in. Avoid being whichever service we work in. Avoid being the “silent majority”.the “silent majority”.

ConclusionsConclusions

Need good quality, evidence based interventionsNeed good quality, evidence based interventions Delivered by a team that is appropriate for the Delivered by a team that is appropriate for the

needs of the client groupneeds of the client group A conscious effort needs to be made to focus on A conscious effort needs to be made to focus on

the environment created in the clinicthe environment created in the clinic For those clients who are struggling, extra, For those clients who are struggling, extra,

individual attention needs to be focussed on them.individual attention needs to be focussed on them. Need to be careful not to create a feeling that no Need to be careful not to create a feeling that no

good quality treatment is possible without a full good quality treatment is possible without a full size MDTsize MDT

Further ReadingFurther Reading

The Lucifer Effect by Philip Zimbardo The Lucifer Effect by Philip Zimbardo Published by Rider & Co. March 2007Published by Rider & Co. March 2007

The analogy of Apples and Barrels was The analogy of Apples and Barrels was taken from “The Lucifer Effect”taken from “The Lucifer Effect”