One service user in particular spoke about our control over collections as a method of social control , utilised to reward or punish people .
RISK MANAGEMENT Incorporating this feedback into risk management has triggered the question of whose risks are we managing . There ’ s a tension between managing and mitigating risks for the service user , and mitigating and managing risks for us as an organisation .
One example – we were concerned that one service user was using heroin on top of her prescription . We followed normal procedure and changed her collections to daily supervised in the pharmacy . Her feedback was that because of her severe anxiety – for which she was on long waiting lists for secondary mental health support – she began missing doses and buying more heroin , because , as she put it , heroin from her dealer is ‘ home delivery ’. We had effectively mitigated our own organisational risks , as the medication we prescribed was now less likely to be misused – however , had we really mitigated the risks to the service user , who was now saying plausibly that as a result of our decision she was using street heroin more regularly than before ?
This dilemma of risk management has an enormous impact on service users ’ lives on a regular basis . By providing a high-strength opiate to someone physically and psychologically dependant on that drug – and who could be placed in severe distress by its withdrawal – and then imposing conditions on continuing to prescribe it , we must recognise the power of coercive impact , and threat of real harm , that we hold over service users . I ’ m not a clinician and I make no final clinical decisions , but as a recovery worker ( and in particular as a qualified social worker trained in safeguarding ) my assessment of the risks present carries weight . That creates a power imbalance and an implicit threat between myself and the service user .
COERCIVE CONTROL Questions of power imbalance and coercion become even more relevant when service users are also engaging with other state agencies that are more openly coercive than drug / alcohol addiction services . There are countless examples of service users trapped in cycles of coercive control by the criminal justice system , often for drug-related offences . This raises for me the dichotomy of multi-agency working between different agencies ( criminal justice and addiction / social work ) that have a different relationship with service users , and which treat drugs in such a different way .
Service users imprisoned for drug-related offences or missed probation appointments have told me the criminal justice system makes them feel their personal circumstances were rendered irrelevant , their essential recovery connections cut short and their lives reduced to a box-ticking exercise . Service users from migrant backgrounds face additional barriers , such as fears of services sharing information with the Home Office and the ‘ hostile environment ’, making many reluctant to seek help .
POSITIVE COERCION
There ’ s a consensus in many treatment services that coercion to require compliance with treatment is necessary in the long run . There are arguments that even in circumstances where a mental capacity assessment would judge an individual to have capacity , their independent agency is impaired over the long term through the impact of addiction on their brain . Many in recovery have emphasised that they found being pushed into engaging with services beneficial at certain points .
The impact of addiction on the brain is agreed both from biological neurosciencefocused perspectives on addiction , and alternative perspectives such as Gabor Maté ’ s ‘ biopsychosocial ’ paradigm of addiction . Maté argues that a continuum of addiction runs throughout our society ,
Addiction support , medication control ( under the Misuse of Drugs Act 1973 ), and multi-agency working must be placed in the context of the ongoing ‘ war on drugs ’, which many people argue has had the impact of exacerbating structural inequalities , traumas and the health and social damage of drug use .
PROFESSIONAL POWER Working in drug and alcohol services has made me more aware as a practitioner of the power contained in my professional role . While in practice my job role involves exercising power , as part of safeguarding , risk management , medication control and multiagency working , what I ’ ve tried to do is have more open conversations with service users about the nature of the systems they ’ re engaging with .
My aim is to position myself not as a ‘ gatekeeper opposite ’ but rather an ‘ advocate alongside ’, who will explain every process and seek to help them navigate systems and legal frameworks which may in many circumstances be unjust .
Tom Zagoria is a recovery worker and social worker at Change Grow Live
By providing a high-strength opiate to someone physically and psychologically dependant on that drug ... and then imposing conditions on continuing to prescribe it , we must recognise the power of coercive impact , and threat of real harm ...
with more extreme forms of addiction developing in the early childhood environment when the ‘ neurobiology of the brain ’ s reward pathways ’ develop . Continuing and ongoing stress in life – which can be related both to ongoing traumas , as well as service failures – continues to create and renew predispositions to addiction over the course of life .
Nevertheless the service user remains the person with the most expertise regarding their own life , and it ’ s the responsibility of the practitioner to respect this and support the service user to make their own choices as safely as possible . This can be done using tools of motivational interviewing and other social work techniques .
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