comment
Post-its from Practice
A level plAying field
Effective treatment
starts with a meaningful
partnership, says
Dr Steve Brinksman
Gary had
been in
and out of
treatment
for years;
he knew
more about
substance
use and
misuse than
most doctors
and he
knew it.
We recently had a new doctor join our practice who
had worked elsewhere for a number of years. I was
chatting to her about how she was settling in and
interested to hear that she felt the biggest difference
was that we were a genuine partnership working
together, whereas where she worked previously she’d
felt that she’d been a partner in name only.
This led me to ponder on the many occasions we are
in situations with clients that are essentially unequal in
terms of who holds the power, and how this can cause
dysfunctional relationships. Sometimes this is due to
pushing back against perceived authority, and
sometimes from complete passivity – neither of which
is likely to produce the best outcomes.
Gary had been in and out of treatment for years; he
knew more about substance use and misuse than most
doctors and he knew it. However he also frequently
used on top, was in and out of prison, and was hep C
positive. He had dropped out of treatment with the
community treatment agency about six months before
registering with us.
The first time we met I let him talk, and the second
and probably the third and fourth as well, then
gradually we started to explore what had happened in
his life and what he really wanted. By now he was on
60mls methadone and still using heroin and crack a couple of times a week. I was
keen that he increased his medication dose to see if we could stop the on-top use;
he wasn’t.
Despite his bravado and subject knowledge about street drugs it became
apparent that he had very low self-esteem and that this was tied in with his poor
literacy. We have an excellent adult education college in Birmingham and with a little
encouragement he eventually contacted them and started a course to improve this.
The change in Gary was profound. He started to develop real confidence, rather
than just a front. He met people who had struggled like him, and who like him were
looking to make a positive change. He stopped his own ‘use on top’ without ever
agreeing to an increase in medication dose.
I thought I knew what was needed for Gary from a medical perspective, and yet
what was really needed was for us both to form a real partnership where he had
the confidence to talk openly about what mattered to him and I listened and helped
him achieve his goals.
Whatever our professional role may be, the balance of power seems heavily stacked
in our favour by those we see. We need to realise this and make an extra effort to
develop meaningful partnerships that facilitate change rather than impose it.
Steve Brinksman is a GP in Birmingham, clinical lead of SMMGP, and RCGP
regional lead in substance misuse for the West Midlands.
He will be speaking at the DDN Conference on 22 February,
www.drinkanddrugsnews.com/ddn-conference-2018
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resources corner
Listening to
the service
user
The informative messages of a ‘user’s view’
DVD are as pertinent now as a decade ago,
says George Allan
While ‘voices of recovery’ are now being heard, less has been forthcoming in
recent times from service users about their experiences of the system. While
the findings of controlled trials must remain the basis on which treatments are
provided and services designed, it is critical that these are enhanced with the
views of the service user.
Although it was produced over a decade ago, what the five people
interviewed in the DVD Substitute Prescribing: the user’s view (Exchange
Supplies and The Alliance) have to say remains highly relevant. The title is a
misnomer: ostensibly the film presents their opinions of methadone but
underneath this is a commentary on what makes a good service. We cannot
hear these messages often enough. I have watched the DVD a dozen times and I
continue to learn from it. While extremely valuable for sparking discussion with
inexperienced practitioners and students in a range of disciplines, experienced
workers should watch it: it provides a check list of best practice.
The messages are simple but profound, and can be grouped under headings:
THE CHALLENGE OF CHANGE. Trying to stop using is hard but with each attempt
the person will learn more. Prescribers need to appreciate that, in the process of
weaning onto OST, some continued use is likely. A struggling service user can lead
to a worker becoming fed up – an attitude that the person will soon pick up.
PERSON-CENTRED SERVICES. Services may state that there is choice but, in
reality, some offer limited options and restricted prescribing. One services user
describes how strange he felt when an agency asked him, ‘What do you want?’
The importance of counselling beyond key working is stressed.
ACCESS. While this has improved since the film was made, the need to ‘jump
through hoops’ to obtain certain services often remains. The service users talk
of ‘continually having to prove yourself’.
DROPPING OUT. One bad experience of a practitioner or service can lead to a
person disengaging for a lengthy period. Waiting for specialist services is
another factor. These issues are particularly pertinent in the light of increasing
rates of drug deaths and the need to retain the vulnerable in treatment.
This only gives a flavour of the range of issues the service users explore in a film
that is enhanced by their personal optimism and humour.
The DVD is available at www.exchangesupplies.org
George Allan is the author of Working with Substance Users: a Guide to Effective
Interventions (2014; Palgrave)
• On his last Resources Corner, DDN would like to thank George for his insightful
contributions and wish him well as he retires as chair of the Scottish Drugs
Forum (SDF).
February 2018 | drinkanddrugsnews | 9