Drink and Drugs News DDN Feb2018 - Page 9

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 www.drinkanddrugsnews.com Find more resources at www.drinkanddrugsnews.com 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