Whether they take place in the GP’s surgery, a prison healthcare wing, a hostel, or a drug service waiting room, the first crucial interactions can build trust and hope – or reinforce feelings of stigma, frustration and defeat.
As we discussed in the first part of our Clearer Conversations series (DDN, May, page 12), early interactions around medication can make or break the ‘therapeutic partnership’ at a very early stage. Clinical expertise is just one crucial part of the skill set; the other is rooted in effective communication.
People need to feel heard, respected and involved in decisions about their own care. We heard what a vital difference the right conversations make – and what goes wrong when people are under-informed, judged and excluded from decisions about their own health.
In this article we ask for insights from the Salvation Army, an organisation used to meeting people at many stages of addiction and homelessness – the stakes could not be higher in terms of having the right conversation.
Encouraging people to talk about their experiences highlighted some interesting junctions in the road – times when communication led to a breakthrough, or missed a vital opportunity.
First taste of support
David is a current service user on a programme designed to support those addressing their substance use, one of the Salvation Army’s many services.
He spent several years moving in and out of treatment and his story shows the difference that supportive conversations have made to his progress.
After leaving prison he had spent time in rehab, but was asked to leave after he relapsed and began using heroin again. He acknowledges that staff did give him ‘quite a few chances to sort things out before they said I had to leave’.
He got in touch with a GP and was put straight back on a script – the option of buprenorphine this time, instead of just methadone – and was then referred to Bristol Drugs Project. The Junction Project was a turning point for him in terms of peer support and staff with lived experience: ‘The staff give you advice if you’re coming off too quickly or things like that… but it’s pretty much up to you. They let you have a say.’ There was also no time limit to come off the script.
Decisions about medication were made together and rather than being pressured to achieve abstinence or provide negative samples, the focus was on support and progress. He wasn’t scared to ask for help.
He also now sees his shared care worker every two weeks – a prescriber based in the doctor’s surgery: ‘I go in for half an hour and we sit and chat, I tell him how things are going. And he asks if I need to go up or down or whatever, or am I happy with what I’m on.’
When asked what he’d tell someone who’s never been in treatment before, he’d say: ‘Just don’t be scared to ask for help… the support workers are there to support you, you know. The support isn’t perfect, but it’s there.’ He’s appreciated being able to go into the office whenever he needs to speak to somebody.
Now, not later
Danny, a specialist support worker on the programme, with lived experience himself, agrees that those early conversations are critical.
‘People are often at their lowest point when they come to us,’ he says. ‘If people are actively using, there’s no punishment; no taking away the script. Instead they work with the person and ask ‘what can we do to support you more? What wraparound service can we give you? What other agencies do we need to get involved to help you through this?’
His client group experiences particular stigma around homelessness, which he says makes him feel quite emotional: ‘I see service users struggle so much in reaching out to GPs and doctors, and it’s just so wrong. I have conversations with GPs and their attitude is just shocking at times. It shouldn’t be an uphill battle every time our client wants to see a GP or engage with the right services.’
One of the biggest improvements he’s seen is rapid access to prescribing and same-day restarts. ‘So it’s great to be able to say, come on, let’s go and get your script sorted today. It gives them a bit of reassurance.’
But he also sees how quickly motivation can disappear when they don’t get the structure or support to address their use, or when there’s a long wait to get it. ‘The intervention is needed now, rather than later,’ he says.
He mentions a client who’s going into detox on Monday after waiting three months. He’s been seeing a clinical worker weekly to have bloods taken, plus tests and an alcohol diary to assess drinking levels – all needed by the facility to see how long the detox period needs to be. So keeping the client engaged is absolutely essential: ‘This is the first time he’s set foot into any sort of treatment at all. So it’s huge for him… his life is dependent on it because he doesn’t see any other way out of his alcohol dependency.’
‘Dragging people to these appointments’ can be made slightly easier when the services involved are proactive about the relationship, keeping the support worker updated about care plans. ‘I’m really fortunate because we have Horizons, a team that work at the hostels, and I’ve got a really good relationship with them,’ he says. ‘But it does feel like we have to go out of our way to get a foot in the door, to get to be known. I think services can be better about just coming in and introducing themselves.’
He’s grateful for the computer system that’s made things easier: ‘I can log on and see anyone’s treatment plan and what they’re doing, where they’re at, when their script needs renewing, and if they’ve been collecting their script on a daily basis… It’s a real holistic approach whereby everyone can see everyone’s involvement.’
Collaboration leads to change
For Craig, a service user on a similar programme in Cardiff, entering treatment while in prison felt very different from his experience in the community.
Wanting help, he disclosed his use and asked for support, only to be told he needed to provide three positive urine tests before he could access medication. ‘I said, so what’s the point of me telling you that I’ve got a fucking problem?’ he remembers. ‘You’ve just had a positive off me, isn’t that enough?’
The process took a month, during which he had to continue sourcing drugs inside prison. He remembers feeling that there were few conversations about alternatives and little discussion about different treatment options: ‘They just said methadone. They didn’t really say anything else. I don’t think there were any options.’
Yet his experience began to change once he entered community treatment – but only when he had a supportive keyworker and the conversations became more collaborative. When he wanted to slow his methadone reduction, she listened: ‘I said I was really clammy at night and asked if I could stay on the same dose for another couple of weeks. She was like, yes, all right, don’t worry.’
He’s now preparing to transition to long-acting buprenorphine and feels much more involved in his treatment. ‘Support is there if you want it,’ he says. ‘They can only offer so much and then it’s down to you to take it.’
For people seeking help, these conversations may determine whether they engage, walk away, or try again another day. For treatment providers, they are a reminder that while clinical guidance matters, the human side of treatment matters too. And very often it’s that first conversation – and the willingness to keep having it – that can make all the difference. DDN
‘A good support worker can change the game.’
Zoe Jenkins is addiction development officer in homelessness services at The Salvation Army. She gives us her perspective.
For people accessing drug and alcohol treatment and support, there are huge disparities across the board. The process can be long-drawn-out with many hurdles to face, and sometimes people are waiting weeks, if not months, before they’re in receipt of a script. Keeping motivation up and keeping someone engaged for that time can be really hard work for everyone involved.
Criminal justice services tend to offer a more rapid access prescribing pathway and some localities offer quicker routes for people with complex needs, but even then it can be weeks.
I understand clinical policies need to be followed, but the timescales are a big hurdle. It’s like going to the gym for the first time and being turned away because you’ve got to wait till next month to have a gym induction or you’ve not got the right shoes – you’re probably not going to go again because your motivation has been affected or you feel really let down, so you have a McDonald’s instead.
You may have to provide several positive urine tests, attend appointments, meet several nurses and doctors and be told to come here or go there. For someone in active addiction, timekeeping can be really difficult and constantly meeting new faces is too daunting. Unless they’ve got a support worker to encourage them and really orchestrate that, some people never get off the starting block.
Some people have fantastic relationships with their workers at drug and alcohol support services. But many don’t even know their workers or may have only met them for a real light touch – ‘How are you? Everything ok? Cool, see you next month.’ It’s not always, but this does seem to be the majority. I suppose it depends on the person and how much they want to engage, but I also think it’s down to the relationship and how much a worker remains flexible and resilient to poor engagement.
The multiagency approach differs from service to service, and staying informed as a support worker really does depend on where you are. Some service providers will share appointment times with you, follow up with calls and emails and check in with allocated workers regularly, which works really well. Others don’t, and ultimately the service user ends up missing out on vital support.
Some people don’t know what day of the week it is because their addiction is so encompassing, so having a support worker who keeps tabs on you and takes you to and from appointments changes the game. It helps eliminate those barriers. I’ve known of people being removed from waiting lists or taken off their OST after missing an appointment they were told about four or five weeks ago. Had their support worker known, this may not have happened.
For some people, thinking outside of the box and offering flexible working arrangements is what’s needed, especially when someone first reaches out.
Grateful thanks to Zoe Jenkins, colleagues and clients at The Salvation Army
This series on Clearer Conversations in OST has been made possible by a grant from Camurus, who have had no involvement in the content of these articles.
Clearer Conversations is an ongoing series and we would love to hear from you if you are willing to share your experiences of treatment – please email the editor, claire@cjwellings.com