Care and Support

This section discusses how care and support appeared in both practice and principle. It illuminates the fundamental aspects of interaction between practitioner and service user by demonstrating how care was experienced and then translated into a helpful

entity. It reflects the importance of well timed intervention using a motivation- intervention model (Table 20, Page 173).

‘Care and Support’ as a subcategory shared concepts related to the subcategory ‘Attitude’, this was attitudes of carers, practitioners and society. Among these the prime concern was possession of a non-judgemental approach. The manner in which care was conveyed held a high level of importance; care was descriptive of the intervention and the motivation to intervene. The motivation to intervene was conveyed in a number of ways, an example of which was providing adequate time, access and privacy to talk in confidence; signs of respect. In other words successful care was at least two dimensional. It was incomplete without the deliverer conveying that they cared, equally the absence of competent care and care coordination type skills indicated an unsatisfactory intervention.

The overlap with ‘Treatment’ (a further subcategory) was also emphasised. Treatment delivery, medication or cognitive behavioural intervention for example, required supplemental strategies for success. Prescription of medication for instance required an explanation from a trusted practitioner (who cared), talking therapy such as cognitive behavioural intervention would require an empathic attitude to be conveyed; a recognisable caring approach being the central element.

Empathy has an established role across the range of psychological therapies. Carl Rogers described empathy in his thesis (Rogers 1975) as being the ability to listen and reflect accurately in order to demonstrate concern and connectiveness to clients. Whilst the value of empathy in therapy is proven at least as successful as psychotropic medication in determining improvements in mental health (Torrey 1995) and effective within substance misuse work (Miller & Rollnick 2002) it is a more recent development for mainstream psychiatry to consider the therapeutic effect of empathy in severe mental illnesses such as schizophrenia (Singer 2001). The nature of empathy is profoundly interpersonal and requires the empathiser to ‘taste’ the recipients’ experience. In the context of substance misuse, sexual abuse, severe mental illness, post traumatic stress and many other conditions the vicariously absorbed psychological stress involved in the empathising process is marked. This may

infrequent. Yet it is indisputable that effective therapeutic intervention rests on authentic empathic relationships (Jordan 2000). If one examines the earliest work around the function of empathy in therapeutic exchanges, Laing’s (1965) for instance, the need to engage and accept the person as a whole is critical. Viewing the dual diagnosis service user against the potential backdrop of homelessness, criminality, harmful behaviour, relapse, unpredictability and so forth, holistic acceptance can appear unfeasible for many. Add the ingredient of inconsistent motivation levels the therapeutic challenges the client group presents can feel overwhelming. Help theory is instrumental in representing the dual diagnosis client in an optimistic light; it brings to prominence previous hidden motivational factors, in turn encouraging engagement. Empathic engagement and its impact as an antidote to loneliness and isolation can not be underestimated hence its salience in my findings.

Support within the context of this section was described as requiring the prerequisite caring attitude of others but also identified practical interventions. An example was assistance attending an appointment (benefits, doctors) or help obtaining accommodation. Furthermore demonstrating the magnitude of support in itself was significant. Joint working arrangements between agencies and teams were indicators of a high level of effort and complexity, conveying to participants that as individuals they “counted”.

I was ostracised….but working with the team (assertive outreach team)

its, its, they’ve opened doors for me, they don’t judge me, they don’t judge me at all, which is why I’m getting help, why you’re here today and Nairobi House (detoxification and rehabilitation unit), these are all very positive things that… you’re not on your own, and you’re not being judged or condemned. You’re being understood and you’re being helped (practically).

Once they get that into their minds I think they respond to that. It’s a shame there’s not more for other people who are left to fend for themselves, who are being judged and ostracised by society, just ‘cos they’ve got a stigma and they do drugs.

Well the support, they come and take me to appointments, they come once a week, just had my injection today, they pop in to see how I am, they helped me to get on a course, so that way, in that respect they’re great but once I had err, a CPN, support worker and they came round one day and (inaudible) you’ve got to come clean that you’re on

amphetamines, says (CPN) if you are, they can help me. They said if you don’t say anything, you won’t, you can’t, so I admitted that I was. And they just took all the care away.

I think it’s the same syndrome as smokers, who go to, who go to a GP with a bad chest. And say that they smoke, and they say ‘well cut down on the smoking and we’ll see, we’ll treat it then’. I think it’s, I think its, the wrong thing to do. I mean, that person is probably inside, probably crying for help, and would respond to help, given the opportunity. (Sid)

This subcategory (‘Care and Support’) therefore identified two perspectives or two key elements; the essence and the pragmatics of care. Whilst distinct elements, they are paired here because they were found to be largely interdependent. Figure 8 shows the cyclical action of the two elements.

As illustrated below the subcategory ‘Attitudes’ connects to ‘Care and Support’. The “right” attitude identified by participants assumes a value base of being non- judgmental (Stage 1 of Figure 8). This essential property diagrammatically precedes those properties identified as care or support related. They occur simultaneously in practice however.

Figure 8. Care as a Prerequisite Property for Helpful Interventions

1. Genuine consistent

caring approach contingent upon non judgemental value base 2. Care conveyed within an empathic approach 3. Care establishes a relationship foundation of trust 4. Timing and knowledge of a helpful intervention is essential in order to capitalise upon the ‘care’ connection

Interventions that proved helpful (Stage 4) reinforced the prior established ground (care / trust, Stages 2 and 3) upon which their success was dependent. This diagram and narrative illustrates two key elements – regard for the person (care) and ability to help (support). Care features as a central aspect of subcategory ‘Attitude’, whilst support is an associated concept of subcategories ‘Medication’, ‘Safer Drug Use’ and ‘Treatment’.

The timing component of Stage 4 was linked to the motivational stage of the participant. Here the matching of an intervention to the motivational level had more than one effect. The delivery of an appropriately timed intervention not only improved the chances of a more helpful outcome, it also demonstrated to participants that the practitioner was aware of their needs in relation to their specific preferences.

The participants’ preferences proved to be ordinarily based upon their motivational stage. Overleaf, Table 20, ‘Motivation and Intervention Cross-Walk’, adapted from previous research (Holland 2002) provides examples of appropriately matched interventions in relation to levels of motivation.

The relevance of motivation lies in the development of theory where the key determinant of helpfulness from this subcategory appeared to be care and the demonstrating of such care. The mechanism of conveying care appeared empathic in nature, therefore to build trust and deliver appropriate interventions insight into the motivational state of service users had to be acknowledged.

Whilst the concepts of care and of support have been elaborated upon the examples from which they emerged are important sources of contextual evidence and are listed below in Table 21, ‘Essence and Pragmatics of Care and Support’. They demonstrate how participant experiences and expectations resemble the research and policy background, particularly the key elements of recovery as described by Drake et al

Table 20. Motivation and Intervention Cross-Walk (Holland 2002)

Stage of Motivation Intervention Precontemplation

The absence of any thoughts or behaviour concerning substance use reduction.

Engagement

Despite absence of motivation the potential to develop a working relationship based on trust is present. At this stage clients have multitudinal problems around issues such as housing, welfare and health. Opportunities emerge immediately whereby a worker can assist with alleviating such problems leading to a therapeutic alliance. Preparatory work essential for later stages. Successful engagement is the development of trust and acceptance of 'help' however small.

Contemplation

The presence of thoughts (not usually behaviour) and

ideas concerning reduction/cessation of substance use, and/or recognition that life problems might be derived from substance use.

Persuasion

A variety of strategies encouraging a client to understand the consequences of substance use are employed. Neither coercion or confrontation is appropriate - they merely compound the substance use or undermine the efforts to empathise. The emphasis is upon generating motivation for recovery from within an individual. Persuasion is most effective once engaged; however interventions have considerable overlap which suggests that stages of motivation are not entirely discrete.

Behaviour Change

The presence of changed behaviour consistent with (i) reducing the adverse effects of substance use and/or (ii) reducing or abstaining from substance use.

Active Treatment

The strategies employed to support reduction of substance use range from pharmacological adjuncts (e.g. Methadone, Buprenorphine) and detoxification to psycho-substance education (individual/group) and assertive substance refusal training. Clients at this stage are becoming proactive in their efforts but require constant support and encouragement.

Change Behaviour

Maintenance

A stage of consolidation, where reduction or abstinence from substance use is established.

Relapse Prevention

Active treatment strategies are equally applicable here. Identifying triggers or predisposing factors of substance use are essential. Client and worker collaboration in devising contingency plans in the event of substance use relapse or 'near misses' may involve other workers, friends and family.

Maintaining strategies of social approval and material/practical benefits reinforces progress. Continued input over a period of years not months will be required for a stable lasting recovery.

Table 21. Essence and Pragmatics of Care and Support Essence (displaying of care) Pragmatics Accurate prioritisation of needs Finding accommodation

Knowledge of the range of accommodation types/ quality Benefits advice and intervention

Advocacy Obtaining help from other agencies “Opened doors”

Persistence and flexibility

Attending appointments (in otherwise chaotic or de- motivated circumstances) “They just pop in”

Recognising social relationships

Outings with people Conveying regard and

respect

Helpful staff

Reliability Consistency of services/flexibility

Collaboration Joint working *“Joined up – not pillar to post”

Care coordination / case management / Care Programme Approach (helpful to non-mental health agencies to be fully involved)

Confidentiality and communication “Good communication across services”

Relapse signatures / prevention / longitudinal support Assertive out/in-reach / practical offerings (home, benefits, company, crisis bed)

Detoxification after-care Valuing progress and

working long term

Employment (keeping job – employer support)

Motivating Encouraging attitude from staff - “a safe place” (to talk)* Phone calls every day

*Feedback

“italics” denotes partial quotes. * denotes full quotation below.

Feedback - I’ve got a key worker, I come here and I also go to Creamfield. I go to the city gym. I started a computer class, which I’d never touched in my life, laptop, first time yesterday……and yeah, I’m getting supported here ( day treatment centre), I’ve got one-to-one counselling, psychiatric help as well for my depression, anxiety, and I have seizures as well.

A safe place to talk

Non-stat/ informal

- well I think that the staff, they do a good job, because they are there and they will listen to you if you’ve got a problem, and that’s why – even if I go to the groups, I do talk in the groups, but if there is something that I need to talk about, I don’t talk

Staff must convey care Directive v non-directive Reliable Policy CAT

in a group, that’s why I’ve my one-to-one. I prefer it to be private that. They’ll listen.

Joined up not pillar to post - I’ve got to see another psychiatrist here next Tuesday, which I’ve been told they are going to try and correspond with each through the hospital (psychiatric outpatients) as well as here and try and work a network of helping me more, which I find helpful, it will be a bit more better. (Ron)

This section has revealed the two dimensional character of ‘Care and Support’. Its essence (caring) and its pragmatic application (intervention) that constitute helpfulness have been examined. Implicit in Ron’s comment is the need for effective joint working and coordination of care as espoused by the CPA. The following subcategory of ‘Treatment’ develops care and support concepts further by focussing directly on what I have named the pragmatics of care; the practical intervention rather than the interpersonal foundation of trust and respect.