Mental health, drugs and the call to re-instate harm reduction

Published in Drug & Alcohol Today. December 2006

David Chaisty
Email: davidchaisty@reasonability.org

There is a risk harm reduction is being taken for granted. Despite saving many hundreds of thousands of lives from HIV and AIDS and the ongoing value it provides to drug and alcohol treatment, its principles have not travelled well – and at worst are being forgotten or shunned by some hardliners. Here, David Chaisty champions the logic and power of harm reduction to re-assert its use not just among drug or alcohol problems but for people with mental health issues.

December the first was World AIDS day as well as the 25th anniversary of the first HIV/AIDS diagnosis(3). Since then, harm reduction has been at the very heart of HIV and AIDS prevention

However, despite the many gains over the years the meaning of the risks has deminished. In particular AIDS is not seen as threatening and incurable as it once was. Our tactics to tackle the problem need to be rethought.

A recent Ipsos MORI survey of 2,048 adults found that over the last five years there has been a serious widespread decline in public awareness of how HIV is transmitted (1).

The dawn of a new approach

Harm reduction was championed in its onset as bold and courageous. It was predominantly characterised by shared nursing practices such as realistic barrier methods and safer injecting techniques. In essence it accepted that no matter how distasteful certain behaviours might seem to some, such as gay sex and injecting illicit drugs, it was efficacious to work with these behaviours to lower threats and damages.

It could be said, in principle at least, that society’s health and safety benchmark was raised so that instead of being left to hit rock bottom before changing certain behaviours, certain groups of people were no longer so readily dismissed.

Today Harm Reduction has become more than a response to prevent HIV/AIDS, it is a staple weapon in the politics of ‘drug work’. Although many still see this method as promoting drug use, its original rationale as a pragmatic health-based behaviour modification programme based upon the promotion of liberation and reason is very well established.

In the pursuit of harm reduction it is, however, difficult to wholly evaluate the harms we are reducing. Clearly the need still exists to prevent blood borne viruses and drug-related deaths.
These are key outcomes of the national drug strategy (5), as stated by the National Treatment Agency and the Home Office. But what about less easily quantifiable such as risks to self and others associated with mental health? Particularly with high incidences of stimulant use and the way these substances can ‘mimic’ psychoses?

Harm Reduction is central to contemporary political practice

State support of harm reduction has resulted in an increasing array of tactics to meet their stated aims. The number of disposal powers for courts wishing to ‘treat’ drug misuse has sharply risen. Regional purchasing powers now bring together most community groups so that local authorities are obliged to work to reduce and manage substance use via Drug [and Alcohol] Action Teams.

The newest police agency in the country, the Serious Organised Crime Agency, defines its key driver as ‘harm reduction’ owing largely to its intelligence function and wider remit to tackle criminal action holisticly.

In psychiatry, however, the very phrase ‘harm reduction’ can be met with blank expression and/or an assertion that it belongs to drug treatment services.

This is clearly unacceptable and needs to be redressed to enhance capacity and better support those who want to change and those who help to manage change.

Anyone who has ever worked or stayed in psychiatric wards will know there is very limited and inconsistent access to drug education literature and objective, practical information about drugs. A possible reason for this can be found in DSM IV (6). This internationally recognised diagnostic tool implies that all drugs are powerful and a matter best left to experts.

Yet with so many people interested and willing to experiment with drugs can we afford to limit knowledge or drug management to ‘professionals’.

This is not to advocate drug use as per se or deny that an individual’s intentions may be at odds with treatment or abstention.

Harm Reduction and Mental Health, moving forward

We have yet to see a bench mark figure of the numbers of people compulsorily admitted under the Mental Health Act to hospital with substance use issues . Similarly we do not know the numbers nor the pathways taken by people detained under Home Office restriction orders who have substance-related issues, such as ‘mentally disordered offenders’ to whom Section 41 (the power of higher courts to restrict discharge from hospital) has been applied.

Government figures suggest dramatic increases in the use of psychiatric services by substance mis/users. Carol Flint MP, for example states that "The percentage change in the number of people entering drug treatment between 2003-4 […] and 2005-6 […] where cannabis has been identified as the primary substance of misuse, is an increase of 117%." (7)

Dominant social structures based upon hard sciences have a massive influence on our general understanding of many issues. This can skew knowledge so that it is almost impossible to think of some problems as anything other than cause and effect.

Take for example certain states that are ‘drug-induced’. There is no flexibility for psychiatry to think of ‘drug-related’ dilemmas. This is because the classification tool used by psychiatrists to diagnose problematic mental states speaks exclusively of ‘Mental and Behavioural Disorders DUE TO Psychoactive Substance Use’ (F10 – F19 Diagnostic and Statistic Manual, American Psychiatric Association).

If we are to further reduce harm to self, others and carers and benefit from a more democratic and inclusive model we need to be thinking more holistically and strategically.

A more dynamic and sophisticated understanding of how drugs work

Understanding how drugs work is complicated. While information on drugs is more broadly available on the internet, it is generally not shared, particularly as a matter of routine. Budgetary pressures, staff shortages, and demands for productivity and efficiency all often conspire to restrict the ability to offer time to discuss these matters(8).

Norman E. Zinberg’s(9) ubiquitous “drug”, “set” (frame of mind), and “setting” (environment and situation experienced at the time) is a good way to understand a person’s drug experience. This enables us to better expediently see the whole person ‘in situ’, offers a better understanding of the action of a substance and also values a person’s life experiences.

A specific practical aid to casework is the inclusion of ‘timelines’. Namely a joint mapping exercise to review a life history of illicit substance use and also mental health history. Often the comparison of these offers helpful and interesting insights.

Similarly this approach offers greater understanding of the influence and risks of life factors to drug using experiences and of drug using experiences to vulnerable mental health states.

A more honest, democratic and participative care plan

It has been said that most Care Programming Approach’s (CPA is, a care management system first introduce in 1990 to UK psychiatry) defeat the ideal of a tailored and individualised plan for a persons care.

According to a recent review of CPAs, “Service users expressed concern at the lack of attention to their wider social care needs within their care plan, particularly when the focus has been on problems, risk and subsequent treatment rather than building on their strengths towards recovery. There was equally a concern by service users that not enough attention is paid to contingency or crisis planning. Carers also aired views about their lack of involvement as partners in the care assessment and planning process.” (10).

Put simply it is possible that many care plans will read the same; monitor mental health, comply with medication, abstain from illicit drugs, attend to personal hygiene and engage in a structured day.

Used effectively this tool can empower by sharing power and legitimising a persons experience and validate emerging skills to direct life choices more healthily.

Advocates opposing recent proposals for Community Treatment Orders (where a compulsory treatment plan is given to those living in the community) (11) tend to prefer an assertive outreach approach –.an approach that is not without its own critics, who question some of its engagement techniques

Assertive Outreach (12)
Assertive outreach is a bespoke, proactive approach to helping people with severe and enduring mental health problems in their own homes. It is used when the relationship between the services and the user is complex and where service users might have difficulties managing their daily life. In particular, repetitive admissions to hospital can lead to a breakdown in someone’s social networks and that can exacerbate an already complex set of problems.
Assertive outreach is based on a sense of optimism, creativity and finding solutions to problems. It is about doing things in a new way.
The final objective of assertive outreach is not to get someone into other services, like a local mental health day centre, but to enable them to have a fulfilled quality of life.

The Assertive Outreach Approach is commonly designed to be flexible. In so being it is perhaps a little more prepared and equipped to focus on small steps and achievable goals.

It is often said that this is a means of engaging with those where the need exists and where it will be effective. In a more recent study (2003) Wheeler, Tyrer et al state that methods inclusive of assertive outreach are: “no different from atypical antipsychotic medication, cognitive–behavioural therapy or even antibiotics. Applied indiscriminately, without consideration for ‘dosage’, intensive case management may be ineffective or even counterproductive.” (14).

However, in the literature so far mentioned there appears to be no mention of the implementation of harm reduction as a strategic means to improve clinical, social nor organisational outcomes.

Implicitly we are offered an ongoing series of tactics to meet specified targets. Rarely is the target to reduce harm and the indicators of this mission left to be determined at the point of delivery.

Capacity

At one time the phrase ‘a hand-to-mouth existence’ meant a person’s potential is limited by their need to meet basic needs. If we expect people to engage in abstract actions such as care-planning we might benefit from asking if the person can foresee the benefit – such as look further than the hand to the mouth.

The impact of the new Capacity Act (18) which comes into force this year may well change how we perceive and engage with people as well as how we understand and map our goals. The Government states that the Act “will provide clear guidelines for carers and professionals about who can take decisions in which situations.” (19)

A notable constant in enabling change is the degree of ‘engagement’ and how service benefits are perceived. Again we know there are people who do not engage and who are ‘encouraged’ or cajoled into making care plan agreements that are vilified when they struggle to establish their position.

It is possible to again refer to the founders of Assertive Outreach (Ludwig, Farrelly & Frank) to see how opposing positions between person and professional can become established. They argue that “weapons of insanity” are used by some people in the ‘engagement process’. It is easy to see how this can be equally applied to any sector of health and social care;

Implicit in our discussion of the “code” are five important clinical “facts” which, we believe, underlie the behaviours of chronic schizophrenics.

First, these patients can use their insanity to control people and situations.

Second, they have an indomitable will of their own and are hell bent on getting their way.

Third, one of the basic difficulties in rehabilitating these patients is not so much their “lack of motivation” but their intense, negative motivation to remain hospitalized.

Fourth, insanity and hospitalization effectively pay off for these patients in a variety of ways.

Fifth, these patients are capable of demonstrating an animal cunning in provoking certain reactions on the part of staff, family, and society at large which guarantee their continued hospitalization and its consequent rewards in this article we shall term them the “weapons of insanity.” (20)

Harm reduction works best when it can take on different perspectives (such the doctor’s desire to apply a treatment regime, unclinical partner’s desire to support positive change and the person’s need/desire to get help) and is honest about what can be achieved.

Many people with mental health problems live in fear. This can be from wondering where the rent is coming from, having to repeat behaviours that are established as essential rituals or anticipating the next statements being made from an ‘imaginary’ voice.

In this sense it is possible to develop a view of the capacity of the partners involved in the agreement making process that is limited by the situation a person finds themselves in. This can be any party. For a professional response, however, we would expect more transparency and honesty in the process.

It is refreshing for people to witness the discourses between professionals when trying to work things out – particularly when it involves the specific achievement of a given goal, what that goal is and where the value of it came from.

By sharing our intentions and laying bare the strategies deployed to achieve these we potentially avoid battling for clarity as the other partner (often the recipient) is now more aware and informed of the intent and strategies contemplated. We might say that this is a holisitc awareness and availability of appropriate intelligence.

Here harm reduction is a process where “the worker becomes a consultant who assesses the client’s needs, provides information and options, and allows the client to set her/his own goals.” (21).

Here strategic intent is well mapped and explicitly clarified and differences between person and professional (or protocol/agency etc) noted. Finally both parties thereafter set their own goals and notes are taken where agreed and/or required and shared.

The goal may be engagement with discourse or medication or drug reduction programmes. Whatever the method, honest communication that respects capacity remains core to harm reduction.

Harm Reduction and rehabilitation

If health and safety are our current benchmark then welfare has to be the third wheel to stabilise our balance. A person’s wellness or quality of life has to be a core factor if they are to fare well or live independently.

There are so many carers struggling to help others manage apparently chaotic and damaging substance use that it must surely benefit to have at our disposal a view of overall quality.

In evaluating what harms are being reduced the Serious Organised Crime Agency speaks of the consequences of harm to people and communities, economic impacts (a Government report estimates the harms associated with class A drugs to be £13bn a year), underlying harms and overall harms (23).

Therefore providing support for reasons other than ‘to make things better’, or to reduce risks, we might legitimately also consider helping someone change their habits.

Simply put we might refer to this as a process of ‘rehabiting’. At which point it will be easier to refer to rehabilitation knowledge and skills without surrounding the practice with professionalism or brick walls.

In turn the inevitability of change can be shared so that others feel they have more of a stake in it. Again agreed and achievable goals validate harm reduction and offer shared care approaches between all interested parties. Treatment need not be our only goal.

Governance

The United Nations Economic and Social Commission reminds us that the concept of "governance" is not new. Simply put it means the process of decision-making and the process by which decisions are implemented (or not implemented as the case may be).

Their eight principles neatly encapsulate many of the practices mentioned in this article. The principles are participatory, consensus oriented, accountable, transparent, responsive, effective and efficient, equitable and inclusive and follow the rule of law – and are very hard-won goals.

With harm reduction we are able to use the pursuit of these ideals as a beneficial process for everybody involved. Or put another way; all those with a stake in reducing harm (24).

Developing belief, trust and confidence is crucial for effective implementation of good governance. This applies equally well to harm reduction. And is perhaps most pertinent for high-risk practices, such as psychiatry where the practice of harm reduction offers the most effective balance to the time and attention spent focusing on risk.

Effectively enabling others to take reasoned choices based upon an ability to foresee risk may well be an ideal and it is one that we often struggle to achieve.

Harm reduction is a philosophy of care and/or a statement of intent that offers a binding influence for all stakeholders. In this sense it also offers a clarion call towards general and overall improvement.

The call for courage

Harm reduction is, as stated, a statement of intent and an intelligent and courageous means of identifying needs and meeting them. It is dynamic, holistic and aims to develop foresight. It offers a unique philosophy to balance risk assessment and management and has the potential to make services more accessible to people who should be and need to be credited for the knowledge and skills they have and the efforts they make.

It is a capacity-building exercise to engage with others to better manage risk and change. This is mostly a core function of care exercised by all carers that support people, particularly drug users with mental health issues. As such we are all engaged in changing habits, or re-habiting.

Harm reduction does not detract from the need for well-evidenced and politically scrutinised intervention methods. It is already being practiced by many people engaged in the delivery of care.

By embracing the maturity of harm reduction we can all assist the National Treatment Agency and those taking the challenge to tackle AIDS by reinvigorating the practice by working towards achievable goals together with greater respect, honesty and courage.

As Professor Appleby recently told the BBC on the day of the publication of the most recent paper from the government of psychiatry and risk;

“it was often difficult for staff to establish which patients posed the biggest threat to society. Staff are dealing with degrees of risk all the time and to some extent they become used to the fact that patients are carrying a degree of risk. Being able to spot from time to time when that risk is changing and beginning to escalate is more difficult than simply knowing there are risk factors around." (25)

Perhaps being able to spot the necessary harm to reduce might make the perceptible difference necessary for people to feel more involved and cared for. If the established practices of risk assessment and management are struggling it must surely help to try an allied approach.

In the words of Marjorie Wallis of Sane “It is not a question just of resources or laws but, as has been highlighted, [but] the failure to identify people at risk when all the red alerts were in hindsight flashing.” (26)

It behoves us to make harm reduction a mission for us all.

 

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