A message to the President

Barak Obama will come into office on 20th January with a hefty in-tray, not least a global financial crisis and a war on two fronts in Afghanistan and Iraq. It is unlikely that international drug policy will figure highly in the pile, but here is a reason why it should.

Less than two months after President Obama takes up his post, the UN will be reviewing its ten year drug strategy. The political rhetoric of 1998 was a 'drug-free world we can do it', specifically a commitment to rid the world of coca, opium and cannabis. Not surprisingly, it has proved an 'aspirational' target; the $6n US investment to clamp down on coca production in Colombia, for example, has seen a 15% rise in cultivation according to a report requested by the incoming Vice-President Joe Biden, chairman of the Senate Foreign Relations Committee.

Since around 2004, the language of international drug policy has been shifting; phrases such as 'proportionality' in relation to drug offences and 'the unintended consequences of international drug policy' have been creeping into UN official documents and public statements. The European Union has been increasing its contribution (and therefore its influence) to the UN drug control budget while at the same time offering a less fundamentalist approach than traditionally associated with the United States who have dominated the discourse since the first international drug conference a hundred years ago next year.

It is that history that President Obama should revisit because as many historians have pointed out, racism lay at the root of much of what became universally accepted laws against the use of drugs. Simply put, drug laws were crafted at least in part as a way of controlling minority communities. The laws against opium use targeted the Chinese community brought over to build the US rail network. Southern sheriffs demanded larger calibre guns to mow down 'cocaine-crazed' black men, the same cocaine given to slaves working the plantations and the docks to make them toil longer and eat less. And (again) 'drug crazed' Mexican migrants were cited as a primary reason for controlling cannabis use in the USA when most of the population had hardly heard of it, much less use it.

This is not a plea for wholesale and instant drug law reform; as unrealistic an aspiration as 'a drug free world' etc etc. But at least, the genesis of drug laws in America, a narrative of demonisation and stigma exported round the world, should give the President some food for thought. With the UN poised to review its drug policy, much of it actually at odds with the UN's own policy on human rights, he could use his considerable influence both as US President and as a declared champion of inclusion to shift the balance of drug policy away from a century of law enforcement and towards public health and human rights.

Who is driving Tory drug policy?

"With a few brave exceptions...drugs policy is an area where British politicians have feared to tread."
Home Affairs Select Committee, 2002

"I feel extremely strongly about this subject and desperately want to see a reduction in drug abuse and better paths to enable people to get out of it. If one takes a slightly progressive - or, as I like to think of it, thoughtful - view, one can sometimes be accused of being soft. I reject that utterly."
David Cameron MP, 2002

The phrase 'a week is a long time in politics' is a truism. Given the fast moving, uncertain and increasingly surreal times we live in, 'at the time of writing' is a helpful proviso for any prediction of the outcome of the next general election. Despite a recent boost in approval ratings for the Prime Minister, the Conservative Party maintains a healthy lead in the opinion polls - so what might drug policy look like under a Conservative government with David Cameron as Prime Minister?

Within weeks of becoming an MP in June 2001, Cameron joined the influential Home Affairs Select Committee. A month later, the committee announced an inquiry into the effectiveness of drug policy and the government's ten-year drug strategy.

Published in 2002, the committee's report concluded that drugs policy should primarily deal with problematic heroin and crack users, 'rather than towards the large numbers whose drug use poses no serious threat either to their own well being or to that of others'.

The committee's recommendations included support for the reclassification of cannabis from Class B to Class C, ecstasy from Class A to a Class B drug and a review of Section 9A of the Misuse of Drugs Act ('with a view to repealing it, to allow for the provision of drug paraphernalia which reduces the harm caused by drugs'). On drug treatment the report declared that 'all treatments and therapies should have abstinence as their goal', but also called for a substantial increase in spending, an expansion of methadone so that it became universally available and stated that 'there is still an urgent need for harm reduction actions...both a treatment strategy and harm reduction strategy are necessary...' The report concluded by recommending that the government discuss with the United Nation's Commission on Narcotic Drugs alternative ways of tackling drugs globally 'including the possibility of legalisation and regulation'

Cameron did not vote against any of the recommendations in the report - indeed, he voted against several amendments proposed by another Conservative Party member. In a parliamentary debate on drugs policy in December 2002, he spoke specifically in support of heroin prescribing and the use of safe injecting rooms. His comments on drug treatment are particularly pertinent in light of the recent polarisation of the debate between 'harm reduction' and 'abstinence': "I understand that there is no single method of treatment that always works. we need to have a variety of methods....Although residential places are not the only answer...I support the proposal to increase the number, while retaining all the existing treatment options."

In October 2004 the then shadow home secretary, David Davis MP, announced to his annual party conference that a Conservative government would make the fight against drugs a 'top priority'. Accusing the Labour Government of presiding over an 'epidemic' of drug use and of 'standing aside' from the problem he said: "Some people say we have lost the war on drugs, I say we have not begun to fight it." The Conservatives pledged to "accelerate" random drug testing in schools, increase drug rehabilitation places ten-fold (from 2,000 to 20,000) and reclassify cannabis from Class C to Class B. The speech alarmed advisers in Downing Street.

It was probably no co-incidence that a few weeks later - with an eye to the general election expected the following year - Tony Blair announced new measures to 'crack down' on those who "peddle the misery of drugs". What became the Drugs Act 2005 was born. To many, the 'tougher than thou' stances on drugs underlined the crude politics of the issue.

Has Cameron kept faith with his progressive and open approach since becoming party leader in December 2005? One of his first acts as leader was to commission a number of policy reviews. A Social Justice Policy Group was established, chaired by Iain Duncan Smith MP. It established a separate 'addictions working group', chaired by Kathy Gyngell, to look specifically at drug and alcohol policy.

In light of Cameron's publicly stated support for a more 'progressive' approach to drugs policy there was the possibility that the policy review would nudge party policy closer to the views of the party leader. Cameron's response to the Joseph Rowntree Foundation report on drug consumption rooms, published in May 2006, echoed his previous stance. While the Government barely blinked before saying no to consumption room pilots, Cameron did not rule them out: "...because anything that helps get users off the streets and in touch with agencies that can provide treatment is worth looking at." The issue was to be looked at as part of the party's policy review.

The addictions working group report was published in July 2007 - and delivered a damning verdict on the Government's drug policy: 'Under ten years of Labour's drug strategy, policy itself has become an intrinsic part of the problem. It has been a costly investment in failure.' Both barrels were fired: "Spending is often wasteful, unwise and misdirected...bureaucracy has grown dramatically...has further entrenched addiction...[Treatment is a] misguided system of social control [with] counterproductive targets...Enforcement appears weak...drug education in schools...could be doing more harm than good." And so on. Although the report accepted that methadone has a "useful and positive role in the treatment of addiction", methadone prescribing was branded as a "harm reduction" measure and harm reduction approaches were attacked. A criticism was that the rapid expansion of methadone prescribing has been politically and target driven rather than need driven, and that abstinence-oriented treatment had been intentionally marginalised. What could have been a measured call for an expansion in residential rehabilitation and a greater focus on abstinence got caught up in the polarised and 'either/or' tone of the report and its presentation.

The addictions working group report has not been formally adopted as party policy, but by filling a vacuum its headline theme of 'abstinence-versus-harm reduction' has continued to gain traction. It has set the mood music for the Conservative Party's responses to critical media reports on the drug treatment system over the past 12 months, notably by the BBC's Home Affairs editor Mark Easton, on the relatively small proportion of people leaving treatment 'drug free'. In October 2007 David Davis wrote as shadow home secretary to the chair of the House of Commons Public Accounts Committee asking for an investigation into drug treatment, describing the investment as “massive failed expenditure" - "This is an absolutely shocking revelation which speaks volumes about the Government’s incompetence and distorted priorities. It is yet more evidence why we should focus spending on getting addicts off drugs, and not just spend money managing their addiction.” In response to more recent drug treatment figures (October 2008) shadow home secretary, Dominic Grieve, said: "the Government's entire approach of simply trying to manage addiction is wrong...these figures show that despite a significant increase in investment there has been a paltry increase in the number of addicts going clean. This failing approach is compounded by Labour's mixed and confused messages on the dangers posed by cannabis and ecstasy."

The latest official Conservative Party statement on drugs policy can be found in Repair - Plan for social reform published in October 2008. It accuses Labour of an approach of "maintenance and management, which has failed" and promises to introduce an abstinence-based Drug Rehabilitation Order and "residential-abstinence orientated programs" including day-care programs. There is no further detail.

As to what the commitment to increase abstinence based treatment may cost, the Scottish Conservative Party pledged in its manifesto for the 2007 Scottish Parliamentary Election that it would spend an additional £100 million a year on drug rehabilitation (saving, it claimed, £1 billion a year on policing, prisons and healthcare services). If the commitment were replicated in England - assuming an additional spend rather than a reallocation within existing budgets and matched on a population basis - the drug treatment budget would have to increase by up to £1 billion a year.That is, of course, extremely unlikely.

To date, the only recommendation in the Select Committee report Cameron has stepped away from is on the classification of cannabis, justified on the grounds that the drug "is so much more powerful than it use to be." The government's decision to go against the advice of the Advisory Council on the Misuse of Drugs and reclassify cannabis back to B has neutralised Conservative Party attacks on the issue.

When Cameron talks about "compassionate Conservatism" and the need to fix "broken Britain", he usually refers to the problems caused by drug and alcohol misuse - but stops short of specific pronouncements on drug policy. In a recently published book, Cameron on Cameron, when challenged on cannabis classification he said: "...I think the whole classification system is in need of a major overhaul because it seems to me that the ABC method does not really get it right...These evaluations are all based on the 1971 Misuse of Drugs Act, and a lot has changed since then. And I think without in anyway weakening the illegality of drugs that the classification system needs a major overhaul." An interesting return perhaps to the backbencher who supported "thoughtful" drug policy reform.

There are both punitive and progressive strands within Conservative Party drug policy, to some extent embodied, respectively, by successive Conservative shadow home secretaries on the one hand, and the party leader, David Cameron, on the other. Just as 'only Nixon could go to China', a right-of-centre government may adopt a progressive approach to drugs policy, but to date there are few signs of Conservative drug policy moving closer to the views of its leader. It will be interesting to see how this contradiction plays out over the coming months. Unless Cameron changes his views, he could be leading a government with a drug policy he does not believe in.

Author: Martin Barnes, chief executive of DrugScope

This is an extended version of an article published in the November/December edition of DrugScope's Druglink magazine.

Drowning by Numbers

When are we going to be able to do the jobs we trained for
without having to play childish numbers games, asks drug
worker ‘Beth’, in her second instalment on the reality of
working in frontline drug services.

It’s that time of the month again. I am feeling tired, irritable
and generally frustrated. It’s affecting my colleagues as well.
Unfortunately no herbal remedy or HRT will help this. It’s time
to send off the National Drug Treatment Monitoring System
report (‘NDTMS’ for those in the know).

“There are three kinds of lies: lies, damned lies, and
statistics." I am sure most people recognise these words of
Mark Twain and I suspect that other drug and alcohol workers
will groan with recognition on hearing them.We can use
statistics effectively to support any point we want to make.

I chatted with a colleague who is under great pressure to
increase the numbers of drug users on the day programme he
runs.

“That’s good, 33 per cent of the clients in this group are
drug users,” he said.

“Great,” I replied. “How many turned up for the course
then?”

“Three,” he replied. (Well done to Jim for being 33 per cent
of the clients on the course.)

So when I check I have got everything ‘right’ for the latest
NDTMS report I ponder on what is the purpose of these stats.
Actually, as anyone I work with will tell you, I don’t ponder: I
mutter and swear quite a lot.

I think about one client I have been working with, off and
on, for most of the time I have been a drug and alcohol
worker, or probably far too long in official terms.

What has our positive outcome been? Well, he is not dead
and he is not in prison and he has not attacked anyone. These
have all been very real risks over the years. At the moment
our harm reduction focus is to shift him from bingeing on
amphetamines to go back to regular cannabis use and to stay
of booze. His last brush with the law, about ten years ago, was
when he stabbed someone when he was drunk. He knows that
alcohol brings out a violent aspect to him which he does not
want to risk re-emerging. The cannabis, although he can get
rather depressed, is a better option because he eats and sleeps
on this, unlike the amphetamine binges which leave him
gaunt, exhausted and occasionally psychotic. My hope is that
he could envisage life without any substances but that is a
goal too far at the moment. Still, in terms of our NDTMs at
least he is a drug user. Tick. Very good.

I understand something of how statistics are used to
analyse social trends and experiments in social science.
People are very varied and rather unpredictable, and changes
happen for all sorts of reasons: some people even stop using
substances without any professional intervention (but don’t
spread that rumour around too much).

So if we try to establish if any particular event has an effect
we need to measure the difference between what would have
happened anyway by natural variation or chance, and what
has happened in the group affected by the event.We look for a
significant difference between the results for the group left
alone and the group being subjected to whatever we are
looking at.

Statistics can compare, for instance, the number of adults
smoking, using drugs, driving a car today to how many were
doing it, say, five years ago. These sort of figures are the ones
that often appear in the news along with speculation about
why this is and what it means for the future. They are often
accompanied by inaccurate and meaningless extrapolation,
using them to show that, possibly, by 2030, 90 per cent of us
will be watching the television for 22 hours a day while
smoking home grown skunk.

Then we have stats as a marketing tool. ‘Eight out of ten cats
prefer…’, ‘Visible wrinkles reduced by 25 per cent’, and so
forth. Any one who has a cat and /or wrinkles (I have both)
will know that cats are always a law unto themselves and if
they have a mind to turn up their noses at fresh salmon and
go and chew on a dead mouse instead, they will do so. As for
wrinkles, well you stand as much chance of stopping them
with face cream as King Canute did commanding the tide to
halt.

Which of these is the use to which our NDTMs statistics are put?

As service providers, we are set goals. I have no problem
with that. I want clients not to have to wait for appointments.
I want clients to engage and attend long enough to achieve
their goals. I want them to be discharged for positive reasons.
My work matters to me. My clients matter to me and I want to
offer them the best and most effective service I can.

So am I totally in tune with our local DAAT and the NTA?
No, because I am expected to achieve unattainable goals (100
per cent positive discharges – how is that ever going to
happen?). But more than this I am expected to provide the
statistics required, not by improving and developing the
service, but by what can best be described as ‘constructive
accounting’. I have become a ‘spin doctor’.

Perhaps I am going a bit mad at this time of the month but
I have a strange and rather wonderful dream. My dream is
that the role of the regional DAATs and DATs would be to
develop and support services. My dream is that the NTA
would use statistics not to show 8 out of 10 clients prefer
Models of Care so as to sell their product, but to collect good
quality, accurate information that would open debate and
contribute towards identifying how we can achieve
challenging goals. I mean achieve them by making changes to
services, not by learning how to give the right answer.

At school I learnt a couple of things about cheating. One
was that anyone who got 100 per cent in an exam was always
suspect, because people don’t. The other thing was about
getting the right answer in the wrong way. As I struggled with
maths I would sometimes try, when I got to the end of a
problem, adding another line of fake working out. In this way I
would turn my wrong answer of say, 8, to the right answer of
10 (taken from the answers at the back of the book) by
slipping in the line 8+2=10. It rarely worked. It could work with
teachers who were lazy markers but of course it never helped
me to work out how to get 10. What I did learn eventually,
from a better teacher, was that understanding the working
out, even if you go a bit wrong with the numbers, is a better
way to develop an understanding of maths.

Who is doing the ‘working out’ with drug and alcohol
treatment services?

We are under constant threat. I have to make 8=10 because
if I don’t, I will lose my job. My colleague is delighted at his 33
per cent drug users group because he has been told that
alcohol users ‘don’t count’.We have a regional Drug and
Alcohol Action Team but we are being threatened with
decommissioning – not because we don’t have enough clients
(we all have full case loads) but because about two thirds of
them are people with alcohol problems.Why are there more
alcohol clients? I would enjoy a meaningful discussion with
our commissioners about this, but meaningful discussions
don’t seem to be wanted, only statistics. Where does the
Alcohol Harm Reduction Strategy for England (AHRSE) fit into
this? I think Jim Royle of the Royle Family would be able to
answer that.

I have been in this business long enough to remember the
days when we provided few statistics, collected funding from
a hotchpotch of charities and grants, had sparse records and
muddled through in a way that would cause any DAAT
commissioner to spontaneously combust. (Now there’s a thought).

Despite the wrinkles and the cat, I don’t want to go back to
the good old days because I know that we often worked in a
risky way. The thing was that disasters didn’t happen and
many clients did engage and did make positive changes,
because we provided ‘an opportunity for the service user to work
towards living in a way he or she experiences as more satisfying or
resourceful’. Sometimes that happened in a week or two,
sometimes in a year or two. Sometimes it involved detailed
care plans sometimes not. Sometimes it was tier two work,
sometimes tier three, but mostly a bit of both. What we did
was that we tried to provide what the client needed, not try to
make the client fit what the service needs them to be and do.
We could have provided a much better service then and we
could provide a much better service now, but how can we get
there?

If you want to find the quote above in italics look in Models
of Care. It is the definition of counselling provided by the
British Association for Counselling and Psychotherapy, used in
Models of Care in the description of tier three, one to one work.
I am not a maverick. I do look at Models of Care. There is a lot
of thoughtful, well-researched information and guidance in
there. However, I feel I am swimming against the tide.

That ‘time of the month’ feeling is spreading and the ad in
our local paper for a trainee estate agent at a salary much the
same as mine looks very attractive. When are we going to be
able to be honest about what we do, varied and unpredictable
as its outcomes might be? Until we can we are going to carry
on ticking boxes with one eye on our expiring contracts and
struggling to find the energy to do the jobs we trained for,
with the clients we want to help.

In The Flesh

This article appears in the latest issue of Druglink. It is written by a drugs worker under a pseudonym and delivers a poignant reality check right into the heart of the current debate about treatment and recovery

I work in the real world of drug and alcohol treatment. I wouldn’t say it is totally unrecognisable from the interventions, policies, procedures and guidelines published in Models of Care, NTA guidelines and DAAT policies, but it has to be translated to fit. Perhaps at best the guidelines and the reality are as similar to one another as classical Latin is to Italian slang in the slums of Naples. They’re clearly connected but they need a lot of interpretation.

I work in a smallish combined statutory and non-statutory agency in a smallish northern town. The service offers structured, care-planned, psychosocial, one-to-one interventions for drug and alcohol users with complex needs (Models-of-Care-speak). In other words I sit down with people so lost, confused and generally f****d up that most of the other workers in the agency don’t know what to do with them. Either that, or they’ve tried and feel they aren’t getting anywhere.

Of course, I can speak the ‘classical Latin’ of the people who have the power to give us more (or more likely, less) funding, those who give us our targets and then threaten us with being put out to tender if we don’t achieve them. I can ‘strut my stuff’ when needed and present the work of the agency at meetings in the way that I know people want to hear. I can talk about tier two and tier three, behavioural focus, cycle of change, relapse prevention, coping strategies, self-efficacy and (lets throw in a name to impress here) Zinberg. If pushed, I can talk about Rogers, Freud, CBT, cognitive dissonance, constructivism, node mapping and I can even suggest I have a fair idea about DBT and personality disorders. So gosh, what a lovely ‘toolbox’ I have and how well supported I am by the agreed assessment and monitoring tools provided by my local DAAT!

Right. Back to reality. Here is a day at the sharp end. I have seven clients booked in to see me today. In order to satisfy the target set by the DAAT for our tier three caseload, I should make sure that I see five in a day, so I must allow for DNA’s (Did Not Arrive). I have challenged the powers that be over these unrealistic targets by reminding them of the FDAP guidelines for supervision, the time I need to liaise with other services, the time needed to put notes on the frustrating and complex database that churns out the stats to prove our worth. However, and here comes the stick yet again, I have been told that jobs will be cut if targets aren’t met.

So it is fair to say that I am ambivalent about the attendance of these clients. I want them to attend because I want to carry on helping them as best I can. There may also be clients here who have not attended for the magic 12 weeks, which apparently ensures that treatment will be effective. I know that retention rates are another target that we must satisfy to get our funding.

I look at the seven names and see seven complicated and struggling people who need my total concentration in these sessions. If they do all attend I will be exhausted at the end of the day and may struggle to find time for a lunch break. So, hand on heart, I hope they don’t all come.

The first one does come – highly anxious, low self-esteem, continued drinking, peculiar thinking patterns, strange and possibly abusive relationship with her husband. I guess she could be labelled dual-diagnosis, but as the only dual diagnosis worker has an 18-month waiting list and doesn’t accept anyone who might be labelled personality disordered (as this client might) the dual-diagnosis label has no value anyway. She has been coming to see me for about six months and has had a dysfunctional life involving heavy drinking for about 30 years. I know that change will be slow, but I don’t know at what point the guidelines will decree that she should be better.

We revisit two of our regular topics – her relationship and her fear of not drinking. I get out a bit of paper and draw diagrams on the basis of what she tells me. “It’s a vicious circle isn’t it?” she says. I smile and nod. Week by week I try to nibble away at her irrational thoughts and dysfunctional behaviour by offering her a safe place and a safe person to question what’s going on in her life. She would benefit from some community support, but our community support worker post was axed about a year ago.

I get a break at this point, as the next client doesn’t appear to be coming today. I know that he is still drinking, waiting for a detox (let’s hope we are within our waiting time targets). He suffers from mood swings and serious depression. Mental health services have passed him on to us because he drinks heavily – not because he doesn’t have a mental health problem. He is on a scary mix of prescribed medication, about which his GP seems to be far less concerned than I. The client denies any suicidal intentions, but I suspect this is to ensure his medication is not challenged. His life is made particularly difficult by living alone in the roughest part of town, but with the housing problems we have here he is lucky, frankly, not to be on the streets. By the way, our housing support worker post has also been axed. Anyway, last week this client turned up a day late, so maybe that will happen this week.

Client three arrives. My first challenge is to consider how much of my horror about her appearance I reveal. She has been beaten-up by her ex-partner. She sits and shakes and tries to pull her hair over the dent in her forehead. Her hair covers some of the bruising but her face is black and blue and swollen all down one side. He has held her by the hair and punched her repeatedly in the face. She is frightened he is going to kill her. So am I.

I sit and listen. No tools, no techniques, just genuine human compassion and concern. I want her to be safe and ask if I can contact Women’s Aid to ask about a refuge. She agrees. “I’m still not drinking and I’ve only had one spliff”, she says with a somewhat bent smile. Am I doing relapse prevention? I want to capture the perpetrator and lock him away for a long time. I want to send her out with a bodyguard. When she has gone I fill out a risk assessment, ticking a lot of boxes.

Another session follows immediately with another client with a black eye. He is quite cheery and gives me a big smile. As he talks I notice the scrapes and bruises on his knuckles. He has been in a fight, but it was just “male bonding”. He also tells me about another violent incident which he feels was justified, but nonetheless has some concerns about. This acceptance of violence as a way of managing life is hard to hear after the last client. I become far more directive and challenge him to think about the implications of this. We’re like Pinocchio and Jiminy Cricket – I am his conscience. I wonder if this is what he is looking for, and I wonder if this helps him to take responsibility for his actions. Remarkably he goes on to tell me he has reduced his drinking and has not used cocaine for six days. I wonder what intervention accounted for that.

The next client is a woman I worked with through her child protection proceedings. Despite having had one of the worst histories I have ever heard, including violence, abuse and the murder of a close relative, she managed to stop drinking and using drugs during the proceedings. Her daughter was “the only good thing that had ever happened”. Despite this, her child was removed and put up for adoption. Her GP has now referred her back in again. I have never seen such despair. At several points in the session, tears flow silently down her cheeks. She is pale and thin and has lost a tooth since I last saw her. I should be doing a health care assessment which asks if the client has a dentist, but there are no dentists in town willing to pick up NHS clients. It would be an insult to ask her. She sees nothing of any value in her life. My impression is that she is only still alive because she does not have the energy to kill herself. I put my forms to one side and ask questions to try to find some glimmer of hope. She is coping with life by using alcohol and crack cocaine. She is most definitely pre-contemplative in the cycle of change. What would be on her decision matrix? Reasons to change: ‘I might die’, reasons to continue: ‘I might die’. The only hope I can see is that she has attended her appointment.

I want her to know that I care about what happens to her even if she doesn’t. I want to form a therapeutic relationship with her but I don’t know what to offer. What therapy label would make her feel that life was worth living? The best I can do is to say I am here and I want to offer whatever support I can. She makes another appointment, but in my heart I don’t know if I will see her again. Another risk assessment to complete and a letter to the GP spelling out my concerns – will those things help? I suppose I feel I have done what I can but it is nowhere near enough. Oh – and I failed to complete a TOP (Treatment Outcome Profile) form.

Four clients. Great, almost up to target and at last the chance for a lunch break. I chat briefly to some of my colleagues. There is always a lot of humour here. I suspect it is part of our coping strategy. It fits with the resilience model I learnt about recently – another tool to hone. Walking through the town centre in my break I think about the model of how we should work. Assessment, health care assessment, risk assessment, care plans, shared care meetings, treatment outcome profile, sessions x 12, client better, discharge. Have any of the people who compile the theory experienced the sense of powerlessness that I feel right now.

Back in the office the next client arrives, not bruised or crying or in crisis. Great. Actually, he was unlikely to DNA as I have a prescription for methadone to give him. I definitely have something to offer here. I have picked this client up from another worker who is off at the moment so before he gets his prescription I ask him to tell me a bit about himself. I am a bit surprised to hear that he has been on methadone for eight years and is still using street heroin on top. Am I just a legal drug dealer? I can’t honestly say if it is my ego (wanting to show the other worker I can do better) or a concern for the client, but I slip into motivational mode. “So is the heroin use working quite well for you then?” By the end of the session he is saying he wants to “knock it on the head”. Sounds good, but I have been in this business long enough to know that one hour in a weekly session has 167 hours elsewhere to compete with. However, I come out of the session feeling quite up-beat.

The last one is here. It is my first meeting with this guy. Referred to me with problems controlling his anger and cocaine use, he has mentioned briefly to another worker about being beaten by his drunken parents as a child. He is leaning forward in his chair. He looks anxious, smiling with an almost childlike desire to please. I have on my lap a 27-page assessment form, a risk assessment and a TOP form.

I introduce myself and he tells me, nervously wringing his hands, that he has never really talked to anyone before about the difficult things in his life. I put the forms on the floor and say: “Would you like to tell me about yourself?”

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