We could instantly reduce the number of overdose deaths if this medicine were more widely available

Please circulate where approriate, help us to save lives.

Naloxone Action Group - England

What do we do with a medicine that prevents certain death for people with a particular condition—and is safe, cheap, and easy to administer?

  1. Immediately make it accessible to those who can administer it when such a life-or-death situation arises.
  2. Make it available to no one except doctors and emergency room workers.
  3. Endlessly debate the particulars of how and when it should be widely introduced.

If you picked number one, that would seem to be a reasonable choice. Unfortunately, it would also be incorrect. With few exceptions, answers two or three apply in the vast majority of the world when it comes to the medicine naloxone.

Overdose remains a leading cause of death among people who use drugs, particularly those who inject. Increasing the availability and accessibility of naloxone would reduce these deaths overnight.

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TEMPLATE LETTER FOR TAKE HOME NALOXONE PROGRAM CAMPAIGN (NAG ENGLAND)

(To whom it may concern),

I am contacting you in relation to a current national campaign to reduce drug related deaths in England. In light of the recent 32% rise in drug related deaths bringing the statistical data of those dying from overdose involving opioid substances in 2013 to a staggering 765 deaths, each one preventable.

Please find attached below a brief timeline of Naloxone from it’s inception up until present .

https://futuremoves.wordpress.com/2015/01/07/a-brief-timeline-of-naloxone-for-reference/

As you will see there are a number of periods where there has been open endorsement from a number of sources here in the UK. These endorsements have been made by:

Professor John Strang in the British Medical Journal (1996).
ACMD (Advisory Council for the Misuse of Drugs) (2000) (2012)
UK Clinical Guidelines (2007)
NTA (National Treatment Agency) (2007) (2009)
MRC (Medical Research Council) (2008)

The department of health chairperson Jane Ellison sent a letter, in July of last year, to the ACMD giving clear direction as to a date for commencement of National Naloxone program from October 2015….

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/340711/IversonNaloxone.pdf

This letter lays out a clear and direct plan of action which advocates for training and any other preparations to be supported ‘prior’ to the date given for roll out and was a direct result of the MHRA survey which returned an overwhelming show of support for the provision of Naloxone in the community.

I feel that a delay until October 2015 is irrational given the evidence of support given and believe that this delay warrants a judicial review based on the evidence collated globally and also from the National programs in both Scotland and Wales where take home programs have had a positive effect on th statistics surrounding drug related deaths. I also feel that this delay is a serious breach of human rights in that every human being has the right to access life saving medication and the right to live. This delay has the potential to interfere with the right to life and also the right to a family life.

Given the case that I hereby put forward for direct and immediate action towards implementation of Take Home Naloxone programs nationally. I would be grateful if you could reply to my concerns by:

A: Informing of what is currently happening locally to put this program in place
and
B: Informing me of the reasons for delay in implementing a local program.

I look forward to further correspondence with you regarding this issue.

Yours sincerely,

A RESPONSE: MY VIEWS AROUND CURRENT BARRIERS IN DUAL DIAGNOSES.

Firstly to qualify me for being in a position to input on this subject. I have been involved in drug user advocacy and substance use research on many different levels,  including dual diagnoses, which occurs in a high number of those accessing support through services and mutual aid groups. My role in the field is to add a realistic voice to an often idealistic approach in dealing with and supporting those with multiple disorders and reduce the risks and harm to those living with various conditions including pre-treatment, treatment, aftercare, stigma and various other issues that arise during the care of those I come in contact with. I am lucky enough to be employed in the drug and alcohol sector in UK and also dedicate a lot of my personal time to researching and supporting those living with conditions within our communities.  I would like to also take the chance to thank Louise Rugman for her input and research in this topic and for her ongoing support with regards to the support and care of those living with dual diagnoses, homelessness, and a number of other related issues,  despite her living with an ongoing condition herself. An inspiration by all accounts whose input into my response was valued and informative.

Many thanks Opi Ferum our Australian connection for the thought provoking questions.

1: How do you see people who use substances first-hand living with a mental health issue being treated in the current field of alcohol and other substance care? Do you see harm reduction practices being practiced or not?

With a basic understanding of a number of co-morbid conditions, I’d agree that there has to be first and foremost an element of reducing the risks and harms in this line of care. A number of mental health conditions are not curable, and are indeed long term, and therefore the emphasis needs to be on reducing the harm to the individual and their significant others with regards to minimising the symptoms of the condition and various other aspects of the condition. Harm Reduction  focuses on the minimisation of the physical, social and legal harms, primarily, of those who are living with any kind of condition or disorder among other aspects of care. However, when there is an underlying element of substance use running alongside the condition, which realistically there often is. This can cause controversy with regards to the continuing care for an individual if not addressed and implemented correctly, which unfortunately seems to be all too common. I agree that some form of development orientated practice must also be administered into the care but wholeheartedly feel that the basis of any care, and throughcare,  especially when dealing with dual diagnoses needs to be firmly rooted in reducing harm and minimising risk to the individual whose care is priority and this should be carried right through the journey of that individual, and, those surrounding that same individual without prejudice or discrimination for the use of substances restricting ongoing support.

Harm reduction primarily deals with reducing the consequences of high risk behaviour and sets out to improve the positive outcomes of an individual with regards to supporting them to get the best out of their current situation regardless of their condition. An ideal model of care that I would suggest would be, first and foremost establishing a solid rapport with an individual who is currently living with dual diagnoses, this is imperative with regards to the continued care of that individual. There are a number of benefits here with regards to mutual aid being an integral part of the care of an individual with regards to the concept of an ‘expert by experience’, however due to the nature of the condition there is an obvious need for more comprehensive care and attention, there are agencies that operate a buddy system, whereby the peer support can be advocated for throughout the whole journey of the individuals care. This has proven to be quite effective where practiced. Establishing the cost benefit ratio of continued use and the possible effects when engaging in risky behaviour of any type associated with the condition can be a positive aspect of engagement, however this is not always paramount in an individuals mind when having an episode, for instance, but, it does serve as a positive piece of work with regards to raising awareness around pro’s and con’s of continued use and perhaps preparing a proposed care plan to support specific situations once triggers are recognised. Relapse prevention and setting individual goals for change are again an imperative topic for discussion with regards to an individual’s care. Discussing possible coping mechanisms for any given situation and looking at how to deal with crisis as and when it arises. Mutual aid forums and positive social network interaction again is something I advocate for with a passion, right through an individual’s care and beyond.

So, do I see this working effectively in services designed to care for and support individuals with co-existing conditions. Yes, I do see this happening, but not as often as I would like to…sadly there seems to be a lack in partnership working to fully support an individual living with dual diagnoses.  Also another take on this from an individual who has accessed service for dual diagnoses is that there is an element of confusion with regards to the message being delivered on interventions. Her view was that harm reduction was openly advocated for and promoted within the mental health support service, however, most of the therapies demanded abstinence? One specific report that I have been given in a number of feedback scenarios is access to Dialectic Behavioural Therapy. This is now being highlighted as a therapy that could be used in drug and alcohol services but until then is primarily given as a therapy via mental health services and complex needs teams. This however along with a number of other therapies that are specifically aimed at promoting wellbeing within the sector ‘demand’ abstinence, even from prescribed OST, and therefore there are a number of dual diagnoses individuals who will not be able to access a number of therapeutic treatment options. This in turn excludes a number of individuals with dual diagnoses from entering effective therapeutic alliances with supportive structured therapy options until not only have they moved away from their substance use, but, also way from their OST as well, I have met a few who have been put in the unrealistic situation where they are being ‘pressured’ to implement rapid reduction detoxes to continue their care, or face closure until such times as this is achieved.  Therefore by my reckoning, the tools needed to promote well being are not always fully available, and further to that are not accepting of the fact that there are those who may relapse during the therapy, due to stress and a number of other contributing factors. This unfortunate situation has arisen a number of times both in my personal life and also in my professional capacity where there has been an almost non-existing care plan offered from mental health services dealing with dual diagnoses other than a demand for abstinence when referring in for support for substance use, or, completely the opposite, an extremely comprehensive care plan that cannot be put into action until abstinence is achieved, putting undue stress on the individual going through the process.   Now although I understand that there are a number of reasons why abstinence would be suggested, the main one being it is hard to diagnose an individual who is currently taking a substance which could possibly alter the chemicals in the brain to a point that a correct diagnosis may not be reached immediately, which could cause further distress with the individual, also the fact that substance use on top may not be as effective when using illicit substances on top. However, this becomes a catch 22 situation if an individual is self medicating and presenting with dual diagnoses. If there is no structured joint work between substance misuse services and mental health services and this demand for entire abstinence becomes a barrier to dual support for a dual diagnoses, then, this in my opinion leaves a wide opening for lack of persistent and consistent care and promotes a support network that is fraught with holes. Which are all too easy for those seeking care to fall through.

So to summarize yes I do see harm reduction initiatives working well in Mental health services but there is room for improvement and a more responsive and productive alliance with other services and also within service, to reduce the stress for an individual in the system, by promoting clear and direct access to consistent therapies designed to reduce the risk, without unrealistic ‘requirements’ being imposed or exclusion for substance use, especially substitute medications therapy.

2: How do you personally see harm reduction as a sensible approach to dealing with substance use and mental health? After all, a lot of people that use substances are co-morbid in diagnoses.

I see harm reduction as being of maximum importance when dealing with those living with co-morbid issues in this context. Firstly, as I have stated there are a number of dual diagnoses individuals that have conditions that are ongoing and require ongoing assistance and intense support. Mental illness is not something that can be taken lightly and most definitely not something than can be covered with a blanket policy under the abstinence banner. There are a number of diagnoses that until science and research moves forward, which it does on a daily basis, are constant and require consistent reviews at any particular time to reduce the risk and harm to the individual and those surrounding the individual, as mental health and substance use  can also be a strain on family and significant others, which needs to be, and indeed is, focused on harm reduction with a view to supporting all involved to achieve the best out of a current situation or occurrence, or general well being.

With bipolar disorder for instance there are a number of contributing factors that require a solid and comprehensive approach based in the harm reduction ethos. This is a condition that presents itself with a number of reasons that support harm reduction due to the nature of the condition. Although there are major concerns that would advocate for the abstinence route, and this should at all times be the desired goal, it is not always as clear cut as it may appear. Bipolar and substance use go hand in hand, and, this condition is one of the more prominent that I have come in contact with, with regards to dual diagnoses. Yet as I have said before, a lot of the proposed therapies that are designed to support an individual with this particular diagnoses are aimed at those who are abstinent? Therefore, putting a major barrier up for those who are living with similar conditions, rather than, supporting and offering alternative therapy,  to increase chances of any positive steps towards recovery, by definition, from certain aspects of the condition.

The duty of a substance misuse support agency is primarily to deal with the substance side of dual diagnoses and with all the best intentions it is not really common that you come across a practitioner that is equally qualified in both sides of this coin, this being said, as a practitioner in the substance misuse field when I am dealing with those with current and historic dual diagnoses I am constantly advocating for joint, partnership working for the better outcome and not always successful in this due to unrealistic requirements for continued care and support, which is not ideal in supporting an individual through the process.  Although I have no doubt there are a number of highly trained individuals out there who do have a full understanding of both sides (I unfortunately am not one)  Therefore, they would primarily be dealing with the substance and all it’s related issues. However, once a certain level of reduction in substance use is reached there is the risk of relapse due to the mental health condition taking prevalence, especially if the individual has been using a substance to self medicate? This is where I feel the abstinence call from mental health services gets taken out of context and should be re-evaluated with regards to a demand for abstinence, amongst other things. And this is again where a number of those with dual diagnoses end up falling through the net through lack of joint working between services, or unrealistic requirements being set out prior to continuation of care.

Harm reduction in the role from the substance misuse angle provides a solid safety net for those who are going through the mental health service support network and may fall through the net for a number of reasons. That being said harm reduction drug and alcohol services are not an alternative or as I have heard it affectionately called a ‘dumping ground’  for those who structured support within the mental health service is proving to be partially unresponsive. It is a complimentary support service to run alongside the already existing support network yet all too often seems to be seen as a completely separate service prior to mental health service engagement.

Another issue that rears it’s ugly head here in this arena is the fact that there were a number of services set up to deliver specific services based in dual diagnoses, exclusively,  but due to the payments by results scheme, which has been a roaring success?? the services which were aimed specifically at this field were not seen to be a financially secure ‘investment’  in that the outcomes of ‘complete’ recovery as a dual diagnoses outcome is not always achievable in this particular arena. Thus putting pressure on the relevant services to enforce policies and procedures that are not truly reflective of the individual needs. There is clear and professional guidance for mental health services to promote joint or collaborative working relationships for the due care and attention of an individual that presents with dual diagnoses, however, those services are now commissioned based on a recovery model that given the nature of the condition is unrealistic to uphold without ‘enforcing’ specific requirements, one of which unfortunately is the abstinence ‘need’ for therapy in certain cases. Herein lay the dilemma where if an individual is not currently abstinent or not seen as being someone who can achieve abstinence, in a specified timescale, they then become a burden on service that has targets to meet in order to secure it’s funding for the next year. Harsh but sadly the truth. Hence the lack of joint working or restricted joint working until abstinence is achieved. Verging on Nimby-ism?… possibly!

3: How do you feel a mental health diagnoses affects a person that uses substances? Do you feel it puts them in a position whereby their drug use overshadows their mental health, for example? Or the opposite? Or don’t you think it makes any difference?

I think that a mental health diagnoses can be a lot to deal with for an individual, but at the same time can be a relief due to there actually being a basis for otherwise unexplained episodes during the individual’s life. Whatever the outcome following a diagnosis there is without doubt an element of stress, confusion, fear, and a number of other contributing factors that could put an individual at added risk. Its not every day that you are given a diagnosis that could have a major effect not only you but on every other aspect of your life and those involved in your life.

This can have quite an effect on an individual. And in turn on their substance use, if this is a co-occuring trend in that individual. I wouldn’t say that it doesn’t make any difference as it most definitely would. The effect however would depend massively on the individual. Neither ‘should’ overshadow the other as both are issues that overlap in a number of ways and both are relevant in the progress of the other, however, I can see how one could take prevalence over the other at any given time during the individual’s journey. Another reason for comprehensive dual support.

Again relaying from a discussion around this with my partner, who has been through this situation. When given a diagnosis, although there was a sense of relief that went alongside it there was also understandably a sense of overwhelming fear and lack of understanding that came with the diagnosis which resulted in her pulling away from services for a period of time to digest the information, an obvious reaction in a situation of this magnitude, however…..this highlights a concern, in that, this is obviously a testing, scary period and quite a vulnerable situation for an individual, yet with the facts being presented to the relevant services, she was then able to ‘disappear under the radar’ for a number of years without due care and attention being given to support the news given. Surely there is a duty of care here with regards to this? Or am I mistaken in believing that this may be a regular occurrence that repeats itself in similar situations, which, given the serious risky behaviour (a recognised trait) that could follow, could put an individual in the red on the RAG system, (high risk to self or others) and in a precarious situation. Here I have to ask, how is it possible for someone to effectively disappear, and in all honesty, be able to disappear without being subject to some kind of preventative measure being taken to ensure minimal risk to the individual after being given news of this kind? However, once resurfacing the first place she accessed was the substance misuse service for support as it was made  clear on her first access in treatment, where she was diagnosed with her condition, that her substance use would have to be dealt with prior to her mental health issues being effectively addressed?

There are a number of research papers and debates surrounding dual diagnosis that are almost reminiscent of the chicken and egg scenario, however this seems small in comparison to the fact that there is an individual presenting with a need for immediate support regardless of what came first. Surely? This would transpire during care within a systematic approach that involves substance use and mental health services joint working for the better towards an outcome that promotes well being for the individual.

I must also add here that there is a massive responsibility here on the way news of this nature is delivered to an individual and also how it is seen to be supported in follow on care. Both sides of the care spectrum here are of equal value in promoting the best outcomes for an individual when on the outside devising further care plan. however as I have said there will be different responses from every individual who finds themselves in this situation. And each individual response should then be taken into account with regards to next steps with the care of that individual encompassing all avenues of care equally and with dual importance inclusively.

If one is left to put more emphasis on the other then I fear that the evidence would create a never ending circular effect rather than one of positive steps forward towards any positive definition of recovery.

4:  How would you like to see services engage with people that use substances with a co-existing mental health issue…for example…would you like to see more advocacy for mental health issues within the alcohol and other drug community? Are more services needed? If so. can you think of any in particular?

Collaboratively? There seems to be a distinct barrier towards supporting individuals with dual diagnoses and other co-existing conditions. And  trend for ‘either or’ support. Not totally, I might add,  but it does exist and it is quite frustrating to a professional trying to wade through the paperwork and the requirements and the target setting etc, etc, to meet specific requirements set out to ensure continuity of  care. So, that being said, is it any wonder there is a high rate of drop out in dual diagnosis recovery statistics. There is also the existing and very relevant social inequalities issue around differing support and care that also adds a little spice to the state of play. Another issue worthy of debate on another platform, social, economical, environmental, etc….

With regards to advocacy within substance misuse services I feel that there is always room for more advocacy for something of this magnitude which is of high importance and can be severely detrimental to an individual if they are not given an all inclusive support package to coincide with the delivery of a diagnoses. Having said that I am fortunate to be able to say that, in my experience, there has always been a frontline approach within substance misuse services towards mental health issues in ensuring there is full support and wrap around service engagement when dealing with dual diagnoses at every level, within remit. I do think that there could be more peer support and support groups put in place on the mutual aid front to support individuals living with dual diagnoses. And that this is something that is possibly being overlooked in the current abstentionist movement. Because of the high risk of relapse in thoughts feelings and behaviours, as well as substance use, however, this is where harm reduction is all inclusive in it’s outlook to promoting ‘full’ recovery and supporting those for who ‘full’’ recovery may not be possible, in every aspect of their lives. It supports the individual to achieve a full and positive outcome regardless and also to achieve acceptance both personally and within their respective communities regardless, without putting unrealistic targets, requirements and aspirations on them at the same time.

With regards to services, it is unfortunate that there were services out there that were primarily set up to deal with dual diagnoses, but as mentioned previously they are being systematically dispersed due to cuts, and, being in the unfortunate position of not meeting current payments by results criteria. A sad state of affairs where an already stigmatised group of people are now being restricted in care options because of financial and economic distress. The negative impact this could have on an individual seems to have been lost in a quagmire of finance and social cleansing. Perhaps if we were to challenge that brilliant marketing tool for big pharmaceutical companies, the DSM, and bring it back to individual care rather than profit then there would be more realistic and less idealistic approaches and more funding to put into supporting these individuals rather than paying out extortionate fees for excessive over prescribing of medication.

More services are always needed to cover dual diagnoses, in my opinion, however a re-assessment of those already existing services that are involved in the care and attention of those with dual diagnoses would serve purpose for the time being in a climate of ‘more for less’ at the cost of less intense care and support for the individual at the heart of it all . And a more open and inclusive approach to dealing with and supporting those who are living with co-morbid conditions which includes more support groups aimed at peer support and mutual aid and more public understanding of the realities of dual diagnoses.

It would appear that there is a flaw in the current recovery agenda that does not take into consideration those for whom ‘full’ recovery may not be possible, and with current financial cuts hitting the sector hard where it is most effective, and indeed most needed, the safety nets are being dismantled and taken away from the providers that cater for those who are caught in the middle.

THE PARADOX OF DRUG POLICY REFORM.

  There have been many individuals, organisations, NGO’s, etc,  that have stood up, and indeed still do, for the civil and human rights of people who use drugs (PUD’s) many have made significant and positive change happen, many still fight to reduce the risks and harms to PUD’s under dangerous and destructive policy and procedure. Raising awareness of the stigmatising and discriminatory practices that serve no purpose other than to demonise an already vilified and vulnerable group.

   In some countries illegal importing, exporting, sale, or possession of drugs constitute capital offences that can result in the death penalty. 33 countries and territories that retain death penalty for drug offences, including 13 in which the sentence is mandatory. These countries include, Afghanistan. Bangladesh, Brunei, China, Egypt, India, Indonesia, Iran, Malaysia, Morocco, Pakistan. Saudi Arabia, Thailand. United Arab Emirates, Syria, Vietnam. Even in the USA the United States Supreme Court in Kennedy v. Louisiana struck down capital punishment for crimes that do not result in the death of a victim, but left open the possibility for “offenses against the State” – including crimes such as “drug kingpin activity” including very large quantities or mixtures of heroin, cocaine, ecgonine, phencyclidine (PCP), lysergic acid diethylamide (LSD), marijuana, or methamphetamine.

 In China and southeast Asia, PUD’s are detained compulsorily in government run centres tht declare they are there to enhance “treatment” or “rehabilitation”. There is no element of treatment or rehabilitation in these facilities and PUD’s are held without the due process protections and less rights than those locked in prisons, no access to legal repressentation, no right to appeal, and no judicial oversight of detention. Some are detained for years without ever receiving any form of evidence-based drug dependency treatment,  in isolation cells, forced to work, and abused by those who should be there to provide care and support. Some forms of torture that are used in these centres incude electrical shocks and many in the care of these centres are sexually abused. There is no process to determine drug dependence either cinical or otherwise.

  These centres also lock up the homeless, street children, and those living with mental illnesses. None of those who are held in these centres are given any kind of health care even in it’s most forms. There may be contact with health proffesionals but this is usually in the form of mandatory HIV testing, forced blood donations, scientific research, (mostly involuntarily) and a number of other inhumane practices.

  Investigations into issues such as risk factors for HIV infection among injecting drug users (IDU), HIV prevalence, effectiveness of behavioural HIV/STI prevention interventions, and the efficacy of particular modalities of drug treatment have repeatedly shown that these practices are inhumane and unethical and yet these practices still continue. The practices are often described, by those who run the facilities as, training centres focusing on “physical exercise, education, information, and job training for PUD’s in the city” What is actually meant by this is that those in these centres are forced to work for at least 8 hours a day as labour therapy, they are forced to attend educational classes but denied any access to standard or recognised educational equipment, the educational content aimed at promoting the needs of the area they live in and not based on educational values or the needs of those being educated. Very basically, PUD’s and other vulnerable individuals who are held in these centres are treated worse than animals and isolated from the outside world. Completely with no civil of human rights and this treatment is indefinite spanning out years in most cases with a high number of those incarcerated dying under the conditions they are forced to live in. The surrounding communities support these ethics because it is easier to use detainees than it is to use someone who lives a ‘normal’ life when looking for employees or similar needs and it is also a lot cheaper therefore research and investigations into the running of these facilities is hard to achieve and access to the majority of them is impossible.

This and a number of other reasons make drug policy reform campaigning a matter of civil disobedience in areas where this kind of treatment is normal practice, and even in some more advanced countries. Campaigning for better programs and more humane practice in most areas is seen as controversial and can at times be dangerous to those who openly advocate for positive reform. This civil disobedience is also related to facilities such as drug consumption rooms, promotion of life saving medications, decriminalisation, equal rights for PUD’s and handing out clean equipment. Most of these actions have been carried out by passionate and dedicated individuals whose principles came before the risks they took when advocating or initiating programs that provided safer practices and safer environments for PUD”s.

It’s ironic really that in order to reduce the risks and harms of those who use substances you must put yourself at risk of harm in some cases, but for the greater good. It’s also ironic that despite this being seen as a form of civil disobedience, it is also based on insurmountable evidence that suggests, in fact proves,  that the practice advocated for is the most effective, positive and productive way to address the issues in most communities and yet many communities stance is quite the opposite in content.

There is however a paradox that presents itself when looking at policy reform. From a political angle those in power must find a solution that reduces the harms to the majority of their constituents. And this can mean economical, financial, emotional, mental, physical, etc. Now by social design that has been manufactured for years, vulnerable groups within communities have been portrayed as being less productive and at times damaging to communities with regards to crime statistics, cost on health services and such, unemployment statistics, homelessness, etc. So when looking at policy reform in any arena there is a conflict of interests when making the decisions that would be of maximum benefit. and when looking at who would be more satisfied with the outcomes of such policies there is more reason to look at the outcomes in potential for votes rather than ethical, public health outcomes.

The need to look at policy objectively, looking at socio-cultural needs, societal influence, public health issues, cost effeectiveness, etc is long overdue but is also a problem that needs to be addressed in stages with both sides of the argument being critically assessed and dissected and this might also mean that there will be recognition on both sides that some draconian policies and procedures have caused more damage than good and this might be where the delay originates from with regards to looking at the overall cost of some of these policies. Based on the evidence presented at the beginning of this article there have been a number of human rights ignored with regards to policy and agenda that have resulted in the deaths of high numbers of PUD’s and members of other vulnerable groups within communities and this would have to be held accountable if realistically taking effective and evidence based policy into account.

There lies the paradox of those who are in a position to make the changes, but even the most ignorant of those in power must know that change must occur, and to delay it any longer simply gives more space to add to the long list of fatalities and other heinous crimes that, in content, by far excede and outnumber any other casualties of war and war crimes in the course of history. The war on drugs, a war on people, needs to end and it needs to end now.

NALOXONE: THE ROLE OF USER ACTIVISM.

NALOXONE: THE ROLE OF USER ACTIVISM

It has been shown throughout history that if 3.5% of the general public stand up against social injustice and move for positive change then it will indeed happen….the last hundred years provide the evidence, sadly this is not the age for evidence based policy and therefore we need to stand taller and shout louder, but change will indeed come”

The role of user activism is clear and precise in it’s aim and objectives. Primarily the role is to raise awareness of the everyday issues experienced by those who are living on the frontline and experiencing the real effects of policies and procedures that affect them. Providing evidence base to counteract idealogical policies that neither support nor reflect the true needs of the user community.

Activists, both individually and in groups, have successfully initiated change in a number of area’s where it was sorely needed and the effects have been instrumental in supporting whole communities within communities to live positive and productive lives in the face of adversity, ignorance and discrimination. Exposing elements of fear of that which is not understood, misrepresentation, misunderstanding, scapegoating, etc, in media, politics and the medical industry to mention few.

As long term global economic trends sway towards a reduction in profit rates and the competition soars to an all time high, the pressures these put on governments, corporations and organisations, have produced a period in which fundamental issues of political and economic structure are at stake an the response is a divide-and-rule political arena to promote stability. This in turn promotes the negative outlook on specific groups of individuals by the term affectionately known as ‘the politics of scapegoating’ People who use substances are extremely vulnerable to this particular form of political escapism. This can, and does, divide communities in ways that weaken opposition to socioeconomic changes and policies and strengthens punitive and individualist ideologies. This then has the negative effect of allowing policies that maintain or increase drug-related harm to continue seeming less an ‘error’ than perhaps a rational way to defend the interests of the powerful.

This therefore, in my opinion, shows that there is indeed a desperate need to develop a political understanding between the policy makers and activist to expand the concept of ‘politics’ and take it beyond specific interest-group politics. Consideration of when and how it might be best to work with groups of individuals for social change from the bottom up, rather than the opposite way round. This political trickery is not only evident in the user community as the current display of negligence with regards to people’s hopes, fears, housing, employment, economic and financial security, becomes common practice in all aspects of the political arena. This may seem like a negative outlook, however, it also can provide the opportunity for collective action against the social-structural sources of the problems.

The term harm reduction has, of late, almost become a taboo subject that despite being firmly grounded in evidence based policy and procedure. In the current climate the harm reduction community is facing disinvestment and the health and safety of people who use substances, which should be of paramount importance, is not being seen as the priority that it should. This is having a detrimental effect on huge numbers of individuals within our communities. The harm reduction ethos is simple…

* To reduce the harms and risks to whole communities by raising the awareness of public health issues faced by people who use substances, looking at productive and positive cost effective solutions to the harms and risks to whole communities.

* To provide a platform for mutual aid support based on effective programs and past experience that has proven to promote the health and safety of all involved. A place where identity and a like-minded train of thought promotes unity and progress in the interests of all involved.

* To support others with similar issues or a vested interest in the care and support of those within the community by consulting and advocating at all levels on a global scale to increase the understanding of the risks and harms that may come with substance use on both individuals and whole communities.

The term harm reduction is ever evolving as the numbers of those involved grow bringing a different perspective and understanding to the platform. As trends and substance use changes, so does the concept and reach of its community members, but it’s core value is to always promote the health and safety of every member of the community by focusing on the individual’s wellbeing based on the above three main objectives.

User activism can take on many forms and ‘activism’ can be something as simple as writing a letter. Anything that ‘consists of efforts to promote, impede, or direct social, political, economic, or environmental change, or stasis‘ can be collated under the umbrella of activism.

The role of user activism in Naloxone provision is to raise awareness around the issues that are current in our communities with regards to drug related deaths etc. With the recent 32% rise in drug related deaths there is a dire need to provide evidence to support any kind of program that promotes reduction. It is clear that current agenda and policy does not effectively reduce the harms or risks that people who use substances face on a daily basis and based on my earlier comment around disinvestment this looks set to get even worse unless something is done about it and a return to evidence based policy and procedure can be reinstated and funded properly to secure the health and safety of the community it represents. As the evidence adds up to show that naloxone works, and the resistance loses its footing, the pressure must be applied to keep the momentum going. Activists all over the world are coming together and providing the evidence needed to support this program. With the current statistical data in UK showing that, on average, 3 individuals die every day of opioid overdose, the need for this program speaks for itself. Those living with the loss isn’t just restricted to the user community, this effects every single member of the community, emotionally, physically, mentally, financially, etc.

This can be approached by a number of ways with regards to activism and actively promoting naloxone in the community. There are a number of websites and groups that have all the information needed around naloxone, the product, the uses, the evidence, the statistics and the law to start a campaign or indeed to join an already existing one. There are also a number of groups and organisations that offer free training. Which once it has been given can be cascaded wherever needed. Lobbying local politicians, and other similar members of the community is another angle that can be taken. Petitions either hand collected or electronically collated can be used to approach health and wellbeing boards, clinical commissioning groups, service providers and other similar groups or organisations. Mutual aid groups and collectives can be set up and have proven to be successful in the form of action groups and harm reduction cafe’s where the main topic has been, but not exclusively, drug related deaths and solutions to reduce the effects this has on communities.

Making yourself available for any consultation in any arena that evolves around the topic and joining the dots in your community. As members of an already vilified and demonised community it is in the interests of everyone who has ever suffered at the hands of ideology, ignorance, discrimination and all it’s trimmings to join together and make sure that as a voice we are heard.

The substances that can induce overdose are not restricted to illicit use, in fact, the majority opioid substances that can be evident in overdose situations are prescribed medications. However due to the barriers that have risen through discrimination and socio-political design it is the illicit use that gets highlighted as the main concern and due to the afore mentioned reasons and negative media coverage the design effect is resulting in disinvestment with fatal outcomes as those who use drugs become the scapegoats of a society that has become part of the problem rather than part of the solution for many.

HUMAN RIGHT NUMBER ONE: EVERY HUMAN BEING HAS THE RIGHT TO LIVE….”

CHALLENGING IDEAS IN MENTAL HEALTH.

Defining and understanding mental health and illness.

THINK

Conditions of state of mind if not correctly placed can be stigmatising and create a confusing scenario when discussing with an individual. Always be clear and precise when discussing elements of care with an individual and make sure that what you re discussing or conveying is explained in full with no room for misunderstanding. When dealing with a person who is living with  condition or who is going through a period of mental distress there must be clarity and understanding to reduce the risk of current, historic and future distress and confusion. For instance there is a distinct difference between mental illness and mental health that is at times lost in translation when discussing the topic. At all times your definition must be clear and fully evidenced.

Respecting personal experience of mental distress.

labels are for clothes...

Always refrain from categorising, judgements, etc. Always meet the individual where they are and allow for among other considerations, cultural, religious and social background, a full understanding of the nature and background of an individual should be taken into consideration when working and caring for a specific individual. When approaching a person who is living with a condition it should be approached in the same way you would approach an individual under any other circumstances, with unconditional positive regard, non-judgemental, open-minded and empathetic, always respecting equality and diversity. Anything less could add to the already perceived or at times very real stigma experienced by an individual.

Community care, fear and the high risk user.

There has been a distinct change in the care of individuals in our communities who are living with a condition. This has changed from asylum’s for the ‘mentally unstable’ to care in the community. This does not always promote a change for the better. Way’s of collating and reporting care in the community have been ‘socially structured’ and therefore have a negative impact on those living with a condition in the community therefore adding to the stigma. There is an element of fear and misunderstanding that has been added to by negative media coverage. The social structure has been designed to report the negative aspects of individuals suffering from mental distress. Links between violence and negative aspects and mental distress are weak and most are lacking in evidence to support. In fact when looking at other concerns in the area such as alcoholism and substance use the evidence clearly finds these concerns higher risk when it comes to health, emotional and physical complications. The statistics are clear that violent crimes are more frequent where alcohol is concerned yet due to the reports and the design of the reporting the evidence collated and the way it is collated would have us believe that those suffering mental distress are higher risk.

Mental health as a business.

A lot of this could be attributed to the influence of pharmaceutical companies on the world of psychology. Big pharmaceutical industries have become big business in the field of mental illness resulting in a toxic and lucrative relationship between services designed to support and treat and those that produce medications to treat. This has created a need for individuals and has had a massive impact on the promotion of medication, which in turn has hugely influenced the changing face of mental diagnoses. This has, in effect, created a conflict of interests between ‘real’ care and big business with psychiatry almost selling out to the interests of the big pharmaceutical companies that manufacture the medications designed to treat. The number of diagnosed conditions has effectively grown resulting in a vast and intricate business rather than focusing on real and effective psychiatric treatment and this also began to have an influence on the decision’s made by a small handful of psychiatrists which could result in misdiagnoses and add to the stigmatising of individuals and the negative impact that a diagnoses may have on a specific individual. Also the dependence of research could easily be influenced by this as an effective way of funding research programs. Two prime examples of this are ADHD which when discovered resulted in a huge surge in ritalin and at the same time a huge rise in Autism which demanded a new form of treatment. Antidepressants were the ideal example of big pharmaceutical companies influencing the field of psychiatry and marketing strategies have been created to sell the product to the consumers, in this case the professionals dealing with individuals in frontline situations. This has resulted in misrepresentation of some drugs where side effects were not recorded but were reported. Research not being truly reported difficulties and true evidence being extremely hard to find. This also in turn creates a major cost to the communities and the general public.

Public health and mental health promotion.

When discussing public health there are two angles to consider. The first is reducing the risks to the general public and the second measuring disease and devising strategies to prevent illness. Mental health can be seen as a considerable ‘burden’on public health with it’s cost reaching in excess of £77 billion a year. £12 on the NHS, £23 billion due to the fact that those diagnosed with a condition may not be able to work and the remaining £42 billion attributed to the reduced quality of life and indeed the loss of life among those living with and living with another who has a condition. The relationship between mental health and public health is inextricably linked with most conditions affecting not only the ones who have the condition but also their significant others. Concerns and worries arising from the conditions of a loved one, such as fear of self harm and suicide, schizophrenic episodes, to mention a few, can affect the social functioning of all involved. Quality of life is intertwined with psychological well-being. Alongside this the individual living with the condition, it has been evidenced, have worse physical health than others. This can sometimes be attributed to the side effects of some medications given to treat the condition. Public health incorporates the care of all those living in and around the confines of mental health, this can include: homeless, prisoners, abused individuals, dual diagnoses, and people with disabilities, and also covers all ages. It also covers all platforms from home to hospital and school to work. In order to promote mental health we must address stigma and discrimination at all levels, supporting inclusion at every level and learning about the health, emotional and physical trauma’s faced by those living with the condition and those surrounding and supporting them. This is imperative in supporting an individual to take control of their lives.

KEEP CALM-MENTAL HEALTH

IT’S ALL IN HOW WE BEHAVE….APPARENTLY?

Research over the last decade has shown that some of the major causes of death have come to be connected or attributed to specific ‘risk factors’ These have been, in general attributed to the individuals overall behaviour. So…in this context….lung cancer, cardiovascular disease and stokes have been attributed, largely, to smoking, Lack of excercise and alcohol consumption. It stands to reason that governments and local commissioners may find an element of appeal in this, especially when it comes to public spending, however….anyone with a practical outlook on such an approach would argue this point and advocate to educate rather than deflect. This way of looking at things also shows that those at the lower end of the social scale, suffer a disproportionate amount of disease, and therefore sends out a message that they are the subsection of society that are most likely to indulge in ‘unhealthy’ habits. An argument for the other side of this view would be that if, for instance someone at the upper end of this ‘social scale’ were to be a successful business man who fell foul to a debilitating disease which rendered him incapable of carrying out his daily routines, work, family functions, etc, then he would slowly but surely slide down the social scale and then become a statistic to support the flawed outcome stats that eventually are used to support this debate. How many times have you read articles where a death has been attributed to substances, and excessive substance use, added to the stigma surrounding the drug using community, then a little further down the line found out that there were underlying issues that contributed to the death. The daughter of a police officer in 1995 made headline news death was given to her use of MDMA, but then research brought to light that she also had an underlying heart condition and the main contributor to her death was water intoxication!! 7 litres, if I’m not mistaken, and if I am then the principle can still be taken from the statement. Although there is a need to look at the behaviours of some individuals, articles like this lead us down a path of misleading hysteria and diluted messages, it is not the way forward in public health intervention. 

  Health professionals, politicians, policy makers and similar guiding lights have, in all admission, promoted successfully that an individuals behaviour is not only the prime cause of ill-health but also the main factor in the maintenance of good health. Reinforced by the general media, and thus taken into the public domain, via usual routes and more increasingly social media platforms, this is being upheld with little to no critical debate around it’s scientific origin. Surely ‘Public health’ should be concerned with the the more immediate factors primarily in both the social and cultural structure which can severely affect the health status of an individual rather than the isolated activities of that individual. Dominance of health officials and commissioning bodies who are in a position to define health needs and issues according to their own criteria may well create a serious imbalance in the research being carried out, the quality of the information shared and also the policies that are subsequently adopted to address specific issues. 

A flawed outlook: If we allow ourselves to focus on an individuals behaviour then we may be deflecting attention from the more real and relevant issues that cause that behaviour. Factors in social structure, class divides, etc. If we are to look at the bigger picture, it stands to reason that most individual behaviours are a result of a number of different aspects and attributes. To look at the end result and base our outcomes on solely that is an unsatisfactory way of achieving positive outcomes. If I self harm, it’s okay giving me a band aid and doing an on the spot assessment to assess where I am at at that particular moment in time but does it take away the reasons as to why I self harmed in the first place??? If I use substances as a means of self medicating, taking away the substance then leaves me with the problem and no ‘solution’ therefore I need to look at why I chose to medicate in the first place. Looking at my behaviours is not going to take away the root cause. Another dilemma with the statistical side of this is the fact that most statistics around social class and the issues surrounding are collated by middle classes. The reach of social deprivation and the adverse health experiences of those living in deprived circumstances is obviously going to be in contrast with those living in less deprived status. Mortality rates are more significant in those who are living in disadvantaged conditions. There are a number of different attributes that add to the outcome of behaviours… housing, employment, finance, economic, social interaction, All of these can contribute to a number of significant health problems Statistics have proven that perinatal mortality rates are higher in those who have low capital in the above mentioned areas in their lives. Those who own their own homes have less mortality rates than those who are living in social housing accomodation, Those in stable employment have a significantly higher mortality rate than those who are living in poverty. As I’ve already said as well, if someone is living in high quality of living standards and falls ill then their capital could significantly reduce, not being able to keep employment, not being able to provide for family, not being able to maintain bills and cost of general living, therefore they would inevitably fall from their social standing into a lower category which in turn would turn the stats….flawed.

RECLAIMING YOUR PLACE IN THE COMMUNITY.

 

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RECLAIMING YOUR PLACE IN THE COMMUNITY.

 

Becoming an empowered member of the community means having choices within that community and also having a voice where you’re opinion is valued. Giving back and sharing your experiences with other people can promote this and gives weight and depth to your role within the community. Becoming accountable for your actions, and, facing up to your responsibilities as a recovering individual. Making a difference can promote empowerment and self esteem, building confidence and self awareness at the same time. Having said this you need to be aware of when and how to express your opinion and in what arena your voice would be most effective. The beginning of your journey may be making sure you have a solid foundation on which to build your first step into the community. Exploring your new found direction. Working out your first year plan. Taking risks and trying new things. Learning to accept the consequences of your actions and finding the best ways of dealing with those consequences.

1: What could you do to give back to your community?

2: How would you start this off?

3: Who would be your target group?

4: How can we help you to achieve this?

 

Reclaiming your place in the community can be daunting and at first seem like an uphill battle. But once you start the journey it becomes easier as you involve yourself in more and more. Getting involved in things that you enjoy, volunteering, furthering your education, sports, socialising, attending interest groups. All of these can promote a positive social network and this in turn takes away a lot of the irrational fear that can kick in when making these first steps. Having a nice place to hang out, local café, park, etc. Some areas are lucky enough to have recovery cafes and centres designed for just this. Having a routine that is not all work but involves a fun aspect as well. Making new friends and rekindling old friendships can also promote wellbeing in a new environment. Filling your week with new challenges.

 

1: What fears do you have around re-engagement?

2: What evidence is there to support these fears?

3: How can we address those fears?

4: Where would you like to see yourself in 3 months time?

5: Set yourself a challenge right now to achieve for next week?

 

Redefining self is something  that can take time but where to start is to look at yourself and ask yourself…what are my strengths and resources. Knowing your addiction is only a small part of who you are and knowing what you are capable of and that you are worth so much more than what you give yourself credit for is the key to your foundation. Not allowing yourself to be labelled any more and standing up for your rights as an individual, exploring life outside of your comfort zone and beyond treatment. Be aware of what you can offer and being accountable. Proving to those who repeatedly told you that you would never amount to anything with your life that you are capable of anything life throws at you. You are a survivor, not a victim.

 

1: Who are you?

2: Who do you want to be?

3: What are your strengths?

4: What are your weaknesses?

5: How can you use your strengths to combat your weaknesses?

6: What would the child you were say to the adult you’ve become?

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WARRIOR DOWN PRACTITIONER GUIDE (DRAFT)

WARRIOR DOWN PRACTITIONER MANUAL

 

 

Warrior down projects operate in an unusual environment of being both service provider and host of an emerging recovery community and this dual responsibility requires careful management, not least in maintaining appropriate boundaries in how we respond to a ‘warrior down’ or a  request for help from a significant other. It’s not our place as a provider to outreach someone who hasn’t asked for help, but as a recovery community we can adopt the ‘warrior down’ approach to reach out into the community and provide assertive support.

What do I mean by this? Adopted from a peer-to-peer programme originally designed to provide support and community referrals for Native Americans in recovery, ‘warrior down’ is the cry to signify that a warrior has been wounded or incapacitated and needs help. The warrior down initiative creates a response team to provide support and finds the resources to get that person back into their recovery process.

Recovery isn’t just staying sober – it’s a way of experiencing life through new eyes, new  thoughts, and a new spirit. Re-establishing one’s life following treatment for alcohol or substance abuse or incarceration requires a community effort. Without the support of a knowledgeable family and community, many who try to return to healthy, productive lives find themselves frustrated by the need for a job, training, education, housing, mental health care, medical support or connections with others who value sobriety and healthy behaviours.

Throughout the evolution of the UK recovery movement there has been close liaison with colleagues and friends in the USA, and it was in 2011 that Phil Valentine came to the UK and told us about the White Bison Warrior Down Program. The whole warrior down ethos and philosophy had an immediate resonance to those in recovery communities in the north of England, where small but influential groups of addicts have come together to create abstinence-based recovery communities.

They have done this most obviously in NA and AA – many got there via prison or simply stopped taking methadone and dropped out of treatment. It’s very rare to find people in abstinence-based recovery who got there via community methadone treatment and, similarly, the rooms of Alcoholics Anonymous have facilitated peoples’ recovery and been the driver for them to reach out to those who are still in battle.

Given the numbers of people entering recovery it was only a matter of time before people started to relapse, and we asked ourselves how we should respond. This really is brand new territory. Treatment professionals are not used to assertively reaching out to people who relapse – people in 12-step fellowships may respond with comments like ‘God or drink and drugs will bring them back – one way or the other’, but neither standard treatment assertive outreach or benign 12-step fellowship felt like the right thing to do.

The people who had relapsed had become our friends and allies. They were almost family, and you don’t leave one of your own out there on the battlefield, in the madness of addiction, to die. You go and get them and do everything you can to get that warrior back into their recovery process.

Warrior down response teams are driven by ethical governance as opposed to clinical governance, and they work across geographical boundaries. Recovery communities have been utilising this approach for years. The approach is made up of informal coalitions of work colleagues, treatment professionals, friends and family members, as well as those supporting family members like Loved Ones Unite and Al-anon, faith-based group members and peers in recovery. They operate inside the recovery system, but outside of the treatment system. They respond to anyone who is in need, at any stage of their journey.

Many recovery slogans and clichés have become part of people’s lived reality. People in recovery know that ‘you alone can do it, but you cannot do it alone’, because they have tried it on their own and failed time and time again. They know that ‘I can’t but we can’, they have been that addict or that alcoholic who has sat on their own thinking about recovery while ordering two bags of brown and one of white. Then there is the addict whose thinking turns to drinking: ‘I’ve never really had a problem with alcohol, it was just gear and crack – I’m sure I’ll be OK having a drink.’ These experiences prove that an addict on their own is indeed behind enemy lines – rhetoric soon becomes reality when you realise that we really are in this together.

 WARRIOR DOWN RELAPSE PREVENTION PROGRAM.

PURPOSE: The Warrior down program is set out to provide a relapse prevention and recovery support group for peers who are completing treatment and returning to their community after a period of addiction or incarceration.. It is also set up to provide support for those already on that journey who may be struggling with life on life’s. The principles are based in the altruistic movement that is evident within already established recovery communities and the core value is the therapeutic value of one addict supporting another on their respective journeys. This program has been adopted, quite successfully, by recovery communities up and down the country, peer support groups and recovery champions.

WHAT IS WARRIOR DOWN: Warrior down is the cry used to signify that a warrior has been wounded or incapacitated in some way and needs help. The warrior down program creates a response team that provides the support and finds resources to get that warrior back into the recovery process. This is a peer to peer program that is designed to equip individuals with recovery support and community integration techniques to support a sustainable and successful recovery journey that accepts relapse as part of that journey and puts protocol in place to support that part of the recovery journey. Recovery is not just about staying sober or drug free. It’s about seeing life through new eyes, new thoughts, and a new spirit. Re-establishing ones life following the absence of substances or following a period of incarceration requires a community effort. Without support from a strong knowledgeable social network, peers, family, professionals, etc. Many who try to return to healthy, productive lives find themselves frustrated by the need for employment, training, education, housing, transport, mena tal health care, medical health care, social services, spiritual and cultural support or connections. A positive connection with a like minded individuals, who value their new found way of life,  within the community, who has bee n through the stages of recovery can make all the difference and show that recovery is possible and achievable.

CULTURAL AND SPIRITUAL SUPPORT FOR RECOVERY AND  RE-INTEGRATION:  The original warrior down program has its origins in the Native American culture and some of the principles are deeply spiritual and cultural in  practice. Original healing process  included healing circles and traditional ceremonies. Ceremonial activities have a distinctly spiritual focus, and the incorporation of intergenerational activities that include both elders and children. The involvement of family and significant others in the process is an integral and important part of the process. It is recognised as being essential for the well-being of all involved in the process, which inevitably has an effect in the overall community around those involved in the re-integration process. The teachings of the Elders and the Clan mothers provided wisdom and quidance. Unfortunately some of those that we come in contact with have no family support or significant others in their lives  for numerous reasons and this can be a major barrier to re-integration in some areas. Those who are isolated in this way may benefit from having a mentor, guide, or sponsor as such to provide the same guidance and wisdom around issues that may seem daunting and overwhelming to an individual at any given stage of their recovery journey. Th spiritual pathways provide meaning and purpose but again are a misunderstood concept in that they are not religious in content but can be seen to be in their delivery in certain mutual aid environments. A spiritual act is simply an act done in support of a fellow warrior, such as going for a coffee, meeting up for a chat, helping someone across the road. Cultural activities create a social and emotional foundation for reconnecting and re-establishing a sense of belonging and identity. Most individuals who are on the recovery journey are driven by a spiritual ‘need’ to help others and have a desire to share their journeys with other recovering individuals or those that have that same desire for change. This promotes and empowers re-integration into the community and supports the individual to sustain a balanced emotional, mental, physical and spiritual  wellbeing throughout their journey.

RE-ENTRY BEGINS IN THE TREATMENT ENVIRONMENT BUT MUST BE RECOGNISED AS JUST THAT, A BEGINNING. THIS IS MERELY THE START OF THE JOURNEY WHERE A SOLID FOUNDATION CAN BE PUT IN PLACE FOR THE INDIVIDUAL TO BUILD ON. STRUCTURED RECOGNISED TREATMENT OPTIONS ARE NOT TH EONLY WAY OF RE-ENTRY AND THERE HAS TO BE RECOGNITION GIVEN HERE TO OTHER FORMS OF MUTUAL AID AND PEER SUPPORT AS A VALID AND EFFECTIVE WAY OF INTRODUCING AN INDIVIDUAL TO THE EARLY STAGES OF RECOVERY.

 

 

 

PHASE 1: PROGRAMS FOR RE-INTEGRATION WITHIN THE TREATMENT SETTING.

(medicine wheel and possible 12 step curriculum)

 

The 12 step recovery program is specifically designed to meet the spiritual and cultural needs of member s of the community who are entering the recovery journey and also offers support for those on that journey. There is already a established community that has been successful for over 70 years. It has proven to be successful in its approach and is by far the most recognised mutual aid support network within our communities, however, this is not for everyone and there are other mutual aid options available to those who find the 12 step program is not for them. Of these other forms of mutual aid there is SMART Recovery which is another growing community nationally and is rapidly becoming known as  the ‘alternative’ to 12 step. THE SMART program is a peer led initiative that consists of a series of tools  that are based on tools used in CBT, MI and REBT counselling. The SMART program is a four point program that consists of…

 1: Enhancing and maintaining motivation to abstain.

 2: Coping with urges.

 3: Managing thoughts, feelings and behaviours through effective problem solving.

 4: Balancing momentary and enduring satisfactions  to achieve lifestyle balance.

SMART Recovery is different in that it advocates choice and leaves the individual the freedom to choose what works best for them, providing a number of different options. SMART aims to support the individual towards achieving a balanced and healthy lifestyle and works towards a ‘graduation’ whereby the individual then moves into the recovery community. This is different from the 12 step principle in that the 12 step program advocates for lifelong membership and commitment. Some of the specific tools used in the SMART program include….

CHANGE PLAN WORKSHEET: This is a chart in which you list your goals and how you will attain them, the ways in which you will overcome obstacles and challenges, etc. The process of completing a change plan worksheet clarifies both your goals and the potential roadblocks to attaining them.

COST BENEFIT ANALYSIS: This tool is especially useful for increasing motivation to abstain from addictive behaviour.

THE ABC’s OF REBT: This tool from Rational Emotive Behavioural Therapy, founded by Albert Ellis, helps to identify irrational beliefs, which in turn lead to poor consequences.

DISARM: Destructive Imagery and Self-talk Awareness and Refusal Method, This  tool exposes the thoughts and images which urge us to pursue our addiction as inaccuracies, excuses and rationalisations.

BRAINSTORMING: This technique is often used in face to face and online meetings. A participant introduces a question or problem. Other participants then offer ideas or suggestions without judgement.

ROLE PLAYING / REHEARSING: This tool is used mostly in group environment. An example of which could be….rehearsing how  to avoid addictive behaviour in a chosen situation where there is a high risk or medium risk. Group members would play various roles in the situation and play out the role.

Other possible forms of mutual aid that can be looked at and explored during the initial first phase are Therapeutic communities.. These are community approaches that are based on 14 key competencies highlighted by both David  Kressel and George De Leon.

Other more specialised approaches and ideas for group environment work could be fatherhood initiatives, parental guidance courses….etc..

PHASE 2: RE-INTEGRATION CONTINUES IN THE TRANSITION PERIOD FROM TREATMENT TO COMMUNITY (CIRCLES OF RECOVERY, 12 STEP, SMART, THERAPEUTIC COMMUNITY INVOLVEMENT)

 

Again the need for mutual aid is paramount within this setting and should by this time be established and instrumental in the next phase of development. By this time the individual should have a good idea of where they want to be and which form of mutual aid support best suits their needs….and wants to support them in their new setting. This of course may change as the individual moves on with their recovery and their understanding and needs and wants evolve. This phase of the recovery journey is facilitated by ‘firestarters’.  Firestarters are peers and recovery champions who are established in the community and available to support an individual through mentorship, coaching, sponsoring  and other various ways in which the recovery journey can be enhanced and supported.  Part of the Warrior down concept seeks to support an individual into securing housing, employment, benefit support, social support, emotional support, and general support with etc. and members of the response team should be well versed and trained in these. General  lifeskills and  everyday living skills.  There are a number of individuals in the community who are available to sponsor people and there  are also  a handful of individuals already available in the community who are in a position to support this  by means of a relatively new concept known as recovery coaching. A positive, empowering and innovative approach to supporting members of the community in sustaining their journeys.

RECOVERY COACHING: Recovery coaching  is a form of strengths-based support for persons with addictions or in recovery from alcohol, other drugs, codependency, or other addictive behaviors. Recovery coaches work with persons with active addictions as well as persons already in recovery. Recovery coaches are helpful for making decisions about what to do with your life and the part your addiction or recovery plays. Recovery coaches help clients find ways to stop addiction (abstinence), or reduce harm associated with addictive behaviors. Recovery coaches can help a client find resources for harm reduction, detox, treatment, family support and education, local or online support groups; or help a client create a change plan to recover on their own.

Recovery coaches do not offer primary treatment for addiction, do not diagnose, and are not associated with any particular method or means of recovery. Recovery coaches support any positive change, helping persons coming home from treatment to avoid relapse, build community support for recovery, or work on life goals not related to addiction such as relationships, work, education etc. Recovery coaching is action oriented with an emphasis on improving present life and reaching goals for the future.

Recovery coaching is unlike most therapy because coaches do not address the past, do not work to heal trauma, and there is little emphasis on feelings. Recovery coaches are unlike licensed addiction counselors in that coaches are non-clinical and do not diagnose or treat addiction or any mental health issues.

SPONSORSHIP: Sponsors are people who have worked through the Twelve Steps and are available to help others in their recovery. If you want to work the steps as outlined in the book Alcoholics Anonymous, a sponsor can offer guidance based on their personal experience. However, it is important to mention that your recovery does not depend on having a sponsor. This program will take you on a personal spiritual path, and sponsors are merely messengers of the experience, strength, and hope that this program offers.

While the book Alcoholics Anonymous provides a description of how to work the Twelve Steps, a sponsor can offer specific assignments that help the process along. Moreover, a sponsor’s personal experience can assist us to confront problems, and move through them to change and growth.

You are ready to be sponsored when you have recognized a desperate need for help and a willingness to go to any lengths to recover. A prospective sponsor will suggest that you read the book Alcoholics Anonymous, and may make other suggestions for you to follow before you both decide whether to work together.

There are many benefits to being sponsored. Actively working with someone else offers you a chance to engage in a relationship based in honesty–an acquired skill for many of us with this illness. It is also an important venue to expose the illness and explore spiritual remedies. Usually we have blind spots. A sponsor who practices loving confrontation can help us break through these and gain a deeper self-understanding. Often people find that they are better able to help others because of the example provided by their own sponsor.

MENTORING: Mentorship is a personal development relationship in which a more experienced or more knowledgeable person helps to guide a less experienced or less knowledgeable person through specific barriers that may arise during the recovery journey However, true mentoring is more than just answering occasional questions or providing ad hoc help. It is about an ongoing relationship of learning, dialog, and challenge.

“Mentoring” is a process that always involves communication and is relationship based, but its precise definition is elusive. One definition of the many that have been proposed, is….

Mentoring is a process for the informal transmission of knowledge, social capital,, and the psychosocial support perceived by the recipient as relevant to work, career, or professional development; mentoring entails informal communication, usually face-to-face and during a sustained period of time, between a person who is perceived to have greater relevant knowledge, wisdom, or experience (the mentor) and a person who is perceived to have less.

All of these together, and more, should be integral in the building and initiating of a warrior down response team and all have their own individual place within that team so that all avenues towards recovery are covered and all aspects of a fully inclusive recovery journey can be supported and maintained. All members of the recovery community Also members of the response team here would benefit massively from being involved in shadowing those in the professional capacity who specialise in potential barriers to recovery. ETE (Employment, Training, Education), Housing support, Benefits support, Debt management, etc. All resources should be looked at and made readily available to the community. This list will grow as the community grows. And ongoing training needs and support needs should be addressed and relevant training looked at in order to maintain a high level of support within the community.

PHASE 3: RETURNING TO THE HOME COMMUNITY.

 

Firestarters in local communities set up circles of recovery that are specifically designed to support those reintegrating into the community after a period of isolation, addiction, imprisonment..etc. This can cover a multitude of different aspects in an individuals recovery process and by this stage in the recovery journey those who have been introduced to this program will have become stable and secure in their recovery and in a position to carry their message to those who are beginning this journey. This in effect expands the support network and circle of recovering individuals to offer a wider and more supportive structure for supporting newcomers into the program. The nature of a therapeutic community is that the support of it’s members is never ending and not bound by any timescales. This support is ongoing and is always available to those who have come through the stages of the reintegration process and moved on successfully to become recognised and valued members of their community. Those who follow this process and successfully re-engage within their community can be a major inspiration to those walking into the program for the first time as are those walking into the program for the first time. Regular talks, discussions and events to bring members of the community together can be hosted to show that as members of an ever growing community recovery is possible and achievable. It really does work if you work it

FIRESTARTER TRAINING: This is designed to empower individuals to carry out all aspects of the Warrior down program. Suggested training could include Recovery coaching, sponsorship, mentor training, peer support training, Understanding the 12 steps, SMART recovery training, breaking free online training, boundaries and confidentiality, conflict resolution….the list is endless with regards to what training may be looked at and with the focus always  on the individual’s journey the requirements of the group and indeed the community will be an ever changing, ever evolving natural progression process. This training should be designed to promote all different aspects of a full recovery agenda so that all options are explored and all members are fully armed with the facts in order to give a full and comprehensive package to suit the needs and wants of those they would support and in turn to keep them focused on their own recovery.

To summarise the process:

 

 The first stage of the program is about finding your footing and the right pathway to suit you as an individual. Recovery is all about having choices and support in promoting those choices to enable a solid foundation on the journey you are about to embark on.

 

 The second stage is about finding yourself and clearing the wreckage of your past in order to look at different coping  mechanisms and strategies that would empower the early stages of your journey for a more positive and productive future.

 

 Stage three is about strengthening your relationship with others and building a social network around you of likeminded people who are supportive, non-judgemental and positive in their approach to the community environment.

 

 And finally stage four is about carrying this message and advocating for others by maintaining and continuing to move forward forging a path for others, leading by example. 

HELPING EMPLOYEES SUCCESSFULLY RETURN TO WORK FOLLOWING DEPRESSION, ANXIETY OR A RELATED MENTAL HEALTH ISSUE – ORGANISATIONAL GUIDELINES

These guidelines consist of actions organisations can take to facilitate return to work for employees following an episode of depression, anxiety or a related disorder. They were produced using the Delphi method, http://en.wikipedia.org/wiki/Delphi_method, which is a systematic way of assessing the consensus of a panel of experts. The actions have been rated as
important or essential by expert panels of consumers, employers and health professionals. It is hoped that the guidelines will be used to improve the practices of organisations as they support those returning to work after mental health problems. Helping employees successfully return to work following depression, anxiety or a related mental health problem.
GUIDELINES FOR ORGANISATIONS What organisations can do
The work environment
The organisation should foster a supportive work environment that
is conducive to good mental health and the enhancement of mental
wellbeing. This can be achieved by:
• encouraging staff to discuss stress and seek support when
experiencing mental health problems
• fostering a culture in which disclosure of mental health problems
is accepted
• taking action to reduce the stigma surrounding mental health
problems
• adopting a positive attitude towards those recovering from
mental health problems.
The organisation should be committed to reintegrating all workers
with a mental health problem and should make this known to both
employees and supervisors.
Mental health training should be provided for supervisors and
colleagues to ensure a supportive work environment and decrease
stigma surrounding mental health problems, while providing further
training for supervisors to enable them to support employees with a
mental health problem to remain in or return to work.
RESPONSIBILITIES TOWARDS EMPLOYEES WITH A MENTAL HEALTH PROBLEM
When an employee discloses to a supervisor or other organisational
representative that they have a mental health problem, confidentiality
should be respected unless there is an immediate danger to the
person or to others in withholding that information. To reduce
misunderstandings which could lead to fears of discrimination, the
organisation should make clear the purpose for which they request
or require information about an employee’s mental health problem.
The organisation should ensure that the employee knows who they
can talk to other than their supervisor about their mental health
problems (e.g. a human resources professional, occupational health
provider or trade union representative).
The organisation should provide information to employees with a
mental health problem on taking sick leave due to a mental health
problem or returning to work after a mental health problem. This
should include information on the positive role of work in recovery
from a mental health problem. The organisation should never assume
that an employee diagnosed with a mental health problem needs to
take leave to recover and should support employees with a mental
health problem to stay in work and prevent long-term sickness
absence.
The organisation should encourage employees with a mental health
problem to obtain treatment. Where practicable, the organisation
should offer their employees the support of occupational health
advisers or counsellors. The costs of mental health treatment may
be offset by gains made in reduced absenteeism and improved
productivity at work.
Managing absence
The organisation should make sure that the employee understands
their responsibility to keep it informed of the reasons why they are
absent from work and, when known, how long the absence is likely
to last. The organisation should also provide advice to supervisors on
how to appropriately contact an employee who is on leave because of
a mental health problem.
If the supervisor has contributed, or is alleged to have contributed,
to the employee’s mental health problem, the organisation should
delegate someone else to maintain contact with the absent employee.
If the employee’s mental health problem is related to conflicts
at work, the organisation should engage the services of qualified
workplace mediators.
MANAGING RETURN TO WORK
The organisation should have a coordinator who facilitates employees’
return to work. This person could, for example, be a human
resources professional. The coordinator needs to become familiar
with the employee’s work environment and job content, be able to
communicate and negotiate with staff at all levels, and be sensitive to
the needs of the employee concerned, including any disability issues.
The return-to-work coordinator should also check that the supervisor
of the employee has been informed about the return-to-work process,
and agrees with it and its possible financial consequences.
The organisation should provide a clear set of behaviours that can
be referred to when guiding supervisors on how to manage an
employee’s return to work, as well as provide additional support,
guidance and training to supervisors when they are preparing to
manage an employee returning to work from sick leave due to a
mental health problem.
A return-to-work assessment of both the job and the employee’s
mental health should take place, and the organisation should make
sure that the supervisor understands their role, the employee knows
what to expect and everyone is clear about who is responsible for
action in the return-to-work process. A return to work plan should
be developed for the employee.

THE RETURN TO WORK PLAN

1. when developing an employee’s return-to-work plan,
the organisation should ensure that:
• its approach is fair and consistent, while being flexible with details
• its approach is tailored to the individual
• it offers a variety of options to the employee for a flexible return to work
• it provides the employee with adjustments, flexible working practices
or job task modifications to accommodate their capabilities
• these adjustments are carefully monitored and evaluated, with
improvements made where appropriate
• it informs employees of disability management initiatives so that
they have a greater awareness of roles and resources for making
adjustments
• those who need to know are informed about reasonable adjustment
arrangements made for employees
2. What staff need to know
The organisation should have procedures for making the supervisor, the employee and colleagues aware of the following:
• what a mental health problem is
• how common mental health problems are
• the types of mental health problems
• the warning signs and symptoms of mental health problems
• the causes of mental health problems
• the work-related causes of mental health problems
• the importance of early identification and intervention for preventing or limiting relapse in an employee with a mental health problem
• the things they may notice which might indicate that an employee has a mental health problem, such as effects on attendance, completing
work tasks and displaying unusual behaviours
• the benefits for employees of disclosing their mental health problem to the organisation (e.g. to allow access to supports)
• the fears employees may have about disclosing their mental health problem (e.g. stigma from others and not wanting to identify as ‘crazy’)
• the impact of the symptoms of mental health problems on the skills necessary for work, such as problems with concentration, memory,
decision making and motivation
• that the level of support needed by employees with a mental health problem will fluctuate, as the symptoms of most mental health problems
come and go over time
• how they can reduce stressors that increase employees’ risk of relapse of mental health problems
• how they can support employees with a mental health problem in ways that promote recovery
• how to interact with an employee who is in a distressed state
• how to respond in a mental health crisis situation
• the mental health and disability support services available through the organisation and in the community
• that the negative attitudes of others can be a major problem for an employee with a mental health problem
• the myths surrounding health problems which lead to stigma and limit the potential productivity of employees affected by mental health
problems
• the relevant laws and organisation policies that affect interaction with employees with a mental health problem (e.g. Disability Discrimination
Act 1992)
• that it is not necessary to be without symptoms of the mental health problem to function successfully at work
• that symptom improvements and work performance improvements may happen at the same or different rates
• that, despite looking fine, the employee may still be ill
• that most people with a mental health problem who receive treatment respond with improved work performance
• the value of work for health and recovery
• that the employee might be anxious about returning to work
3. The role of the return-to-work coordinator
Organisations will vary in size and whether or not they have specialist
staff to deal with return-to-work issues. In a large organisation, the
return-to-work coordinator may be a human resources professional,
while in a small organisation it may be the employer or the
supervisor. In this section, the ‘return-to-work coordinator’ refers to
any of these people as appropriate.
Managing mental health problems in the workplace
The return-to-work coordinator should be someone who is
acceptable to the employee. They should not see everything that
the employee says or does as linked to their mental health problem,
and should avoid making assumptions about the employee’s medical
circumstances or what the employee finds stressful or demanding.
If the employee is having great difficulty functioning at work,
the return-to-work coordinator should discuss appropriate leave
arrangements with the employee.
Once an employee has disclosed their mental health problem, it is
vital that the return-to-work coordinator discusses and agrees with
them exactly who else, if anyone, might need to know, and what
information they need to be provided with. The return-to-work
coordinator should also make the employee aware that anything they
discuss with them about their mental health problem will be kept
confidential, unless there is an immediate danger to the person or to
others in withholding that information.
Contact during the employee’s absence
Where an employee is on sick leave due to a mental health problem,
the return-to-work coordinator should maintain an appropriate
level of regular contact with the employee. What is appropriate will
depend upon the circumstances, and an employer should avoid
putting pressure on an employee. The return-to-work coordinator
should negotiate and develop a plan for how they will keep in touch
with the employee and how often. The return-to-work coordinator
should ask the employee who they would prefer to have as their main
contact.
When keeping in contact with the employee, all communication
between the return-to-work coordinator and the employee should
come from a position of care and concern for the employee. The
return-to-work coordinator should let the employee know that they
are not checking up on them, just keeping them up to date, and
should avoid mentioning that colleagues or teammates are under
pressure or that work is piling up. The return-to-work coordinator
should keep a record of contact made with the employee while on
sick leave.
When contacting the employee, the return-to-work coordinator
should use these contacts to:
• find out what help and support the organisation can provide
• explain the return-to-work process to the employee
• discuss any work-based issues that would assist them to feel
confident and comfortable about returning to work
• discuss reasonable adjustments to assist them upon their return
• reassure the employee about practical issues such as their job
security and deal with financial worries
• encourage absent employees to talk to their own doctor, or other
healthcare adviser, about what they may be able to do as they
make progress or adjust to their condition
• ensure that the employee is aware of the sickness absence and
disability policies
At the end of each conversation with the employee, the return-to work coordinator should agree on when the next follow-up contact
will be.
If the employee is too unwell to be contacted directly, the return-to work coordinator should explore if there is someone else, such as a
family member or friend, who can keep in touch on their behalf until
the employee is well enough for direct contact.
Managing return to work
The return-to-work coordinator should consider the approach to
managing return to work that they would take if an employee had
a physical illness, as many of the principles will be the same for a
mental health problem. They should pro actively seek support and
resources for managing an employee’s return to work from relevant
sources (e.g. human resources and occupational health professionals, Chamber of Commerce, unions).
With written consent from the employee, the return-to-work
coordinator should also contact the employee’s healthcare provider.
This allows for a two-way flow of information and increases the
coordination of support for return to work. The return-to-work
coordinator can highlight any factors that might have a bearing on
the employee’s return to work that may be relevant for the healthcare
provider to know. In addition, the healthcare provider can clarify
for the return-to-work coordinator any advice they may have to
assist in an employee’s return to work. However, the return-to-work
coordinator should be aware that if the employee does not wish them
to contact their healthcare provider that is their right.
If the return-to-work coordinator is concerned that an employee is
not yet ready to return to work, they should ask the employee to
provide a report from a healthcare provider stating that they are ready
to work. When the employee is back at work, the return-to-work
coordinator should conduct a return-to-work interview or discussion.

4. The role of supervisors
Information and training
The organisation should provide information to supervisors on how
they can support an employee who is off work or returning to work
after sick leave due to a mental health problem, including:
• their responsibilities for managing the attendance and return to
work of employees with a mental health problem
• the importance of good people management skills, including
effective communication, rather than being knowledgeable about
the employee’s mental health problem
• the organisation’s policy on return to work and how to put this
into practice
• that successful return to work is linked to support from
managers, the degree of control over work flexibility, the demands
placed on them at work, the clarity of their role within the
organisation, and their relationships at work
• the important role the employee plays in their own return-towork process
• what organisational resources might be available for workplace
adjustments
• how to introduce workplace adjustments and monitor the
return-to-work process
• the factors that make it difficult to return to work and how
they can minimise their impact
• what entitlements are available (e.g. family, sick and annual
leave) for employees with a mental health problem
• their legal responsibilities, such as those under the Disability
Discrimination Act
• understanding that it is their role to assist the employee to get
the help they may need, but not to diagnose mental health
problems or to provide counselling
• recognising the limitations of a supervisor’s responsibility
towards an employee with a mental health problem
Supervisors also need to know how to communicate with employees
on sick leave due to a mental health problem. Good communication
requires:
• being sensitive to and understanding the individual and their
context
• managing the expectations of an employee returning to work
• knowing how to have sensitive conversations with employees,
including how to handle those that do not go as planned
Mental health training for supervisors should include opportunities
to practice new skills during the training, and remind supervisors that
they too are employees who can expect help to return to work if they
experience a mental health problem.
WHAT RETURN TO WORK CONVERSATIONS SHOULD COVER
during return-to-work discussions, the return-to-work
coordinator should:
• discuss the return-to-work expectations of the employee by
clearly explaining policies regarding sick days, time off and
other matters related to employee well-being
• explain any changes in the employee’s role, responsibilities
and work practices that have occurred during their absence
• focus on the employee’s abilities and their capacity to carry
out their work, rather than on their limitations
• focus their discussions with the employee on the problems
they experience in the workplace and what actions can be
taken to address them, rather than on details of the mental
health problem
• find out how the employee’s symptoms and treatment
impact on their work and think about how this impact can
be reduced
• discuss with the employee whether any adjustments need
to be made to ease their return to work, while being honest
about the adjustments they can make and those they can’t by
explaining that some organisational factors are out of their
control
• make sure the employee understands the effect of any
adjustments on their pay and other entitlements (e.g. effects
of reduced hours or alternative work)
• discuss the employee’s right to confidentiality and reach an
agreement on when it would be appropriate to contact a
doctor or family member if they become unwell at work.
4. 5. Communicating about mental health problems in
the workplace
The supervisor should demonstrate and encourage awareness,
understanding and openness in relation to the issues of stress and
mental health problems in the workplace. They should acknowledge
the impact the employee’s mental health problem has on the
employee, while making the individual feel that they are a valued
employee in the organization.
Managing return to work
If the supervisor is also the return-to-work coordinator, they should
refer to the recommendations in the section ‘The role of the return-to work coordinator’. Below are guidelines for supervisors irrespective of
whether or not they are the return-to-work coordinator.
During return-to-work discussions, the supervisor should:
• discuss signs and symptoms of any relapse with the employee and
ask how they feel these are best dealt with
• sensitively deliver unwelcome news about their absence or
position in the workplace
• not make promises to the employee that they cannot keep
The supervisor should also be aware that if the employee does not
wish them to contact their healthcare provider that is their right.

 

Reasonable adjustments
The supervisor should make reasonable adjustments for the employee
in the workplace that remove any barriers that prevent an employee
from fulfilling their role to the best of their ability. The supervisor should

examine the employee’s work role to determine whether

there are any factors in the workplace that may have contributed
to their mental health problem. This includes thinking about how
the workplace or the person’s workload may be contributing to the
problem and considering if any changes can be made.
When making reasonable adjustments, the supervisor should be
flexible and treat each case individually, but on a fair and consistent
basis. They should avoid making stereotypical assumptions about
the capabilities of employees with a mental health problem. The
supervisor should also make sure that any side effects of treatment the
employee experiences are considered against their job requirements.
This is particularly crucial in jobs where there are health and
safety risks. These adjustments should be regularly reviewed by the
supervisor.
The supervisor should support the employee to access treatments
by allowing the person time off work to attend appointments and
should investigate other workplace supports that may be available
to the employee, such as an Employee Assistance Program (EAP),
rehabilitation services or a local employment service.
Managing the returning workplace environment
The supervisor should be realistic about workloads and be aware that
some people will wish to prove themselves and may offer to take on
too much. Instead, the supervisor should set achievable goals that
make the employee feel that they are making progress. To make the
employee’s first weeks back as low-stress as possible, the supervisor
should make sure the employee doesn’t return to an impossible
in-tray, thousands of emails or a usurped workspace. The supervisor
should watch out for hostile reactions to the employee’s return to
work and promptly stamp out any hurtful gossip or bullying.
The supervisor should take the time to have frequent informal chats
so there is an opportunity to discuss progress and problems without
a formal (and possibly intimidating) session. However, the supervisor
should ensure that the employee does not feel that their work or
behaviour is being overly monitored or scrutinised, or that they
feel like a nuisance for creating extra work for the supervisor. The
supervisor should ensure that any concerns raised by the employee are
investigated and dealt with quickly.
The supervisor should continue to support the employee’s return to
work well beyond the initial return. However, the supervisor should
avoid fostering a dependent relationship with an employee with a
mental health problem through providing excessive support. They
should reassure the employee that they understand medical and
personal boundaries and will respect them.
Supervisors should work with healthcare and rehabilitation providers
to support employees with mental health problems, and identify
physical and psychological factors in the work environment that can
be adjusted to accommodate an early, safe and sustainable return to
work.
If there are signs of a relapse, the supervisor should review options for
making further adjustments and talk realistically with the employee
about the best way to move forward. In the case of relapse after return
to work, the supervisor should not make any assumptions about
whether or not the employee is able to continue working.
If a disciplinary process is required for the employee, the supervisor
should have a range of options available for this process, such as
counselling, referral to an occupational health specialist etc., as well as
the more usual system of warnings.
If the organisation does not have a return-to-work policy, the
supervisor should suggest that they have one.
6.Having a return-to-work plan
Development
A clear written return-to-work plan should be developed by the
return-to-work coordinator in discussion with the employee. The organisation should ensure the employee is actively involved
in the development of the return-to-work plan, and that it is agreed to
by everyone affected by the plan.
The return-to-work plan should be flexible and adjustable to allow for
changes in the employee’s mental health or workplace circumstances,
and should last for a sufficient time period to allow the employee
to recover. When agreeing on a return-to-work plan, the supervisor
should always be clear on the duration of any amended duties or
supports. In most cases, these measures will be temporary.
The return-to-work plan should be constantly monitored to ensure
that tasks and hours remain appropriate and sufficient supports and
resources remain available. The supervisor should take steps to keep
everyone informed and make sure the plan is respected.

WHAT A RETURN TO WORK PLAN SHOULD CONSIST OF.
• the approximate date of the employee’s return to work

• the time period of the plan

• the roles and responsibilities of all involved in the plan

• a description of suitable duties for the employee

• any reasonable adjustments that assist the employee to remain
at work and remain well (e.g. return to a modified work
role or system, or alternative working hours, whether on a
temporary or permanent basis)

• information about any impact of adjustments on terms and
conditions of employment (i.e. on leave, superannuation,
other employment benefits)

• any advice received from healthcare providers, human
resources etc.

• strategies to handle stress, particularly around workplace
activities that may trigger this for the employee, such as short
deadlines, early meetings or workplace conflict

• the process of ensuring the plan is put into practice

• the process by which the plan will be reviewed, including
review dates and by whom

• signatures of agreement – employee, supervisor etc.
What the returning employee can do
The employee should talk to their supervisor and raise any concerns
they might have about their return to work. They should also
negotiate with their supervisor about reasonable adjustments to assist
with their mental health problem.
The employee should learn the symptoms and triggers of their mental
health problem. They should understand that mental health problems
are sometimes unpredictable, and that their impact on both cognitive
and interpersonal functioning may make work a challenge. The
employee should identify perceived barriers and prioritise solutions
for a safe and early return to work.
The employee should discuss with their return-to-work coordinator
about how to approach their return to work and manage their mental
health problem in the workplace. When talking to their return-towork coordinator about returning to work, the employee should
discuss:
• what their tasks and responsibilities will be
• any work activities that may trigger stress and what helps to
reduce or manage this stress
• how much they can disclose to work colleagues
• barriers to a safe and early return to work
• any specific needs they have (e.g. time off to attend appointments,
inability to do the job in the same way as before becoming
unwell)
The employee should discuss with a healthcare professional about
how to approach their return to work and manage their mental
health problem in the workplace. This should include discussion
of any adjustments to their work that may be needed on a
temporary or permanent basis and how any medication side effects
may affect their work. During a return-to-work assessment by a
healthcare professional, the employee should be aware that it is their
responsibility to report any participation and activity limitations that
are a result of their mental health problem and which may affect their
work. The employee should continue to keep their doctor or treating
health professional informed during the return-to-work process.
The employee should ask for support when they need it, whether
from family, colleagues or supervisors, and should have an agreed plan
with their supervisor to manage the possibility of relapse.
What colleagues can do
Colleagues should welcome back the employee who is returning
after sick leave due to a mental health problem and should not avoid
talking with the person for fear of saying the wrong thing. Colleagues
should be respectful of a fellow employee’s confidential mental health
history and should not pry for details about it.

 

what trade union representatives can do.

This section applies only in situations where the employee is a trade union member.
The trade union representative should:

• encourage the employee to co-operate with their employer on a return-to-work plan and use the
opportunity offered by a return-to-work interview to ask for help with work-related problems
• reassure the employee that details about their mental health problem cannot be given to others
without their consent
• encourage the employee to talk to their doctor about going back to work and about any side effects
of medication that may affect their safety or performance at work
• encourage the employee to talk to their doctor about any adjustments to their work that may be needed on a temporary or permanent basis
What family and friends can do

Family and friends should:

• provide practical support to allow the employee to return to work (e.g. childcare, transport,
household tasks)
• support the employee in meeting their obligations under the return-to-work plan
• leave the decision about when to return to work to the employee and their health care professional
• not give negative messages to the employee about their ability to return to work
• positively acknowledge success in return to work
• be aware of early signs of relapse and how these may impact on work performance.
Family and friends should also be aware that positive emotional support can assist the employee’s recovery and return to work, while negative interactions outside the workplace can affect the employee’s ability to return to or remain at work.