Analysis of Addiction Service

Colin O’Rourke

Sankalpa Addiction Services

Sankalpa is a Sanskrit word meaning idea or notion formed in the heart or mind, a solemn vow or determination to perform and a desire or definite intention.

History of the agency

The Millennium Carvings program which was established in 1998 and was supported and funded by FAS and the Local Drug Task Force (LDTF). Designed to deliver rehabilitation programs for stabilised or former drug users in the Finglas/ Cabra area it offered holistic programs exploring individual creativity together with therapeutic rehabilitation programs. Millennium Carvings evolved into Sankalpa and continued to create an holistic and therapeutic environment utilising artwork and creativity. This allows clients participate in their own recovery process while addressing some of the complex needs of service users through personal development and group work. The LDTF now ensure Sankalpa adhere to the National Drug Strategy.

Agency Ethos

‘A sustainable pathway out of addiction leading towards a culture of recovery in Finglas & Cabra, built by support organizations and service users working in solidarity’

The characteristic spirit underpinning the Sankalpa culture is that of client centered therapeutic environment in a creative, holistic environment, the emphasis being on community. In creating this community that enables the clients to change intrinsically, the realization being that the client understands what motivates them better than the therapist, change comes from within. It is recognised that the relationship between the client and the therapist is of prime importance when evaluating the success of the therapeutic process, and that the cornerstone of recovery is this relationship.

Aims

Sankalpa aim to respect the dignity and rights of the client in a just and safe environment while understanding that sole responsibility for any addiction is the responsibility of the client that developed it. In doing so it hopes to enhance intrinsic worth in a therapeutic environment that values learning with a view to facilitating the healing process. It is believed that the therapeutic process is assisted by creating a space where drug related harm is minimised and where well organised levels of drug services are made available. Best practice and evidence based interventions are aimed to be utilised as is the support of non medical treatment of pain. Sankalpa aim to promote problem solving and critical thinking with their clients while remaining honest and open minded in their affairs.

Objectives

To meet their aims Sankalpa deliver quality programs while utilising trained staff who are focused on achieving the desired outcomes by being part of the continuum of clients’ recovery and linking and partnering with other agencies to assist in this continuum. Sankalpa support clients by offering CE schemes to assist with moving on to employment and education. They offer accredited further education to clients’ presenting with addiction issues or stabilised on their medication and assist motivated clients in the continuum of recovery by way of the development and implementation of their therapeutic model.

What kind of treatment approach underpins the agency?

The Sankalpa therapeutic model is psychosocial, client centered and evidence based. It utilises structured interventions the aim being to reduce or stabilise the harms associated with illicit drug use. The therapeutic work is mainly done in groups and uses Cognitive Behavior Therapy (CBT), Community Reinforcement Approach (CRA), Motivational Interviewing (M.I) and Mindfulness. One to one sessions include goal setting, reviews and assessments. It is understood by employees of Sankalpa that access to education and employment that may previously have been out of reach due to social deprivation can be the cornerstone of successful recovery.

Components of the treatment approach

Sankalpa views drug addiction as a psychosocial condition implying that psychological and social elements are at play. Non directive humanistic approaches and a belief in a clients ability to intrinsically ease their own suffering lie at the heart of the Sankalpa system which accepts people as they are without judgment. The practices employed are with a view to reducing possible adverse health effects and social consequences of drug use. Is believed that abstinence although a worthy goal is often unworkable and so reducing drug consumption although preferable is not key to the work carried out.

Sankalpa’s multidisciplinary approach recognises the importance of adult education, creativity and social activities and four core services underpin the work that assists in increasing a client’s recovery capital.

Explore is a program that works towards building confidence in clients by preparing them for further education.

Access (a pre-entry to Turning Point) supports clients who wish to stabilise their drug use .

Turning Point is a four month day program for those who wish to stabilize their drug use and to work towards reducing the harms resulting from this use.

Connect to the Workplace is a community Employment (CE) scheme that aims to introduce drug free clients into the community and focuses on training, work placement and education.

Evaluation of the Agency – 10 marks – 275 words

What does the agency do well?

Sankalpa meet the criteria expressed in their therapeutic model by the creation of a community and fellowship where clients from various stages of recovery can come and be listened to non-judgmentally within groups, one to one counseling and key work while also benefitting from having a creative and social outlet. Compassion, respect, dignity, solidarity and empathy are words that describe the work that is carried out.

Staff at Sankalpa receive regular supervision and appraisals which ensures they do not work beyond their competencies and have an understanding of what is expected of them. Professional development by way of training/ learning opportunities enhances these competencies.

I feel that the culture of any addiction service is greatly influenced by the demeanour of the staff and in Sankalpa the staff appear composed and serene. Clients tend to adapt to this attitude.

The clients are comprised mainly of men (70%) with 52% of those presenting with heroin related however Sankalpa now find that service users now present with poly substance issues. Sankalpa recognize that these drug users experience educational disadvantage and so unemployment. From a sample group 83% had left school early and 80% were unemployed. The services provided address these issues.

Service users have a real voice in the development and implementation of services at Sankalpa and there is evident service user involvement . Complaints and surveys are seen as a way of improving the service provision and the use of a suggestion box is looked upon favorably. During my time in Sankalpa a group was being set up comprised solely of clients to look at various aspects of their own recovery (including Sankalpa’s role) without any staff involvement.

What are the challenges facing the agency?

As with many addiction services at present funding is no longer guaranteed and is dependent on the delivery of a quality service. At present this funding is streamlined from the HSE. The service remains accountable and transparent prioritizing good governance.

Clients at Sankalpa always come first and the question is whether or not they actually feel they come first, the dilemma being how behaviors are addressed, control asserted and power imbalance sustained without changing this.

Sankalpa are building a culture primarily by word of mouth. As the agency is known to the public as an ‘holistic‘ agency it must be taken into consideration what that means to the public. In Sankalpa holistic means all aspects of the person is taken into account. Mind, body and spirit.

Harm and risks associated with the workplace are controlled by implementing health & safety policies and safety statements incorporated in the safety management system and so promoting a culture of safety. Sankalpa have detailed policies governing all aspects of the service provision an example being maintaining that all children have a right to be treated with respect and understanding and be safe at all times. As such they are compliant with children first standards (the national guideline for the protection of children.) If physical, sexual or emotional, neglect is discussed with a staff member it is reported to an onsite child protection officer who then takes appropriate action.

At present I am interested in getting more experience with group work and this was the focus of my time with Sankalpa. The groups I was involved in were at various stages of the wheel of change (Procheska ref) being either in a place where they were still actively using drugs and wishing to stabilise or were already abstinent or stable on prescribed medication and making plans to enter employment or education. Each group was comprised of a lead facilitator and I, and had up to eight clients. The culture of the groups was based on a shared belief in the possibility of a life free from drug use. Loose (2001) discusses the importance of people in addiction having their story heard and sees addiction as the opposite from speech. In the groups a forum was provided where speech could be safely used and allowed for ‘norm transmission’ and ‘socialisation’ to occur.

The aim of the first group (Turning Point) was to see how the clients’ efforts at becoming or remaining stable on their illicit drugs or prescribed medication (be that prescription tablets or methadone) was progressing and to develop discrepancies around their ambivalence towards their drug use. The group began with a five minute guided meditation that put participants at ease for the rest of the session. The facilitator used M.I techniques fluently and moved through the clients using open ended questions and affirmations while regularly reflecting and summarising and at all times resisting the righting reflex. The effect of using the M.I was that the clients felt genuinely listened to and understood without being judged and so were quite honest and open within the group. I realised that in comparison, the groups I have been facilitating outside Sankalpa believe they are using M.I but are actually missing out on the ‘spirit’ of M.I. In these previous groups open-ended questions are used frequently and facilitators do create a space for clients’ to change intrinsically yet reflecting and summarising were not evident. My own efforts at reflections had in the past been viewed as putting words into clients’ mouths.

In the therapeutic art group clients created various items e.g. Mother’s Day cards. Other than its obvious therapeutic value this group allowed clients become very relaxed with facilitators as it did not feel like a formal intervention. This allowed them to be quite open and honest about their situation while allowing me the time to practice my M.I or Brief Solution Focussed skills. I was very aware of boundaries when dealing with clients but I don’t feel this was detrimental to the relationship although there was an obvious power imbalance. Clients tended to presume that I had some say in whether they had access to treatment or not and my perception of initial conversations was that they seemed rehearsed on the part of the clients, the dialogue possibly used many times in the past with various agencies in a bid to assist them on the road to recovery. This quickly moved on to reasons treatment had failed in the past and what they would do different given the opportunity to return. Change talk was then evident. Insight into their current situation or how they now viewed their ambivalence appeared to be the main reasons for their urgency to access treatment centres and perhaps this was as a result of Sankalpa key workers and counsellors developing discrepancies with the prevalent M.I style.

The Access Group was made up of clients who were still actively using drugs but who wished to become stable and as such clients tended to be less focussed than other groups and cross talk was more evident. M.I was used less and direction and guidance was given but the result was that the clients stayed interested in the process. I believe that a direct approach with these clients was quite valuable as some were at pre-contemplation/contemplation (Prockeska ref) (maybe action if self referral as attending without reward) and as such had few concerns regarding substance use. I did however feel that as direction was given it was possible that clients were saying the ‘right’ or what they felt facilitators wanted to hear. From this group I have gained a greater confidence in dealing with resistant and ambivalent clients.

I was also involved with ASSIST (The Alcohol, Smoking and Substance Screening Test). ASSIST is a screening tool supported by the World Health Organistaion (W.H.O) that I completed with clients to gain an understanding of the history of their drug use and determine a risk factor for each substance discussed. ASSIST focuses primarily on the three months before the assessment and a brief intervention or discussion was then carried out with the client. Linking current drug use with the risks involved can help motivate clients to change. When completing ASSIST the only issue I had was when clients were still actively using drugs and each question that required a single word answer came with a story. I felt I had to shut clients down after each question to get it completed. I see the value of this as a tool if it can be returned to and repeated at a later date allowing the worker gauge improvements in a client.

Identify a learning goal as a result of this interaction

I was initially nervous and worried about the words I used in every group and I found when I was not involving myself that I was not as tuned into the conversation as I could be. With this came a feeling that I was a part of the group and not a facilitator which was something I had to push past. I was also aware that I was worrying that I would interrupt the other facilitator, my thinking being that they probably had something more relevant to say. The root of this I believe to be in how debriefing in my groups in the past had been rolled out. I am now learning to accept criticism of how I am in groups and previously saw it as a rejection of sorts, either defending and explaining my words or justifying them in some way. I did not find this in Sankalpa where I believed any feedback was coming from a place where I could learn. For instance it was brought to my attention during debriefing that I had been offering my opinion by my facial gestures alone or by my seated position on the chair and this I fully accepted and came to understand.

In these groups I did enjoy developing discrepancies and dealing with ambivalence and I found that over time the presenting issues tended to follow a pattern. As such I believe that in the future I will hear the same ambivalences often and I can respond accordingly.

I believe that clients felt that I have walked the same path in the past and although this was never discussed it seemed to be an unspoken given and one that I am quite comfortable with. I have become aware that although the work is all for the clients benefit it is as also about me finding meaning in my own past. If my past is to benefit me in some way today it is in understanding what a client is going through and offering a different level of empathy than someone who has not walked this path. In saying that self-disclosure never felt necessary.

My time in Sankalpa when not in a group setting gave me plenty of time to reflect on my own attitudes and reactions to what came up in group, the realisation being that speaking less and leaving a client with their own silence rather than trying to rescue or finish sentences for them is more beneficial. It also made me aware that I must remain neutral and calm at all times in groups irrespective of my own feelings.

I was asked to be leading facilitator in a psycho education group the topic being ‘Self-esteem’. I turned this down and when I actually co-facilitated the same group the subject matter made me realise the very reasons I turned it down were rooted in my own self esteem. I feel I would have grown stronger by allowing myself to follow through on something that put me outside my comfort zone and allowing myself to make mistakes that I could learn from.

I found that from my present work both in one to one and group that I am becoming a little too M.I focussed and so missing out on a huge explorative piece having a tendency to plan my next words so carefully that I am not fully hearing what the service user is saying. (Abram, 2013) says that attempting to ‘say the perfect thing’ is a huge obstacle to empathising.

Cohesion was built within groups peers and a community was made available to clients that was not based solely on substance abuse rather in ways to address issues surrounding their drug use.

By attending Sankalpa clients were addressing the affects of boredom, isolation and loneliness that they may have been experiencing in their lives.

All self-disclosure was confidential. Owning the fact that one has an issue with addiction and voicing that in front of people can be daunting but it does make someone accept and face up to their problems.

The socio-emotional behavior displayed by the group tended to be positive, the mood was light hearted, the group was cohesive, morale was high and all members showed an interest in the wellbeing of the group. Getting and staying clean and helping others do likewise were the main task of this group.

I began to feel quite stressed out at one point during my placement because I felt I was not doing enough of what was expected of me but during supervision a better understanding of my role was explained and this put my mind at rest. This enabled me to see the value of supervision I a way I hadn’t seen before. I feel that in future I will get this understanding earlier with whatever agency I work with.

I found my experience in Sankalpa to be very rewarding, in particular being allowed to see how different facilitators work and how it may be possible to take on what I consider to be the more favorable aspects of each style and that which sits best with my own personality.

Abram, T. (2013, September 27). Barriers to Empathy. Retrieved from Michegan State University: http://msue.anr.msu.edu/news/barriers_to_empathy

Loose, R. (2001). The Subject of Addiction:Psychoanalysis and the Administration of Enjoyment. London / New York: Karnac Books.

6) Taking care of staff and ourselves.

Assisting clients with the continuum of rehabilitation by way of partnership with other agencies and services

Rate of Governance code.

The Department of Social Protection fund employees involved in CE schemes and fund the CE schemes of clients.

Motivational Interviewing (M.I) and building a culture

(ref)