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March 8, 2024
#40 - Dame Carol Black: UK Drug Policy, Recovery Pathways, Addiction Workforce Challenges, Mental Health Integration & Trauma Informed Care
Matt welcomes back Professor Dame Carol Black for her second appearance on the Believe in People Podcast.
Dame Carol, recently awarded the prestigious Grand Cross, the highest level in the order, and is awarded rarely and recognises only the most exceptional and sustained service to the UK. Fewer than 80 women have received the honour and Dame Carol is the first female doctor to be made a Dame Grand Cross.
Celebrated for her instrumental role in shaping UK's drug policy, Dame Carol's efforts secured record government funding of £780m to address drugs misuse. Her impactful reviews on drug abuse have catalysed a cross-government approach, reshaping strategies to tackle drug-related challenges.
Matt delves into her insights on the integration of mental health and addiction services, emphasising the crucial role of trauma support. He also explores Dame Carol's influential independent reviews on employment prospects, health, work, wellbeing, and sickness absence, all pivotal factors influencing productivity.
The Believe in People Podcast explores addiction, recovery and stigma.
If you or someone you know is struggling then this series can help.
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Transcript
WEBVTT
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This is a Renew Original Recording.
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Hello and welcome to the Believe in People Podcast.
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My name is Matthew Butler and I'm your host, or, as I would say, your facility.
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Today we have a returning guest in Grand, dame Carol Black, a trailblazing figure awarded the rare Dame Grand Cross for her relentless dedication to combat drug misuse in the UK.
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As the first female doctor to receive this honour, dame Carol's impact is unparalleled.
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Her groundbreaking reviews on drug abuse have not only secured the record government-funded, but also sparked vital conversations on tackling drug-related challenges.
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Join us as we delve into her remarkable journey on advocacy and transformation.
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First of all, would you like to introduce yourself?
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Yes, I'm Carol Black.
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I wrote the independent review for the government on drugs and now I'm the independent advisor on combating drug misuse.
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Thank you so much for coming on Again to the Believe in People Podcast.
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We don't get many returning participants.
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I think maybe the second returning participant, we have possibly the third, but a lot has happened since we last spoke to you and we have to thank you because when we did our first podcast review, that did help us get some eyes on the podcast and the local story and it was the podcast where the local authority and the council actually really took notice of what we was doing and everyone was very interested in what you have to say.
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So we got some really good feedback on it.
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So we've been really keen to do another one since Last time we spoke to you, it was a few months after the publication of Part 2 of your report, and here we are, nearly 18 months later.
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Can you perhaps give us an update on the landscape since publication, highlighting any positives that you've seen since changes have started to be made?
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Well, a huge amount has happened since my publication, because after that, of course, we had to secure or with it, we got the money from government.
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And then the new 10-year strategy and it is important to say this is a journey, it's not a one-year journey, it's a 10-year journey, and that was December 2021.
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And then we had all the business of setting up the local arrangements.
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You know, the new combating drug partnerships.
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The senior responsible officer, the person who we need to locality was going to chair that, the bringing together of all the different organizations that might be able to help us deliver the whole system approach, which is quite different from what we had before, which was really, by the time I wrote the review, we really had a treatment service that was not much more than opioid substitution therapy, quite frankly, so little money had been put into drugs recovery and treatment.
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It was really in a very poor state.
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So I guess the honest truth is we're climbing a mountain, it's not.
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You can't just snap your fingers and do this quickly.
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So there was all the practical stuff of putting in, if you like, the structure, the framework, the processes, and then there was the real and serious problem of the workforce, because, you know, a lot of people had left the service, a lot of expertise had gone.
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So that has been, I think, for most providers, a big challenge, because we're no longer just looking for more drug workers.
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I do not want more of the same.
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I didn't write the report to have more of the same.
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I wrote the report to have change.
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So you know, we need more psychologists, we need more psychosocial interventions, we need people who are experts on getting people into work.
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We need expertise on housing and how to help people find housing.
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We need real recovery programs.
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These all need people to deliver them.
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So I think really the big thing to say is we're at the beginning of the journey.
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Yes, I've seen some places where they really understand what is needed and they're actually going about it, shall I say in the way I wrote the report and they've understood the importance of mental health and trauma.
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They know they have got to have proper recovery program.
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They may use one of the lived experience groups you know the Leros.
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They may do it differently and they're trying very hard to bring people together, including the police, the criminal justice system, social care.
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They understand collaborative working.
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Then I've seen places that are just doing more of the same, and that, of course, is disappointing, and we need to help them to understand that that's not what it's going to bring about a change.
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It won't reduce the deaths, it won't get us more people in treatment and it won't reduce crime.
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So I think it's a mixed picture, but there's definitely areas where they've really understood it and they're getting on with it.
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I don't.
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I mean speaking statistically.
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I can't say too much in terms of what we're doing, but I've definitely noticed changes on a day to day sort of perspective for us here in Hull.
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Last time we was at your home once we finished the podcast we spoke a little bit about individual placement support.
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We never had that in Hull at the time and now we have a team of three people working on it and they've had some really nice success stories as well that we've seen.
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I think one of the problems that they're having is getting recovery coordinators who were doing the day to day were fighting that uphill battle of having a case load of 80 plus people to invest in individual placement support.
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What would you say to those key workers about the importance of getting people involved in IPS?
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Well, the first thing I would say having 80 clients is rubbish.
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You can't do it.
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You can't do proper treatment and recovery.
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There's something wrong with the commissioner, there's something wrong with the commissioning process that permits a provider to have only one worker to 80 people.
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So I mean, I think that's an impossible task, but I think it is.
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It is also, in my humble opinion, the responsibility of both the commissioner and the provider to ensure that the people working for them understand that part of recovery is having something meaningful to do and for many people that is work, paid work.
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It might not always be paid work, you know.
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It might be volunteering to start with.
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You may need to have to upskill someone.
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But the value of a paid job to someone who's had no self-confidence, who really hasn't got many personal assets, it's invaluable in helping recovery.
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But I you know you shouldn't really have more than 40 individuals to one drug worker.
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I think that's one of the biggest problems that we find is just case loads being unmanageable and there are differences.
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I spoke to a colleague man called Jamie who works in the making every adult matter team, the meme team, and he has 15 people on his case load and I said how was that?
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He said, oh, it's definitely manageable.
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But even though 15 sounds like a low number, these are 15 very complex people and that's why they have the meme offer.
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So even then he said it might sound like a low number but he said it's still during, it's still very complex.
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But speaking to a key worker who has between 17 and 80 people in the books, they're looking at him thinking, oh, you've got it easy and it's obviously two really different things that they're working with.
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But even however easy, no person who's taking hard line drugs is necessarily without challenges and without problems.
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They need time, they need input.
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They don't need a method-owned script alone.
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Absolutely.
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For individuals currently struggling with addiction and mental health challenges, it can obviously feel like an uphill battle.
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From your extensive experience and understanding of these issues, what message of hope and support would you like to convey to them, and what resources or strategies do you believe can make a meaningful difference in their journey towards recovery?
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Well, I think, first of all, what I've been trying to do is to get the message out there loud and clear everywhere I go, that mental health and trauma is part of addiction, it is not a separate thing over here, and that you will only treat somebody's mental health problems when they've stopped taking whatever is their drug of choice.
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They wouldn't be taking the drug, probably if it wasn't for the trauma and their mental health issues.
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So we have a whole cultural change.
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That's quite difficult because professionals have brought about that divide, not the people who are drug dependent.
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It is the way we have delivered these services that we've separated them out, and you would never say, let's say, if you had prostate cancer and let's say rheumatoid arthritis, no one would dare say to you well, when you've got your prostate cancer under control, we're going to treat your rheumatoid.
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You might be really crippled by then.
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We wouldn't, we're not allowed to do that.
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So why are we allowed to separate these two?
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So the first thing is the message has to be changed and then what we're really asking local authorities to do is to think about how are they going to co-commission mental health and drug recovery and treatment.
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Now some of them will say this is almost impossible to do.
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But if you look at Staffordshire, staffordshire has done it.
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They have joined their resources.
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They've got through all the difficulties of protocols, procedures, bringing budgets close together, sharing back office functions.
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They they actually deliver their mental health and trauma support and their treatment and recovery as a whole package.
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You don't have to go to two places.
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So I mean that's the ideal and in the meantime we just have to do it, I fear, almost authority by authority, finding out what their challenges are.
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Absolutely saying you're not going to get good results until you deal with mental health and trauma.
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And there's a big push in the Department of Health.
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There's a big piece of work going on between NHS England, which of course delivers mental health services, and OHID, which is responsible for the treatment and recovery.
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A big piece of work on mental health, seeing how do we bring, how do we really sort this out and bring it together in a considered way.
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So one of it may seem like a very small success.
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But talking therapists as you probably know, very few people with addiction have been able to get talking therapists because the people who deliver the talking therapist say oh no, no, we won't be able to work with you because you've got a drug problem.
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Theoretically and in all their regulations they're not supposed to do that and we've now met very much at right, at the centre, with the top of the people in talking therapies and that will gradually change.
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Won't change quickly.
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We will have to help people who deliver talking therapists to understand a bit more about addiction and those people who are treating addiction need to be able to treat anxiety, mild depression and stress.
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You shouldn't have to refer that into a mental health service.
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So you know it needs them to understand each other's problems and work together.
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So I would say there's huge attention on this.
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I can't sit here and tell you there's quick wins because it's a big problem, but there are several areas in the country where they've already managed to do the right thing.
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Yeah, obviously, we're kind of going into that now because I always say we've established a small multidisciplinary mental health team, largely based on your recommendations from two years ago, and this team consists of qualified psychologists training assistant psychologists and mental health nurses through the joint CGL NHS dual diagnosis project.
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So how do you envision teams like this growing and evolving both in Hull and across the nation?
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Well, I think they must evolve according to the local need.
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I mean it won't look the same in any two places.
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I don't think providing a good needs assessment has been done by the local authority before it commissions its service.
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That needs assessment ought to be able to inform what do you need in a service?
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You know?
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How many psychologists do you need?
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What do you need in terms of mental health support?
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Or perhaps a mental health social worker?
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I mean, how complex are your cases?
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I think you can't just say that every area of the country is going to have the same need when you I don't know the level of deprivation in Hull, for example, but I've just been in Liverpool, one of the most deprived cities in the country there you will really have to put in.
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You know there are going to be numerous problems that are related to trauma and mental health and you probably are going to have to really put in you know a really good supply of mental health and trauma support.
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So I think it's it's variable and I think you learn as you go, because we've not been doing this properly before and there's not been really good mental health support.
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I think one's got to learn how to work between the NHS and the provider if they're not the same organisation.
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And, as I say, I think the people who work for the provider of treatment and recovery need to know how to treat anxiety, stress and depression.
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The NHS mental health services need to start to understand addiction and to be able to do some simple things there.
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How do you perceive the role of mental health support in advancing the recovery agenda?
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I don't think you can go through recovery.
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Quite frankly, I will have very few people without mental health and trauma support.
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Maybe a few.
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But I think we know statistically for those people who are really very drug dependent.
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So particularly our heroin and crack cocaine users, I think near on 70 plus percent of them have had a mental health or trauma.
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They may have had a terrible childhood, they may have been in and out of prison, all kinds of things.
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It's.
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It is so, it is so much part of addiction and if you want people to go on that journey of recovery, then for me there's no question you need you need good communities of recovery.
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You don't need a professional doctor alone in a recovery unit.
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You need people who've been addicted.
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You need people who've done that journey.
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You need people who are now able to walk with someone while they go through it.
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They can do that much better than a clinical professional.
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So I'm very keen that we develop proper recovery communities In that there needs to be work, there needs to be the ability to get a job or to do something meaningful, and then there needs to be safe housing.
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I mean one of the biggest, biggest challenges, especially well, for example, in London, where housing is just so difficult to get.
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It's no use doing all the hard work of helping someone stop their drug of choice and then sending them back to live in a hostel with somebody who's shooting heroin.
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I mean, none of us could survive that.
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None of us.
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We had a podcast participant where it's shut now.
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There was a big hostel in Hull where a lot of our well homeless service users would often be situated and when we talked to her on the podcast and was like, how do you know about Achievement Recovery, she said it was I could scar drugs or I wouldn't even get my feet wet Because it was just rife within the hostel.
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So if you're someone like her in the situation, she wouldn't.
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The reason why I found that story so inspiring was she was.
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She got recovery in that hostel, but the difficulty she must have faced when, like say she could in the same way that we're in this hotel now, she could just scream across the room and that was it.
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Somebody come knocking with her and, do you know, two minutes in and there you go, they have scored.
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So to do it under those circumstances is exceptional, but almost impossible for most as well.
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And you know what we, the work that's been going on with the Department of Housing is to try and understand, because we don't understand.
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You know you can't just say, well, I've got you a roof over your head.
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You need to understand what sort of housing is best required and needed for that particular person.
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Now, you might not always be able to get it, but you need to be able to understand what the journey requires, and there's no point putting in all this hard work if, then, you can't provide the wrap around that's going to enable the person to really come through recovery.
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I had a story today, really inspiring, from a lad that really found his recovery through the help of religion, and that's something that I find really interesting because it's not something that as a service that we can really push or say here's what to do.
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So, talking to them, there's the project there that they have and the community that they've set up, that recovery community that's set up really inspiring.
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They've just been around like-minded people, but I do find it as an aphiast myself.
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Do you know what?
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I've heard?
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These stories there's that pattern that goes, but then there's another pattern that goes.
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Well, actually, if that's what works, that's incredible.
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That doesn't matter.
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If that's what works, absolutely.
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What works for you may not work for people.
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What opportunities do you think exist for developing specialised roles, such as social workers, to better make the unique needs of individuals in recovery and with addiction issues?
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I think if you're going to develop the role of a social worker, first of all we have one role that's been developed, not for addiction but would be very useful for addiction.
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There is now a training to become a mental health social worker.
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That is now a government department of health funded training programme.
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It's called Think Ahead, so anyone now can add mental health.
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One of the things I'm trying to secure at the moment is that that programme can be expanded so that we can train a mental health addiction social worker.
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If you think about it, those three things are things that any person who is drug dependent might need.
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So the mental health component, some knowledge of addiction and a social worker.
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So we're in discussion with the Department of Health whether or not that programme, which is delivered on the academic component, is delivered by a middle sex university and then the clinical training is in our mental health trust whether we can just enlarge that.
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So I think people, certainly centrally, are discussing how do you utilise other roles?
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How do you utilise the role of a pharmacist and you could do a mental health addiction nurse.
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I think Do you know, because you need people who've got a variety of skills.
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It's not a difficult one to use this?
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No, absolutely not.
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I mean, we've got in our team.
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We've got a mental health nurse, for instance, that's got a really good addiction background, but that isn't part of her role as such.
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That's from a previous role that she hasn't understand enough.
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So it's really beneficial that she has that experience, but really on paper that wasn't required for her to do that role.
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So, yeah, I think that sort of amalgamation of those different things is necessary.
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In these cases, you could train on the job could you?
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Yes, absolutely.
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Mental health nurse.
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If they go into a good treatment and recovery situation, surely can learn on the job.
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Absolutely Trauma-informed care is gaining significant attention and forms the foundation of the work of the Renew Mental Health Team and many other teams in the city.
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There are ambitions for all to become a trauma-informed city.
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What are your thoughts on trauma-informed care and how it impacts the communities we serve?
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Oh, I think it's crucial.
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So many people who tell me their story tell me about trauma, and even if they don't give you all the details, you know that they've had perhaps a very difficult childhood.
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Perhaps they've grown up in a house where their parents have been addicted or where there's been domestic violence, and the trauma doesn't always have to be that sort of trauma.
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I still remember one young lady who said to me you might think that my upbringing was in a good middle-class family and you know I didn't have any trauma, but her parents worked abroad and she was sent away to boarding school from very young and she hated it.
00:22:57.895 --> 00:23:11.480
She was taken heroin by the age of 15 and she said it took her a long while to recognise and then deal with what, for her, was her trauma.
00:23:11.480 --> 00:23:30.980
It wasn't the trauma of being physically or sexually abused, but it was trauma, and so I think having people who are trained to help people deal with this trauma is a crucial, not just a drug addiction.
00:23:31.874 --> 00:24:00.920
I mean, I've had some interesting conversations about trauma through this podcast and one of the things that I found really interesting was people start taking drugs because of the trauma, of course, but once they're at that point of, okay, I'm in addiction, they experience something called continuous trauma, where they're putting themselves in a position of sex work, for instance, and by being a sex worker to fund their already existing drug habit, they're now experiencing sexual assault and rape and then that is fair to add into the trauma and then it just keeps going on.
00:24:00.920 --> 00:24:05.608
So it's not necessarily just a root cause of trauma that started the addiction is.
00:24:05.608 --> 00:24:11.575
You've got to unpick the initial trauma, then all the trauma that's followed on while they've been using substances as well.
00:24:12.029 --> 00:24:16.361
And that probably would be the trauma might well be made if you were sent to prison.
00:24:17.010 --> 00:24:17.231
Absolutely.
00:24:17.231 --> 00:24:18.698
Yeah, prison itself can be traumatic.
00:24:19.711 --> 00:24:24.762
I mean you can think of all kinds of things whereby it's additional trauma.
00:24:24.762 --> 00:24:28.786
So you've got multiple episodes.
00:24:28.826 --> 00:24:29.750
Yeah, absolutely.
00:24:30.131 --> 00:24:30.692
And I don't.
00:24:30.692 --> 00:24:32.979
I mean, I think that again is a journey.
00:24:32.979 --> 00:24:36.940
So I think trauma informed care is invaluable.
00:24:37.530 --> 00:24:40.157
Yeah, as it's been really interesting and I managed.
00:24:40.157 --> 00:24:50.940
The volunteers and our service and all those that have taken on the trauma informed training have found that so beneficial, not just for their practice but look at their own behaviours as well.
00:24:51.069 --> 00:24:55.898
Like they said, it's weird, you know, really unpicking their own past lives and that's why I react in this way in that situation.
00:24:55.898 --> 00:25:02.214
That's why I don't enjoy working with someone who has this status and authority and there's all these sort of things that really interests someone.
00:25:02.214 --> 00:25:02.596
Pick with it.
00:25:02.596 --> 00:25:21.876
Despite two decades of evidence based and expert led guidance on supporting individuals with co-occurring conditions, ie mental health and substance use disorders, change of in mental health systems and the culture of some mental health service seems slow to progress and perhaps even resistance to change.
00:25:21.876 --> 00:25:26.199
What do you believe needs to be done to accelerate the process?
00:25:26.891 --> 00:25:34.218
Well, I think I answered that right at the beginning, really, because I think you've just got to keep talking about it.
00:25:34.218 --> 00:25:44.439
Every time somebody says to me they need to be treated separately, I stop them and say, stop, this is not like that.
00:25:44.439 --> 00:25:53.142
Addiction is so related to and connected to mental health and trauma.
00:25:53.142 --> 00:25:54.605
You cannot.
00:25:54.605 --> 00:26:17.143
So I mean you first of all got to change the language, you've got to get the mental health professionals to think differently about this, and we need the support of the Royal College of Psychiatrists, you know, because they could be a great advocate for us in changing this language, in changing the attitude of people.
00:26:17.143 --> 00:26:21.660
We need the psychologists to change their attitude.
00:26:21.660 --> 00:26:24.919
So culture isn't easy to change.
00:26:24.919 --> 00:26:37.221
And then we need the practical steps that allow two services to come much more closely together and, as I say, in the very best of all worlds be co-commissioned, absolutely.
00:26:38.433 --> 00:26:59.058
I mean, I think I spoke to you when we did the first podcast, but I remember years ago the difficulties of mental health and in the sense of we'd work on an individual, mental health problems, substance use problems We'd refer them to mental health because they need mental health support and they would bat them back to us and say, no, the reason why they have mental health is because they've got addiction issues and because they're taking substances.
00:26:59.058 --> 00:27:00.914
That doesn't happen as much now.
00:27:00.914 --> 00:27:02.777
We actually have well, I don't think it happens at all.
00:27:02.777 --> 00:27:13.662
We actually have really good pathways with mind, the Holonese Shorker Service and obviously, as I mentioned already, the multidisciplinary team of clinical psychologists that we've created in terms of a real mental health team.
00:27:13.662 --> 00:27:15.390
So there's definitely improvements.
00:27:15.390 --> 00:27:21.248
But I completely understand what you're saying about the co-commissioned service for mental health and substance abuse.
00:27:21.288 --> 00:27:22.894
I mean that is all under one roof.
00:27:22.894 --> 00:27:28.195
That is ideal, but I think it may not be possible everywhere.
00:27:28.195 --> 00:27:51.560
But surely the communication and surely each of the mental health sort of providers and the addiction providers, the people who work for them, should to widen their minds and learn how to deal with each other's challenges to a certain degree.
00:27:51.560 --> 00:27:58.439
Of course, I don't expect an addiction provider to deal with schizophrenia.
00:27:58.439 --> 00:28:00.144
I mean, that would be ridiculous.
00:28:00.305 --> 00:28:00.928
Yeah, of course.
00:28:01.681 --> 00:28:05.737
And therefore you need a proper referral into a proper mental health service.
00:28:05.737 --> 00:28:15.726
But I do expect people working in addiction in the future to be able to deal with a person's mild anxiety, mild depression or stress.
00:28:15.726 --> 00:28:20.954
That is not difficult, I mean, I trained as a rheumatologist.
00:28:21.661 --> 00:28:30.844
Yes, I remember you saying I didn't refer people with hypertension that was ordinary, straightforward hypertension or somebody with irritable bowel.
00:28:30.844 --> 00:28:48.053
I didn't bother the cardiologist and the gastroenterologist they're too busy and I'm a doctor and I have been trained, so I'm perfectly capable of treating hypertension or treating irritable bowel in its mild you know, ordinary form.
00:28:48.053 --> 00:29:01.830
So that's what I mean by people just stretching their minds, realizing they just have to be a little bit more elastic and flexible in what they're prepared to do.
00:29:03.059 --> 00:29:09.566
So what role do you see service users playing in the development of mental health services within drug and alcohol treatment?
00:29:09.566 --> 00:29:18.707
I mean, one of the big things at the moment is the buzzword that I'm hearing a lot right now is co-production and obviously having service users involved from the beginning up to the end and stuff like that.
00:29:18.707 --> 00:29:20.530
So what do you think of that?
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