Dan Mushens looks at how a harm reduction approach can help those receiving care
Supporting people to recover from alcohol related brain damage (ARBD) and to live independently in their own homes is the primary function of our supported living service.
Historically, we promoted ourselves as an abstinence based service meaning those accepting our support needed to express their desire to abstain.
If someone was intoxicated when we arrived at their front door to support them, then that was deemed sufficient enough reason to retreat and leave. It felt almost punitive- as if we were chastising them for relapsing.
This never sat well with most of the team because it meant leaving vulnerable people alone in their homes when we all knew we could have offered some form of assistance, however small it may have been.
A potential fall could have been prevented by moving furniture; malnourishment combated by support with meal preparation and encouragement to drink water to rehydrate and take medication doses were all missed opportunities.
A harm reduction approach is often considered the opposite of a zero tolerance abstinence based approach, which is still prevalent within many services around Scotland.
And there is a need for such abstinence based services too, especially for people living within care home settings when the sobriety of one individual can’t be compromised by the misuse of alcohol by another.
Over recent years however, we have shifted towards using the harm reduction approach in our support delivery. We no longer have the precondition that someone must be living alcohol free – or even be at a stage in their recovery that they wish to be living alcohol free.
Of course, we continue to educate people of the benefits of living without alcohol, such as the higher chance of sustained and meaningful recovery, which increases independence and their ability to self-manage.
We do this with unconditional positive regard and respect for their autonomous decision making and do so without judgement.
Reflecting on our old criteria, it now seems ironic that we would withdraw our support when someone relapsed and presented as drunk. It’s at this very moment that they are at their most vulnerable and in the greatest need of our assistance.
We now use our in-house designed Step Up programme to initiate discussions. Based on various themes of recovery such as: relationships with alcohol, effects alcohol has on the body and what local resources may be available for people to access in their communities.
The Step Up facilitates a structure to allow us to deliver alcohol brief interventions (ABI) at various stages of someone’s journey, with motivating and encouraging a constant challenge.
In its simplest form, promoting harm reduction is all about mitigating the likely negative outcomes of chronic alcohol misuse, which in our service user group has advanced into ARBD.
For a person living with this illness and still actively drinking: lethargy, confabulation, lack of appetite, lack of insight, reduced mobility and forgetfulness are all evidenced on a day-to-day basis.
An example of some of the harm reduction interventions used so far include supporting someone to maximise their income to allow them to purchase a tablet.
Then, on the days when we arrive to find the person intoxicated and unable to safely walk into the community, we support him to use his tablet to minimise potential harm.
He uses a food ordering app to have a hot meal delivered to his door to ensure he doesn’t miss out on his nutritional requirements.
He is also in a routine of visiting the cash machine daily to check his bank balance. When he is unable to leave his home to achieve this, then he is supported to use his banking app to do this, which prevents his sense of frustration and anger from building up.
These interventions reduce the potential for harm to occur, as his falls in the community have increased over recent months resulting in significant physical injuries. However, his mobility is otherwise excellent during his periods of abstinence and support to engage in the community is something that is wholeheartedly promoted.
Another person we support had his electricity meter located above his front door, which required the insertion of a key fob each time it required topping-up. He had already fallen off a stepladder when trying to do this during intoxication, which resulted in facial injuries.
After discussion, he was supported to have a smart meter installed meaning topping up at the local shop and no longer requiring access to the elevated meter anymore. Again, this reduced the likely risk of harm from climbing up a stepladder and potentially falling off.
A final example is of a woman we support who seldom attends healthcare appointments due to significant ARBD related cognitive deficits, breathlessness and lethargy.
She has been supported to have at least some of her health needs attended to in the comfort of her home. Podiatrists, opticians, occupational therapists, dieticians, dentists, doctors and nurses have all visited over recent years to reduce the harm from her apparent alcohol induced self-neglect.
Total abstinence will always be the preferred route to recovering from ARBD, but I don’t think it’s a case of either/or, but more of a case of one approach complementing the other.
Finally, abstaining from alcohol is a form of harm reduction, which originates within the individual, and if extra support from other people or agencies can reduce harm further, then all the better.
Dan Mushens is a recovery practitioner for Scottish mental health charity Penumbra and works in the charity's Glasgow ARBD Supported Living Service
