Effective treatment starts with a meaningful partnership, says Dr Steve Brinksman.
We recently had a new doctor join our practice who had worked elsewhere for a number of years. I was chatting to her about how she was settling in and interested to hear that she felt the biggest difference was that we were a genuine partnership working together, whereas where she worked previously she’d felt that she’d been a partner in name only.
This led me to ponder on the many occasions we are in situations with clients that are essentially unequal in terms of who holds the power, and how this can cause dysfunctional relationships. Sometimes this is due to pushing back against perceived authority, and sometimes from complete passivity – neither of which is likely to produce the best outcomes.
Gary had been in and out of treatment for years; he knew more about substance use and misuse than most doctors and he knew it. However he also frequently used on top, was in and out of prison, and was hep C positive. He had dropped out of treatment with the community treatment agency about six months before registering with us.
The first time we met I let him talk, and the second and probably the third and fourth as well, then gradually we started to explore what had happened in his life and what he really wanted. By now he was on 60mls methadone and still using heroin and crack a couple of times a week. I was keen that he increased his medication dose to see if we could stop the on-top use; he wasn’t.
Despite his bravado and subject knowledge about street drugs it became apparent that he had very low self-esteem and that this was tied in with his poor literacy. We have an excellent adult education college in Birmingham and with a little encouragement he eventually contacted them and started a course to improve this.
The change in Gary was profound. He started to develop real confidence, rather than just a front. He met people who had struggled like him, and who like him were looking to make a positive change. He stopped his own ‘use on top’ without ever agreeing to an increase in medication dose.
I thought I knew what was needed for Gary from a medical perspective, and yet what was really needed was for us both to form a real partnership where he had the confidence to talk openly about what mattered to him and I listened and helped him achieve his goals.
Whatever our professional role may be, the balance of power seems heavily stacked in our favour by those we see. We need to realise this and make an extra effort to develop meaningful partnerships that facilitate change rather than impose it.