How did the Worker Engage the Client into Harm Reduction?

Sally s Story Background of the Client Sally, a twenty-six-year-old single female, applied for the OASIS Project jointly organized by the Society of Rehabilitation and Crime Prevention, Hong Kong and Kwai Chung Hospital with her self-initiation. As an adolescent, she ran away from home and became involved with a delinquent peer group. She first began using heroin when she was sixteen. Her parents got divorced three years ago. The relationship between her parents involved problems of extra-martial affairs and family violence. At this time, she was living with her father in Tsing Yi but little communication was found between them. She lacked emotional support from others such as her family or friends and felt very isolated socially. At this time that she applied for the detoxification program, she was unemployed. In the past, prostitution was a source of income for her drug use. How did the Worker Engage the Client into Harm Reduction? Sally s motivation to solve her drug problem was high. It was much easier to engage Sally into Harm Reduction approach. Moreover, as Sally was assisted in preparing for the admission of the detoxification program, she was ready to accept the concept of Harm Reduction. During counselling, worker tried to identify Sally s concern and to consolidate her motivation in achieving self-determined goals. Sally was helped to explore both the positive and negative aspects of drug use. Sally s own choice and the influence of which on her were also emphasized. 83

Harm Reduction Strategies Chosen Progressive Harm Reduction of Drug Use: - Changing drug use and practice Lifestyle Change: - Improving personal and health care - Improving family life - Leaving drug subculture Frequency / Purpose of Contact: Frequency: - Two interviews per month with weekly phone contact Purpose : - To encourage Sally to receive treatment to follow up on her medical problem in consequence of her injecting drug use. (i.e. the infection on her right leg and the wounds on her arms)to increase Sally s awareness about the risk resulting from her drug-taking habit to her health. - To encourage Sally to reduce the amount of heroin to an agreed timetable and to gradually replace heroin through regular methadone maintenance. - To encourage Sally to participate in activities such as religious gathering and family gathering that reduce he social isolation. - To enlighten Sally to think about the plan about her life after completing the detoxification program. Comment on the Effectiveness of Harm Reduction Strategies Chosen Sally is seen as a good candidate for Harm Reduction approach. Her motivation is sufficiently high to follow through the agreement. It was found that Sally could carry out the plan of reduction of her drug use successfully. Two weeks following the intake interview, Sally started to reduce the amount of heroin intake and finally 84

stabilized on 45mg methadone daily. As she reported, she succeeded in stopping injection of heroin and planned to reduce the dose of methadone. At this time, she is now stabilized on 5mg of methadone per day and is anticipating in joining the detoxification program (OASIS) of Kwai Chung Hospital. Sally had limited experience of detoxification and abstinence. She had low confidence in solving her drug problem and re-establishing her life. The process of reducing of drug use enhanced Sally s sense of mastery and control and gave her an early success experience. It surely brought positive influence to Sally s long-term rehabilitation. Her sufficiently high motivation was one of the factors leading to reduction of drug use. The medical problems (the infection on her right leg and the wounds on her arms) also enlightened Sally to think about the undesirable effect of heroin injection. At the time Sally was staying in the hospital, most of the staff of the ward and those volunteers from a religious organization showed great encouragement to Sally and thus supportive atmosphere was created. The above factors contributed to Sally s success in reducing drug use. Another aspect of Harm Reduction approach was about lifestyle change. During the intervention period, she learned about all the risks involved with drug taking. She was also educated about the importance of clean and safe injecting. In addition, she was encouraged to use medical and other service in a way to solve the medical problems and life events, instead of using drug or avoidance. Although Sally felt a great deal of pain inflicted by the wounds on her arms or infected area on her right leg, she was not willing to receive medical treatment. She did not go to see a doctor because she felt shameful at her drug-taking behaviour. However, with further encouragement and intervention on her problem-solving approach, she finally sought medical advice for her infection and stopped injecting for the sake of her health. Sally was also encouraged to review her present lifestyle and to participate in activities such as religious gathering and family gathering that reduce her social 85

isolation. Sally got more insight about the role of drug played in her life. Although she got more understanding about the importance of changing her lifestyle, she was unable to put it in action. Negative self-image and fear resulting from long-term isolation with the community hindered her in taking step. No prominent progress was observed. The volunteers of the religious organization visited Sally frequently when she stayed at the hospital. It was found that relationship was established between them and Sally s interest in joining the religious activities or community service was also aroused. Ah Fai s Story Ah Fai, 33-year-old, started taking heroin at aged 20 something. He could not believe he would stick on it for 8-9 years after his first attempt. At that time, he was still ignorant of heroin and soft drugs. Accidentally, his friend invited him to try. Not sure what it was, Ah Fai, for the first in his life, took the heroin by sniffing. He remembered he was bothered by love affair at that moment. He found heroin was able to release his depressed and guilt feeling. As months went by, he stuck on heroin unconsciously. He got marry and people thought he had a harmonious family and led a happy life. But deep in his heart, he knew he needed heroin. Even so, he did not want to stop. He found it was useful for him to light up his boring life. Until his drug problem was discovered, did he start his first attempt to detoxify. His family was shocked and they push him to go to Mainland China for detoxification. He could overcome the withdrawal pain in Mainland China. But driven by psychological craving for heroin, he relapsed shortly after his return to Hong Kong. Trying to deceive his family, Ah Fai kept telling lies. But he was betrayed by his 86

poor appearance and behaviour. He used up his money and his wife always quarrelled with him. Under family pressure, Ah Fai entered to religious residential treatment centre. He stayed for 7-8 months. He enjoyed the pleasant life, no need to think about money and family problem. But he did not plan for his future. After discharge, having no life goal, even he got a job, he relapsed out of boredom and addicted friendship s influence. The family was disappointed and angry. To pacify them, Ah Fai finally joined Methadone Treatment Program. He also hoped to lessen his heroin dose by methadone treatment. At first, he really could substitute heroin by methadone. But facing the monotonous life and addicted peers influence, he fried two dishes later. The better was that he could take lower dose of heroin than before. Then, Ah Fai kept on working daily, going to methadone clinic daily but also injecting heroin once daily. He continued to cheat his wife and to have various excuses for using up his money. He knew he had guilt feeling but he dared not to tell nobody. Why not to change? He said he had accustomed himself to this way of life! Changes happened when Ah Fai started contact with the social worker in methadone clinic. At first, he was passive to talk to the social worker. But gradually, he found the social worker could be a resourceful person helping him to change. He was willing to disclose his attitude and feeling on his drug problem later. He realized he was only 30-year-old. He had a healthy family who still loved him and more importantly, he still had a whole life ahead of him. Because of heroin taking, he wasted 8 years, a lot of money, normal family life and to tolerate the emotional pressure. He was motivated to change. He made up his mind and he got a plan! Ah Fai steadily decreased his dose in heroin and methadone. Referred by the social worker, he was admitted to Kwai Chung Substance Abuse Clinic for detoxification in the final stage. In hospital, he had deep thought on his past. He expressed his 87

suppressed guilt feeling on his good friend, wife and family. He admitted he had too many excuses on and on. He became more rational to plan for his future. After finishing the two weeks treatment, he still felt weak physically. But in his mind, he was clear with strong belief to start a new life! After discharge, Ah Fai mainly stayed at home. Regularly, he returned to Kwai Chung Substance Abuse Clinic for voluntary work. Meanwhile, social worker kept visiting to him. He was also willing to undertake urine tests. Ah Fai s cooperation consolidated his wife s confidence on him. She worried Ah Fai would think of heroin again so she urged him to start working as soon as possible. In fact, Ah Fai also felt uneasy when his son asked him why he needed not to work. But he hesitated. He doubted if he had entirely recovered and was able to handle a full time job. Having careful consideration, Ah Fai finally accepted social worker s referral. He joined the Pui Hong Express Company. Since then, he became a reliable staff in the company. Up to now, he had been working for two years! With a job, he made new friends. Some of them were ex-addicts. He could feel the mutual support and trust. His social life was broadened as he could join other social activities after work. In the past, he was working for heroin. But now, he got meaning in work and he enjoyed the working relationship. When facing problem or having low mood, he was able to share with friends instead of suppressing. Contrary to his past, now life is full of choices, no more loneliness. He did come across his addicted friends. Some of them died of overdose. He thought it was pity. Learned from the experience, Ah Fai treasured his drug free life. After work, he continued his voluntary work in Kwai Chung Substance Abuse Clinic. On one hand, it enriched his life experience. On the other hand, it enhanced his awareness on maintaining abstinence. He realized abstinence was not simply not 88

to take drug but it was a kind of positive thinking and normal life pattern. Since he worked in Pui Hong Express Company, his wife showed stronger confidence on him. Ah Fai no longer needed to deceive. He had the freedom to utilize his spare time and money. Being sponsored by Pui Hong Association, Ah Fai learnt driving and he succeeded in getting the driving license later. It was a positive reward for him. His effort was recognized! In the last two years, Ah Fai could identify his life was absolutely different from what he was when he was still taking heroin. He realized he would lose everything easily by simply taking heroin again. But he did not want to be like that. He treasured his family, the job, the friends and the freedom he possessed. This time, if he gave them up, he knew it would be very difficult to get them back! Comments This case shows that detoxification and rehabilitation treatment for drug abusers is not simple. They need to go through a long term learning process with repeated failure. Close supervision makes treatment more effective. It is important to enhance drug abusers self-awareness and rational decision-making. Methadone Treatment Program provides convenient and accessible services for drug abusers. It is easy for them to make services registration. Methadone treatment minimizes the harms in their daily life. It is very like a lifeboat. As supported by voluntary treatment and career counselling, it is still hopeful for them to lead a new life again. 89