Causas que han Originado la Erosión Costera en el Distrito de Huanchaco

With malice toward none; with charity for all; .. .let us strive to finish the work we are in: . . . to do all which may achieve and cherish a just and lasting peace (Abraham Lincoln, second

inaugural address, 4 March 1865, in R. Basler ed. Collected

Works, 1953, vol. 8).

Introduction

In times of peace, the gates of Janus' Temple were kept shut. Within the walls and closed gates peace and serenity flourished. There are many analogies with the process of 'recovery' in the Janus story. 'Recovery' represents at the same time a 'beginning' of a new phase of life, and the ' end' of an old one. People are developing new habits, skills and friendships as they leave old ones behind. Treatment settings (whether inpatient or outpatient) . were the metaphorical

temples which provided sanctuary and respite from the turmoil of intemperate

insanity. They also provided a place of rest and an environment of peace in which 'recovery' could take place.

Living and discovering a life is a social activity, not something one undertakes

in isolation. All the ' consumer' participants acknowledge help from an outside source, that most frequently being treatment, therapy or counselling. It is the circumstances under which these are provided that captured the energy and imagination of the staff 'participants' in this study. In this chapter I will focus on the structural configurations from within which 'recovery' can take place, and 'maintenance ' be supported.

If one considers the trajectory of coexisting disorders on a continuum from

acute illness � wellness, services are provided at the level of acute illness,

stabilisation and rehabilitation. The time-frame varies according to individual

need, but the 1996 Ministerial Inquiry into Mental Health Services (pp. 233-234)

proposes a model that agrees the immediate/crisis phase lasts two to seven days, the acute phase seven to ten days, the recovery phase, fourteen to twenty days with a follow up phase of six to twelve months. These first two to seven days and subsequent twelve months are the points in time at which consumers engage with services. Because of the nature of coexisting disorders and the needs of consumers, these services are located within a health context and interventions are aimed at symptom amelioration and early recovery strategies.

Services are offered in several ways in New Zealand. Both mental health and

alcohol and drug services were identified in the 1993 Government Strategic

Health Plan as 'core business'. That is, they were considered to be essential to the health and well-being of New Zealanders and New Zealand society. They continue to be provided at a Government level through the DHBs (District Health Boards). In addition, services have also been contracted out to NGO's (non-government organisations) to provide non-acute services in the

community. DHB mental health services offer ad hoc intervention for drug and

alcohol problems in their own client group. This tends to be staff dependent

rather than system oriented ie. in many mental health services, interventions around alcohol and drug issues are dependent on individual staff members with the knowledge, skill and interest. When they resign, the service is discontinued. So concerned were they by this random approach to alcohol and drug input to mental health services, Todd et al. (1999:3) recommended that

/I all mental health services be required to undertake comprehensive assessment

and treatment planning of presenting patients which addresses both mental health and alcohol and drug problems." Likewise, alcohol and drug services may or may not deal with a mental health component of a client's problems. The recommendation to this group of services by the same team (Todd, Sellman

& Robertson, 1999:3) for structure and development was that /I alcohol and drug services . . . be . . . partially integrated into Mental Health Services at a managerial level". In Auckland, this has happened, with the result that alcohol and drugs services now have access to the specialist services of a psychiatrist. This provides for the clients with the most severe mental health symptoms, but does not necessarily serve all those with a need. These services are offered on a continuum of care from inpatient to outpatient and are augmented by specialist dual diagnosis services. NGO (non-government organisation) services such as

Odyssey House offer recovery in a therapeutic community and organisations

such as Challenge Trust give community support to those living in their own

homes or supported accommodation.

The recovery phase of discovering a life was the point at which the paths of staff and consumer participants intersected.

When I asked the staff participants about working with people with coexisting disorders I had expected them to comment on the intrapsychic and relational aspects of recovery for the clients, and their (staff) input into this recovery. By and large, they had a different way of conceptualising client need in recovery. They felt their 'clients' were best served by attending to some of the meta issues of care. These included structural concerns such as who provides the service,

how it is funded, and the operational issues of staffing (including the skill base required).

At each point in recovery staff saw themselves assisting the client in taking

responsibility, sobering up, developing skills and incorporating an understanding of mental illness and substance abuse into their identity as human beings.

Although they could not sober up on the client's behalf, they were able to

provide information, offer strategies and support that made this more likely.

Assisting with the transition to taking responsibility for one's life and life

decisions, and incorporating the 'illnesses' into images of self, were the final

goals of treatment. This happened in a way that allowed the consumer to achieve a balanced and fulfilling life. It was often seen as an 'end point' at which the client was discharged from the service.

Staff did this through addressing the model conflict created by having to work

with the disparate treatment models of mental health and substance

dependence, and attending to concerns about integrated and cultural dimensions

of care. Finally, in order to support the clients appropriately in recovery, they

worked to resolve issues of engagement practices of services and the skills and

knowledge base of staff.

By focusing on the structural and operational concerns of service provision, the

staff participants felt they best contributed to the recovery of the client group

they served.

Two of the key issues the staff participants raised (the model conflict and

integrated care) are, to some degree, one and the same but I want to deal with

them separately here because they require different responses. The model

conflict is something that can be addressed on a local level with good will and

negotiation on the part of the staff involved. The matter of integrated care and

the related arguments about the provision of generic or specialist services are

structural in nature and require a systems response with the attendant funding and resourcing issues.

Key Issues for Staff Participants

Integrated Care

More than ten years ago, M�off (1989:1031) wrote of the 'dually diagnosed':

" . . . despite the powerful impact of this population on the service delivery system, advances in treatment and training have been surprisingly slow." He

speculates that one possible contributor to this problem of developing established treatment protocols for dual diagnosis patients is "the conflict that frequently arises. when addiction treatment programmes and mental health treatment programmes try to collaborate." Minkoff cites Ridgely et al. (1987) as saying lithe fields of mental health and substance abuse have different foci, different philosophies and a history of contentious behaviour toward one another." More than twelve years later and 12,000 miles away, it is still an issue we grapple with in our treatment services today (Warren & Wilson, 1994). There are many ways that treatment for both disorders occurring in the one individual can be provided, and this has led to the development of some 'hybrid' programmes that effectively integrate both mental health and substance abuse treatment (Ridgely, 1991:29). 'However, before treatment can be integrated, a treatment philosophy that incorportates both mental health and substance abuse into a unified conceptual model needs to be developed. Ridgely (1991:30) has trawled the literature on integrated treatment programmes and advanced a set of principles that need to be reflected in essential service elements, no matter where that service is being offered. Interventions need to:

. . . engage clients in services, motivate them to seek specific substance abuse treatment, provide comprehensive assessment of alcohol and drug and mental health problems, provide concomitant treatment including a core set of mental health and substance abuse treatment interventions, provide or orchestrate relapse prevention or other after-care interventions, and develop linkages between the alcohol, drug and mental health treatment systems.

In this piece of research, treatment to those with coexisting disorders was being provided out of three distinct health services, each with a different orientation; mental health, alcohol and drugs and a specialist dual diagnosiS focus. In addition, some of the services were government owned and controlled through the then Crown Health Enterprise system (now District Health Boards), and the others were NGOs (non-government organisations).

Waveney worked for an NGO supporting consumers in the community: 'Coexisting disorders' is coming to be seen as such a specialty that people get scared of it, yet it is not a great mystery. Whilst it is true that consumers do have a lot of needs, and present with a lot of problems, only part of their problem is with their mental health or their alcohol and drug use. The rest is the way these issues impact on managing their lives. Our problem is

often with trying to meet their needs from inside a service that is not set up to cater for them.

Most of the staff working in a 'single provision service' (mental health or alcohol and drugs) were keen to see the establishment of a specialist service to whom they could refer on. Staff working in a designated 'dual diagnosis' service felt overwhelmed by the enormity of the demands on their time, knowledge and skill, and were keen to see generic workers trained up to offer this comprehensive service in a variety of settings. Ivan found one way of keeping his job manageable was by gate-keeping through the referral system to

the I specialist' dual diagnosis service he worked in:

We've tried out a few systems regarding the referral system. It safeguards us from being inundated with a lot of incoming clients . . .ideally it would be a good process for case managers to do a lot of the basic assessments.

The Todd Report (1999:3) was emphatic that lithe development of both the

specific role of I dual diagnosis' workers and 'dual diagnosis' units be

discouraged" . This could be overcome by each specialist service taking on an advisory role for the other.

Model conflict

A variety of models or theoretical orientations are used to inform treatment and therapy that is offered in both psychiatric and addiction settings (Stuart, 1998:55). According to Stuart (1998:55), each model is /la way of organising a

complex body of knowledge" and is used clinically to suggest 11 reasons for the

observed behaviour, therapeutic treatment strategies, [and] appropriate roles

for patient and therapist" (Stuart, 1998:55). The predominant models of

analysis and care in a psychiatric setting are medical and psycho-social. The medical model sees that "behavioural disruptions result from a biological disease process . . . and treatment consist[s] of medication and supportive therapy" (Stuart, 1998:56). In this world view, the patient complies with prescribed therapy and reports the effects of therapy to the therapist. The therapist (usually a doctor) undertakes an examination, formulates a diagnosis and prescribes a therapeutic approach. Because in this medical view of the

presenting behaviour 11 an abnormality in the transmission of neural

impulses . . . and neurochemicals" (Stuart, 1998:62) is thought to occur, medication that corrects this chemical imbalance is usually part of the solution. Given this theoretical framework for assessment, it follows that the medical model dominates the intervention in the immediate crisis and acute phase of the illness. According to Stuart (1998:62) "therapy is terminated when the

patient's symptoms have remitted", thus making this period in which the medical model dominates somewhat time limited.

However, the medical model on its own does not account for the recovery period in its entirety, and other branches of research " focus on stressors and the human response to stress" (Stuart, 1998:62). The stress adaptation model developed by Stuart (1998:66-81) takes account of the biological, psychological, sociocultural, environmental and legal-ethical context.

Psychological models focus on "the individual and intrapsychic processes and

interpersonal experiences" (Stuart,1998:58), and draw heavily on

developmental processes and basic human need. Hildegard Peplau (1952, cited in Stuart, 1998) in her ground breaking work on interpersonal processses in nursing, saw the "two interacting components of health [as] physiological demands and interpersonal conditions".

Addiction treatment services are equally beset by model conflicts of their own. The two competing perspectives are at opposite ends of a continurim; from dependence with a solution based on abstinence from all mood/mind altering drugs (Shaw, 1985:35) at one, to brief interventions aimed at reducing the harm

caused by problem drinking (Bien, Miller & Tonigan, 1993:315) at the other.

The disease hypothesis of dependence is premised on the centrality of psychobiological alterations to the body, and fits with the "cause, symptom, treatment concept" (Shaw, 1985:39) of the medical model and abstinence based therapy. At the other end of the continuum is the harm minimisation/risk

reduction model, and. while abstinence is the ultimate harm minimisation

outcome, harm minimisation is usually interpreted as the antithesis of dependence. Intervention is based on motivational enhancement and has as its goal, "reduction of harm caused by alcoholj drug consumption rather than

abstinence" (Bien, Miller & Tonigan, 1993:315).

The Twelve Step approach has always been a source of conflict within 'professional treatment' services. Some 'professionals' see it as a useful adjunct to more psychological treatment models, others see it as a 'blind leading the blind' self help approach that has never opened itself to rigorous scrutiny or evaluation, and has no proven value. While some authors (Twerski, 1993:44) argue that Twelve Step programmes may not be as effective when there is coexisting emotional or psychiatric disease, others (Segal, Silverman & Temkin, 1995) argue that "these types of programmes often have a higher appeal to individuals who . . . have a dual diagnosis of mental illness and substance abuse disorder than do traditionally operated programmes." Perhaps the issue is not

self-help/Twelve Step versus 'professional' programmes, but the difference between rehabilitation and recovery, with 'professional' treatment services

offering rehabilitation and the Twelve Step programmes, recovery.

The final dimension in the 'model conflict' is the training backgrounds of the staff participants. They came from a variety of disciplines (psychology, nursing, social work and counselling), each with their own theoretical traditions and specialist practices. They operated out of an eclectic model of care that was influenced by their training, the predominant model of their

workplace, and also accounted for the way in which the ' clients' made sense of

their ' illness' .

It was the competing demands and capacities of the medical, psychosocial and cultural models that provided a challenge to staff to find a way of working in the 'inter-model space'.

Most of the staff participants were working with people in the acute/ sub-acute phase of an active episode of mental illness or addiction. Most of their clientelle were in the process of detoxification and/ or still being medicated and

many were still experiencing alterations in perception in one or more of the five

sensory modalities (sight, sound smell, taste, and touch). Staff spent energy in helping to manage 'symptoms' at the same time as trying to re-integrate consumers back into the community from which they had come. This necessitated a flexible and integrative approach using two or more potentially conflicting models. The models of mental health and addiction treatment. Waveney was working in a community mental health environment that took clients straight from an acute setting:

As health professionals . . .in relation to dual diagnosis, we're still upgrading out of a medical model, and that actually stands in the way of doing what you need to do to work with this group of people . . . there are ways around it and we can be

creative with it . . . but I also think as health professionals we

need to challenge the medical model. . . and encourage self­ responsibility. It's almost like we've got a bit of a brokering role.

For staff working in an alcohol and drug setting the problems became even greater. From a community alcohol and drug service Toni found that:

. . . about a third of my client group has a dual diagnosis . . .long complicated looking stuff . . . and its difficult because we are a

service that's set up to be a brief intervention service . . .1 mean I

this is not brief intervention . . .I've had to get an okay from the management to go on seeing her.

Whatever the model that informed their clinical practise, Todd et al. (1999:3) argued that " all patients with coexisting disorders [must] have access to mental health and alcohol and drug clinicians who have adequate skills to assess, formulate and implement treatment plans . . .including their cultural needs." Meeting Cultural Needs

The socio-cultural model focuses on the importance that culture and social conditions play in both the definition of mental illness and addiction, and the solutions to them. Within the New Zealand context, there are a number of indigenous perspectives that inform mental health (and subsequently alcohol and drug treatment) provision (Durie, 1994:67). The Whare Tapa Wha model forms not only the basis of Maori health provision in Iwi-based treatment services, but it has been adapted in many forms into mainstream services:

. . . Briefly, the whare tapa wha model compared health to the four walls of a house, all four being necessary to ensure strength and symmetry, though each representing a different dimension: taha wairua (the spiritual side), taha hinengaro (thoughts and feelings), taha tinana (the physical side), taha whanau (the family). (Durie, 1994:67)

According to Durie (1994:71), these four dimensions of health were originally portrayed as a set of interacting variables, not dissimilar from the holisitic view that is familiar to most health professionals in New Zealand. Western health practices have been informed by the World Health Organisation (WHO) cognate holistic definition of health:

. . . a state of complete physical and social well being, and not merely the absence of disease or infirmity. (Miller & Keane)

However, unlike the WHO understanding of health, the Whare Tapa Wha model is "firmly anchored on a spiritual rather than a somatic base" (Dtlrie,