Two sides of the same coin: patient adherence and staff turnover in substance misuse settings
Butler, Carolyn Maeve
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This thesis portfolio includes two studies, a qualitative grounded theory of treatment adherence in people who inject drugs (PWID) and a systematic review of staff turnover in substance misuse services. The empirical paper is presented first, the findings of which led to the systematic review. The qualitative interview study arose from observations made within a clinical trial for the treatment of chronic Hepatitis C (HCV). The Chief Investigator of the ERADICATE trial team initially approached the Adult Psychological Therapies Service to investigate what seemed to be an anomaly – patient engagement with HCV treatment had far exceeded expectations. Indeed, positive treatment adherence is not common among PWID. What is more remarkable is participants continued the trial while experiencing the highly aversive side-effects of interferon, a medication known to mimic opioid withdrawal. It is important, if not crucial, to acknowledge the wider socio-cultural context in which this thesis portfolio was produced; the political landscape changed significantly over the course of writing. Divisive judgements about what characteristics make a person worthy and deserving of resources, became more dominant in public discourse and heightened the author’s awareness to these aspects in the data. PWID are among the most marginalised, and stigmatised groups in society. Several of the participants interviewed were homeless and all were at various points on a relapsing trajectory of injecting drug use. Perhaps positive treatment adherence in this population is counter-intuitive because intuition is often based on assumptions derived from implicit biases. Indeed, until 2008, Scottish policy systematically denied HCV treatment to PWID. Due to the assumption that re-infection was inevitable, treatment was seen to be wasteful. Epidemiological studies now show is that public health is significantly improved when PWID are treated, as population prevalence goes down. Completing this thesis led to an examination of fundamental assumptions, not just relating to the participants or the data, but also relating to the question of what Clinical Psychology is. What can we contribute to the science of human behaviour? How does a self-aware mind arise and become autonomous? What leads adults to mentalize and enact their intentionality through particular behaviours, like taking medication? In grappling with these questions, the reader will detect the influence of developmental theorists, Vygotsky, Erikson and Bowlby. Seminal experiments, such as Tronick’s still face (Tronick, 1989)1 and Harlow’s monkeys (Harlow and Zimmerman, 1958)2, alongside newer fields of interpersonal neurobiology and developmental trauma have supplied the soil in which to ground the data gathered in this study. From our earliest days we are designed to absorb stimuli and integrate our perception into a gestalt. When PWID are characterised as “chaotic”, there is a failure to appreciate what this may really reflect: difficulty making sense of internal experience resulting in the absence of order, coherence and meaning. Therefore, the ontological presupposition underlying both the empirical paper and systematic review, is that humans are resilient, relational beings. When the correct conditions and contingencies are in place, our innate propensity to learn and grow can manifest in positive, adaptive behaviour. Narratives are not only ways of seeing the world, but ways of constructing it; we live through and are created by the stories told by others and ourselves (Murray, 2003)3. The public narrative of scepticism that has emerged around scientific endeavour, makes it all the more incumbent upon researchers to carry out their work with personal conviction, integrity and transparency (Rea, 2017, February 22)4. This qualitative analysis was completed with a high level of scientific rigour. Indicators of quality were employed throughout, for example, particular attention was paid to preserving the colloquial expression of participants in transcription and substantiates the authentic representation of their voice. The resultant grounded theory shows that the interpersonal context is a key part of adherence behaviour among PWID. This finding precipitated another question, if good quality relationships are important for patient engagement, how do staff stay engaged in the task of providing consistent, sensitive care on a sustained basis? The current evidence base on supporting and preserving compassion did not substantiate a systematic review, however, the opposite phenomenon, people leaving their jobs has been explored. As Clinical Psychologists we are able to connect with and influence different audiences by skilfully adapting our language. In order to appeal to managers and team leaders, the most pragmatic way of framing staff disengagement, was to examine actual staff turnover as a ‘hard’, concrete outcome. The methodological quality of studies included for review was reasonable in the context of methodological limitations. Findings point to the importance of collective support, good quality relationships and job satisfaction in mitigating against turnover in substance misuse services. This thesis portfolio is a sensitive and pragmatic understanding of engagement in both PWID and staff with the respective systems within which they are embedded. The results are contextualised and oriented toward medical colleagues working in HCV treatment, service leaders and fellow applied psychologists.