Joint activities and tasks and one-on-one interviews enable the development of positive therapeutic bonds based on ‘optimal proximity’, thus improving the prospects of successful treatment outcomes – Photo: Shutterstock, licence CC
By Andrea Ríos Rognone – The Dianova Foundation Uruguay administers various programmes addressing mental health issues, particularly the problematic use of psychoactive substances, in the areas of education, prevention and treatment. Dianova Uruguay is dedicated to developing activities that actively contribute to self-reliance and social progress, notably through human-rights based therapeutic programmes. People from all walks of life, various age groups and different social, economic and cultural backgrounds, benefit from these programmes. The latter consist of different forms of intervention, the majority of which are social aid programmes conducted in partnership with the National Network for Drug Treatment (RENADRO) and the National Council on Drugs, and designed in keeping with the National Strategy to Address the Drug Problem 2016-2020.
Addiction and older people
The expertise developed over 25 years enables us to understand the uniquely vulnerable state of the older people who consume psychoactive substances, especially in the case of people with a long history of drug use deeply rooted in a subjective criteria that is closely related to the importance that the drug represents for them.
In this regard, in the case of older people with an extensive history of drug use, the vulnerabilities usually worsen according to the decline in their mental, physical and for the most part social health. It is in this last field that the role of institutions, public health, social policy and drug policy become especially relevant, as in their life time these people have undergone a number of treatment programmes which have proved unable to help them achieve more healthy living habits in a sustainable manner.
Specific vulnerabilities
Drug use is related to many factors which must be taken into account. Chief among them are personal characteristics. However, in the case of consumption by older people, special attention must be placed on their socio-emotional environment and their traits within this context. The specific vulnerabilities related to age and biopsychosocial deterioration may present particular difficulties in maintaining spaces for care and support within their primary environment. This could occasionally create situations of family exclusion and social marginalization.
In these cases, each person’s level of access to healthcare becomes vital. Depending on public policies, this level of access may facilitate or impede assistance seeking. A major risk is that once access is impeded, people may become homeless, thus increasing their level of vulnerability.
Person-centred interventions
With that in mind, at Dianova Uruguay we believe that every intervention should be implemented in the context of person-oriented care. The latter is essentially a human-rights based approach that primarily demands that the beneficiary be recognized as a legal person, with their own rights, and entitled to make decisions about their life and health, and encouraged to exercise their right to a decent life.
Interventions must be tailored to each person’s needs and at all times involve safeguarding and promoting human rights, in conjunction with the methodological approach, thereby guaranteeing equal access to care.
The work must be adapted bearing the gender-based perspective in mind in order to guarantee equal opportunities for everyone without discriminating according to people’s sexual or gender identity.
Individualized treatment processes
Bearing the method above as the main methodological framework, person-oriented care implies that each therapeutic process is individualized. The objective of interventions is to promote healthy living, self-reliance and social progress through active listening and the identification of the person’s needs and difficulties, as expressed by them and while respecting their views. Recognizing people in treatment as individuals implies to prompt them to participate actively in the construction of their own therapeutic project. In order to do so, the motivational approach is highlighted as a means of communication.
Chanaes’, a centre of the Dianova Foundation Uruguay, specializing in dual pathology, i.e. the coexistence, in the same patient, of an addiction to one or more substances together with another psychiatric disorder – photo: Dianova Uruguay, licence CC
Establishing a relationship based ‘optimal proximity’
In the first instance, it must be noted that interventions of whatever sort, however long they may last, must encourage the creation of a welcoming, close and flexible support facility in which people feel heard, respected and supported. Creating a safe emotional environment where people feel protected and contained fosters bonds of trust with staff, promotes adherence to the processes and increases the chances of achieving the proposed goals.
The residential programme involves a particular way of creating therapeutic bonds, where the skills of the qualified personnel are put into play in order for them to work as closely as is ideal with beneficiaries.
In other words, at a sufficiently functional emotional distance for the processes not to be hampered due to personal factors from the members of staff, and at the same time, through an ‘optimal proximity’ necessary to ensure that the counselor’s commitment to the therapeutic process is based on true professional empathy. The attitude of counselors is therefore critical. It is an attitude of collaboration with clients based on the acknowledgement and encouragement of their strengths and abilities, which is likely to promote spaces that foster the process of change.
The person as a whole
Person-centred, singular approaches facilitate the recognition of each facet of an individual’s life, thereby engendering interventions based on a biopsychosocial perspective. The person is understood from his or her personal and individual dimension and in a family, community and social context, at a historically, culturally, economically and politically determined point in time, which participates in the construction of his or her subjectivity.
It is by considering the situation’s complexity and the multiple factors that affect people’s lives, that projects are reinforced by the integration of the different actors who are part of the person’s family, community and social context. Priority should be given to strengthening the person’s socio-affective support networks – while considering the family and community environment from a territorial approach – and institutional networks in order to promote sustainable health processes, in particular access and adherence of people to aid resources, while taking care to promote overall health.
Individualized processes imply recognizing the person in their singularity and subjectivity. Thus, interventions do not target drugs or the person’s diagnostic classification, but rather the person themselves and their subjective perception of their life, difficulties and relationship with their drug of choice.
This endeavour is carried out with a view to managing risks, harm and pleasure, all of which are associated both with the use of psychoactive substances and with the various risk factors which affect the person’s life.
Quitting drugs, a treatment goal among others
The therapeutic and pedagogical work that is carried out makes it possible to recognize the risks and possible harm associated with the person’s decisions, while at the same time empowering their decision-making based on better knowledge of the consequences of these decisions. The approach to risk and harm management is based on the principle that people have the right to make their own decisions about their lives. From this perspective, putting an end to drug use and maintaining abstinence is one possible option, but not the only one.
A flexible model, based on cross-sectoral partnerships
In view of the predominant role played by the person themselves in the therapeutic process, interventions should be flexible and dynamic, adapted to each person’s situation and respectful their choices and moment in life. To this end, we must reaffirm the individualization of the therapeutic process as well as the need for an ongoing readjustment of the therapeutic project in order to achieve treatment goals.
We must insist, on the one hand, on the interdisciplinary and cross-sectoral nature of the interventions, but also on the coordination and the necessary complementary nature of the various professional skill areas and the different institutional stakeholders involved.
Networking is undoubtedly the most relevant response and, as professionals, we must always question our daily practices and our way of optimizing resources in a relevant intervention framework that is likely to achieve the objectives in a sustainable way.
In conclusion, I would also like to highlight the role of our institutions, particularly in creating evidence-based evaluation processes, in order to achieve constant improvement in person-centred intervention practices. The staff must also question their daily commitment so that it adapts to the person and not the other way round and so that it promotes equal opportunities for all, and in particular for older people who are particularly vulnerable.