9 Training and Support

Introduction

9.1 Two recurring themes of this report are that AIDS is a new disease about which knowledge is constantly changing, and that the needs of drug misusers with HIV-disease can not be met by any single agency. Adequate care depends on co-ordination between and delivery by a wide spectrum of agencies who understand the implications of both drug misuse and HIV-disease and have up-to-date information about both. Training will be a cornerstone of achieving this.

9.2 Evidence we have received indicates that training in drug misuse and HIV-disease is currently patchy, varies greatly between District and Authority, and in general is not receiving the priority it needs in terms of resources. In a climate of financial stringency, training allocations are often easier to prune than many other budget items, particularly where the courses can be seen as extracurricular. District Health Authorities, local authority Social Services Departments and the Police, Probation, and Prison Services should earmark funding for training on drug misuse and HIV-disease. Non-statutory sector staff should be involved in these training courses. In the longer term, training should form an integral part of the costing of services, including non-statutory services. The resources specifically allocated for drug misuse and AIDS could also be used, under joint funding arrangements, for training purposes. Those running courses should ensure training is available to staff in the non-statutory sector who are involved in direct service provision.

9.3 The evidence we have received suggests that although an increasing number of people are aware of the basic facts about HIV transmission and AIDS and have received basic training or information, this has been to some extent in a vacuum. They have not been working with people who were antibody positive or who had developed AIDS. Thus, additional, focused training is essential when someone using the service is known to be antibody positive or to have AIDS. Similarly, if a fellow member of staff is found to be antibody positive, staff may well need to re-examine their fears and prejudices. New developments will create further training and support requirements.

What training is needed?

9.4 Staff education and training should be a continuing process. Not only will the working environment change as more clients or patients become infected and ill; perhaps more importantly it is not possible to deal with the information, awareness, attitudes and skills development needs of staff in a single training event.

9.5 The ACMD is currently writing a report that will consider the training needs of staff in relation to drug misusers in general, and which deals in detail with the training needs of specific staff groups. Here we are concerned with the more general training needs of staff who work, or will be working, with drug misusers with HIV disease. In this context, we have identified three main components of training:

i. Awareness and Attitudes: exploring feelings, fears, emotions and prejudices about drug misuse, sexual behaviour and people with HIV disease.
ii. Knowledge: learning facts about the transmission, symptoms and progression of HIV disease and the needs of infected people; and facts about drug misusers — the drugs they take and the physical and psychological effects these have, their lifestyle, language, and concerns.
iii. Skills: learning how to carry out specific tasks and achieve particular aims, and gaining the confidence to put this into practice.

9.6 In theory, each of these aspects of training could be taught separately, but the best courses will incorporate aspects of all three. Knowledge should never be imparted in isolation, but always in conjunction with attitude training. This is because the facts about HIV disease and drug misuse cannot be absorbed by people unless they challenge their own preconceptions, fears and beliefs. Knowledge and attitude training alone, however, are not enough to enable staff to do their job properly. Staff also need to learn how to do the job. Conversely, no matter how skilled an individual is, he or she will be unable to respond appropriately to a client if attitude problems have not been properly addressed. Training should be targeted towards the needs of particular work settings and staff groups, so the balance between these three components will vary, as will the level, content and method of delivery of each.

9.7 Training should also be concerned to enable staff to review the service they provide and to stimulate them to decide on and make changes in service delivery where the present service offered either inhibits attendance or is inappropriate to the needs of clients.

Awareness and Attitudes

9.8 Attitude and awareness training should have clear objectives which will address the concerns and fears of staff in such a way as to bring about appropriate behaviour change in staff who deliver services. It should be evaluated and monitored against this objective. Undoubtedly, one of the greatest needs of drug misusers with HIV-disease is for staff who are friendly, approachable and non-judgemental. Attitude training should address this need. It should:
—    provide a re-statement of information about HIV-disease and/or drug misuse;
—    give staff an opportunity to express their feelings and anxieties about working with drug misusers with HIV-disease;
—    address and respond to staff's fears and prejudices.

Knowledge and Assessment

9.9 There is an immediate need for training in the basic facts about drugs and drug misuse, and HIV-transmission and the nature of HIV-disease. Many of the service providers whose responsibilities we discuss in this report have expertise in one of these two areas, but not both; others – particularly generic workers – may have little knowledge or expertise in either. It can be particularly difficult for non-specialist staff, especially those in the non-statutory sector, to obtain authoritative, up-to-date information about HIV-disease since this is an area of rapid change.

9.10 In the future, drug misusers will form a substantial proportion of those who are ill with HIV-disease. All staff who care for, or are likely to care for people with HIV-disease must therefore learn about drug misuse and the management of drug misusers. Obviously, the degree of knowledge required will depend upon individual responsibilities, but there must be a general heightened awareness of the particular needs of drug misusers.

Skills

9.11 As a general principle, it must be recognised that the acquisition of skills is a long-term process, which requires wide-ranging and continuing training. The skills we discuss here cannot be "learnt" in a short one-off course.

Achieving and Supporting Behaviour Change

9.12 Achieving and supporting behaviour change is important whether or not the drug misuser is anti-body positive. However, the evidence we have received suggests that a significant proportion of drug misusers, on learning of their positive anti-body status, may relapse into drug misuse or engage in increased high risk behaviour. It is essential that staff are trained to provide pre and post-test counselling and that they receive training to assist them in reducing the likelihood of an individual resorting to high risk behaviour.

9.13 In our first report we emphasised the benefit of encouraging drug misusers to attend services, and that behaviour change would be most effective where the client could identify clear advantages for him/herself. Training should be developed, therefore, which enables staff to counter the hopelessness associated with a positive diagnosis. In particular, training should be provided:—

—    to enable staff of drug services to talk without embarrassment about sex and sexuality to promote positive approaches to the enjoyment of safer sex;
—    to promote safer drug using practices where clients cannot immediately stop drug misuse;
—    to assist drug misusers monitor their own health and appreciate the benefits of healthy eating and improved care of their own health;
—    to develop mutual support networks for drug misusers.

Experience has demonstrated that drug misusers are willing and able to change their behaviour. It is important that staff should learn to identify and set realistic objectives with clients which are geared towards reducing or eliminating harmful behaviour.

Coping Skills

9.14 In addition to achieving and sustaining behaviour change, those working with drug misusers will need specific training to assist both them and drug misusers to cope with the onset of illness and the stages of the disease. As illnesses develop there will be an increasing need for inter-disciplinary work between a number of professional groups and concerned individuals. There will be considerable benefit in joint training in order that all those involved may have a common understanding of each others' roles.

9.15 Training will be required to assist staff dealing with clients' depression, suicidal tendencies, bitterness, resentment, denial and anger. Because many drug misusers may still be living at home with parents or a partner, training will also be required to assist in the re-building of damaged relationships in order that the family and friends of the drug misuser may be in a position to provide continued support. Where drug misusers have partners and/or children, training may also be required for the family in order that they might support behaviour change. Such training should include methods of managing stress and for avoiding sexual transmission of infection. Family and friends will themselves need emotional support.

9.16 With regard to achieving changes in sexual behaviour, staff should realise that both men and women can find it difficult to adopt safer behaviour even when they understand the reasons behind it. Partners may pressurise them to "prove" their love by offering unprotected sex. When clients are being educated about safer sex it is important not only that factual information is provided but also that strategies for implementing new behaviour are also discussed.

9.17 For those working with drug misusers, the additional problems arising from HIV infection are likely to increase the stress they experience. Training will be required to enable them to cope with loss and bereavement and to deal effectively with stress.

Staff Support

9.18 Allied to training in coping skills is the issue of staff support. Staff must take action, and be helped, to look after themselves if they are to be in any position to offer a service to others.

9.19 We have heard telling evidence from the United States about the high level of "burn-out" experienced by staff working with people with HIV-disease. The work can be physically and emotionally draining, requiring a high level of energy and commitment in the face of great intensity, stress and sadness. There are likely to be concentrations of drug misusers with HIV-disease in certain areas, placing extreme pressure on a relatively small number of staff. Added to these difficulties, staff may harbour fears about becoming infected themselves.

9.20 Working with drug misusers to help achieve behaviour change, is not straightforward, and may lead staff to confront professional and ethical dilemmas. Sometimes interventions will not succeed in their aims; sometimes they will make things worse. This adds to pressure on staff, who may feel vulnerable unless they are confident of the support of colleagues and managers.

9.21 Staff of all grades in all likely settings must be adequately trained for working with seropositive drug misusers; staffing levels must be adequate; and staff must have access to emotional support, be it through mutual support groups or external agencies, including line management where appropriate. To ignore these needs will be counter-productive as staff resign, or spend periods of extended sick leave, thereby creating additional pressures for their colleagues.

Conclusion

9.22 Many staff in a range of services will require training if they are to provide support and care to drug misusers who are seropositive, or ill with HIV-disease. Those who are currently in the front-line of caring for this group — including staff in many non-statutory services — should be awarded greatest priority for training in the short-term.

9.23 We have identified three key areas of training. What is provided in specific instances will vary according to local and individual needs and circumstances. It is essential however that training and staff support are given the priority they deserve if we are to be able to provide a skilled, caring and effective response to the needs of drug misusers with HIV-disease.