Drug Abuse

HELPING THE HELPERS

• a plea for structural support of 'heart'workers -

Paper presented at the 5th International Conference on the Reduction of Drugrelated Harm, March 6-10, 1994,

Toronto, Canada

by Bart Majoor, clinical psychologist -

Head of the Department of Training and Methodology at the Netherlands Institute for Alcohol and Drugs (NIAD), Utrecht, The Netherlands.

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"Some people will never burn out

because they were'nt on fire to begin with.."

1: Introduction

The subject of my paper is Helping the Helpers, the workers in the Harm Reduction-field. What do they need to do this work properly? What kind of support for them is effective?

As an introduction I want to make two statements that are important starting-points for my presentation.

My first point is about the context in which these workers are doing there job. It is about - what I would call - the pollution of drugcare by the medicalisation ánd criminalisation of drugaddicts.

The treatment out of the traditional medical-psychiatric approach to addiction favours the disease-model and is directed towards total abstinence of the drug. Very few drugaddicts appear to be able to do so. That is why we started to develop the Harm Reduction approach in order to be able to at least reach the drugaddicts and reduce the drugrelated (extra-)harm done to them by the actual sociopolitical context.

The criminalisation of druguse causes complications in the care for drugaddicts too. One could say that working with drugaddicts is very polluted by the fact that heroin, cocain, etc. are illicit. Working with drugaddicts nowadays means more and more: keeping them of the streets, keeping them quiet, providing tons of methadone to keep them satisfied, making them less dangerous, less repulsive, less sick, taking them out of the sight of society, marginalizing them in fact even further....

In terms of working with drugaddicts - being in daily contact with those people - this illicit context is always present. It penetrates in every aspect of the clients' life, so it appears in every meeting between helper and client. It creates a depressed, often negative atmosphere.., ánd perspective!

The criminalisation of druguse sets on a proces of deterioration on the individual level. Deterioration describes a proces of pollution, declining and social upheaval of a person who is dependent on an illicit drug in the actual social context.

Deterioration is mainly caused by social factors, although physical and psychological factors play a role in this process. A drugaddict becomes part of a negative spiral of deterioration because his/her environment reacts in such a way (by stigmatising and criminalising) that expulsion takes place. The drugaddict will then isolate him/herself more and more and withdraw in a subculture or scene with very different norms and values. This creates a very complicated context for people who work in this field.

The pollution of care for drugaddicts by medicalisation and criminalisation makes life unnecessarily harder for our clients and makes working-life much more complex and often draining for the workers.

So, when we talk about Harm Reduction it is very important to pay attention to the workers and how they survive in their job.

My second statement is related to the first one and is a plea for structural support for drugworkers. It is about the importance of a Human Resource policy within the organisations that work with drugaddicts. It cannot be a coincidence that Harm Reduction Management and Human Resources Management have the same shortening: HRM...

It is wellknown by experience that working with drug- and HIV-problems on a daily base out of the Harm Reduction perspective requests a lot of personal involvement, as well as specific abilities from the worker.

Employees represent 80% of the budget of careprograms. The staffmembers and multi-disciplinary teams are far and away the most important means of production. My reasoning is that if a carfactory has a maintenance team to keep the machines greased, and an administration office has a contract with specialists to maintain computers and other office machinery, it is only logical that an institute in the mental health care sector (and especially those institutes that work with drugaddicts and HIV-clients in the actual sociopolitical context) should invest time and money in workers who are the most important element in their production process.

That is why I want to talk about HRM in this field: structural support for workers in the harm reduction drugfield.

The rest of my paper will contain the following elements:

1- what is required of workers in harm red. programs?

2- what is 'The Staff Burn Through Phenomenon'?

3- resistances to structural support of workers

4- a model for structural staffcounseling

5- some concluding remarks

2: Helping the helpers

I have called this paper 'Helping the Helpers' and that is exactly what structural support is all about at an institutional level. To support a worker in the drugfield is not simply about how an institution can provide a pleasant and informative instruction course for its staff. As far as I am concerned, that is just one of the answers to the question of how to help the helpers in their work and support them structurally in such a way that the quality of the organisation as a whole and its services will improve.

What exactly is required from a worker in harm reduction-projects for drugaddicts? What does professional expertise mean to workers in low-threshold programs, shooting galleries, methadone-maintenance programs, outreach-work, social rehab-projects?

And, how can they acquire this expertise?

Although these are questions we cannot hope to fully answer here, there are nonetheless several points worthy of remarking upon in a general sense.

• Sociopolitical context: pollution of care

As I said in my first statement, working in the drugfield is an occupation that makes specific demands on the individual, the team and the organisation. Working daily with people in psychosocial distress requires both considerable knowledge and a wide range of complex skills, together with the right involvement and attitude.

But when it comes to educating an effective worker for this field, we still don't know exactly what is the right sort of knowledge, which are the correct skills. All we can observe is that logical, causal associations are not easy to make, and that it is impossible to say with any assurance that if you teach a person any particular given subject, they will automatically make a better worker. And when we do know what are the necessary skills, this knowledge is often not accessible, in the sense of written down in articles/books or professionally translated into training-programs.

In our field, it would appear that the gap between theory and practice, between art and knowledge, is a considerable one.

The physical and psychosocial deterioration of our clients that is mainly caused by prohibition, creates a different context for working in the drugfield compared to other mental health care fields. We are still looking for ways to operationalize the concept of 'harm reduction' - in spite of the constant, dominant variable of prohibition - into effective methods of working. The history of working in harm reduction projects for drugaddicts is still very short and by trial and error the professional workers try to find their way.

Or, as Elvis Costello puts it in an interview about how he made all these wonderful songs: "...When you are technically speaking a clumsy guitarplayer, you happen to find just the right notes.., and that is where it's all about..!".

What does this say about what a worker in the drugfield requires? To name a few characteristics:

A worker in this field has to be 'clumsy', in the sense of not knowing how it all works. Nobody knows exactly how it works. Apart from professional training he needs an open attitude to sense what is the right thing to do given a certain client.

A worker has to find a practical answer to the dilemma of guiding a client back to society to reduce drugrelated harm, while that same society is still hostile to this client and will isolate him/her again. So, what you need here as a worker is a lot of courage, inventiveness and most of all solidarity with the position of your clients.

There is also the sense of bad perspective that drugworkers experience when they put a lot of energy into a client with hardly any result that is appreciated by the general public, policy makers, etc. Clients will relapse in heavy shooting again, will get HIV because of a lack of clean needles, they will keep on using cocain allthough their methadone-doctor will kick them out of the program and ofcourse they will eventually go to jail again and again and...

In fact, a worker in the drugfield is allways over-asked. Society ánd the clients allways want more; they are both very needy..: The oral identification of our consumptive society ánd of our dear clients. They drop their problems in your lap expecting you to solve them right now..! This puts even more pressure on the worker which forces him/her into the responsibility-trap (professional helper syndrome): the workers start to take over the responsibilities and roles of the clientsystem ánd of those of the community/society. Irrealistic demands are constant stressors for workers in the drugfield so they will need a lot of stress-endurance.

• Harm Reduction-work: daily practice

Careprograms that work out of the idea of reduction of drugrelated harm need to be highly accessible for clients, so rooted in their community and highly flexible. These characteristics aren't exclusive to this field, but it is pretty sure that as a harm reduction-worker you need a lot of tolerance and respect for the client and their community.

Harm reduction means in the first place that you can accept the fact that your client is using drugs. The goals of care-interventions become very different and differentiated from the traditional ones.

The only way to run a harm reduction-project is to keep up a 'living' project that respires the local community it works for.

This is what outreach is about. Helpers shouldn't be sitting behind desks in big buildings far away from the lives of those people they work with. It has become too much of 'institutions helping people', rather than 'people helping people'.

An important aspect of this quality of helping is that the patriarchal, expert attitude of the traditional helper should be replaced for a worker-approach that ásks local communities to define the amount of access a worker gets.

More than ever we need to listen to the clients' needs, we need to be a 'guide' in stead of the traditional 'expert' we were often trained to be as a professional worker.

In the Rivera-report on Outreach a worker stated that the well known asymmetry in helping relationships within this concept of outreach tends to favor the subject rather than the worker. I like that a lot! Finally we start asking clients what they want.. What is more and more needed from the workers is an open, service oriented attitude towards their clients.

We are working a lot on that issue on our department of the NIAD. In our DIMS-project (Drugs Information Monitoring System) we analyse drugs that are sampled from the illicit market and feed the information back to drugusers. A service that is ofcourse highly appreciated by these people so that it gives us access to this group to experiment with new safe use and safe sex prevention strategies.

We are developing all kind of parafernalia for IV-drugusers in the context of AIDS-prevention. We developed a Basics Box in which you have all you need to inject a substance.

(For those who are interested in the Basics Box, it will be presented at this conference in another presentation by my colleague Franz Trautmann).

The broader idea is to change needle exchange programs into 'supermarkets' where drugusers can buy anything they need to set a clean shot. Well.., almost anything, of course the most important product (legal and payable drugs of controlled quality) will not be found in our little supermercado.

• Knowledge, skills ánd attitude

We are still wondering around the question what a worker in this field requires.

There exist, for example, big differences in the ideas and skills propagated by the important counseling schools and the training each provides. Research into the effective factors in counselling and psychotherapy indicates that counselors from different schools can be almost equally successful in practice, despite having undergone dissimilar kinds of training. The differences in methods do not appear to have a recognisably different effect on their clients and the conclusion would seem to be that counselors often work much more intuitively than they would have us believe (or perhaps than they would hope).

In respect to training for professional mental health service workers, one can conclude from the above that the value of acquiring knowledge and skills is directly related to the individual foundation into which they are assimilated - the character and personality of the individual worker is a main factor in determining their effectiveness as a helper.

An increasing awareness of this is reflected in professional literature when reference is made to the qualities required by psychiatrists, psychologists, social workers and nurses in a methodical approach to the professional provision of aid and assistance. Reference is also made to research into the role of motivation and inspiration in the individual's capacity to work and continue working; into the role played by client response; and to research concerning the nature of the satisfaction that social workers expect to find in and through their work. In addition, the Staff Burn Out Syndrome and the Helping Profession Syndrome are also deserving of attention in the search for the phenomenon 'mental health service worker' in general, not to speak of workers in the drugfield.

On the level of the clients' behavior workers will have to deal with games and manipulations, differences in norms and values; with a negative atmosphere in general.

The heterogenity of the population of drugaddicts in terms of personal background and style and psychopathology is enormuous. The only thing they share is a problematic way of coping with reality; they have all developed a dependency on illicit drugs but out of very different motives. This asks of workers a lot of knowledge and skills (f.i. general diagnostic and counseling skills), but especially a very flexible and open attitude towards the client while at the same time protected and steady in their own existence/ego. You may have learned all you need to know about f.i. the psychopathic personality. This doesn't mean however that you know how to handle a psychopathic drugaddict in the actual social context. You will have to find out and I assure you out of experience that this is not an easy task.

In my opinion, working with a methodical approach is very important and should be encouraged. We should stimulate new research-approaches that are being developed to describe these methods and their effectiveness, we should encourage the professional dialogue between workers and support the dialogue between universities and workers, between knowledge and art..

• Worker-motives and -needs: unconscious pitfalls!

The two reasons most commonly cited with reference to the motivation of those involved in mental health care are 'wanting to work with people, to help people' and 'a bent/strong inclination  towards self exploration and the stimulation of one's own personal growth through the process of helping others'.

Within these ideas lie the two great pitfalls facing the workers in this field: the desire for intimacy and fantasies of grandeur. These worker-motives and -needs contribute to make intimacy, distance and closeness the difficult areas in a working relationship, and developing the ability to differentiate between one's own needs and those of the client, without having to sacrifice or eliminate either one, is a considerable task for everyone involved in professional helping.

During the course of a career in the drugfield, one can talk of a continually changing balance between on the one hand necessary knowledge and skills, and on the other, a sometimes difficult and changeable combination of personal expectations, motivations and traits. The professional support for drugservice workers should therefore be both structural and sufficiently flexible to leave room for the changeable needs of the individual concerned.

It should be an ongoing process of support in which there is room for cognitive and behavioural factors and, more especially, in which attention is paid to the emotional development of the individual. Drugservice workers are not 100% mentally fit Super Heroes, despite the fact that one can reasonably expect them to be aware of what it is they 'contribute' to a client contact, and of the influence that this is likely to have on the helping process.

In the daily reality of working with drugaddicts out of the harm reduction perspective, the importance to the profession of 'attitude' and personal qualities and skills is all too often underestimated. In my opinion, professionalism in this field is synonymous with the availability of relevant knowledge and skill born of an involvement with the client but marked by an awareness of one's own personal qualities and limitations.

• Head-heart dilemma in workers

So, as a worker in this field you need hard ware (knowledge, skills) and soft ware (motivations, personality traits, involvement). You need head and heart...

The idea comes from my 15 year experience as a psychologist/staffguide for (outreach)workers in several low treshold careprograms for drugaddicts in Rotterdam and as a trainer/supervisor at the NIAD. During those years I learned a lot about what influences the conduct of workers/helpers when they are doing their job. I gradually understood more of the knowledge, skills and especially the attitude that are needed to do this work.

As a person you are involved in this work. What does this mean? Helping a person is meeting him or her. Like I said already, it should be people helping people, rather than institutions helping people. So, as a helper one's personality is in a sense instrumental to the job.

Still, there is a difference between you and your role at work because you need a form of protection. Some workers try to survive in their job by 'too much role': those are the 'extra-professional helpers', the head-helpers who work at considerable distance from their clients. They are often welltrained but they use it as a defense. They hide themselves behind their role as a worker, behind the hard ware.. The client isn't able to meet this head-worker through all the defenses which are often disguised in analytic skillfullness, cynicism, words, etc.

The other extreme as a survival-pattern in this job are the heart-helpers. They act in their job as if there is no such thing as a professional role. There is no difference between me at home or at my job. They feel so close to the client that they become over-identified with them. The dangers of this survival-pattern are obvious: the heart-helper will be easily used and manipulated, easily hurt and frustrated.. Their collusion with the client makes these workers not effective in that they tend to take over all respons-ability of their clients.

These are two extreme survival-patterns that helps people structure their beliefsystem at work, their expectations about their role at work. Anyone can place him/herself somewhere along this continuum between Heart/Love-type and Head/Will-type.

With all I said before about working in a Harm Reduction-project within the actual sociopolitical context, I hoped to make clear that workers in this field need ofcourse both heart and head. Out of a general need for protection, workers develop out of their personal stories a working-attitude that fits more into the heart- or head-approach.

By being conscious of this identification we can develop a better balance between those two aspects or qualities of working with people and become more effective as a worker.

Some kind of 'professional protection' is needed in this work. No protection at all, or too much of it, doesn't work. How do we find a balance; how can we teach workers about this?

Anyway, I think that the 'head-heart dilemma' in workers is an important worker-variable in the analysis of obstacles and facilitators of optimal harm reduction-work, in that it tries to describe the ability of the worker to allow himself to create the right social distance towards a certain client. If the worker has all the knowledge (from epidemiological and field research), all the skills (from training) but can't allow him/herself to really meet the client, he won't be effective as a helper - whatever that is with a certain client.

The 'head-heart approach' proves also an important drugteam-variable in that it is effective to balance the team in terms of those two qualities (because that is what they also are.!).

Beside the link between the concepts of head- and heart-helping and the archetypes of will and love, there is ofcourse an interesting link with 'male' and 'female' qualities.

The 'head/heart' dilemma that this represents is one that every professional helper is confronted by. For workers in drugservices this dilemma is even more present. Both head and heart are needed in the efficient provision of help, but in practice the tendency is increasingly to survive by means of 'head-mental health care'. The answer of today's 'mental health care managers' to the 'head/heart' dilemma has been to rely increasingly on the hard ware: knowledge and skill, the digitalisation of the mental health care system by means of registration and classification, and a stream of new and often fashionable methodologies.

Why shouldn't we forget the heart-approach? Because it has proven to be effective! An important operationalisation of effective 'heart'-ness in this job is the concept of empathy.

Vanaerschot wrote about empathy in an article entitled: "Empathy: a process marked by retention and release", in the Dutch Magazine for Psychotherapy (4/1990): 'I think that sincerity is the most essential element in a fundamentally empathetic attitude. Only those with a capacity for continual reposition can attune themselves to another. Only those who can permit confusion and fluidity within themselves and still feel secure, that know (or have experienced) that this is not destructive, can facilitate this state of being in another and simultaneously remain composed. Only those who know inside what it means to be 'in development', to continually let go, can remain in touch with 'another layer' in the client and help to once again make supple and fluid what is set and blocked. This demands not only courage, but also and above all a belief that a new order will arise from confusion and chaos..."

How can one teach skills such as these to professional helpers? A capacity for empathy is clearly one of the more useful elements in the caring process and Vanaerschot even describes empathy as "the royal road to 'knowledge' of the client's perception..." But how does a worker learn the 'sincerity' required? Where can they find the necessary courage and belief? And how does one support and 'steer' a professional development of this kind?

De Vries (1993) writes in a recent article on empathy that one-sided interpretations of Rogers' concept of empathy has caused a simplification of it into a mental 'trick' one can learn (Ericson!). It is a far more complex concept in which not only the clients' feelings are reflected but also the understanding ('Verstehen') of the clients' reality plays an important role. The receptive and non-judgmental attitude of the empathetic counselor opens up to change, not only of the client, but also of the helper.

Professional demands of this nature ask of every professional helper continuous attention as to the dynamics of all the personal motives and needs that play a role in their work, while a lack of awareness as to their existence will result in both a loss in capacity and ineffective behaviour in the field.

That is why the subtitle of my paper reads: A plea for structural support of 'heart'-workers. We need more heart-elements in harm reduction-work to be effective, but the circumstances under which we work are often uncertain, threatening, rigid and unprotective...

The only way to solve this dilemma for workers is to support them in this process on a structural base. How to do this I will explain in paragraph 5, a model for structural staff counseling.

3: The Staff Burn Through Phenomenon

In the first part of my paper I drew the image of what workers in this field require to do their job effectively. It cannot be a clear picture yet, the job is too new, but the unique combination of qualities these workers need, probably became clear enough. It takes quite a person to be able to survive in the drugfield as a worker, and it takes even more heart and head to be effective as a helper while enjoying your work.

In my experience as a staffcounselor, people don't have all those qualities in a balanced way when they apply for the job. In a constant process of trial and error they learn gradually what they need to know and develop a personal style that needs to be balanced over and over again.

There will be frequent mistakes, unpredictable situations, etc. where the worker cán learn from if he/she is helped. F.i. constant attention is needed to guide a young worker through the first stage of desillusionment. If they are left alone with this experience their crises will become more severe and eventually they will burnout.

The burnout phenomenon among professional helpers is expressed at an organisational level in lengthy or frequent absenteeism, high sickness level, a high staff turnover, a low level of job satisfaction, a high frequency of conflict, ineffective delivery of services and eventually client damage.

For both the intrinsic and extrinsic reasons mentioned above, it seems to me that burn out phenomena within the profession cannot come as a suprise to anyone familiar with what the work actually entails. Because of the presence of personal and altruistic motives and expectations, a process of accumulative frustration is certain to result in disillusion, and the exhaustion this causes is what we call the 'staff burn out syndrome' - which is in fact a normal crisis in which the individual worker leaves behind ineffective 'helper behaviour' and has to find a new balance between load and capacity.

Such crises are perfectly predictable in this field and seem normal. The burning out rather comes from the lack of support these workers get so that a little fire can turn into a disaster.

In this respect, I have a decided preference for use of the term 'burn through' rather than 'burnout' because of the more negative connotation of burn out. I also don't talk about a burn through 'syndrome' but about a phenomenon'. Burn through is not an illness but rather a phenomenon in a working-life. By 'burn through' one can refer to the analogy of the rocket, in which a no longer functional stage is done away with during the course of a mission that can then be continued with less mass, or as they say at NASA, of abortion.

With a more sympathetic terminology, the drug worker in a 'burn through' crisis can be said to have rejected inefficient professional behaviour and opted for a new direction in his or her professional life.

Or, as Edelwich puts in his book on burn out of professional helpers: "...thinking of frustration or depression as an educational experience may not make it more pleasant, but understanding its place in the rythm of our development can help us be at peace with it...".

Burn out/through is not simply a question of individual failure, but is better seen as an ecological malfunction. Because the organisation, the individual and everything surrounding them are all part of a related and dynamic process, the burn out of an individual worker can also be seen as an indication of (hidden) problems within a team or within the organisation. Often organisations fail to see an individual burnout in this broader perspective.

Working in harm reduction-projects demands unique qualities. Work becomes 'a calling', a way of life, rather than a profession. Either you do the job or you don't. In terms of a traditional career perspective there is nothing for the outreach worker to look out for. Sometimes this horizontal career results in the experience of 'being trapped' in the job.

If the burn out phenomenon in all its many and diverse forms is structural to working with people, and encouraged by the present extrinsic conditions of the profession, then institutions within the drugfield should take account of it structurally. By means of a combination of early recognition of symptoms and counselling, these crises can become a 'burn through' to a stage of being a more mature and effective helper; in practice however these normal crises too often lead to a true burn out or destruction of the whole 'rocket'.

Someone said about burn out: "...Some people will never burn out because they weren't on fire to begin with..".

For me, this statement sums up everything I have said so far. Workers in harm reduction-projects are unquestionably 'on fire' with respect to both their profession and their clients, and one can talk of a relatively large personal 'investment' or involvement. This continually brings them into a grey area between their private and professional lives. The role played by helpers in their work is different from that in their private lives, but in their case the two have a greater influence on one another than in other professions, resulting in a lack of clarity concerning the line that divides 'person' from 'worker'. Personal characteristics and qualities are instrumental to the profession of mental health service worker and are therefore deserving of structural maintenance.

4: Resistances to structural support of workers

Until now I have talked of the content and reasoning involved in structural maintenance of workers in this field. There was a time that I asked myself why it was that people were slow in acknowledging the benefits of both ongoing training and of structural support for drug workers. These days, I have come to believe that the resistance I have detected is born of an opposition that is rooted at several different levels.

In the first place, in the juggling act preceding the reservation of realistic budgets, reluctance is exhibited by policy makers, health care managers, those granting subsidies and the Dutch medical insurance system. Many institutions regard ongoing training as something with which to balance the budget, but in my opinion this represents the sort of misplaced thrift typical of short-term thinking. People regard both individual and team counselling as luxuries, often associating them with the overdemocracy and navel contemplation characteristic of the 1960s.

Secondly, mental health service workers themselves also display a reluctance to fully embrace the reality of ongoing training. If one is to work not only on the advance of new knowledge and skills, but also on character and personality - as basis for the methodological approach - then sincerity and trust are important conditions for ongoing training. A few days spent on a course is one thing, but a regular thorough examination of the kitchen where I cook the secret recepies for my clients is another. Before you can turn your back there is talk of competition, and in the final analysis this is born of the fear that one may be found less in comparison with a colleague or, even worse, an assistant. People are reluctant to admit that there is something wrong, and denial is one of the important hallmarks of burn out/through.

In addition there is a fear, sometimes justified, of appearing vulnerable to colleagues. There is fear of conflict, failure or even dismissal.

Thirdly, one can see that training within the institutions is often relegated to a way of binding people, rewarding them, or easing them out of a particular position. In this way it can become a means of exercising power for the boss and a reward or salary prothesis for the worker. It is striking to see how few mental health service workers are prepared to contribute to their own training or further education, and this is not a just a question of a limited budget or a lack of ambition. People wait and see and expect their superiors to provide both means and method. Despite the fact that for both parties this should be a joint enterprise undertaken at the crossroads common to the interests of individual, team, organisation and client.

Finally, the 'area' in which ongoing training is undertaken often proves to be a confusing maze for all concerned. A jumble of definitions, unrelated activities and forms of counselling; of flow charts and educational plans that often incite reluctance in exactly those who are supposed to put theory into practice. The supply of courses for mental health care workers is both fast and furious and fragmented, with pressure mounting still further because of current demands for quality and efficiency from both policy makers and from institutions themselves. Not to mention the fact that many are those who see a lucrative market in training and development and place the emphasis on quantity rather than quality.

In addition, ongoing training is also, as a result of these developments, often put to the wrong use. Decisions and details as to where, when and how to implement ongoing training are decided upon without being preceded by a thorough analysis of the tasks and problems involved.

5: A model for structural staff counselling

By structural staffcounseling I mean a very broad concept containing all the elements that contribute to an integrated personnel policy - an internal staff counsellor functioning parallel to the line of the organisation but in close contact with the director, team coordinator, personnel staff, team members and other individual workers.

The aim of the function of staff counsellor is to create conditions within which both individual staff members and multi-disciplinary teams can operate in the most efficient and effective way with regard to achieving the goals of the institute itself.

Tasks that arise from the function of staff counsellor are:

1 - Team counselling

Regular team meetings can help to prevent the isolation of individual workers who are not performing well. Attention can be given to subjects such as interaction within the client-staff systems, cooperation, early recognition of burn through symptoms and the handling of conflicts. Sometimes the staff counselor is the fire-brigade, but most of the time his efforts are directed at making the workers and the team as a whole more fireproof!

The policy of the institution and the team's own perception of harm reduction with drug addicts are the factors that then determine the context within which these matters are discussed.

2 - The promotion of ongoing training

This task of the staff counsellor concerns keeping the teams aware of current developments in mental health theory and technique, and the provision of training in the practical skills required in relation to the clients that form the institute's particular target group. A staff counsellor can stimulate the study of relevant literature and advise and counsel in the training of individual workers.

Staff members sometimes follow an external course of study and a complaint often heard is that they do not put into practice what they have learned. Sometimes because the person concerned is incapable of applying it to the existing methods of approach or because of a fear that they will become isolated in their new insight. Or a problem can arise because the person doesn't know when or how to pass their new knowledge on to colleagues. In these situations, a staff counsellor can often find didactic ways of making knowledge and skills acquired elsewhere, either by a staff member or indeed by themselves, available to the rest of the team. One way of turning a great deal of wasted time and energy into a good investment!

3 - Individual counselling

Every drug worker will experience an individual need for support and for ongoing training at some time during their own professional development. Each has their own way of learning and in the course of regular individual meetings with the staff counsellor, 'made to measure' methods can be discussed and defined. In one case this may involve the simple transfer of theory, not unlike learning to sail down a canal.

In another, an individual may require an increased awareness of professional routines and norms and a new training in specific skills, a process more in line with learning to sail down a river.

And yet another will need support in their emotional development with respect to their role as mental health service worker. In this case, symptoms of burn out may be involved, introducing to the contact the element of crisis intervention. And to extend the metaphor, one can say that these more emotional learning processes can best be compared to riding the rapids in a wild-water raft: difficult, violent and unpredictable.

A staff counsellor should be capable of providing support in all these situations, or at least of successfully providing an idea as to where support can be found. It is clear that in the course of their career every worker will require from time to time support in one form or another. Peer group consultation, supervision, counselling in work or practice, career counselling and study tuition are all terms that deal with a part of the answer, and each is very closely related to the other. Somebody from within the organisation that has already established a relationship based on trust can provide, with a much greater chance of success, the right answer in the right form at the right moment.

4 - The integration of new team members and trainee counselling

These are jobs that are often undertaken badly or not at all, a situation that can result in unnecessary complications with clients. A staff counsellor can devote systematic attention to new teammembers and so prevent them from going under in the complex daily routine of any mental health care service.

5 - Consultation

At the request of an individual worker, the staff counsellor can be consulted over specific problems with clients. Interesting structures for learning - such as live supervision - can be arranged with a minimum of effort. The staff counsellor is well known to the worker ánd to the client, so the confidence and trust which is vital to an effective supervisory relationship, is already there.

6 - Putting institutional policy to the test

The staff counsellor is involved in the routine of daily work, present at meetings and as much as possible aware of the patterns of communication between client and workers. The workers, the team and therefore the organisation should continue to be aware of and follow the clients' development, integrating the information gained in their method of approach. The latter should never be defined, but remain a dynamic theme to which structural and ongoing attention is given. A staff counsellor can stimulate this development and provide those involved with information.

7 - Research

The staff counsellor is an important processor of information. By stimulating and/or participating in research into the effect and value of the adopted method of approach, an additional stream of information is created, of importance both for and concerning the organisation. At the same time, this information contributes to the general formulation of theory within the profession, for which there is a great necessity, in any case within the field of drug dependance and harm reduction. Further, the staff counsellor is responsible for the publication and presentation of research results both in professional literature and at conferences.

The tasks I have described here give one a good idea of the function of staff counsellor within an institution. The precise nature of that function can be changed, depending on the available budget, the sort of work and the specific needs of a team. The model provides for optimal reaction and modification with regard to the continually changing actual need for structural support in the broadest sense.

Structural staff counselling is an integrated application of diverse elements that can guarantee 'maintenance' for an individual drug worke or a team at any given moment in their development. Each institution, each team and each individual worker should regularly come to their own conclusions regarding staff counselling, upon which policy with respect to ongoing training can be modified accordingly. Here we are talking about the creation of 'made to measure' drug care being matched by the creation of 'made to measure' staff counselling.

Ongoing training can then become a process of interaction in which the differing interests of clients, workers and the organisation flow together in a continual 'feedback circle' that determines the quality of the service offered.

6: Some concluding remarks

By way of summing up, I would like to come to some general conclusions regarding structural maintenance of drug workers and make a few suggestions as to its form and implementation.

• Short term thinking and misplaced thrift are instrumental to the perception of investing in workers as an item with which to balance the budget. Policy makers, those in charge of granting subsidies, managers and individual workers should be better informed (or educated) about the possibilities of staff counselling in the way it was described.
• The organisation of training and supervision at an institutional level is often of an occasional or subjective character. It is often used as a means of exercising power or perceived by the worker as a salary prothesis. It is insufficiently recognised as an excellent management tool for the achievement of effectiveness and quality within organisations involved in drug care.

HRM = Human Resources Management = Harm Reduction Management!

• We should ask ourselves exactly what structural maintenance of workers should mean in this field. The present emphasis lies too much on knowledge and skills (the hard ware) and not enough on the 'art of being a helper': a unique balance between head and heart. The use of an individual worker's character and attitude as basis for methodological approach is insufficiently recognised and acted upon, both in professional training and in daily practice.
• Working in the drugfield creates a lot of stressors. This brings about a lot of wounded helpers. In a lot of cases burnout could be a normal moment of crisis in the development of an 'adult drug worker'. Burnout can be (limited to) burnthrough when it's symptoms are recognised in time and expertly handled.

So, it is okay to burn out, the trick is not to make an ash of yourself!

• The model for structural staff counselling is a plea for real Human Resource Development in a field in which the quality and satisfaction of an individual worker can determine to a very important degree the quality and effectiveness of the product: the provision of efficient and successful harm reduction-services to drug addicts.
• Finally, and I go back to my first statement about the 'pollution of care' in the drugfield by the sociopolitical context, we should never forget that prohibition is a main cause of our clients' problems. However succesful we are in reducing drugrelated harm in our daily work, we should keep on asking what role we play as drughelpers in keeping the system of prohibition going. Maybe we become so effective cleaning up the mess that society never realises that it ítself is a main cause in the societal drugproblem.

We are the medical troops or maybe the Red Cross in the War on Drugs. We take care of some of the bad symptoms of prohibition which is fine, but it should never put us to sleep. Reducing drugrelated harm is fine, revealing the main cause of drugrelated harm in order to get rid of it, is even better..!

What society needs, is information right from the working floor to show what is really going on. So, write about it, speak up, become visible in your professionalism. That is what drug workers in harm reduction-projects can contribute to the slow process of social realisation that the prohibition of drugs is an illusion of controll, that causes the biggest part of drugrelated harm..

I wish you all you need to do your interesting job!

Amsterdam, February 19th, 1994

Bart Majoor

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SHEET 1 (Statements)

1- Pollution of Drugcare

2- Structural support of DrugworkersSHEET 2 (HRM) HRM = Human Harm Resources ReductionManagement Management SHEET 3 (Overview)

1- what is required?

2- The Staff Burnthrough Phenomenon

3- resistances

4- a Model for Structural Staff Counseling

5- some concluding remarks

SHEET 4   (What is required?)

1- socio-political context

2- daily practice of harmreduction

3- knowledge, skills ánd attitude

4- worker motives and -needs

5- head-heart dilemmaSHEET 5 (Burnout/through) Burnout: raket die in z'n geheel neerploft Burnthrough: raket die eerste trap afstoot, maar door vliegt..!

SHEET 6 EN 7 (resp. Resistances en Model)

reeds gemaakt!

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