On Your Best Behaviour

Behavioural contracts - designed to improve health outcomes - are relatively common in a number of areas of healthcare. For example within an obesity treatment programme, patients may have to agree to undertake a set amount of exercise a day or week to remain on the programme. Within drugs treatment, this is often called "Contingency Management" and might include for example, the use of a more liberal dispensing regime (eg take home scripts) as a response to abstinence from other drugs demonstrated through testing.

We can use other kinds of contract too - which commit people to a kind of code of conduct while a client of the service. These "good behaviour" contracts are useful when an individual has behaved in a way that has risked the safety of themselves or other people within the service. I'm not in any way troubled by the sensible and appropriate use of this type of contracting.

However, it seems there's a trend within the drug and alcohol sector to apply these sort of contracts universally. That is to say, in some services every single person who attends a drug and alcohol service for support will be asked to sign a contract to say they will "behave themselves". Sometimes these are free-standing; sometimes they conflate issues of clinical safety (use on top, etc) with setting standards of social behaviour. I've seen examples of both myself in tenders from commissioners and tender responses by a range of providers. I have also heard of providers having this as a standard part of their treatment or recovery support offer in every service they deliver.

I spoke to some people using or working in English drug services. Nick Goldstein - service user and writer about drugs and alcohol told me:

"If I had any doubts about my service's suspected negative opinion of me they were removed on signing my behaviour contract-my service clearly don't trust me and the contract is a warning"

One worker I spoke to who wanted to remain anonymous said

"Unfortunately I think that many people accessing services are seen as ‘bad’. It feels like there has been an erosion of the relationship between the service and service users. The contracts are used as a tool to provide a rationale for whatever punitive measures are used in response to challenging behaviours. Our service uses a scoring matrix to decide what sanction will get issued. Score over a certain point, and the service is withdrawn and you are excluded. I’ve never known as many people excluded from the service since the latest provider took over. The combination of contract & scoring matrix removes any pragmatism or person centred response to a situation and proves a blunt tool"

For a while in my 20s, I was employed in mental health advocacy. It was an exciting and challenging time for me working with people who had been institutionalised for the majority of their life within the psychiatric establishment. One of the things I learned was the practical impossibility of having a compliant upheld or even responded to, within a system that regarded everything you did and said as an expression of your mental illness. Complaining about treatment was regarded at best as "commonplace patient behaviour" and at worst as disruptive aggressive and non compliant. Services struggled to improve treatment outcomes because they were predisposed to discount the views of those whose critique was most meaningful - the people who attended.

This is one reason why I am disturbed by the proliferation of punitive contracting within services - its endangers peoples ability to protect themselves from inappropriate or unfair treatment. But I have other concerns too. It seems to me that to prejudge every individual who attends a drug treatment service as disruptive or aggressive is profoundly stigmatising, and calls into question the 'recovery friendliness" of any provider or commissioner. As the much missed UK Drug Policy Commission said in their report "Getting Serious About Stigma"

"Stigma ... has a big impact on recovery once in treatment. The low self-esteem of people in treatment prevents a belief in recovery. "

There is another reason this concerns me. If - as I know some workers and providers would contend - these contracts are an essential protection to keep our services safe for clients, works and volunteers - then what on earth has happened to our sector?

Are levels of conflict now so great that we can only protect people within them by using such a draconian and stigmatising measure as universal good behaviour contracts? If they are, then why is this the case? I asked a specialist officer from Local Government about how they saw conflict and attitudes towards drug users within statutory and voluntary services:

"The nature of how we engage with most drug users (more specifically those on or close to the street) is generally punitive and as much as the voluntary sector can be viewed as providing treatment on the cheap (compared to the statutory sector) they are also a form of policing on the cheap.   Which is fine if it doesn’t influence the relationship to the point where services are hostile to the people who they should be serving."

In primary care "good behaviour" contracts like these are used when patients have already behaved in a way thats violent or aggressive. They're an alternative to removal from a practice. If the contracts don't work, patients can be removed from a practice list, but they will still be provided with access to primary healthcare through whats known as the Special (or Violent) Patients Scheme. The Medical Defence Union - one of the main providers of legal advice and support to doctors and other clinicians in the UK, has this to say about these agreements and their use in mainstream medicine:

"The contract should be viewed as a useful tool in rescuing a deteriorating professional relationship before it becomes unsalvageable, rather than as a punitive measure. The MDU advises using ABAs only in cases of persistent bad behaviour that would inevitably lead to a breakdown in the doctor-patient relationship and removal from the practice list."

Does the apparent proliferation of universal "good behaviour" contracts across our sector suggest that relationships between professional and individuals are deteriorating and close to "unsalvageable" even before people even walk through our doors? If services are experiencing levels of bad behaviour by clients that justify this approach, then what is causing all of this conflict? Or is this a result of the tesco- isation of our treatment system - where one size fits all? Are there better ways for us to deal with the challenges of seriously challenging behaviour within services?

Does your service use "good behaviour contracts"? I'd be really interested to hear about your experiences.

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