Duty of care, harm reduction & young people in care: an effective approach to working with volatile substance users.

Duty of care and harm minimisation are often portrayed as being incompatible. This is particularly so [n the context of young people who are the subject of court orders and in residential care who engage in volatile substance inhalation. This view appears to stem from the belief that harm minimisation implies support for drug use, and thus breeches client duty of care.

This paper outlines the principles of duty of care and harm minimisation, discusses harm reduction in the context of duty of care for young people in care, and then looks at harm reduction and statutory clients inhaling volatile substances. It suggests that a coalition of the principles of duty of care and harm reduction is the best basis for formulating effective service responses to the needs of young people in care. It argues that such services will then contain the pre-conditions for more effective therapeutic interventions that address the complex problems of trauma, abuse and neglect experienced by many young people in care.

Duty of care

The Department of Human Services (DHS 2000) discusses duty of care in the following terms.

A duty of care is a duty to take reasonable care of a person. The Department owes a duty of care to anyone who is reasonably likely to be affected by the Department's activities. These may be:

* clients;

* the families and carers of clients (for example, where they are injured as a result of a psychiatric crisis team failing to respond in a reasonable time); and

* certain groups of people in the community (for example, people living near a prison who could be affected if a dangerous client escaped) (DHS 2000, p. 7).

The law of negligence does not impose impossible burdens upon staff or management, nor does it require anyone to be clairvoyant.

The only "burden" imposed is the requirement to act reasonably. If staff do not act reasonably and people are injured, then the service will be held accountable.

There are three parts to the definition of negligence. These are:

* Duty of care--there must be a duty of care owed by the service. Different members of the staff (CEO, line managers and individual workers) can owe a duty of care in any particular situation. Depending on their role and position, each worker in a service will be expected to do different things to ensure that their duty of care is not breached.

* Breach of duty of care--the staff must have done something a reasonable person would not have done in a particular situation, or have failed to act in a situation. A duty of care can be breached either by action or inaction.

* Injury--some harm must have been caused to the person because of the unreasonable action of the staff.

The need to avoid acting negligently is relevant to all decisions and actions of staff; therefore, staff are required to act reasonably in all aspects of their work.

The following factors must he considered for a member of the staff to make a reasonable decision in relation to foreseeable risk:

* the risk and seriousness of harm to the client and any other person;

* the availability of precautions to reduce or eliminate the risk of harm to the client or any other person;

* any laws that may impinge on what occurs in a particular situation;

* the usefulness of the activity which involves risk;

* any legal or statutory requirements or specific directions; and

* the prevailing standards of the relevant profession.

Under the laws of negligence, duty of care is breached if a person behaves unreasonably. Failure to act can also be deemed unreasonable. Considering how a hypothetical reasonable person would have behaved in the same situation assesses the reasonableness of what has been done, or not done. If the person's job requires special skills or training, the relevant staff member will be assumed to have the same skills or training. This means that a manager's actions will be measured against the actions of a reasonable manager, the actions of a youth worker will be judged according to those of a reasonable youth worker, and so forth.

What is considered reasonable will depend on all the circumstances. What is reasonable in one situation will not necessarily he reasonable in another. There cannot be a set of ready-made answers to all the dilemmas and situations that could arise in the area of a service's operations.

Harm minimisation

Harm minimisation forms the basis of alcohol and other drug (AOI)) policy in Australia. A harm minimisation framework has three platforms on which strategies to respond to drugs and related issues are based:

* Supply reduction aims to reduce the production, distribution and consumption of drugs.

* Demand reduction aims to reduce the demand for drugs and therefore consumption through drug education, health promotion programs and other strategies, such as pricing controls.

* Harm reduction aims to reduce the risks associated with the consumption of drugs in order to achieve positive health outcomes for the user and others involved, without necessarily reducing consumption.

Harm reduction aims to reduce the level of risk and harm associated with using drags and drug-related activity by helping people who use drugs to do so as safely as possible, without necessarily reducing or stopping consumption.

Alternatively, supply and demand reduction strategies almost invariably concentrate on preventing or reducing AOD use regardless of whether the result is an increase or decrease in harm.

A common misinterpretation is that a harm reduction approach encourages or condones AOD use, therefore not catering for people seeking to attain abstinence. On the contrary, the goal of becoming abstinent is one of a range of strategies that a person might employ to reduce harm. Again the core goal is the reduction of harm.

Harm reduction and duty of care

Common sense dictates that any practitioner in the human services field would direct their energy towards the minimisation of harm for their clients and others in the community. However, there are times when practitioners with the best intentions intervene and inadvertently cause more harm for clients than if they had not acted at all. The foremost principle of harm minimisation is therefore to do no further harm.

Harm from substance use can come from a range of different sources, not just the type of drag and how much is used. The five main sources of harm related with AOD use are:

* acquisition

* administration

* intoxication

* behaviour associated with intoxication

* withdrawal

The prime focus of a service utilising a harm reduction framework is on the health and well-being of its clients. With this in mind, it is understandable that workers may be very concerned when the choices made by a client involving substance use are potentially destructive and harmful. It is not possible to stop people making choices, and not helpful in terms of adolescent development. However, it is possible to offer young people opportunities to make choices and to act in ways that are both constructive and safer. It is also possible to acknowledge the choices a young person makes, especially those that are likely to be harmful and, with the young people, investigate strategies that will reduce or prevent the potential for harm.

A service following this process is one that is seeking to engage the young person and enable them to better manage the circumstances of their lives. This puts the service provider in an excellent position to explore a range of issues with the young person and assist them in learning from the experience. Practice wisdom suggests that the quality of the relationship between the primary worker and the young person is a significant feature of service effectiveness. It is also identified as a key feature of programs that are successful in addressing the needs of young people experiencing complex behavioural and social problems (Sherman et al. 1999).

Duty of care requires us to balance the rights and freedoms of the individual with those of the community, taking into account the capacity of the individual to conceptualise the problem and formulate a response.

When considering our duty of care towards young people who are engaged in problematic drug use, the following issues should be considered:

* If no action were taken, what would be the outcome?

* What action would result in the least degree of harm to the young person and/or the community?

* What are the potential short-term and long-term implications of each possible action?

* What are our statutory responsibilities to the young person?

* What are the legal rights of the young person?

In general, then, harm reduction approaches are commensurate with our responsibility to enact a "duty of care", since the goal of best practice should be to reduce drug-related harms for the individual and the community.

The Royal Australasian College of Physicians notes that a harm minimisation approach to substance use accepts that for many users, there is no "quick fix". "Some people in our community will respond to prevention and early intervention programs, but others will not. Harm reduction strategies aim to reduce the harm to the latter. The moment that someone starts using illicit drags, it should primarily be a public health issue, not a legal one" (RACP 2002).

Most adolescents, in terms of the Stages of Change model developed by Prochaska and Di Clemente (1986), are at the pre-contemplator or contemplator stage. Strategies that attempt to engage young people in a dialogue about their individual circumstances, including drug use, may be more effective than attempts to coerce them into treatment. Similarly attempting to force clients to abstain from substance use when they are not willing participants may well be counter-productive. Commentators on best practice with substance-using adolescent offenders have also come to this conclusion (Pearl, Morton & Hamilton 1999).

Harm minimisation does not imply support for drug use. By giving priority to practical, immediate steps to reduce drug-related harm, harm minimisation measures presume that there will be situations where drag use will continue, at least for the present time. In such situations, the user's decision to continue is accepted as fact. This does not mean the decision is approved of. Rather, it is simply assumed that for the present the user is going to continue his or her drug use, and that the most appropriate intervention must work within that fact (Single & Rohl 1997, p.49).

Harm reduction and volatile substance users

Statutory clients with problematic substance use often have a number of issues that may need to be addressed, including:

* a lack of stable, secure accommodation;

* a history of abuse and/or neglect and/or trauma;

* family difficulties and/or deterioration;

* lack of involvement in the education system or work force; and

* isolation from and a lack of connection to the wider community.

There is a high correlation between youth homelessness and problematic substance use. The case histories of Youth Substance Abuse Service (YSAS) clients reinforce the research undertaken by Burdekin (1989), Brown (1991) and Manning (1995) that found a large percentage of homeless young people used a variety of substances as an attempt to dull their awareness of their own circumstances.

A harm reduction approach to working with such young people maximises the potential for them to develop. It has the objective of decreasing the young person's reliance on drug use and reducing the level of risk to which he/she is exposed, as its prime focus is on the health and wellbeing of each individual within their own particular circumstances.

A harm-reduction approach to the inhalation of volatile substances by statutory clients addresses a range of risks and harms associated with their use:

* acquisition--committing criminal offences (theft) to obtain the substance;

* administration--use of plastic bags leading to suffocation, directly spraying butane into the throat causing it to freeze, leading to asphyxiation;

* intoxication--the effect of chemicals such as butane, propane, toluene and trichlorethylene on the heart, liver and brain;

* place where the inhalants are used--dangerous sites such as railway stations and alongside roads, or inaccessible places where it is difficult to get help or there are no phones available to call an ambulance;

* behaviour while intoxicated--falls, being hit by trains or motor-vehicles, driving while intoxicated, being at risk of sexual or physical assault while intoxicated; and

* post-event--further use by the client to stop withdrawal symptoms or postpone the effects of the inhalant wearing off.

The utilisation of a harm-reduction approach allows a dialogue to occur between the young person and the worker about these issues. This allows the development of a relationship between the worker and the young person, and is in itself a protective factor for the young person.

The "just say no" approach, however, focuses more on the use of the substance than the associated harms, does not acknowledge the prevalence of substance use within the community and assumes that substance users are deficient in knowledge, self-esteem or skills. This both stigmatises drug users and ignores the pleasure and other benefits of drag use (particularly as an attempt to address trauma). The approach works against meaningful dialogue between young people and workers and does nothing to decrease harm and increase safety (Scavuzzo 1996; Wysong, Aniskiewizc & Wright 1994).

A "zero tolerance" or "just say no" response to statutory clients inhaling volatile substances is problematic for a number of reasons:

* It is inconsistent with national and state drug policies that advocate a public health approach to all substance use issues.

The recently completed Drugs and Crime Prevention Committee Inquiry into Public Drunkenness final report (Drugs and Crime Prevention Committee 2001) has for this reason recommended that the offence of public drunkenness be decriminalised.

* It will not stop young people inhaling volatile substances.

By way of example, the fact that drinking alcohol in most situations is illegal for those under 18 years of age does not stop many young people from breaking the law by purchasing and consuming alcoholic beverages.

* It fails to address the underlying issues behind substance use. For example, many children and adolescents who uses volatile substances indicate that they do so for fun and excitement, as an experiment to see what happens, as a cheap alternative to alcohol and cannabis, and because they are easily obtained by theft or purchase. Others, however, may use volatile substances to assist them in dealing with current or past traumatic events. A "zero tolerance" or "just say no" approach to statutory clients who use volatile substances can impede meaningful dialogue and is not a good basis for establishing therapeutic interventions that address trauma.

* Duty of care issues

If the use of volatile substances were criminalised, youth and welfare services would have to address complex "duty of care" issues in relation to the way they work with intoxicated clients, given that duty of care can be breached either by action or inaction. If a client were to be refused service, and their substance use put themselves or others in the community at risk, this would then leave workers and services in the unsatisfactory situation that Victoria Police currently finds itself in at the time of writing, as noted in their submission to the recent Parliamentary Drugs and Crime Prevention Committee Inquiry into the Inhalation of Volatile Substances for the Purpose of Intoxication (Drugs and Crime Prevention Committee 2002).

A harm reduction response to statutory clients who are inhaling volatile substances recognises that there are some young people who are either unable or unwilling to stop using at this point in time, and is an appropriate exercise of duty of care.

Role of secure containment

It is entirely consistent within the harm reduction approach to place a client in a secure environment such as a Secure Welfare Service. Very young adolescents who do not yet have a set of internal frameworks and boundaries may need to have these frameworks and boundaries imposed upon them externally through placement in a Secure Welfare Service. Such a placement may occur, for example, when a young person's protracted and continual use of volatile substances is judged by care staff to place them at immediate risk.

Such a placement aims to provide the young person with a temporary respite from the use and effects of volatile substance use, and enable staff to renegotiate a care plan. During this time a more thorough assessment can be undertaken in an effort to more fully understand the function that the use of volatile substances has for the young person.

It will be important during this time of respite to ensure that (if not already in place) a primary worker is identified who will work closely and intensively with the young person in an ongoing when they leave Secure Welfare for whatever community placement is arranged.

It may be that this cycle of placement repeats itself a number of times, reinforcing the importance of an identified primary worker who continues to engage with the young person despite chaotic behaviour and changes in placement.

It is important to consider the appropriateness of placing such a young person in a residential program that contains other young people who are continuing to use volatile substances. There is also a "duty of care" to not place young people who are not using volatile substances in placements where this does occur. In this instance the "duty of care" to be applied involves "doing no further harm" by inappropriate placement decisions.

Conclusion

An understanding of the coalition of harm reduction and duty of care principles is integral to creating effective responses to the complex needs of young people in care who inhale volatile substances. We have argued that the contraposition of the concepts of duty of care and harm reduction leads to a confused, inadequate and potentially harmful service response.

References

Brown, H. 1991, Report on services required for adolescents with drug-related problems, Taskforce Community Involvement Centre, Melbourne.

Burdekin, B. 1989, Our homeless children: Report of the national inquiry into homeless children by the Human Rights and Equal Opportunity Commission, Australian Government Publishing Service, Canberra.

Department of Human Services 2000, Duty of care, Department of Human Services, Melbourne.

Drugs and Crime Prevention Committee 2001, Drugs and Crime Prevention Committee Inquiry into Public Drankenness final report, viewed 24 March 2004, <http://www.parliament.vic.gov.au/dcpc/Reports%20in%20PDF /Drunkenness_final_report.pdf>.

--2002, Inquiry into the Inhalation of Volatile Substances for the Purpose of Intoxication--discussion paper, viewed 24 March 2004, <http://www.parliament.vic.gov.au/dcpc/Reports%20in%20PDF/ Volatile Substances discuss_paper.pdf>.

Manning, M. 1995, 'Heads off their drugs: Drugs, youth and residential treatment', Deakin Addiction Policy Research Annual, v.2.

Pead, J., Morton, J. & Hamilton, B. 1999, Towards best practice drag services in juvenile justice centres, Department of Human Services, Melbourne, viewed 24 March 2004, <http://www.dhs.vic.gov.au/phd/0003185/>.

Prochaska, J. & Di Clemente, C. 1986, 'Towards a comprehensive model of change', in Treating addictive behaviours, process of change, eds W. Miller & N. Heather, Plenum Press, New York.

Royal Australasian College of Physicians 2001, From hope to science: Illicit drags policy in Australia, Health and Social Policy Unit, viewed 24 March 2004, <www.racp.edu.au/hpu/policy/drugs/current3.htm>.

Scavuzzo, M. 1996 Harm reduction protocol--as practiced by the Chicago Recovery Allianace, viewed 27 May 2004, <http://www.anypositivechange.org/harmREDprot.pdf>.

Sherman, L., Gottfredson, D., MacKenzie, D., Eck, J., Reuter, P. & Bushway, S. 1999, Preventing crime: What works, what doesn't, what's promising: A report to the United States Congress, Dept of Criminology and Criminal Justice, University of Maryland.

Single, E. & Rohl, T 1997, The National Drug Strategy: Mapping the future--an evaluation of the National Drag Strategy 1993-1997, AGPS, Canberra.

Wysong, E., Aniskiewizc, R. & Wright, D. 1994, 'Truth and D.A.R.E.: Tracking drug education to graduation and as symbolic politics', Social Problems, v.41, n.3.

Rowan Fairboirn is the Senior Policy Officer of the Youth Substance Abuse Service, located in Fitzroy, Victoria. David Murray is the Executive Officer of the Youth Substance Abuse Service and also Vice-President of the Children's Welfare Association of Victoria.

Rowan Fairbairn and David Murray argue that duty of care and harm minimisation are not mutually exclusive concepts when it comes to caring for young people who choose to inhale volatile substances. In fact, the most effective approach to treating the trauma often associated with this substance abuse requires the two concepts to work synergistically.