01.09.2014 "We don't judge whether the lifestyle they choose is good or not."
Interview with Kaspar Zölch. What happens with addicts once they reach an age at which they are dependent on care and support in residential facilities? The care homes and homes for the elderly that accept them are still few in number. The Solina Spiez in the Bernese Oberland accommodates 180 persons in need of care. Ten of them are former drug addicts now receiving methadone or Diaphin (the pharmaceutical proprietary name for pure heroin) in the framework of a substitution programme, and 25 are alcoholics. Solina Spiez director Kaspar Zölch talks about his experiences with his colourful mix of clients and their very specific needs.
spectra: Mr Zölch, what's special about your facility?
Kaspar Zölch: We look after 180 residents aged from 18 to 104, a third of whom are under 65. They're all seriously or very seriously in need of care – we score about 8.2 out of a possible 12 points on the care-level scale. Besides elderly residents and people with dementia, they include younger multiply disabled or cancer patients without any medical perspectives, and persons who are referred to us from psychiatric facilities. To some extent, our residents reflect society as it exists in the outside world. We focus primarily on the question: what do people bring with them when they come to the Solina? Each and every one of them has resources. These provide the basis for life in our facility.
Everything is mixed in our departments. We don't have any disease-specific dedicated units for dementia, multiple sclerosis or hemiplegia. We are committed to mixing our residents. There are nine people in a residential group. They're assigned in accordance with the available resources, independently of age and gender or whether somebody comes to us with a dependence problem. We've been implementing this philosophy for about seven years, and the results are good.
Most of our residents have restricted mobility – very many of them use wheelchairs. The focus is on their wellbeing. Applying care, medical and social therapy measures, how can we guarantee each and every one of them a sense of wellbeing in this phase of their lives? It all centres around key issues such as self-determination, freedom from pain and zest for life.
You've also been looking after addicts here for the last ten or so years.
Yes, many of them come here from the heroin prescription programmes in Berne, Burgdorf, Biel and Thun. Or from hospitals in which they have landed after, for instance, an accident. The youngest former drug addict is 38, the oldest 58. Time spent living on the streets shortens life expectancy massively. Most suffer from a huge underlying psychiatric disorder on which they have then – to some extent as self-therapy – planted their addictive behaviour. About three quarters of them are men, one quarter women. They're all chronically ill, and the focus is on their wellbeing. Guiding them towards abstinence is not our main goal. We don't judge whether the lifestyle they choose is good or not. If someone wants to reduce their substance use, we naturally provide them with support.
What differences are there between alcoholics and opiate addicts?
Alcoholics are harder to manage than residents undergoing substitution treatment. With Diaphin-substituted patients we have the option of imposing sanctions. Anyone whose breath test shows they have too much alcohol in their blood is given methadone in place of Diaphin, which they do not appreciate at all. In fact, this aversion to methadone is so strong that people would rather miss out on the home's seaside holidays than Diaphin. That's because we're not allowed to take Diaphin over the border.
How did the staff react when you began taking in dependent drug users?
At the outset, there were considerable concerns. Many of the staff were opposed, believing that such people did not belong here. They were afraid that medicines would be stolen or used for dealing, and they couldn't imagine carrying an alcohol testing device on the medicine trolleys and having patients on substitution therapy blow into it before the medicine is dispensed. Today, caring for Diaphin patients is very straightforward – it's an illness like any other.
As a rule, residents have to administer their intravenous dose themselves. It's too much to ask of the care staff that they search for a suitable injection site in veins hardened by years of intravenous abuse.
How do you deal with alcoholics?
The consumption of alcohol is permitted in Switzerland provided we behave properly and have enough money to purchase it. In this country we can drink like a judge and smoke like a chimney – it's just the way it is – and it's basically the same in a long-term care facility. What's crucial is the limit with regard to the medicines being taken – particularly in the case of patients on substitution treatment. Depending on the circumstances, we look for appropriate measures: limiting the amount drunk, controlling patients' intake via their spending money. We also sometimes try to regulate alcohol intake: one beer in the morning, one at noon, one in the evening and one for the night. This works well in some cases, and the patients no longer have the stress of procuring the alcohol.
It's more of a problem when, because of their previous drinking habits, someone is no longer able to make decisions for themselves and their behaviour is becoming a huge threat to their health. In such cases, alcohol consumption should actually be prohibited. But who decides whether someone is still capable of making decisions for themselves? Many don't want to live in abstinence, even though it's the only way of ensuring their survival. This can sometimes lead to highly sensitive conflicts.
How are such problems solved?
We regularly organise "round tables" with the residents concerned, family members (if any can still be found), carers and support staff, legal guardian/representative, social services and sometimes the pastor. The discussions can become very heated. How does the person involved want to lead their life and what is needed to assure their personal wellbeing? If someone consciously wants to spend their lives three sheets to the wind, they are allowed to do so – we are not a moral authority and have no educational mandate.
What kind of daily structure do you offer residents?
There's a very low-threshold set of activities in the creative workshop. We work there with residents on a very individual basis and they can also earn a little pocket money. In addition, we have a number of therapy groups – painting, cooking, men's and women's groups, etc. A certain structure is also created by having residents carry out everyday tasks such as setting and clearing the tables, tidying their own rooms, making their own beds and taking part in small personal hygiene training groups.
How are the former dependent drug users regarded here in Spiez? How do they get on with the other residents of the home?
Relatives sometimes have a problem with the fact that their grandmother's room is right next door to someone with a history of drug-taking. But when they come for a visit and see for themselves how the residents get on together in everyday life, their prejudices are usually dispelled.
In the village, we're accepted up to a certain point. There's nothing we can do about it if residents set off with their walking frames to Aldi, Coop or Landi to buy five or ten cans of beer at 50 centimes each – they can scarcely afford more than that on their maximum of ten francs a day pocket money (which may also have to stretch to cigarettes). Some of them try begging. This causes bad feeling and talk in the village. People ask why 60 million francs are being spent on building a home for "people like that"?
How do the residents get on living together?
There are few problems among the residents. With dementia patients in particular, other people's past histories are irrelevant. What is crucial for them is whether they're respected as human beings. There are certain rules of etiquette that have to apply to everyone. Elderly people of more refined habits sometimes have greater problems with living together. Having to share bedrooms is certainly a problem, but this will be resolved when the new building has been completed: then we'll have single rooms only.
Drug-related crime and drug dealing feature prominently in life on the streets. Have you also got to address these issues?
Some things cannot be prevented if we allow certain freedoms and let everyone lead – within the limits of the law – the kind of life they want. We intervene in cases of illegal drug use that go beyond personal needs, and we draw a line at repeat offences. But those concerned already know this.
Smoking hash is also an issue. Cannabis is basically not tolerated, but we don't police the home. Smoking is in any case not allowed on the premises, except on balconies and in the designated smoking room. Those who smoke in the open air do so at their own risk. If drugs are left lying around for all to see, they are confiscated by the staff. But cannabis is also used officially: some residents, particularly those with cerebral palsy, receive hemp drops for medical reasons.