Intensive outreach based support for adults with long standing, complex AOD issues

Venetia Brissenden, Catchment ManagerKate Petch, Senior Clinician

Background• Intensive Support Service (ISS) running since

2004• Funded through Commonwealth NGOTGP• Arose from a clinical file audit of clients admitted

to the adult residential withdrawal unit in 2001• Found a large number (110) of clients who had

engaged in two or more residential withdrawal episodes in a 12 month period • 33 had 3 or more admissions • 2 had 7 admissions

Presentations

• Often crisis driven• High rates of failure to complete withdrawal• Early exit from service with no opportunity to

arrange follow up or failure to follow through with post-withdrawal treatment plan

• Involvement with multiple service providers but little collaboration between services

• Substance use seen by client, family and other workers as the ‘intractable problem’ preventing forward momentum in other domains

Characteristics of clients

• Challenging, or treatment/therapy interfering behaviours

• Co-occurring chronic or episodic conditions requiring long term service approach (eg poor physical and/or mental health)

• Multiple service usage without resolution of issues

• Homeless or at risk of being homeless

• History of family dysfunction and/or abuse

• Social isolation and lack of supports• Long history of entrenched

problematic substance use – most commonly alcohol (and historically heroin)

Addressing a gap in the service system

• Appointment based counselling services not appropriate – high DNA rate and failure to engage

• Current CRC limited – only 15 hours. Can take some time to develop a treatment plan with these clients

• Episodic crisis and treatment interfering behaviours make attending residential programs and group programs difficult

ISS

• Long term intensive support (3-12 months, though often longer)

• Low case load (approx. 10 clients at any one time)

• Significant outreach component in order to accompany client to appointments and activities

• Delivered by a senior clinician with strong case work and therapeutic skills

• Ability to provide both practical, active support and therapeutic interventions in a variety of settings

Characteristics of the clinician

• Senior role with experience in working with complexity

• Strong engagement skills in outreach settings – • Initially very gentle, lots of rolling with resistance• Moving to gently challenging with lots of checking• Identifying and working with defences• Anticipating crises before they arise

• Reliability - extremely important not to let these clients down and to deliver what is promised

• Good service coordination skills• Matching pace of intervention to client

capacity so as to build confidence rather than overwhelm

• Able to reframe setbacks• Able to tolerate a level of crisis and

dysfunction

Characteristics of the work• Slow development of treatment plan ensuring that it

incorporates the clients expressed needs –even if this is not an obvious AOD treatment goal

• Sometimes focusing on other needs first for quite a while

• Extensive work sorting out communication between all services involved and ensuring clearly defined roles

• Sometimes feels like two steops forward three steps back

• Frequent relapse and crisis• Helping to address high level of previously

unaddressed or poorly addressed physical and mental health needs

• Lots of outreach• Hanging in there while destructive patters

repeat and looking for points of traction

Challenge and response

• Clients often have behaviours or attitudes that create barriers for service provision. • Working on helping the client learn effective social skills e.g. how

can I get what I want and need?

• Longstanding patterns of self-destructive and dysfunctional behaviour that creates ‘crises’• Helping client to identify patterns and their own agency in events

and to form new more functional patterns

• History of negative experiences in health and social services and low expectations of treatment• Smooth the interactions between services and clients – advocate

each to the other

Example

• Beth - Long standing heavy alcohol use – frequent ED presentations, DHS involvement, family breakdown, unstable housing, significant childhood trauma, BPD and OCD, depression and anxiety, long history (10+ years) of presentations in crisis but disengages early from treatment

• Over time have identified that can do therapeutic work with Beth at 0.02 BAC but over 0.03 the work is around safety planning

• After 12 months of work with Beth she has completed Making Waves program and working on a referral to spectrum. Has significantly reduced ED presentations. Still drinking, though less intensely, with some periods of abstinence

Case exampleFrank, 57Background:• longstanding: past heroin use, pill and alcohol use • has been on methadone and serapax for 10+ years , nil other

medications• ABI from use• longstanding forensic involvement primarily substance

related, on Corrections order and at risk of re-offending• serious hx trauma & likely past episodes major depression -

untreated • longstanding AOD service engagement driven by forensic

concerns

Frank, 57Outcomes• ISS referral June 2016• Initial work: support completion Corrections order, GP appt,

and referral for Hep C+ tx.• Outcome: Diagnosis of liver cancer – unfortunately terminal Key work: • support change in interpersonal patterns of behaviour and

perception, and support liaison with service providers• support change in use patterns• support re: diagnosis and service engagements when

necessaryChallenges: speaking about death and dying….