intensive outreach-based support for adults with longstanding, complex aod issues
TRANSCRIPT
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Intensive outreach based support for adults with long standing, complex AOD issues
Venetia Brissenden, Catchment ManagerKate Petch, Senior Clinician
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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
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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
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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
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• 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)
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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
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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
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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
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• 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
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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
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• 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
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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
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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
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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
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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….