This briefing is based on the work of the Homeless Link Health Inclusion Project, who conducted a major research survey in 2002 on working with people with multiple needs.
The full document (pdf) is available here.
Introduction | A definition of multiple needs | Engagement and Assessment | Co-ordination | Brokerage | Advocacy | Top tips for Interagency relations | Staff Training | Qualification and Experience
It is commonly accepted that people with mental health issues often also have substance use issues, and indeed vice versa. People with mental health issues may use substances to self-medicate for their symptoms: to alter their feelings, moods or experiences of hearing voices, feeling low or paranoid for example. They may also use substances because their mental health problems leave them socially vulnerable, excluded, bored or easily preyed upon. In the past, there have been difficulties working with people who present with both mental health issues and substance use issues, as mental health teams may feel they cannot intervene successfully while the patient is using substances, and addiction services may not feel equipped to deal with a client with mental health needs and refer them back to mental health.
The term dual diagnosis is used to describe individuals who have concurrent mental health problems and use substances. The complexity for this group lay in the fact that many mental health teams would be reluctant to engage with someone actively using drugs, while substance use teams were also reluctant to engage with someone with mental health problems. For an up-to-date picture of the issue, see the resources below.
Background
Good Practice
NEW Practitioners' Guide to working with Substance misusing clients with mental health problems is produced by the Home Office for Criminal Justice Intervention Team workers, but has applications for many other professionals.
The Handbook is now on sale - order hard copies from Turning Point or download a PDF version here
As we can see from the definition below – a holistic view of the person and consideration to each of their areas of need is necessary to make positive change in an individual’s life and increase their ability to live stably and happily.
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A typical homeless or ex homeless person with multiple needs will often present with three or more of the following, and will not be in effective contact with services:
If one were to be resolved, the others would still give cause for concern.
This briefing looks at multiple needs in terms of providing a holistic service to individuals. This is best achieved by considering the range of needs a person has, and how you can best help them obtain support for these needs from the relevant specialist agencies, which means effective interagency working, and finally, providing training to your staff to enable them to have more productive interventions with people with a range of needs.
Four cardinal points originally set out by the Elmore Community Support Team in Inhabiting the Margins (Dewhurst, 2000) are a crucial underpinning structure for working with people with multiple needs at each stage of the resettlement process.
Before a client is accepted into a service preliminary enquiries should be made to assess the situation and the appropriateness of the referral. Once a client is accepted any immediate needs must be attended to. A picture is built up of a client's situation and wider needs, and a relationship should begin to develop.
The worker makes sense of the wide range of agencies that can potentially offer a service to the client with multiple needs. The worker also ensures that these agencies are linked, and aware of each other's involvement with the client.
This is a key function with the client group, which can include brokering the clients to the services, where a service has rejected or banned the client for whatever reason. It also involves brokering the services to the client, when the client is excluding themselves from a service or accommodation for whatever reason.
From time to time advocacy is needed on behalf of these clients, when an agency or an accommodation provider is not delivering a good or appropriate service to the client.
When working with clients with diverse needs, the importance of inter agency working cannot be stressed enough. No one service would be able to fully cater for the whole range of needs that a person may have, so linking in with specialist agencies is paramount.
Good relationships, particularly with the statutory sector, can be facilitated through formal arrangements such as referral protocols, liaison agreements, case conferences and the exchange of client information.
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The research conducted by the HIP showed an alarming lack of formal arrangements between statutory services and voluntary homelessness organisations when dealing with service users with multiple needs. The practice of exchanging client information within agreed procedures is also uncommon. The HIP report recommends that this be urgently addressed.
We recognise that staff are very experienced in working with this client group, and have successfully supported homeless clients with multiple needs over the years. Indeed, at the recent National Conference on Personality Disorder, it was mentioned that resettlement workers, hostel and day centre staff have been successfully working with clients with multiple needs, including personality disorder, who had been failed or excluded by mental health services as too difficult to engage, or who could not be helped. It was mentioned that this may be due to these workers having fewer negative and pessimistic pre-conceptions of those with multiple needs, particularly personality disorders.
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Overall, two-thirds (67%) of respondents said that they felt that their staff were adequately trained to work with the client group. To test this assertion, we detailed the specific areas that staff should be trained in. From the table below, we can see that although the agencies believe that they are adequately trained to work with homeless people with multiple needs, it would appear that on key issues they are not.
Whole sample Substance misuse = 89% Mental health = 84% Challenging behaviours = 78% Personality disorders = 44% Offending behaviour = 44% Physical health problems = 29% Vulnerability because of age = 27% Borderline learning disabilities = 24%
This would need to be a staged process, offering an ongoing training programme for existing managers.
Homeless Link thinks it is vital that professionally trained and experienced people lead the management of direct access projects working with people who have dual diagnosis or multiple needs. This professionalism could be at either manager or deputy manager level. Deputy level is better, as they usually have the responsibility for the day to day running of the hostel. There was another opinion from the tasking group that the manager should hold the qualification, so as to have the necessary decision making level of power to implement change. Good assessment will be crucial to the client’s getting an appropriate and good service from the hostel, and the principles of assessment need to be well understood and implemented throughout all of the stages of working with this client group. Regular training on assessment will enable staff to provide the best service that they can. See here for more information on assessment.
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