2017 VAADA Conference presentation - Venetia Brissenden and Kate Petch consider ReGen's Intensive Support Service program model and the capacity of the Care & Recovery Co-ordination service type to support people with complex needs.

1. Intensive outreach based support
for adults with long standing,
complex AOD issues
Venetia Brissenden, Catchment Manager
Kate Petch, Senior Clinician

2. 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

3. 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

4. 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

5. • 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)

6. 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

7. 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

8. 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

9. • 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

10. 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

11. • 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

12. 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

13. 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

14. Case example
Frank, 57
Background:
• 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

15. Frank, 57
Outcomes
• 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
necessary
Challenges: speaking about death and dying….