Assessment and referral

Introduction

Homeless people are diverse and present with a broad range of needs. This is also true for those clients who are affected by alcohol and other drug (AOD) use. Assessment can help us target our interventions effectively and, when indicated, to refer on effectively. While there are some useful general guidelines, some groups, for example, women, young people, Indigenous Australians and people with mental health problems have additional specific needs, and it is important that these are taken into consideration and understood by service providers.

Assessing the client

The first step when assessing a client is to determine whether they actually have an AOD problem that merits your intervention and/or engagement with a treatment service. Amongst details gathered by accommodation support providers (such as name, occupation, health needs, etc.), you should collect information about a person’s history of alcohol and other drug use. This should include questions about whether the person is currently using drugs and/or alcohol, what types, in what amounts, for how long and how regularly and when did they last use. This will assist in making a decision on what kind of help you can offer and/or whether referral to an AOD treatment service is necessary and, if so, which specific service will be most appropriate for their particular condition.

A checklist is provided below for identifying client characteristics that need to be considered when determining whether a client is at high risk. As a general guide, the more items checked, the greater the risk.

Chronic health problems that might result from sustained AOD use also need consideration. Information on the long-term effects of different drugs is available from the Australian Drug Foundation “How Drugs Affect You” series of pamphlets (check their catalogue at http://www.adf.org.au). Finally, there may be circumstances (such as a high risk of self-harm or harm to dependents) that may warrant involuntary treatment under a court order on the advice of a social worker, which is possible under legislation in some jurisdictions. See Legal issues for more information.

Even clients who are deemed to be low risk should be monitored on an ongoing basis if workers are in a position to do this. It is important to remember that clients’ situations change, as does their AOD use.

 

Engaging clients

Exploring and enhancing the desire of clients to reduce or solve their problem(s) is an important part of engaging them and/or referring them to AOD treatment. Poor client engagement and subsequent poor outcomes may lead to disenchantment with your services and with other treatment services. Factors that have been shown to influence a person’s intent to ‘do something’ about their AOD use include the following:

• Relationship break-ups;
• Family conflict and dysfunction;
• Problems with physical health and AOD related health problems;
• Death of friends and family, especially if AOD related;
• Losing contact with children or having children taken by child protection agencies;
• Recognition that AOD use has become problematic and a desire to do something about it;
• Pregnancy;
• Avoidance of contact with police/justice system;
• Encouragement from service provider staff;
• Awareness of successful treatment outcomes experienced by friends;
• Change of season — such as weather becoming too cold for sleeping out;
• Difficulty in obtaining supply of usual drugs; and
• The need to have a break from sustained AOD use.

Exploring the specific factors that are relevant to your client can help you have an important role in exploring and enhancing their motivation to reduce their AOD problems.

‘Motivational interviewing’ involves a range of approaches designed to help you and your client explore the factors that influence their AOD use. The approach can help clients make more robust and enduring decisions to change. If you are interested in developing this skill, many AOD services arrange training in motivational interviewing. For the purpose of this information sheet, the key features of the approach are described below:

• Listen and reflect your client’s concerns, thoughts and feelings through an empathic approach (that is, being able to listen, understand and communicate your understanding of what the client is telling you);
• Identify discrepancies between their AOD use and their other goals (e.g. ‘You say that you want to get work, but you also realise that this won’t be possible if you drink at the levels you do now’);
• Do not argue with your client if you encounter resistance. Give them time to reassess their beliefs and attitudes or help them consider other perspectives. One key aspect of this approach is to focus on what concerns the client and explore the links to AOD use, as opposed to focussing solely on what concerns you and expecting that they will agree with you; and
• Highlight their self-efficacy (the confidence to carry out a particular act or behaviour), through drawing attention to the gains they may have already made (e.g., not having touched a bottle for a few days).

In short, people are likely to be motivated to change behaviour if they believe:

• Their current actions are resulting in unacceptable costs;
• If they change there will be benefits; and
• They have the capacity to change.

In general, the following tasks can aid in motivating clients to do something to stop or reduce AOD problems:

• Build a helping relationship (e.g. by attending to the things that concern the client). Therefore, support them with practical help (finding accommodation; getting family and/or community support; helping arrange the treatment appointment and attending to practical challenges such as travel to the appointment);
• Explore their concerns about AOD use. Provide information/advice about your concerns, but don’t always expect the client to agree with what concerns you;
• Explore what they would like to achieve and highlight the benefits associated with being ‘clean’ (benefits might include improved relationships, employment, health, etc.);
• Discuss practical ways of how you can help; and
• Elevate their sense of self-worth and competency through achieving simple goals (e.g. being sober for two days; turning up to an appointment sober; eating well; keeping an appointment with a legal adviser) and skills development (e.g. developing their ability to solve problems; developing their ability to succeed in interviews; developing their ability to communicate clearly).

It is sometimes useful to consider the client’s prior experience of help and treatment and determine what the aims of treatment on this occasion will be and encourage a positive attitude towards future treatment attempts. It is important to prioritise all the issues and be realistic about the level of change that can be achieved over a given time period. Simple and realistic goal setting can help this approach.

Need for other interventions?

If there is an identified need for formal intervention and the client is expressing some interest in such help, the next step is to identify an appropriate treatment service. It is important to determine details about the person’s wider circumstances and personal preferences. For example:

• Will the person benefit more from a residential treatment service?
• Will they be better served by a service nearby or one away from their current location (perhaps where they are less likely to be influenced by drug-using acquaintances)?

The following are wider issues to be considered when assessing the AOD treatment needs of clients:

• Family situation (e.g., do they have children or partners that they need to stay in regular contact with?);
• Friendships (will it be advantageous or disadvantageous to locate them away from their local acquaintances?)
• Problems with physical health and AOD related health problems;
• History of violence; and
• Ethnicity (do they have special language and cultural needs?)

If the AOD problem is not acute, the client might be equally or better served by attending to other matters such as housing or family needs, employment or skills training which, in the long term, might serve to minimise their AOD use. Some studies have found that improving the quality of people’s lives in areas such as employment, housing and relationships are important components of intervention, can contribute to reductions in the level of AOD related problems and help people maintain gains.

Referring the client

In order to know how best to refer to a service, it will be helpful to have some information about what sort of interventions are offered. For example, some services specialise in treating particular AOD users, such as injecting drug users while others offer a broader service. You can usually access this kind of information by telephoning the Alcohol and Drug Information Service or equivalent service in each state (see the contact details below).

While case-workers often have their preferred treatment providers, be aware that in metropolitan areas there are many services to choose from, although this may not be the case in regional areas. One option is to contact a referral agency to assist in making this decision. Below is a list of AOD referral agencies:

ACT

ACT Community Health
(02) 6205 4545

NSW

Alcohol and Drug Information Service (ADIS)
(02) 9361 8000
1800 422 599 (toll free)

Northern Territory

Amity House
(08) 8981 8030

Queensland

Alcohol and Drug Information Service (ADIS)
(07) 3837 5989
1800 177 833

South Australia

Alcohol and Drug Information Service (ADIS)
(08) 8363 8618
1300 13 13 40

Tasmania

Alcohol and Drug Service (ADIS)
1800 811 994 (toll free)

(03) 6336 5577
(North: Launceston)

(03) 6429 8555
(North West: Ulverstone)

(03) 6230 7901
(South: Hobart)

Victoria

Directline
1800 888 236 (toll free)

Western Australia

Alcohol and Drug Information Service (ADIS)
(08) 9442 5000
1800 198 024 (toll free)

1800 629 683 (toll free)

Supporting the client

Once a client is placed with an alcohol and other drug treatment program, there is much that homeless service workers can do to assist the client both during the program (in the case of non-residential treatment) and afterwards.

Helping with withdrawal

Some clients may be dependent on drugs and consequently may experience withdrawal symptoms. These vary from drug to drug and their severity is affected by factors such as the degree of dependence. Thus, some people may simply experience mild discomfort for a few days, while others may become quite ill, some symptoms may endure for many weeks and they may benefit from medical management. Some withdrawal symptoms are readily self-managed, some are managed by specialist services on an outpatient or inpatient basis.

Most specialist drug services have developed protocols for managing withdrawal for a range of drugs. It will be worthwhile working with such services to develop protocols for your agency. Some simple steps may help your clients:

• Provide information about what to expect in withdrawal. Some studies have shown that providing such simple information increases adherence to a withdrawal regime. Helping anticipate symptoms can help you and the client plan how to respond;
• Explore if they have found something helpful on other occasions when they have experienced withdrawal;
• Decide if external help or a residential withdrawal service will be needed (determined by type of drug, degree of dependence, other factors such as history of seizures, physical health etc.); and
• Having plenty of rest, adequate fluid intake and good nutrition.

Non-residential services

During participation in a non-residential program, it is important that the client has safe and stable living arrangements. They may also need assistance with various problems that arise as a result of their participation in the program. These problems may include:

• Clients having unrealistic expectations of what can be achieved by treatment and rehabilitation services;
• Clients having difficulty focussing on content of programmes;
• Many treatment programs have clear rules and regulations which may not be flexible enough to meet the needs of some homeless individuals;
• Clients with cannabis related problems may not be always recognised and accepted on to programmes;
• Service providers may judge clients due to their appearance and behaviour and in turn ignore, discount or reject them;
• Clients may have difficulty understanding entitlements, health benefits and subsidies that they are entitled to and may have difficulty in paying ‘gap’ fees;
• Perspectives of treatment goals for client and providers may differ;
• Underlying cognitive impairments may be overlooked by providers;
• Homeless clients may become anxious and distressed around institutions and persons in positions of authority, such as doctors and clinic staff; and
• Homeless clients may have complex underlying health issues that need to be taken into consideration while undergoing treatment. For example, mental health problems which may be undiagnosed, untreated or under treated; hepatitis C; dental health problems, nutritional and respiratory problems are common.

Establishing a clear communication link with the treatment service can help address these problems. Also, consider simple practical support such as facilitating access to treatment services:

• Can the service provide a clinic in your agency?
• Can staff accompany the individual to treatment, at least on the first appointment?
• Can transport be arranged?).

Once a client has completed a treatment program, it is important to assist the individual in maintaining their treatment gains. The following strategies may help:

• Good follow-up from providers. This can be difficult for those who experience homelessness, particularly for those who are not long-term residents of supported accommodation providers. It is sensible to both explain and write down follow-up arrangements. Often it will be necessary to use assertive outreach strategies to continue to engage homeless people. Some services have provided mobile phones to clients in order to ensure that follow-up arrangements are complied with. It is important that provisions to follow-up progress are made upon completion of the programme;
• Clients need help to avoid going back into the same situations and social circles that encouraged or sustained their AOD use. Assisting clients in associating with non-drug using acquaintances, or encouraging them to frequent other areas where drug use is not prevalent, are among the measures that can help an individual maintain treatment gains; and
• Consideration needs to be given to the fact that homeless people often have a range of more chronic and complex problems — relationship break-up, child access, financial debts, unemployment — and drug use often exacerbates these. While it is often not possible for treatment staff to assist their clients in overcoming all these problems, understanding and encouraging clients to undertake positive steps towards addressing them (e.g. by facilitating access to legal advice; relationship counselling; financial advice etc.) may, in the long term, be pivotal to reducing their drug or alcohol dependence.

Some final words

If a client is in crisis or intoxicated it may be difficult to understand what they need or want. Listening carefully to them, staying calm, using client centred principles and showing empathy and respect, will minimise chances of the situation escalating (See Opportunities to assist).

A good helping relationship can often be built if we first attend to the client’s initial needs. Therefore, it is important to be aware that homeless people often have a number of issues and needs other than AOD use. These include physical and mental health problems, financial issues and family related problems. A holistic approach addressing the needs of clients will help build an effective helping relationship that in turn will help you respond effectively to AOD related problems.

While it may be difficult to make major changes in the short period of time that homeless people are in contact with services, there is much that you can do to reduce harm, improve quality of life and increase the chance of successful engagement with clients who are affected by AOD use. It is important to ensure that each contact is meaningful. Research has demonstrated that there is an ‘accumulated dose’ effect of treatment, suggesting that there are long-term benefits to multiple exposures to treatment over a period of time. Short contacts are not always ‘failures’ or of little use — most people who successfully resolve AOD problems have made several attempts.

 

Source

The information contained in this guideline has been sourced from interviews with homeless people, focus groups with practitioners, consultation with experts in the field, and a review of homeless studies undertaken by researchers at the National Drug Research Institute, Ted Noffs Foundation, WA Drug and Alcohol Office and St Bartholomews House for the Australian National Council on Drugs in 2007.

Additional Sources:

West Sussex Misuse Services. West Sussex Substance Misuse Assessment Form from the National Treatment Association website (http://www.nta.nhs.uk)