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Why be complex needs capable?

People with complex needs often fall through the gaps of health service provision by encountering cultural, economic or social barriers to accessing health services. They are often further disadvantaged when their support and care needs increase because they cannot access the services they need.

"Each individual with complex needs has a unique interaction between their health and social care needs and requires a personalised response from services." (Rankin & Regan 2004:1)

Defining complex needs

Complex needs are not easily defined. They depend on the individual and their situation, and are often referred to as 'multiple unmet needs'.

Complex needs can be viewed as a framework for understanding multiple, interlocking needs that span health and social issues. Every person accessing drug and alcohol services has multiple needs; however, it is the interaction of these multiple needs that leads to complexity: "Each individual with complex needs has a unique interaction between their health and social care needs and requires a personalised response from services" (Rankin & Regan 2004:1).

On this website, drug and alcohol or co-existing drug and alcohol and mental health and cognitive impairment or involvement in the criminal justice system are defined as complex. These issues are likely to:

  • Interact with a client's drug and alcohol use, which may impact on the development of care plans, including how treatment and therapeutic services are delivered
  • Have an effect on the way a client participates in drug and alcohol programs
  • Result in a client displaying a range of behaviours that may require services to adapt part of their programs.

Complexity is not the same as difficulty, though people with complex needs are commonly labelled as 'challenging' or as 'having challenging behaviour'. Clients with complex needs may challenge your way of working but there are many strategies you can use to enhance your practice to support the different needs of clients.

Best practice in working with people with complex needs involves continually reflecting on your practice and considering new ways to provide support while incorporating the holistic principles of respect, flexibility and engagement. The pathways of clients to treatment services are all different, and it can't be assumed that providing care in the same way to all people will be effective and result in positive client treatment outcomes.

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Equity and access

It's important to consider particular complex needs issues such as cognitive impairment and criminal justice contact when thinking about the equity and access obligations of your service and of drug and alcohol treatment services more broadly.

Equity is "concerned with creating equal opportunities for health and with bringing health differentials down to the lowest level possible" (Whitehead 1990:7). This definition is based on the idea that everyone should have a fair opportunity to attain their full health potential. Inadequate access to health services contributes to health inequity (Whitehead & Dalgren 2006).

Access concerns the opportunity or ease with which a person or community can use services. A commonly cited barrier to accessing health services in Australia is geography, but issues of economic access (affordability), appropriateness and cultural access also need to be considered. 'Cultural access' refers to the existence of cultural enablers or barriers for people from diverse backgrounds in accessing available services. If there are cultural barriers, a person may consider a service unacceptable and not access it, even if they need it. Cultural barriers include services and/or health workers:

  • Not being accommodating enough of language and/or cultural diversity
  • Not considering the needs of people with low levels of literacy or education, and
  • Lacking awareness of the day-to-day restrictions in the lives of clients (Whitehead & Dalgren 2006).

Consider your legal obligations relating to equity and access, as specific legislation has been developed to protect human rights and prevent discrimination on the basis of age, disability, race and/or sex. From a human rights perspective, all organisations providing health and social support services should consider equity and access when determining program availability and providing services, to ensure programs are available to people who most need them.

For information and resources on state and federal human rights and anti-discrimination legislation, including the Disability Discrimination Act 1992 (Cth), Australian Human Rights Commission Act 1986 (Cth) and Anti-Discrimination Act 1977 (NSW), go to www.humanrights.gov.au.

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"Everyone should have a fair opportunity to attain their full health potential. Inadequate access to health services contributes to health inequity."

Who is entering your service?

Many drug and alcohol services in the non-government sector currently provide individualised care and services to people with a range of complex needs. However, you should be aware that people may have specific needs that are not evident when they first arrive. These needs become apparent as a person progresses through a treatment program and/or adapts to the treatment environment.

A consultation survey with NADA members undertaken in 2011 as part of the NADA Practice Enhancement Program (PEP) found that over half of the responding organisations had over 50% of clients involved in the criminal justice system. One-third reported that at least 20% of their clients had a cognitive impairment (Community Sector Consulting 2011).

As well as clients having complex needs, there will also be a high degree of 'hidden' disability among people accessing drug and alcohol services. Many clients entering your service presenting with drug and alcohol and mental health concerns will have experienced significant levels of childhood and adult trauma, the effects of which are often unrecognised and the symptoms of which are often seen or labelled as challenging. Often clients won't have formal records to indicate that they've experienced mental illness or have an intellectual disability or acquired brain injury. Additionally, people with a mild form of cognitive impairment may have developed a range of compensatory strategies that mask their low levels of functioning in some areas. Masking the effects of a disability is often associated with previous experiences of stigma or discrimination.

Due to numerous barriers to access, many clients with complex needs will have failed to access services until they require a high level of support. If they have previously accessed a service or been in an institutionalised setting, such as prison or a mental health facility, don't assume they would have been given the opportunity to receive treatment for a drug or alcohol problem or other physical health or social support issues.

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Pathways to complexity

People with complex needs accessing drug and alcohol services will all have different pathways to their current circumstances as a result of their unique life experiences. A common feature for many clients who present with complex needs is a history of marginalisation and disadvantage, trauma (including childhood and/or adult sexual, physical and/or emotional abuse), dysfunctional family relationships, low educational attainment, low or no employment, and stigmatisation.

Often for people who are marginalised, what is essentially a social or historical phenomenon (the result of factors external to the person) is presented as a biological or psychological characteristic (the result of factors internal to the person). The person is then perceived as not deserving of support because it is their 'fault' they are in their present situation (Burton & Kagan 2004).

This type of approach produces further barriers to accessing support for a person, creating a cycle of marginalisation and compounding the disadvantage, as illustrated in the following figure.

Cycle of Disadvantage

Source: Adaptation of Department of Families, Housing, Community Services and Indigenous Affairs 2009.

"Often for people who are marginalised, what is essentially a social or historical phenomenon ... is presented as a biological or psychological characteristic ... A person is then perceived as not deserving of support because it is their 'fault' they are in their present situation."

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Social determinants of health

It is widely recognised that higher rates of ill health result from the influence of social and environmental factors such as being poor, experiencing unemployment, and living in unsafe housing situations (Whitehead 1990; Wilkinson & Marmot 2003). These factors, depicted in the figure below, are often referred to as the social determinants of health. These types of factors tend to cluster and reinforce each other to make some groups, including clients accessing drug and alcohol services, marginalised and vulnerable to a range of health and social problems (Whitehead 1990).

According to Saggers and Gray (2007) socioeconomic positioning is often cited as the main determinant of health, but gender, ethnicity, social and emotional wellbeing, cultural differences and disempowerment are all contributing factors in determining health outcomes. The longer a person lives in disadvantaged circumstances, the more likely they are to suffer from a range of health problems (Wilkinson & Marmot 2003).

The layers of the determinants of health

Global Ecosystem

Source: UN Economic Commission for Europe (2007), from Barton & Grant (2006), drawing on Whitehead & Dahlgren (1991) and Barton (2005).

"...health is not dependent on the physical wellbeing of individuals. It is also dependent on key indicators such as education, financial status, adequate housing, sanitation, diet, and access to a range of goods and services. When considering health, you need a model that has a focus on structural inequalities, not just a focus on personal stories of misfortune. Also you need a model that acknowledges a history of oppression and dispossession, and a history of systemic racism" (O'Donoghue 2007, cited in Kratzman et al 2011:6)

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Trauma

Experiences of trauma can have a lasting impact on a person's life. Certain experiences and behaviour can trigger traumatic memories, causing a person to experience severe emotional distress and other symptoms.

Traumatic experiences include child abuse, physical abuse and assault, emotional or psychological abuse, rape or other sexual assault, neglect, family separation (particularly forced separation), domestic violence, witnessing conflict, and migration. Often people accessing drug and alcohol services have experienced one or more traumatic events, particularly those who've experienced mental health and drug and alcohol issues and have cycled between out of home care, homelessness and institutionalised settings such as prison.

Intergenerational trauma and Indigenous people

It's vital to take into account the effects of intergenerational trauma when working with Aboriginal people and communities. The impact of colonisation on Indigenous Australians continues to directly and significantly contribute to the health and social inequalities experienced by Aboriginal people today (see figure below).

Aboriginal people experience significantly poor health outcomes compared to non-Aboriginal Australians, including an average life expectancy for males that is 21 years less and for females almost 20 years less than the total population (Australian Indigenous HealthInfoNet 2005, in Carson et al 2007).

"The trauma and suffering that Indigenous people have experienced over generations have contributed to the burden of disease, substance misuse and incarceration" (NIDAC 2013:1)

Aboriginal people also experience significantly higher rates of incarceration. Indigenous adults are 14 times more likely to be imprisoned than non-Indigenous adults (ABS 2011, in NIDAC 2013), and almost half the young people in juvenile corrective institutions aged between 10 and 17 (between 2010 and 2011) were Indigenous (Australian Institute of Health and Welfare 2012, in NIDAC 2013).

Past Australian government policy and practices enabled the destruction of Indigenous kinship groups, languages and cultural rituals through the forcible removal and separation of Aboriginal and Torres Strait Islander children from their families and kinship networks over some five generations (Ranzijn et al 2010). The Bringing Them Home report (HREOC 1997) concluded that the forcible removal of children was an act of genocide and that the consequences for Indigenous peoples continue to reverberate today.

Indigenous Australians have been affected by extreme personal, collective and cultural trauma, with the effects of trauma in one generation being the causes of trauma in the next. The effects of past traumatic events are compounded by further traumas, lack of self-determination and other negative reoccurring events. This creates a continuous cycle of trauma that is difficult to break and is exacerbated by ongoing individual and institutional racism experienced daily by Aboriginal people (Purdie et el 2010).

Effects of colonisation on Aboriginal people and communities

Colonisation Affects

Source: Cunningham & Stanley 2003.

Trauma and people from a CALD background

People from culturally and linguistically diverse (CALD) backgrounds, particularly migrants, refugees and humanitarian entrants can also experience the lasting impact of trauma across generations, and this may be a risk factor for mental health and drug and alcohol issues (Donato-Hunt, Munot & Copeland 2012). Pre-migration stressors may include torture, trauma, conflict and loss of loved ones. Post-migration stressors may include feelings of grief and loss, economic and social disadvantage, discrimination and racism, and issues with cultural adjustment.

Children of migrants, refugees and humanitarian entrants may also experience a range of stressors that make them vulnerable to substance use, mental health issues and other complex needs, including involvement in the criminal justice system. They may also have conflict with family due to stark differences in upbringing and experiences, peer culture, and feelings of marginalisation and social isolation.

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"The majority of the research that has investigated the psychopathology amongst refugees suggests that resettled refugees are at risk of developing significant psychological and substance-use disorders as a result of accumulated stress before, during and after migration" (Posselt et al 2013)

Institutionalisation

Spending time in highly institutionalised environments - including prison, mental health facilities, large residential units, hospitals, refugee camps, detention centres, boarding houses and out of home care - deprives a person of responsibility, autonomy and control over their lives. They may have few life skills and social supports, and this can result in:

  • Few employment opportunities
  • Poor family relationships, and
  • Difficulty in coping with stressful situations (this may be exacerbated by mental health problems).

These factors interact with and reinforce each other. As a result, a person may struggle to manage regular aspects of life such as maintaining housing and finances, and may find it difficult to access services (UK Social Exclusion Unit 2002). This leaves them vulnerable to inadequate housing situations or homelessness, lack of social support, and developing health problems such as drug and alcohol and mental health issues.

Many people with complex needs have experienced living in institutional settings, often more than one. People with an intellectual disability who've spent their childhoods in institutions (e.g. large residential facilities, out of home care) may experience lifelong difficulties managing daily life.

People who've been institutionalised may display behaviours that are contrary to the expectations of drug and alcohol workers. For example, people who have been to prison may be reluctant to openly express personal information, thoughts and feelings with others in a group setting in a drug and alcohol service, due to the prison culture of not sharing any information to maintain personal safety.

For more information on working with clients who've had contact with the criminal justice system, see Criminal Justice Contact - What You Need to Know.

People released from institutionalised environments often lack adequate connections to health and social support services and regularly face an array of decisions to make. This can be overwhelming, and a person who's finding it difficult to cope may slide back into previous, known patterns of behaviour (UK Social Exclusion Unit 2002) which may include offending behaviour and drug and alcohol misuse. As noted by Baldry, Dowse and Clarence (2011), these adjustment difficulties may be exacerbated for people with cognitive impairment, particularly those with a co-existing drug and alcohol or mental health issue.

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Discrimination and stigma

Experiences of discrimination and social exclusion can have long-lasting impacts on a person's health and emotional wellbeing and may increase their vulnerability to drug and alcohol misuse.

Many Aboriginal people and people from CALD backgrounds experience discrimination as a result of racism. And people with cognitive impairment, physical disabilities or mental illness also frequently experience discrimination. Another group that commonly reports experiences of stigma and discrimination are people who identify as gay, lesbian, bisexual, transgender, intersex or queer. This discrimination may be experienced through social exclusion, verbal abuse, physical attacks or other forms of violence.

As a minimum standard, your service should have policies to ensure service access and provision is free of discrimination and promotes equity. Workers and other clients need to be aware of their responsibilities in respecting others and practising empathy. Systems need to be in place to recognise the indicators of past stigma and discrimination and provide support to reduce the negative impacts on a person's mental health and functioning.

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Find out more

For more information on the various pathways to complexity see:

For information and resources on state and federal human rights and anti-discrimination legislation, including the Disability Discrimination Act 1992 (Cth), Australian Human Rights Commission Act 1986 (Cth) and Anti-Discrimination Act 1977 (NSW), go to www.humanrights.gov.au.

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