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The theory behind complex needs

Good practice is informed by evidence, and most evidence-based practice is informed by theory. Think about how you work with a person and why you're working in that particular way. There are a number of theoretical approaches that are useful for framing practice strategies when working with clients with complex needs. Here is a brief overview of some of these theories.

Holistic practice

Holistic practice means providing care to a person in a way that considers all aspects of their life, including their physical and mental health, living situation and social networks. It doesn't mean that a drug and alcohol worker or service is expected to provide all services to meet a person's needs. But it does involve identifying areas of need, and potentially modifying the way you provide services to a person and coordinate care with other services. Holistic practice is:

  • Person-centred. Care is personalised and focused on the specific strengths and needs of the person.
  • Collaborative. A person participates in making decisions about all aspects of their care. Support is provided to the person if necessary to maximise their ability to make their own decisions.
  • Flexible. The model of care can be adapted to accommodate a person's needs.
  • Strengths-based. The care received by a person should recognise and work towards their strengths and capacities.
  • Focused on engagement and rapport. The model of care recognises that engaging with a person and building a trusted and positive relationship is a key component of fostering personal growth and change.
  • Respectful. The care provided to a person is free from stigma and discrimination and actively works towards making a person feel accepted by the service, the workers and other clients.
  • Hopeful. Care is informed by an attitude of optimism and hope. There's an assumption that a person can be supported to make positive changes in their life, whatever their history or current circumstances.
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"Holistic practice means providing care to a person in a way that considers all aspects of their life ... It doesn't mean that a drug and alcohol worker or organisation is expected to provide all services to meet a person's needs."

Inclusive practice

Inclusive practice occurs independently of any specific model of care. The central idea of inclusive practice is to provide individualised care based on a comprehensive assessment of a person's needs. For individualised care to be possible, the ability to modify program elements to support people with complex needs must be embedded within an organisation's systems as much as possible, so that workers can make use of this ability when required. Adopting a model of inclusive practice should reduce the need for a person with different abilities to highlight their difference when accessing a service.

Consistent with principles of access and equity, inclusive practice can encompass a range of strategies that aim to ensure that as many people as possible can participate in a program or access a service despite their literacy levels, linguistic preference, cultural background or specific experiences in the past (e.g. certain offending behaviour).

You should consider inclusive practice in all aspects of service delivery, not just intake and assessment. It should particularly be considered in relation to service partnerships, when involving support people (including families and carers) in a person's care, and when planning case management and counselling.

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Trauma-informed care

Experiences of trauma have a lasting impact on a person's life. Trauma-informed care is a term used to describe a way of working with people that acknowledges the lasting impact of trauma.

In order to respond empathically to the needs of trauma survivors, ensure their physical and emotional safety, develop realistic treatment goals, and at the very least avoid re-traumatisation, all practices and programming must be provided through the lens of trauma. (Guarino et al 2009:i Guarino et al 2009:i)

There are different views on whether "trauma refers to an event, a series of events or an environment, to the process of experiencing the event or environment, or to the psychological, emotional and somatic effects of the experience" (Purdie et al 2010:135). There's wide agreement, however, on the profound and often devastating impact trauma has on many people.

Practice Guidelines for the Treatment Of Complex Trauma And Trauma-Informed Care And Service Delivery (Kezelman & Stavropulous 2012) have recently been developed by Adults Surviving Child Abuse (ASCA).

The guidelines emphasise a recovery orientation approach and identify the following five core principles of trauma-informed care. These principles pose key questions for organisations to consider and contextualise in specific service settings for implementing a service framework that is trauma informed (Kezelman & Stavropulous 2012:23-27) (note that 'consumer' in the following should be understood as 'client' for the purposes of this website):

  1. Safety. Ensuring physical and emotional safety.
    Key service questions: To what extent do the program's activities and settings ensure the physical and emotional safety of consumers? How can services be modified to ensure this safety more effectively and consistently?
  2. Trustworthiness.Maximising trustworthiness through task clarity, consistency, and interpersonal boundaries.
    Key service questions: To what extent do the program's activities and settings maximise trustworthiness by making tasks involved in service delivery clear, by ensuring consistency in practice, and by maintaining boundaries that are appropriate to the program? How can services be modified to ensure that tasks and boundaries are established and maintained clearly and appropriately? How can the program maximise honesty and transparency?
  3. Choice. Maximising consumer choice and control.
    Key service questions: To what extend do the program's activities and settings maximise consumer experiences of choice and control? How can services be modified to ensure that consumer experiences of choice and control are maximised?
  4. Collaboration. Maximising collaboration and sharing power.
    Key service questions: To what extent do the program's activities and settings maximise collaboration and sharing of power between staff and consumers? How can services be modified to ensure that collaboration and power-sharing are maximised?
  5. Empowerment. Prioritising empowerment and skill building.
    Key service questions: To what extent do the program's activities and settings prioritise consumer empowerment and skill building? How can services be modified to ensure that experiences of empowerment and the development or enhancement of consumer skills are maximised?

These guidelines also identify indicators for service policy review and screening for trauma to support organisational trauma informed care practice.

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Good Lives Model

The Good Lives Model is an approach to offender rehabilitation that focuses on the person's strengths. Programs based on the Good Lives Model are currently used in a range of correctional settings with offenders from a range of backgrounds. The model views offending behaviour as functional, as it is attempting to secure some kind of valued outcome in a person's life. To interrupt the pattern of reoffending, it is necessary to build a person's capabilities and strengths.

Working from the perspective of the Good Lives Model, the focus of treatment and care is for the worker and the client to work together to establish what a 'good life' might look like for the client. There's an emphasis on establishing respectful and non-judgmental relationships between clients and workers. Activities undertaken as part of a program should add to a person's repertoire of personal functioning, rather than being focused only on managing problems.

The good lives model determines ways of living that are beneficial and fulfilling to the individual in meeting their basic human needs … Importantly, the model emphasises autonomy and a therapeutic alliance to support offenders' conception of a good life. (Birgden & Grant 2010:345)

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Strength-based practice

Clients with complex needs face many challenges in their day-to-day lives and will have learned a range of ways to cope. Using strength-based practice to further support these clients can be of great benefit.

Strength-based practice recognises the resilience of individuals and focuses on their strengths and potential rather than their deficits. A strong emphasis on the relationship between the client and the worker and having genuine belief in the client is of key importance. Workers can then help the client to discover and use their strengths in pursuit of their goals, thereby building empowerment and self-determination (Manthey et al 2011).

The six key principles of the strength-based approach are (Saint-Jacques et al 2009):

  • Every individual, family, group and community has strengths, and the focus is on these strengths rather than pathology.
  • The community is a rich source of resources.
  • Interventions are based on client self-determination.
  • Collaboration is central, with the practitioner/client relationship primary and essential.
  • Outreach is a preferred mode of intervention.
  • All people have the inherent capacity to learn, grow and change.
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Person-centred planning

Person-centred planning is an approach that is philosophical as much as practical. The emphasis is on the idea of including the person in all decision-making and planning for them. It's far too easy for any of us to slip into practices that don't support self-determination, particularly when working with clients with complex needs. This is because some people:

  • Face difficulties articulating clearly what they want and need
  • Find it harder to engage in a process if there's no attempt to seek out their strengths and adapt to their needs
  • Are reliant on others who are significantly challenged in responding to their needs, and within resource limitations.

For person-centred planning to be useful and effective, it needs to make sense to the person and be driven by them as much as possible. By using the key element of inclusion for all client decision-making and planning, you use a person-centred approach and support the client with developing self-determination. To remain genuine in person-centred practice requires the worker to always reflect on their practice.

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Positive behaviour support

Positive behaviour support encompasses strategies and methods that aim to help a person reduce challenging behaviours and increase their quality of life through acquiring new skills. It asserts that challenging behaviours serve a purpose and are influenced by a person's social and physical environment. Therefore, in implementing positive behaviour support strategies, a person's wider support network and environment needs to be considered.

Models of positive behaviour support often include:

  • Undertaking a comprehensive bio-psychosocial assessment to determine the function of the challenging behaviour
  • Using the least restrictive alternative to manage challenging behaviour
  • Using positive reinforcement and contingency management to reward and reinforce positive behaviours rather than punishment or negative reinforcement to manage challenging behaviours.

Positive behaviour support strategies are considered effective when interventions result in increases in a person's success and personal satisfaction (Synapse 2011c).

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Which theory is the 'right one'?

Just as there is no one generic presentation of a person with complex needs, there is no one theoretical model or set of principles to follow to inform your individual practice or service response to complex needs. However, what does become apparent when reviewing these approaches are the common themes of client self-determination, working from a strengths-based perspective, and the importance of engagement and rapport. The principles of holistic practice reoccur throughout the theories and practice strategies in working with people with complex needs. Many of these are explored further on this website.

Some of the theoretical and practical approaches outlined above are familiar to, and already applied in, some drug and alcohol treatment service settings. By including and adapting these approaches in your work with people with complex needs, you will be supporting your clients to achieve the best possible individual treatment outcome and promote access and equity within your service for all people needing drug and alcohol treatment.

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