Homelessness and substance abuse in edinburgh

Bethany Christian Trust is a faith-based administration, founded in 1983, working ab initio amongst homeless people in Edinburgh. Though its work was focussed on homelessness, there was acknowledgment that a considerable proportion of stateless clients came with important dependence issues as good. This nexus is born out by the DORIS survey ( 2002 ) , which indicated that 31 % of persons questioned described themselves as being homeless, and many more reported an unsettled lodging state of affairs. ( McKeganey et al, 2002 ) Recent statistics from the Bethany Supported Housing undertaking in Dumfries show that 68 % of appliers have an dependence. ( Appendix 1 ) Of Scots rural councils, Dumfries and Galloway has one of the highest prevalence rates of drug abuse at 1.6 % of the population aged 15-54. ( Hay and Gannon, 2001, p14-15 )

The Supported Housing undertaking in Dumfries commenced in April 2002 when the administration was invited by Dumfries and Galloway Council to develop the service as portion of the local response to national developments in Housing Support, funded through transitional lodging benefit. Whilst the undertaking is non alone, it is unusual in supplying equipped occupancies to persons conditional on them holding to have support ( Supported Housing – Dumfries ( SHD ) , July 2004, Tenancy Agreement ) as opposed to the “ floating support ” offered by the bulk of suppliers. This offers a stable occupancy, where as landlords and support suppliers we are committed to assisting people with a history of helter-skelter life maintain their occupancies.

We operate harmonizing to Supporting Peoples guidelines ( Scots Executive Development Department ( SEDD ) , 2001 ) , which provides clear parametric quantities and definitions for the types of support that can be funded. ( SEDD 2001, p7-14 ) In position of this we do non supply an dependence service, but a lodging support service which is willing to prosecute with some of the most ambitious and helter-skelter clients, with a peculiar committedness to homeless people seeking to turn to their dependences. Behind the Supporting People doctrine is the Regulation of Care ( Scotland ) Act 2001, which in Section 2, 28 ( degree Celsius ) , recognises as vulnerable “ people being, or holding been, dependent on intoxicant or drugs ” .

In this study I will depict the underpinning theoretical base of the administration, and the tools used to assess persons. I will so show how these link with the intercessions offered by the undertaking itself, and intercessions which clients might be encouraged to research through other local services. To exemplify these, mention will be made to organizational policies and processs, local and national authorities publications and academic plants.

The Theoretical Base

Each unit of the Trust portions a common ethos. Underpining the purposes to “ alleviate the agony and run into the long-run demands of homeless and vulnerable people ” is a committedness to a holistic attack, caring for the “ physical, emotional, societal and religious good being of each individual. ” ( SHD July 2004, Mission, vision and values ) The Addiction Team ‘s literature summarises the theoretical account adopted by the administration:

The dependence squad works from the theoretical point of view that all habit-forming behavior is diagnostic of underlying jobs in an person ‘s life aˆ¦ . caused by a figure of different biological, psychological and societal or environmental factors that vary from one individual to the following. ( Addiction Team, August 2004, Information Leaflet )

Underpining this attack to dependences are the rules of the Social acquisition Theory expounded by Heather and Robertson ( 2003 ) . Pulling from research such as Pavolv ‘s “ classical Conditioning ” , Thorndike ‘s “ Instrumental Learning ” and Bandura ‘s “ Modelling ” , they offer a theoretical account which states that “ people behave in the manner they do mostly because they learn to act in that manner. ” ( Heather and Robertson 2003, p128 )

This acknowledgment of the complexness of dependences has mostly, but non wholly replaced the earlier laterality of the Spiritual theoretical account, within the administration. Having an evangelical Christian footing to its work means that the religious component remains important but in the activities of every unit, attention is taken to guarantee persons ‘ rights to believe otherwise are respected. ( SHD July 2004, Information to assist you make up one’s mind )

Appraisal Tools

Two tools have become standard within the past two old ages. The HOMES matrix ( appendix 2 ) is a tool developed for usage within the stateless field, and bears some similarity to comprehensive dependence appraisal tools, such as the Christo Inventory for Substance-misuse Services ( CISS ) . ( Christo, 1998 ) Similarities include its broad spectrum of lifestyle issues ; the simpleness with which hiting can be done and compared over a period of clip and the fact that the client need non be present for completion. Normally the HOMES is completed monthly and is a utile tool for supervising advancement and measuring the effectivity of the service.

The 2nd appraisal has been developed from the Addiction Severity Index ( ASI ) , a specialist appraisal tool. ( Treatment Research Institute, 1990 ) The Complex Needs Assessment Severity Index ( CNASI ) includes all of the elements of the ASI, with an extra subdivision on lodging history. ( SHD July 2004, CNASI Assessment Tool ) Whilst the client evaluation graduated table is retained, the assessor ‘s graduated table has been omitted ; with the HOMES giving chance for the interviewer ‘s appraisal to be recorded.

The combination of these tools agreements good with the background of the administration ( covering with homelessness ) and its theoretical base ( that dependence is rooted in a complex combination of factors. ) In turn toing homelessness and its broad effects on a individual ‘s life, there is a focal point on the cardinal country of dependence which a important proportion of our clients present with. In this attack there is concern for measuring both the job and the individual.

Heather ( 1995 ) uses the Institute of Medicine ‘s recommendation that appraisal be divided into two cardinal countries, “ job appraisal ” ( covering degrees of ingestion, forms of imbibing and measuring of the grade of dependance ) and “ personal appraisal ” ( sing wellness, relationships, and societal stableness. ) This information plays a important function in specifying the signifier that intervention will take. For illustration mental wellness issues may find intervention precedences or if a client is stateless, so residential intervention may be advantageous. ( Heather 1995 p24-29 )

The Effective Interventions Unit ( EIU ) states that appraisal should include a assortment of attacks. Evaluation Guide 7 provinces, “ these tools may non be sufficient on their ain to guarantee that person-centred appraisal is achieved. ” ( EIU February 2002 ) It is our purpose to be client centred in appraisal, and subsequent support planning. However we have to be cognizant of the failings of appraisal. The CNASI ‘s client evaluation graduated table is unfastened to bias in client ego coverage ( for illustration a client may offer responses that they hope might increase their opportunities of being offered a occupancy. ) Similarly the HOMES is unfastened to bias on the portion of the assessor. To maximize the quality of the information gathered, developing in interviewing is portion of initiation and on-going staff development and the overall appraisal of appliers besides includes documentation in the signifier of mentions from other bureaus as suggested by the EIU, ( September 2002, p 81 ) and by Heather who states that the solution to imperfect informations beginnings “ is to utilize as many beginnings of information as possible. ” ( Heather 1995, p32 )

Harmonizing to the EIU ( April 2003, p1 ) “ The intent of appraisal is to place the demands and aspirations of the person in order to inform determinations about intervention, ” this brings us to the chief focal point of this study, which is to show how the theoretical base and appraisal procedures relate to our intercessions.


A important job identified by EIU focal point groups, is that “ participants in the appraisal procedure aˆ¦ experience a deficiency of ownership, and a deficiency of engagement in the concluding determinations aˆ¦ about their intervention, attention and support. ” ( EIU September 2002 p77 ) We are committed to affecting clients in developing and reexamining their support programs, through utilizing the CNASI client evaluation graduated table and the assessment feedback signifier ( SHD July 2004, Assessment Feedback ) which is completed with the client, and signed by the client and the worker.

Appraisal is viewed as portion of intercession. At this phase the footing of the relationship between client and worker is established. Meier and Donmall ( 2004 ) outline the significance of this relationship:

It can be taken for granted that a successful resonance between client and counselor is desirable, possibly even indispensable, for people to go occupied and remain the class of intervention. Developing a working relationship with substance users may be particularly ambitious aˆ¦aˆ¦ staff are prone to feelings of failure and exhaustion because they are often confronted with clients who frequently have terrible jobs in many countries of their lives. ( Meier Donmall 2004, p16 )

Though based on a survey of residential intervention scenes, the rules equate with the doctrine of the undertaking, viz. that we seek to handle clients with empathy and understanding, to be unfastened and straightforward and good informed about substance abuse. ( Meier and Donmall 2004, p16-17 )

Project MATCH concluded that “ no healer features or properties systematically related to patient result ” ( project MATCH research Group 1998, cited in Carroll, 2001, p204 ) , nevertheless, Carroll ( 2001 ) counters that Project MATCH ‘s degree of choice, preparation, consistence of manual usage and close supervising would intend that variableness is minimised. ( Carroll 2001, p204 ) Whilst non claiming the degrees of experience and expertness of Project MATCH healers, rules such as committedness to preparation, consistent attachment to project policies and regular supervising of staff aid to guarantee that the service offered is of every bit high a criterion as possible.

We approach intercession with the position that alteration is both necessary and accomplishable, nevertheless it is best achieved if the complexness of an person ‘s demands is recognised, and alteration is approached in manageable stairss. Though we are optimistic that alteration is possible, we are realistic in recognizing that it is neither inevitable nor additive. Clients will come on, but at times besides regress. The Transtheoretical Model of Change ( DiClemente and Prochaska, 1998 ) provides a model about which we develop our intercession, with our practical application of the theoretical account pulling from intercessions tools including motivational interviewing and backsliding bar. These attacks are non employed as portion of any formal dependence work, but form a important portion of the “ General Counselling and Support ” which help us accomplish our overruling purpose of “ seeing homelessness reduced ” . ( SHD July 2004, Project Information )

The Transtheoretical Model ( TTM ) was ab initio developed by DiClemente and Prochaska in 1983, and has later undergone assorted polishs. It is defined by three concepts. Five “ phases of alteration ” lineation specific stairss necessary to achieving alterations in behavior. In precontemplation, persons are incognizant of the extent of their jobs or are unwilling to alter. Contemplation involves serious decision-making, weighing the pros and cons of the job and the alteration required. Preparation centres on declaration and committedness to implement alteration. In the action phase, programs are implemented, get bying abilities are developed and behaviour is changed. Care is reached after three to six months of action, where new behavior becomes an built-in portion of the person ‘s life style. ( DiClemente and Prochaska, 1998 p4 )

The 2nd concept describes ten “ procedures of alteration ” , the drivers of alteration through the assorted phases. Based on psychotherapeutics theory, they are “ consciousness elevation, self re-evaluation, environmental re-evaluation, dramatic alleviation, societal release, self-liberation, counterconditioning, stimulus control, reinforcement direction and assisting relationship ” . ( DiClemente and Prochaska, 1998 p4 )

The 3rd concept, “ degrees of alteration ” , recognises the complexnesss of an person ‘s life, and how different jobs can interact and perplex the procedure of alteration. ( DiClemente and Prochaska, 1998 p4-5 )

Whilst influential as a theoretical account, it has non been without its critics. Robin Davidson offers a figure of unfavorable judgments, including foremost that “ phase theoretical accounts aˆ¦ . are an unreal cleavage of a of course happening continuum. ” ( Davidson 1998, p26 ) He contends that phases can overlap, and that enforcing clip bounds on phases is arbitrary. ( Davidson 2002, p9 ) He besides inquiries the “ prognostic cogency ” of phase theoretical accounts. Pulling on research by Farkas et al associating to tobacco users, he argues that the phase an person was at was a less utile forecaster than for illustration how addicted a individual was to get down with. ( Davidson 2002, p10 )

In malice of the argument, there remain certain attractive forces of the theoretical account for our work. ( a ) It is utile in its potency for application to the broad scope of jobs our clients present with. ( B ) It is loosely compatible with the Christian ethos of the administration. ( degree Celsius ) The 3rd concept “ degrees of alteration ” encourages us to try to unknot jobs with clients and to interrupt alteration into manageable countries, ( and realistic ends ) without losing our vision of the larger context of their general life state of affairss.

This is evidenced in our usage of the CNASI, where both the overall tonss and the single tonss have relevancy and significance in prioritizing support issues with clients ( SHD July 2004, Assessment Feedback )

DiClemente and Prochaska highlight the demand for pattern to travel from being “ passive-reactive ” to being proactive. ( DiClemente and Prochaska 1998, p12 ) The work of the undertaking draws on rules from two cardinal signifiers of intercession in trying to accomplish this.

1. Motivational Interviewing, developed by Miller and Rollick ( 2002 ) is utilized throughout the support relationship. At one degree, an applier may be contemplating a alteration in his/her lodging state of affairs, but this does non needfully connote that they wish to contemplate alteration with respect to their dependence, or any other job. We can presume some preparedness to alter, but at this early phase there is a focal point on promoting motion from pre-contemplation to contemplation, recognizing that ambivalency may be apparent. ( Rollnick and Allison, 2004, p108 ) Self-efficacy, belief within the client that alteration is possible and underdeveloped disagreement, where persons are encouraged to speak positively about the hereafter, are besides apparent in the attack we seek to take. Motivation remains important in the on-going spiral of alteration, and provenders into support planning and end scene. Evidence of the grade of motive is monitored by such things as maintaining assignments and finishing agreed undertakings and ends, and discussed during regular contact and three monthly reappraisals.

2. Relapse Prevention outlined by Dimeff and Marlatt ( 1995 ) , is non a characteristic of DiClemente and Prochaska ‘s revised theoretical account, but remains a characteristic of our daily work ( though we would non see it as a necessary or inevitable phase of alteration ) . Saunders and Houghton ( 1996 ) conclude that backsliding is non an “ addiction-specific event ” but better understood as a generic human behavior. ( Saunders and Houghton 1996, p843 ) This generic application makes it utile for the wide work of the undertaking. With respect to dependence, clients frequently province that their end is to be abstentious ( we have no difficult statistical grounds to verify this, but it is consistent with the findings of the DORIS survey, that 86 % wanted to accomplish abstention ( McKeganey et al 2002 ) ) , nevertheless, the world is that this end needs to be dissected into accomplishable stairss. Time is taken to measure bad state of affairss and triggers, and develop schemes for get bying with these. Dimeff and Marlatt believe that the Biopsychosocial theoretical account allows backsliding to be viewed in a non-judgemental manner as a error or mistake ( Dimeff and Marlatt 1995, p178 ) . This is helpful in keeping self-efficacy, and we would trust that this is reflected in our pattern, where we offer a safe and constructive environment in which persons can turn to their life jobs.

Beyond the basic intercession of our undertaking, we actively promote clients with dependences to associate in with local dependences bureaus. Interventions include ordering services, community or hospital-based detox, needle exchange and guidance and advice services. ( Substance Misuse Strategy Group ( SMSG ) ) Pulling from local Child Protection policies, the SMSG, has a committedness to:

develop interagency understandings and protocols aˆ¦ . for more effectual and efficient operational and service planning intents ;

develop an interagency preparation scheme which provides an across the board basic cognition and skill base. ( SMSG, p9 )

Co-operation and sharing of information is important across the bureaus, and the undertaking is committed to this, explicating this to clients at the beginning and guaranting that sharing of information is agreed. ( SHD July 2004, Sharing of Information ) This is consistent with the EIU ‘s counsel, which emphasises the demand for “ careful co-ordination ” of services. ( EIU September 2002, p123 ) Underpining this is the demand for trust ( EIU September 2002, p125 ) , and our undertaking can possibly be best viewed as offering a function akin to that of Advocacy where we seek to protect the involvements of vulnerable people, and empower those people in showing their demands and positions. ( EIU September 2002, p128 ) To guarantee that we are carry throughing this function, monitoring of our work is indispensable.

Monitoring & A ; Evaluation

Monitoring has taken topographic point in two distinguishable countries. First we have conducted an economic appraisal ( EIU November 2001, Evaluation Guide 6 ) , puting input and end product costs against the benefits of results ( such as stableness of occupancies, length of stay, cut downing drug usage ) . These costs are on a regular basis monitored through monthly balance sheets, and are used to supply grounds of value for money. Second there is statistical monitoring, which is required for Supporting People intents, but besides allows us to place tendencies and jobs. An illustration of its usefulness came in placing jobs with lodging ex-offenders ; straight from prison, where occupancies frequently broke down rapidly, and intercession was limited. In treatment with prison based bureaus and stateless individuals officers our admittance and assessment procedure was modified and harmonizing to recent statistics is taking to more settled occupancies. ( Appendix 3 ) A farther signifier of monitoring utilises the HOMES matrix, leting us to supervise a client ‘s advancement from the initial baseline of first appraisal through to the point of going. Our monitoring feeds into the rating of our activities to measure “ whether the stated purposes and aims aˆ¦ have been met. ” ( EIU June 2001, Evaluation Guide 1 )


This study has aimed to supply grounds of coherency in the work done by the undertaking, with the purposes and theoretical base happening look in the appraisal and intercession offered. Theoretically we recognise the complex beds of jobs people present with, our assessment procedure utilises tools designed to place these demands, and promote clients to show their positions and research possible solutions. We hope from this to develop client centred intercessions which are realistic and optimistic, though besides able to cover with set dorsums which will happen.

However, this survey has besides highlighted certain failings in our attack.

First, within the undertaking we could profit from farther development of our intercession theoretical account. A similar grade of staff preparation to that given to assessment would heighten staff apprehension of the rules, assisting us to stand back from the twenty-four hours to twenty-four hours engagement with clients, and visualize the broader image of how the phases of alteration interlink and how important the beds of complex demands are. Besides utile would be a stronger appreciation of the procedures of alteration, which drive alteration through its different phases. Development of accomplishments in motivational interviewing and a more thorough appreciation of backsliding would heighten our apprehension of clients.

Second, out with the undertaking there is room for farther integrating between services. We are really cognizant that we bridge spreads between lodging, societal services, wellness and dependence services, which frequently our clients fall into. Locally, the links that do be frequently to make so because of the doggedness and enterprise of workers on the land, or clients themselves. There would be existent benefit if the integrating which there is a declared committedness to could develop at a more strategic and cross-organisational degree.

Presently the undertaking is in the procedure of seeking inclusion on the ADAT ‘s sanctioned supplier ‘s list, this will let us to entree support for a dedicated dependence worker within the undertaking, leting us to travel beyond the limitations of Supporting People, and offer a more focused service to clients as we seek to turn to the interconnected issues of homelessness and dependence.


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Appendix 1

Bethany Christian Trust – Supported Housing, Dumfries

Secondary Problems Indicated By Applicants

April 2002 – March 2004

Alcohol Misuse


Piquing Behaviour


Mental Health Issues


Drug Misuse


Learning Troubles


None Indicated


Entire Applications



The premise ( for Supporting People intents ) is made that the primary ground people present

themselves is their homelessness.

The above information is extracted from routinely gathered statistics, and is presented merely as a rough

index of the proportion of appliers who have an dependence.

Appendix 2

Homeless Outcomes Matrix Evaluation System ( H.O.M.E.S. )

5 = In Crisis 4 = At Risk 3 = Stable 2 = Safe 1 = Thriving

Worker _____________________________________

Client _______________________________________


Initial Assessment













Food and Clothing

Physical Health

Emotional Health

Sexual Health

Substance Misuse



Personal Safety / Risk

Social Interactions /


Support Relationships

Esteem / Education /



Complete the first HOMES at Initial Assessment ( BH ) and Full Assessment ( other Care Services )


Level a†’

Areas a†“

Crisis 5

At Risk 4

Stable 3

Safe / Self 2Sufficient

Booming 1

Shelter / Accommodation

Sleeping out-of-doorss

Using church shelters, c/o friends, prison, seeking crisis referrals

Short term inn, temp accom ‘ , new or at hazard occupancy

Planned supported accom ‘ ,

Long term occupancy with or without support

Food & A ; Clothing

Has no ownerships / dressing etc, utilizing soup new wave, free nutrient

Use of free & A ; low cost nutrient topographic points, few ownerships, usage of Cowgate clinic for vesture

Has own vesture and seeking aid with other referrals and purchases ( sox, efi, housewife )

Accessing all aid to derive ain trappingss, appropriate usage of grants, some cookery accomplishments

Has ain ownerships, good furnished house, white goods etc, has cookery installations and accomplishments

Physical Health

Major wellness issues / disablements / impairment / no medical contact

Use of A & A ; E, homeless pattern in times of crisis

Regular usage of homeless pattern, receives medicine / intervention as required

Receives specialist medical aid, regular prescription, community GP as required

Keeping intervention, ain GP service, usage of mainstream services ( tooth doctor, etc )

Emotional Health

Serious mental wellness issues ( psychosis, suicidal, etc ) , no medical intervention / contact

Use of A & A ; E, repetition admittance to psychiatric attention, appears hard-pressed

Regular usage of homeless pattern and CPNs, has insight into troubles

Receiving specialist mental wellness support, has CPN contact as approp ‘ , non hard-pressed

Keeping M.H. interventions as approp ‘ , positive sense of mental well-being



Multiple sexual spouses, involved in harlotry, high hazard of gestation and/or STD

Hazardous sexual behavior, hazard of gestation and/or STD

Taking stairss to cut down hazard of gestation / STD

Practicing safe sex with consciousness of hazard, healthy gestation

No sexual wellness issues



Addiction out of control ( overdose etc ) day-to-day drug or intoxicant usage

Asking for aid, crisis intercession, utilizing needle exchange

Use of Harm Reduction Team, HOP, TAP or BCT dependence squads

Using CDPS, keeping regular book, successfully detoxed

Reducing book, keeping abstention, no drug / intoxicant abuse

Personal Safety / Risk

High hazard behavior, overdoses, self injury, exclusions, hazard of physical assault, hazard of freeze,

Crisis intercessions, inquiring for aid, verbal menace of force or menaces of ego injury, excluded from bureaus

Use of support bureaus, decrease in hazard behavior and crisis presentations, pull offing ain hazard, non excluded

Specialist support to turn to anger direction, self injury, etc

Awareness of personal safety issues, few hazards taken


No benefits or known income

Benefit, interruptions in claim, non budgeting, imploring, many debts, income from offense / pros ‘ ,

Regular benefits, beggary, some budgeting but asks for loans, money does n’t stopping points, lives twenty-four hours to twenty-four hours

No benefit jobs, approp ‘ usage of money e.g. com attention grant, short term be aftering e.g. buys power card

No beggary, steady income, good budgeting, money stopping points between payments, long term planning


Offending, warrants, periods in prison, does non go to tribunal

Named attorney, consciousness of piquing but no sense of duty

Use of beds, prison outreach, turn toing piquing and outstanding issues

Planned contact with probation, community service, paying mulcts etc

No offending or legal issues

Battle with Support Agencies

No contact or avoids contact with bureaus, whereabouts unknown

Acknowledges workers, sporadic contact merely during crisis, usage / maltreatment of services but non taking existent support

Sporadic contact, asks for / utilizations referrals, inconsistent usage, knows figure of bureaus, can call workers

Identifies with worker by name, phones etc, regular contact, cardinal worker battle, good usage of bureaus

Regular support at ordered clip if needed, uses support suitably

Social Interactions / Relationships

No societal contact or in opprobrious relationship

Small societal contact or inappropriate friendly relationship groups, jobs with relationships

Some steady relationships, day-to-day contact with friend or support bureau

Budgeting for recreational activity, be aftering societal life with friends,

External support, good usage of recreational groups, healthy approp ‘ relationships

Self Esteem / Education / Employment Goals

Very low ego regard, few movable accomplishments, helter-skelter life manner, populating twenty-four hours to twenty-four hours

Low ego regard, isolation and long periods of unsettled life manner, no hereafter programs

Learning new accomplishments, doing positive picks, and looking at options for the hereafter

Researching future programs, prosecuting with short term enterprises, can see advancement, has ain involvements

Good ego regard and assurance, independent, positive about employ ‘ / vol ‘ / preparation / instruction

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