Vital connections

Most drug-related deaths are of people not in treatment. DDN visits Equinox outreach team in Brighton to hear how they engage with a growing population of rough sleepers.

Rough sleeping figures continue to rise. In the government’s latest report, local authority counts showed 4,134 people out on the streets in England on a snapshot night in autumn last year – up 16 per cent on the previous year’s count. Brighton is near the top of the league table with one in 69 people homeless, and the challenge is clear for the city’s outreach team.

Outreach worker Scott (left) with Dolores from Equinox head office and Jesse, manager of the Brighton team.

Among the members of Pavilions, Brighton’s partnership of treatment services led by Cranstoun, Equinox are hard at work at the community base in Queens Road, a few roads up from Brighton’s seafront. There’s plenty going on as usual, and people buzzing in and out offices shared with many other agencies, from housing support to mental health.

While explaining what they do, they break off to deal with an urgent suicide threat nearby. One of the regular clients is threatening to kill himself, having been caught shoplifting again. Anti-social behaviour caseworker Kristina has rushed up there to help out, knowing that he will have been shoplifting to feed a drinking habit of 40-50 units a day. It’s a situation he’s been trying to escape, but he has a girlfriend who drinks and he’s finding it hard to change.

For this man, as with many other Equinox clients, there are no quick fixes. The team members know they are in it for the long haul, explains manager Jesse Wilde. The working model is ‘assertive outreach with recovery at its heart’. In practice this means going back again and again, taking the knockbacks and offering a friendly chat until one day it’s welcomed.

Visiting nurse Mike confers with ASB caseworker Kristina.

‘These are people who will never make that call for help,’ he says. ‘Their life is often a web of chaos, often involving begging and jail. One day something will change – maybe they’ll have had a bereavement – and they’ll want to talk.’ The assertive outreach is the only way, as ‘signposting isn’t going to work’.

The key workers are obviously vital to what happens next, and Wilde explains that their training equips them to build rapport. ‘Some people are avoidant, wary of intimacy or any interaction, even being told “well done”,’ he explains. ‘So we’d keep it very business-like in this case, and chat on the way to appoint­ments.’ In the textbook it’s called ‘attachment theory’; he calls it ‘keyworking by stealth’.

Outreach worker Scott Crossley is well versed in these techniques. He acknowledges that many clients can be ‘chaotic, disruptive and challenging’, but he rises to the challenge of gaining their trust, trying to look at the root of their behaviour, and working out how to offer support.

‘It takes time to establish trust and a rapport,’ he says, and the first stage is demonstrating reliability. They might have complex trauma and personality disorders, and a history of people saying they’re going to do something but not turning up. We’re always going to turn up.’ After a while you see people soften and reciprocate.

It can be a long road, and at the start ‘the worker can be running around a lot, almost like a PA’. But then you need to find a way of ‘handing responsibility back, giving that power back’, so they are not dependent on the worker and can take charge of their own life. The results can be life-changing: ‘We’ve had people who screamed and shouted, and they’re now in their own accommodation, completely different people… but that takes time.’

The scope to work in this way comes from being part of Pavilions, Brighton’s network of support. The important parts of Crossley’s work takes place away from mainstream hubs, ‘taking recovery to people who can’t do mainstream’.

‘You’ve got one person but lots of strands, almost like a spider web, for housing, mental health, whatever they need,’ he says. Through multi-agency working, they can get a support package together, including OST at the right titration.

‘We can get them so we’re holding them,’ says Crossley. ‘We’ve got a platform and can then do the good work of preparing them for a stint in rehab. If you put someone with so much trauma without preparation work into detox, all the years that drugs have suppressed – this filing cabinet of feelings – opens up and these feelings go everywhere.’

The involvement of mental health teams makes a vital difference, he believes. ‘Before, we would do all the work to prepare them and leave them at the rehab door. We can now go on working with them and liaise. The drop out rates are down – it’s been amazing.’ Another success is that the team all carry naloxone in their bags, and consider that this should be mandatory everywhere.

The success of partnership working has energised the team’s proactive approach to trying different initiatives, and Wilde describes how ‘Sensible on Strength’, seen to be working well in Norwich, has been adopted by Brighton and is highly successful in tackling anti-social behaviour and improving public health. Around 200 alcohol retailers have agreed to take high-strength alcohol off their shelves, through working with the local authority and local residents.

‘It’s now rare to see a can of Tennents Super,’ adds Crossley. ‘I never in my wildest dreams thought it would be this successful.’ He recalls how an incident black spot near to an off-licence – a place where an inebriated girl once got run over by a bus – has been transformed. Following pressure from residents the licence was revoked until opening hours were changed and the shop agreed not to sell super-strength alcohol. A local doctor has called the project ‘the single most important health initiative in recent years’.

Such initiatives contribute significantly to the health of homeless clients and are also helpful in improving relations with the local community. Each month progress is discussed at a ‘high impact case forum’, involving police, the substance misuse teams and other community partners, covering the most offensive forms of anti-social behaviour, from urinating on the street to aggressive begging. Ideas and action points from the group feed back out to the day to day work with many community partners, including the church, city college and local residents.

Equinox are in multi-agency office in Brighton, where they can connect with other vital services.

‘There’s an entrepreneurial element to being a frontline worker,’ suggests Wilde. Increasing complexity among clients, mental health services that are stretched to the limit, and the fact that substance misuse and mental health funding still exist separately – not to mention a massive 25 per cent cut of PHE funding to the outreach team – mean that staff are faced with more challenges than ever.

‘One of the things we try to instil in the team is that you need to be assertive and have confidence,’ he says. ‘When you lose posts and money, you have to work more closely together.’

The outreach team also benefits hugely from having members who are themselves in recovery. ‘It’s made them a lot more “no nonsense” about the work,’ he says. ‘They know what a blag is.’

The team also has little time for strategies that sit on the page and make little sense in the hand-to-mouth environment of the street. Crossley dismisses ‘off the shelf’ recovery and talks about harm reduction side by side – part of the ‘whole person’ vision.

‘I hate that word “motivation”,’ says Crossley, referring to target-speak for a moment. ‘Our guys have a different motivation – not to get sick; to get money to get drugs. These guys aren’t going to sit in groups. They have a £200 a day habit and they need to beg. For these people you have to throw “motivation” out the window. If you ask them “do you want to be injecting in the neck?” they’d say no. They have no choice.’