In this first lecture, we explore the term 'multiple and complex needs', considered in relation to current health and social care services design and practice; and how trauma, poverty and inequality are key factors in the development and maintenance of complex presentations.

What are multiple and complex needs?

Around 60,000 people in England experience multiple and complex needs, normally defined as exhibiting at least two of the following: homelessness, current/historical offending, problematic substance or alcohol misuse, and mental health problems.

Marginalisation, poverty, racism and violence are correlated with poor mental health (Paradies, 2006) and physical health (Marmot, 2016, Health Gap). Further research from Aldridge and colleagues (2018) found that socially excluded populations have a mortality rate that is nearly 8 times higher than the average for men, and nearly 12 times higher for women.

Within their 2015 report Hard Edges, Lankelly Chase developed the term Severe and Multiple Disadvantage to capture the overlap between people experiencing homelessness, substance misuse and offender services and to recognise the social nature of disadvantage.

The link between trauma and complex presentations

Research shows that people who are referred to as having multiple and complex needs are very likely to have experienced trauma during their early life and at multiple points over their lifetime. An overwhelming percentage of people without stable housing have been exposed to additional forms of trauma, including neglect, psychological abuse, physical abuse and sexual abuse during childhood and throughout their lives (Hopper, et al 2009). The Lankelly Chase Foundation (2015) found that 85% of those in touch with criminal justice, substance misuse and homelessness services have experienced trauma as children.

There is a strong link between childhood trauma and adult mental distress. A major study of Adverse Childhood Experiences (known as the ACE study) found that the more adverse life events people experience prior to the age of 18, the greater the impact on health and well-being over the lifespan, including poor mental health, severe physical health problems, sexual and reproductive health issues, engaging in health-risk activities and premature death.

The experience of trauma during early life, and then potentially throughout life, has an impact on a child’s developing brain, the resources they have available to manage distressing emotions and the way they can seek safety and comfort within relationships at times of stress. These impacts, and the ways that people respond, will be further explored in the next video.