Rebecca: A collaborative, multi-agency approach

This case study highlights the collaborative efforts between Upside and other local services to provide practical and emotional support to a young female. Rebecca was released from HMP & YOI following a short-term custodial sentence. She was supported by her Upside worker on the day of her release to walk the journey returning into the community with her, and to tackle any barriers met on the way together.

Needs and Initial Challenges

Upon liberation, Rebecca faced multiple immediate challenges, including presenting as homeless. Being a young female and experiencing struggles with addictions and mental health, she was understandably anxious about where she may be housed. Her preference was for a temporary furnished flat or permanent housing. However, the outcome wasn’t what she had hoped and she was given accommodation in an area she had hoped not to go to. Rebecca and her worker combed through her anxieties together, and came up with ways she could herself safe, and can make her environment more homely. Her Upside worker provided emotional support and referred back to Rebecca’s pre-release plan they had discussed together back when she was in custody. This noted those areas she wished to prioritise on her liberation day. Rebecca was able to contact her bank and benefits line, and with help, was able to set these up so her payments were unsanctioned and she was supported financially. Rebecca was thankful for the support and had claimed to her Upside worker that if she was not supported that day, she’d have probably gone to the local shop and bought alcohol in the hope of returning to prison that night; rather than face the challenges of reintergrating into the community alone.

 The final hurdle of the day was her addictions appointment. Rebecca had stated she was “too overwhelmed” to attend. Although Rebecca was provided with mental health and addiction medication from the  prison to manage in the short term, she felt overwhelmed by the number of appointments scheduled for the day of her release. In response, she asked that her addiction service appointment be rescheduled to the following day.

Recognising the supported person’s emotional state and her existing support needs, her Upside worker contacted the addictions team and requested a new appointment. This was arranged for the following day. Her Upside worker committed to accompanying her to the rearranged session to ensure continuity of care and to reduce anxiety related to attending alone. Rebecca and Upside agreed to meet the following day outside the addictions centre at the agreed time.

Breakdown in Engagement and Immediate Response

Despite these efforts, Rebecca did not attend the rescheduled addiction appointment, and told her Upside worker on the phone she was too tired and overwhelmed to attend. Rather than allow this missed appointment to become a barrier to further engagement, her Upside worker went along anyway and used the appointment space to introduce herself in person to Rebecca’s addiction worker, strengthen the connection, and discuss an action plan going forward how to work collaboratively to meet Rebecca’s needs. They discussed the case in depth and decided to take a person-centered approach based on compassion and understanding of Rebecca’s current mental and emotional state.

Joint Outreach Effort

Acknowledging the difficult transition from custody and the anxiety she was experiencing, Rebecca’s Upside and addictions workers decided to take proactive outreach measures. Instead of waiting for her to re-engage with services, the services collaboratively went together to the temporary accommodation where Rebecca had been housed. This face-to-face visit allowed us to assess her wellbeing directly and demonstrate a united, supportive front.

Outcome and Reflection

This collaborative intervention helped to re-establish contact with Rebecca in a non-threatening, supportive manner. It also allowed both services to reaffirm their commitment to her wellbeing and encourage her continued engagement with support services, at a pace appropriate for her.

The visit reinforced the importance of collaboration, communication, and compassion in post-custody support work. Through our joint approach, we were able to prioritise Rebecca’s health and emotional needs without penalising her for missing an appointment—recognising that recovery and reintegration are not linear processes.

Conclusion

This case highlights the importance of multi-agency collaboration in supporting individuals transitioning from custody back into the community. Through our shared efforts, the throughcare support service and addiction teams ensured Rebecca did not fall through the cracks at a critical time in her reintegration journey.

This approach reflects the core values of the Upside Voluntary Throughcare Support service: person-centred care, flexibility, and partnership working. By responding with empathy and initiative, we were able to meet the person supported where she was—both physically and emotionally—and provide the tailored support necessary to help her move forward.