Author: Andre Coleman

Discuss why it is important to support people to have a voice and express their views with confidence. How could care workers facilitate this?

This essay shows why it is important to support people to have a voice and express their views with confidence. In this assignment I will use the case of Suzanne, a social worker who supports Jordan, aged 10 who lives in a foster care home (K101 DVD, The Open University, 2010), to talk about his past and to help Jordan to develop a sense of who he is, his identity and how this can help in developing his feelings of confidence and security. I will also use the cases of Mick and Owen (K101 DVD, The Open University, 2010), who were infected with HIV and will expand my answer with an overview of group support. I will also explain how care workers can facilitate this and the importance of care workers to do this.

By expressing our views we are exposing ourselves to others. Our views are a mirror of our knowledge, feelings, thoughts, past or present experiences and everything else from what we are made deep inside, exposing our identity, revealing our individuality. McAdams et al states that “We are all storytellers, and we are the stories we tell” (cited by Bornat and Northedge, 2010, p.32). It is also very important that we do voice our views with confidence, some can do this independently, but some others need help.

Children, who grow up in the families they are born into, usually have opportunities to find out about their parents and members of their wider family, the places in which they have lived and the reasons for any changes they have experienced. However, children who experience separation from their birth families often face obstacles when it comes to finding out about their birth families and early background. There may be gaps and painful areas in accounts of their identity, and they may have to work out ways of dealing with difficult memories and emotions (Bornat and Northedge, 2010, p.19).

The case of Jordan is an example of a child who is not living with his birth parents and needs help to recover his past. Suzanne is using the “life story work” to facilitate this. Life story work is a method of working with people who for some reason are vulnerable, or who may be going through difficult or challenging life transitions (Bornat and Northedge, 2010, p.19). Life story work gives children a structured and understandable way of talking about themselves (Ryan and Walker, 2010, p.34). With her work, Suzanne is helping Jordan, to know better and talk about his past, with factual information from his files, family and carers, correcting wrong perceptions such as why he was moved from his first foster placement and the negative impression about his birth father.

Reminiscing about the past is important even from early childhood. Mothers and primary carers deliberately set out to share memories and experiences, thereby helping children to build their own sense of who they are. By the time young people reach adolescence they begin to take control of the stories they tell about themselves. As they emerge from family life and make the first moves towards independent adulthood, they assemble a relatively coherent life story, made up of episodes selected for their significance in helping to define their identity (Bornat and Northedge, 2010, p.32).

Suzanne also fully involved Jordan to build his life story book, using pictures, drawings and colours and effectively giving Jordan a voice and a way to express his views. Suzanne’s work is helping Jordan to establish his past, to get to know himself better, and to shape his identity with pride, confidence and security, forming an important foundation that Jordan will take into his future.

Some of our experiences might have an adverse impact on our lives that affects our own identity. Some of us might find difficulty to discuss openly their identity, and need external help to build enough confidence to do so. This was similar to the cases of Mick and Owen who are haemophiliacs, and became HIV positive after receiving infected blood transfusions. Mick and Owen, who were interview by Sian Edwards, a specialised nurse, both narrate how their lives were conditioned by the stigma that their illness carried, mainly because of poor public awareness of their condition. Both Mick and Owen found it easier to hide this part of their identity and reveal it only to a restricted circle of people. Mick and Owen both explain how they were denied opportunities to speak out about their condition as Owen says “Because no-one really wanted to understand about my condition”. Sian Edwards work with Mick and Owen was not only important because it gave Mick and Owen a voice to express their views on their condition, and an opportunity to discuss their true identity, but also because their experience is very useful to educate us. Greenhalgh and Hurwitz suggest that hearing how patients telling the story of their condition can provide ‘meaning, context and perspective for the patient’s predicament … a possibility of developing an understanding that cannot be arrived at by any other means’ (cited by Bornat and Northedge, 2010, p.37). Mick and Owen had to fight with poor awareness and false perceptions that conditioned most of their lives. The more the public is aware about illnesses and their weight on people who suffer from such illnesses, the more patients finds it easier to open up, and discuss their views with more confidence without fear of being misjudged. The DVD activity itself started with a brief overview of Haemophilia and HIV, which improved my understanding of Mick and Owen’s condition, and the way I followed their case with empathy afterwards.

Is not easy for care workers to support people to have a voice and express their views with confidence. In some cases even care workers need assistance from external sources too. A successful method is to involve a number of people who share similar experiences to discuss their feelings together in a group sessions. Professor Doel maintains that “In one-to-one work, the focus is almost entirely on what is wrong. In groups, members are often seen in a new light, with people’s strengths likely to emerge” (cited by Bornat and Barnes, 2010, p.64).

People who have experienced traumatic and difficult events may find it difficult to talk about their experience. Care workers have to be very careful as people, who have experienced traumatic events in their lives, remembering the past may be very difficult and painful, and may evoke emotions that are difficult to deal with. A research by two psychologists found that ex-servicemen gained a great deal from membership of veteran associations which provided practical support as well as a safe context in which to remember dead comrades and talk about their own experiences with others who had had similar experiences (Hunt and Robbins, cited by Bornat and Northedge, 2010, p.44 – 45).

Despite the problems that people with difficult memories face, opportunities to talk and to share feelings can be helpful. Talking in groups can help people to regain trust and feelings of shared understanding. Difficult memories become a part of identity. What seems to be important for people with disturbing memories is to be listened to and for their stories and accounts to be recognised and accepted by others (Bornat and Northedge, 2010, p.47).

In conclusion, in having voice and expressing our views with confidence, our identity plays the most important part. So far I always taken for granted that everyone had their own identity, but today I learnt that some people may be insecure of their identity because they were never told who they are, others may hide their identity as they fear of being wrongly labelled and a traumatic experience can threaten or undermine people’s ability to sustain or communicate their identity. People who have poor sense of identity may feel, unsecure or uncomfortable among others and may isolate themselves in deep silence. It’s important to people to seek support, as help is available. As I pointed out above, different strategies were used by different professionals to assist people to have a voice and express their views with confidence, from individualised care to group support.

Finally I believe that many of us experience episodes when our voice isn’t heard or we couldn’t express our views with confidence. We all feel the frustration and the weakness that this inability brings with, like when we pass through a moment of uncertainty, and we would appreciate even if one good listener helps in.

(Word Count 1,412)

References

Bornat, J. and Northedge, A. (2010) ‘Unit 5: Identities and lives’, K101 ‘Block 2: Working with life experience’, Milton Keynes, The Open University

Bornat, J. and Barnes, F. (2010) ‘Unit 6: Group lives’, K101 ‘Block 2: Working with life experience’, Milton Keynes, The Open University

Ryan, T. and Walker, R. (2010) ‘6: Why do life story work?’, K101 Resources, Milton Keynes, The Open University

McAdams, D.P., Josselson, R. and Lieblich, A. (2006) ‘Introduction’ in McAdams,

D.P.,Josselson, R.and Lieblich, A. (eds) Identity and Story: Creating Self in Narrative,

Washington, DC, American Psychological Association, p. 3.

Greenhalgh, T. and Hurwitz, B. (1999) ‘Why study narrative?’, British Medical Journal, 318, p. 48–50.

Doel,M.(2006) ‘All in the same boat’, Community Care,20–26 July, p. 34–5.

Hunt, N. and Robbins, I. (2001) ‘World War II veterans, social support and veterans’ associations’, Aging and Mental Health, vol.5, no. 2, p. 175–82.

TMA 03 – Part B

Care Skills: Barriers to Communication – Based on Andrew & Rodger’s case.

PHYSICAL

Andrew opts to communicate a private message to Rodger in a public place, where other people could overhear the discussion in full. This has bar Andrew from delivering sensitive information with a more sympathetic approach.

Disability and impairment

Roger is hard of hearing; he also seems to not recall his memories well.

EMOTIONS AND FEELINGS

Rodger indicates that he is an uneasy position and far from comfortable to have this conversation with Andrew. Rodger expresses these feelings by withdrawing and rejecting Andrew’s attempts to talk.

(Word Count 86)

TMA 03 – Part C

Self-Reflective Notes

Even in this occasion, I struggled to compile the essay using material from block 2, and keeping relevant to the question asked. The main difficulty was to adapt material that covered identity, past experiences, etc. and use it to answer a question about supporting people to have a voice and express their views with confidence. Found it a bit tricky.

(Word Count 60)

Page 1

Supporting Individuals Experiencing Loss and Grief.

Loss can be defined as “a condition of being bereaved or deprived of someone or something”. Loss takes many forms, from the bereavement of a loved one to the loss of a door key. Loss can give rise to feelings ranging from deep mental anguish to feelings of annoyance. Grief or deep mental anguish rises from a great significant loss, a loss where an emotional attachment has been formed. Sorrow, deep sadness, regret, misery, unhappiness are words that are often used to describe grief. Deep mental anguish can lead to severe depression or simple annoyance can lead to frustration. These feelings need to be recognised, understood and if necessary treated.

A significant loss that causes grief may differ from person to person and so a situation that maybe painful to one person may not necessarily affect another in the same way. Those losses causing grief however, are more likely to have a major impact on the life of the person suffering anguish.

Death of a loved one is the most common cause of grief. Loss of a partner through divorce or breakdown, loss of a parent by the same means, loss of a relation through breakdown of the family or a family member moving a great distance may also cause grief. The person lost, may have been a major force in the life of the griever. Someone, who provided, love, friendship, influence, protection, assistance, fiscal security are now gone. Feelings of helplessness, insecurity, shock, and coping uncertainties may take hold without that person around, The loss of a pet may also cause grief. A pet that has become a member of a family and is loved as such, dies, one member of the family maybe extremely upset at this loss while another member knowing the pet was an animal and not a human being, they accept the situation. Death is not the only loss to cause grief, the loss of a limb will have a major impact on the person concerned. Feelings of fear, denial, vulnerability, anger, may affect the amputee. In the stages of life, when death is totally unexpected, grief can be more extreme. Extreme grief can also take hold if the loss is of something that is extremely important to that person, for example, redundancy, victim of crime, injury, compulsory relocation.

A persons mental state before or at the time of a painful loss may also contribute to their ability to cope with the sudden situation and how this new situation will affect them. So, grief maybe more pronounced in someone already depressed as opposed to someone who is mentally strong and able to deal with a situation thrust upon them. Emotional and traumatic responses are therefore relative and not absolute.

The loss of a close loved one, partner or parent may cause that person to display their feelings of great sadness by crying, but this crying may also be a display of other feelings that maybe affecting them at the same time. Behavioural, physical and emotional reactions are common place that can leave the bereaved confused, numb, lonely, helpless, and worried. As well as crying, other physical reactions could be nausea, insomnia, anxiety. While the common reactions to loss are denial, depression, guilt, anger, bargaining, sadness and acceptance. These reactions have been used to describe models of grief that take place in a certain distinct manner.

The most well known model was described by Elizabeth Kubler-Ross (1926 – 2004) in her book `On Death and Dying` published in 1969. She wrote this book after interviewing the terminally ill over a four year period in Chicago. She advocated that as a period of adjustment, those experiencing loss went through five stages of grief. This became known as the “stages model”. She believed that those terminally ill patients moved from one stage to the fifth stage in chronological order.

Denial, Anger, Bargaining, Depression, Acceptance, with hope being felt at all stages.

1. Denial and Isolation can be defined as the refusal to acknowledge that something exists or to face facts.

It can be a passing surprise reaction to bad news. Isolation occurs when friends and family avoid the terminally ill patient, they don’t know what to do or say to the ill person.

2. Anger is a feeling of great resentment, rage, annoyance, or displeasure. “Why me?” maybe the thoughts of those who are ill. They may also resent others for being well. Anger can be felt towards those around them, e.g. Doctors or nurses.

3. Bargaining is stated as a brief stage and for those who are terminally ill it tends to be between the patient and God. For those people who are going through a less traumatic situation, they may bargain with their friends and family or employer.

4. Depression can be described as a state of sadness, hopelessness, dejection, which can be either reactive or preparatory, reacting to a past loss or future known losses.

5. Acceptance can take time and differ from each individual situation and tends to be empty of emotions.

This Kubler-Ross model has been important to those working with the bereaved and has been applied in many situations. Other authors have felt that these stages are too strict and that perhaps not everyone goes through all the stages. This said Kubler-Ross brought the subject of dying and grief from behind closed doors and into the world to be discussed, and cared about.

The William Worden model however, took us from the “stages model” to a hypothesis that a definite list of “tasks” must be concluded in order to resolve the issue of grief. In his book of 1991 “Grief Counselling and Grief Therapy” he compares mourning to the “healing process” making the bereaved active in their grief.

1. Accept the reality of the loss.

Acceptance can take time, but the motion of arranging a funeral allows movement towards acceptance. The news of death may bring shock, disbelief and denial to the bereaved but is slowly replaced by the acknowledgement that the deceased has gone forever.

2. Work through the pain of grief.

Acknowledgement of the reactions or pain of grief is important. It is not wise to ignore these feelings as they will not go away, but to be stored away in the mind to appear later. It is essential to deal with the emotions for the well being of the bereaved.

3. Adjusting to an environment in which the deceased is missing.

This means that the bereaved must adjust to their total surroundings, be it spiritual, psychological or physical. The deceased person may have played a role that filled all these needs for the bereaved. Death confronts the bereaved to adjust to a new environment without the deceased, and to find new roles for themselves.

4. To emotionally relocate the deceased and move on in life.

This is the need to “move on” to find new outlets for your emotional wellbeing. This may involve perhaps finding new hobbies, job, relationships and to search for new experiences. There is a need to still have a connection with the deceased but now at a different level. It is important to realise that the deceased is not coming back and to use memories and associated thoughts to evolve this new form of the relationship. Task 4 may take a year or more for some people to complete.

There are many agencies available to those suffering grief, offering advice and support via a telephone line and online. The Child Bereavement Trust offers leaflets and advice for parents who lose children and for children who lose parents and for those children and parents who need support through terminal illness. Age Concern has a wide range of information for those who are dealing with death, giving sensible and to the point help on what to do when someone dies. They also provide assistance on how to put your affairs in order. Cruse – Bereavement Care Scotland supply bereavement support through internet advice, a national helpline and one to one counselling.

A change in routine such as friends relocating away from one another can cause emotional pain if not dealt with correctly. I had to deal with such a situation. Mr D and his friend had daily contact by meeting at the local cafe to have tea and a chat. I had to discuss with my client Mr. D why his friend had to move and that I explained that the move was necessary and for the benefit of his friend.

We had to examine the situation Mr D found himself in without his friend and try to improve it. We discussed the fact that his friend had moved away and that daily contact was not possible anymore but perhaps weekly or monthly contact was still possible. We discussed the possibility of arranging outings to meet one another and to find new social activities to meet new friends. With the agreement of his friend, we looked at technology to improve the circumstances. E-mail accounts to be set up with web cams to keep in touch with his friend. Telephone numbers to be exchanged to allow telephone contact and addresses to be exchanged to allow written correspondence and visits for lunch to be organised. After examining all these choices of contact Mr.D felt much happier knowing that contact with his friend could still take place.

In the event of a death there are certain legal and other procedures that should be followed. These measures differ slightly depending on whether the death takes place at home or in a hospital setting.

If death takes place at home the GP, nearest relative and if the death was unexpected, accidental or suspicious then the police must be called, nothing should be touched if the police are to be involved. If in hospital the body should be identified. Confirmation of next of kin, beneficiary should be identified before personal possessions are released. If an organ is to be donated then death at home tends to make this difficult, the doctor needs to be called immediately and if death takes place during the night then getting a GP in a hurry may not be possible. If in hospital staff tends to discuss with the deceased relatives the possibility of organ donation.

A medical certificate will be issued by the GP or Hospital Registrar if the cause of death is known; this will be required by the Registrar of Births, Deaths and Marriages. A second doctors` signature will be required for a cremation certificate if the deceased is to be cremated. The Registrar will require the medical certificate and also a list of other personal information. If the death is suspicious then the procurator fiscal will become involved, usually via the GP, hospital doctor, Registrar or police. Although anyone may contact the Fiscal if suspicions are aroused. The procurator fiscal may request a post mortem if a doctor cannot issue a death certificate. The next of kin do not need to give consent, if religious, cultural or other objections are to be made, the Procurator fiscal should be informed immediately. A post mortem maybe unavoidable for legal reasons.

A minister of religion is to be contacted if a religious service is required. The undertaker is to be contacted and if a will is available then it should be found and acted upon as directed therein.

Over the years dealing with death has changed. Historically, 80 years ago before the use of professional funeral directors was common place, people lived at close quarters with one another in large families in close communities. Death tended to take place at home as hospital care was not always available and a public health service did not exist. The lack of these services, poor working condition and high incidence of disease meant that death was seen often within local communities, perhaps even a daily experience. The men ordered the coffin and arranged the funeral service but it was the women who attended to the body and had the body “laid out” most often in an open coffin, in the one room of the house usually dressing the body in their “Sunday best”. Normal day to day to activities still took place around the body, with curtains drawn, there would be visits from friends and family, prayers said, they would pay their last respects and reminisce about the deceased. Black, the colour of mourning would be worn. The tea and alcohol would be flowing as a way of consoling the family. As money was tight local communities would collect door to door to help pay for the funeral and the wake. As most people worked and lived in smaller communities, church and graveyard amenities tended to be nearby and so a walking funeral procession took place, usually within three days after the death, few women attended. At the burial those women who attended the service often went home to help prepare food and drink for those who attended the funeral while the men went to the graveside to bury the coffin.

Today, however, the experience of death is not so common. Deaths most commonly take place in hospital and so the use of a funeral director is now tradition, even if death takes place at home. The funeral director takes over the whole process of the funeral by arranging the body, arranging the funeral service and even attending to finding the burial plot or arranging cremation. Contact with the deceased on a physical level e.g. viewing, and dressing the body by family has declined.

As death is a natural process in life, all cultures and religions have developed their own practices of dealing with death. It is important to try to understand the needs of families belonging to both religious and non religious groups and how they deal with the aftermath of the death of a loved one.

Depending on where people live some religious faiths have larger congregations than others. There are many faiths in the UK some with their own splinter faiths, e.g. There maybe as many as 220 different Christian denominations.

Christianity, Islam, Judaism, Hinduism, Mormons are some of the common religions.

Christians tend to have church service and in some cases the deceased has to be a regular attendant at the church. This usually takes place around three days after death. Dark clothes tend to be worn, at the service. Hymns are sung, readings from the bible are heard, eulogies from friends and family about the deceased are given and prayers over the coffin are given by the priest or minister. If a burial takes place, prayers are said at the graveside as the coffin is lowered into the grave and soil maybe thrown onto the coffin. If it is a cremation prayers are said or hymns sung while the coffin departs from the congregations` sight. Food and drink is laid on afterwards for those who attended the service.

Moslems however, tend to bury the deceased 24hrs after death. According to the sex of the deceased, family members ritually wash the body. The body is then laid out after being respectfully wrapped in white cloth. Collective prayers are given and

the body is then buried with the head turned right facing the Holy city of Mecca. It is forbidden to cremate the body. After burial a collective prayer is said with the throwing of soil onto the body in the grave. The style of the grave varies from place to place. An official mourning period of three days with a special meal takes place, this maybe longer for a spouse.

The Baha`i faith is one of the worlds youngest faiths taking its present form in Iran from the Shi`ite Moslem faith in 1844. There is no clergy in the Baha`i faith and so it is the responsibility of the family to arrange and conduct the service with the help of the Baha`i community. The funeral laws of Baha`i are that the body should not be embalmed unless required by law. Cremation is not allowed. The body should be washed respectfully and covered in a white cloth, a Baha`i burial ring is placed on the finger and the body put in a fine hardwood coffin and buried with the feet pointing to the Holy Land. The remains must be buried within one hour’s travel of the place of death. Every service is unique but the only obligation of the family is that the specific “Prayer of the Dead” be recited either at the chapel or graveside.

For the non- religious person a burial tends to be a legal process with funeral procedures taking place by the family as a means of sharing grief and support for those closest to the deceased. This type of funeral tends to come under the heading of a Humanist service. These services tend to be personal and unique to the family of the deceased. The service may sometimes take the form of the family head holding proceedings perhaps in woodland which can also be common for those who follow the New Age movement, or the funeral directors chapel of rest, or a crematorium. Eulogies are read, music is played, memories are shared, and candles are lit, moments of silence followed and final farewells said. The New Age followers tend to pick and choose their beliefs and practices and have no formal holy texts or dogma. Their funeral service may follow that of a humanist funeral but with added prayers, poetry and music that the deceased had used throughout life. They may include eco friendly burials using “Green Burials” with cardboard or basket weave coffin which are bio- degradable with the planting of a tree marking the spot of the grave.

Death can affect many people who have known the deceased and it is important to acknowledge the emotional impact on those affected and to offer support, even sometimes to advise the use of professional agencies.

Works cited
SQA Open Learning pack- Understanding loss and Grief.
David Straker. (). The Kubler-Ross Grief Cycle. Available: http://changingminds.org/disciplines/change_management/kubler_ross/kubler_ross.htm. Last accessed 02/10/09.
Alan Chapman. (2006). Elizabeth Kubler Ross five stages of grief. Available: http://www.businessballs.com/elisabeth_kubler_ross_five_stages_of_grief.htm. Last accessed 02/10/09.
(2002). Tasks of Grief. Available: ubhc.umdnj.edu/brti/FreeholdStudentsVehicularDeaths.doc. Last accessed 02/10/09.
http://www.childbereavement.org.uk. Last accessed 02/10/09.. .. (2009). factsheets. Available:
http://www.ageconcernandhelptheagedscotland.org.uk/helping_you/factsheetsLast accessed 04/10/09.
.. (2009). cruse bereavement care Scotland. Available: http://www.crusescotland.org.uk/. Last accessed 04/10/09.
.. (2009). Grief. Available: http://www.defence.gov.au/result.htm?cx=015740015074813761736%3Abn9d9fdbxdi&cof=FORID%3A11&q=grief#1242. Last accessed 04/10/09.
Jacques Duff. (2005). Grief and the grieving process. Available http://www.adhd.com.au/grief.htm. Last accessed 04/10/09
(2009). religious traditions and belief. Available: http://www.ifishoulddie.co.uk/religious-traditions-and-beliefs-c37.html. Last accessed 04/10/09.
(2009). woodland burials. Available: http://www.ifishoulddie.co.uk/greenwoodlandalternativediy-funeral-c46.html. Last accessed 04/10/09
(2009). non religious funerals. Available: http://www.ifishoulddie.co.uk/non-religious-alternatives-c38.html. Last accessed 04/10/09.
(1993). Baha’i funerals. Available: http://www.sji.ca/bahai/funeral.html. Last accessed 05/10/09.
(2009). Religions. Available: http://www.bbc.co.uk/religion. Last accessed 02/10/09.

The Imbecile Passengers’ Act 1882, have discouraged disabled people from settling in New Zealand. They had required a bond from the person liable for a ship that disembark any person ‘lunatic, idiotic, deaf, dumb and blind who might become a charge on public or charitable institutions. In 1899, The Immigration Restriction Act was made and included in its list of restricted immigrants any idiot or insane individual and those agonizing from contagious/ infectious diseases. The purpose of such policies and strategies was to discourage disabled people immigrating to New Zealand. The government believed that they will become burden to the country and they would not want to waste government funds on them. They saw people with disabilities as a liability and can no way contribute for the betterment of the country.

Funding:

Support for a person with disability usually came from their own families. Any financial support that they received were from charitable organisations.

Attitudes/Stereotypes:

Disabled persons were regarded as useless that is why the government has established and implemented laws and policies to stop them from coming to the country. People with disability were perceived as a burden or an outcast.

Terminology/Barriers:

People in this era called disabled people dumb, lunatic, idiot, deaf and blind. They were often regarded as crazy. Labelling them as dumb means that they lack intelligence or they are stupid. The language that they used created barrier for the person with disability to even develop relationship with other people. Knowing that they were crazy or stupid the society has avoided and treated them as if they have no feelings.

1900
Strategies and Policies:

The Mental Defectives Act 1911 had made a distinction among individuals of unsound mind, mentally infirm, idiots, imbeciles, the feeble minded and epileptics.In 1916, the New Zealand Census identified people who were deaf and dumb, blind, lunatics, idiots, epileptics, paralysed, crippled and/or deformed. Devices and special apparatus were put in place to identify defective children. Standardized care was emphasized especially for mentally incapable person. Children with ‘special needs’ were not allowed to go to school and they were put away in institutions.Some of the positive actions that came out during this period was the Plunket organisation. This organisation was focused on providing care and assistance to children with disabilities and their mother as well. After the world war, majority of the soldiers returning home were suffering from mental illness and physical impairments. The public challenged the government to provide services for the returning soldiers such as psychiatric treatment, physiotherapy and plastic surgery. During this era, the rehabilitation of the mentally and physically impaired into nation was given importance. The Disabled Servicemen’s League further developed the medical rehabilitation for ex-servicemen. In 1954, services offered by the organization became open to the public.

Funding:

In 1950s and 1960s,the orientation towards large institutions for disabled people began to be challenged during the. IHC has set up day care centres, occupational groups and residential care homes. At the same time it followed a more rights-based way in seeking suitable learning facilities for their children. The government’s access to services for disabled people became more community and rights based during 1970’s. After the 1972 Royal Commission into Psychopaedic Hospitals, the authority funds were increasingly focused into building small residential care facilities rather than large institutions.

Attitudes/Stereotypes:

The 19th century saw greater separation of disabled people. The workforce had to be more physically consistent to perform everyday factory operations. Disabled individuals were cast off. They were pictured as ‘worthy poor’, in contrary to work-shy ‘unworthy poor’, and was given Poor Law Relief (money from public funds. They became more dependent on the medical calling for benefits, treatments and cures. Special schools and day-centres were set up separately which denied disabled and non-disabled people the day-to-day experience of living and growing up together.

Terminology/Barrier:

Disabled people were called cripple, epileptics, feeble minded, paralysed and deformed. They were labelled according to their appearance or illness. This has led to harsh criticisms and they became the object of bullying. The barrier is that due to their physical deformities, they became different and made them stand out so right away people would notice them.

2000 onwards
Strategies and policies

In 2000/2001, the government developed the New Zealand Disability Strategy. With the implementation of the new strategy, care for the disabled people has changed dramatically. Before, medical model was used which focuses on the treatment and rehabilitation of the impairments. Nowadays, the Strategy was based on the social model of disability. The model suggests that disabilities occur due to society unable to accommodate the disabled people’s needs. The aim of New Zealand Disability Strategy is to ensure that the person with disability is able to live his life on his/her own term and that their rights are protected all the time.

Office for Disability Issues was set up in year 2002. Focusing on disability across government and to lead the implementation and monitoring of the New Zealand Disability Strategy was its main goal.In 2004, the New Zealand Sign Language Bill was made and introduced into Parliament. It proposed recognising New Zealand Sign Language as the third, official language in the country.

New Zealand has taken a leading role at the United Nations in the growth of the agreement making absolute rights of disabled people.

Funding

The Labour-Alliance Coalition Government initiated a health system reform. In 2001, 21 District Health Boards (DHBs) were formed. Primary Health Organisation (PHOs) we’re developed in 2002 to manage primary care, including general practitioners and their services. New Zealand Public Health and Disability Act 2000

Attitude/ stereotype

For most of the 20th century, disability was thought to be a problem inherent in individuals. This is commonly known as the ‘medical model’, where disability was seen as being something ‘wrong’ with a person, which could be ‘cured’ or at least contained.

Solutions to the ‘problem’ of disability took the form of government and wider society helping to fix or accommodate the problems of those afflicted individuals. This was often by segregating people with the problem and providing a service (such as an institution) to meet their ‘special’ needs. As a result, the ‘human’ needs of many individuals were unmet.

Terminology/ barriers

During this era, the public’s view on disabled people has changed. they have accepted these people on what they are now and has stopped criticizing by not calling them degrading names. Instead of calling them confined to wheelchair or wheelchair-bound, they have changed it to having an impairment with their mobility. This era has also considered disabled people in public areas. Nowadays, they are now prioritized as evidenced by accessible toilets, mobility parking and priority lanes.

Service provision and Access framework

There are a lot of support services available for people with disabilities which are funded by the Ministry of Health. Below are some of the services:

Behaviour Support Services are for people with intellectual disabilities who pose challenging behaviours which make it difficult for them to engage in social activities and develop relationship. Talk to the local needs assessment and service coordination (NASC) for a referral. The NASC will then assess your eligibility for the Ministry-funded Disability Support Services. If accepted, they will work out which service will best meet the needs of the person, their family/whanau and other networks.
Supported Living is a service that helps disabled people to live independently by providing support in those areas of their life where help is needed. This service is available to anyone aged 17 and older. He/she should also be assessed for credibility. With Supported Living, you’ll identify the areas where you need help. These are written in a personal plan.

Areas where support may be needed could include using community facilities, shopping, budgeting or cooking and help them in dealing with agencies such as WINZ or other bank.

A support worker will work with you, usually at your home, but support will be provided at times and places that are agreed. This support is provided by an organisation that is contracted to Disability Support Services at the Ministry of Health.

How do I access Supported Living?
Talk to a Needs Assessment and Service Coordination (NASC) organisation about getting Supported Living.

They’ll assess you to make sure you’re eligible and that supported living is the right service for you. The NASC will then provide information about the Supported Living providers in your area and you can choose who you would like to provide this service. You may wish to gather further information about the providers before making your choice.

Substance abuse is a serious problem. It can cause a lot of problems in people’s day to day functioning. Problems of substance abuse can be correlated to family problems, health problems, school problems and also occupational problems. Bigger problems lay within adolescents that have substance abuse problems. Substance abuse of adolescents between the ages of 12 to 17 has increased to 11.4%. This data was collected in 1997 from the Substance Abuse and Mental Health Service Administration. Their data also presented an increase from 2.2% to 3.8% between the ages of 12 to 13 years old (Substance Abuse and Mental Health Service Administration, 1999). Therefore it is to be said that substance abuse is becoming more relevant at younger ages as time progresses. According to the National Institution of Health, the abuse of Ecstasy has increased in 12th graders from 3.0% to 4.5% and has also increased in 10th grades from 2.4% to 3.5% between the years of 2005 to 2007. Hansen and Ponton indicated that adolescent risk behavior of the use of alcohol, tobacco, and other drugs will only get worse in the future. Adolescents that continue to abuse substances often experience a number of problems. Another substance that adolescents are increasingly abusing is alcohol in which 40.9% of 10th graders reported they had been drunk in the past year. According to the DSM-IV a substance abuse can be diagnosed if there is a continual pattern of substance use resulting in either failing to complete task such as school, work, or home, risking the harm of others by operating heavy machinery while under the influence. If the recurrent substance also creates legal problems by getting arrested or creates social or interpersonal problems within a 12 month period is to be considered a substance abuse. Because of these dangerous affects this paper will focus on the prevention of substance abuse rather than treating it.

Negative Consequences:

Adolescents are taking more risk than ever before. The consequences of these risks can encounter problems that affect their health, their lives, and their futures (Danish, 1997). Because of this early age of substance abuse more and more adolescents who are being treated are found to have more social and emotional problems (Fisher & Harrison, 2000). One major consequence of a substance abuse is that it can negatively affect user’s health. Adolescents that are abusing illicit drugs increase their risk of death by suicide, homicide, accidents and illness (McCaig, 1995). The results of the drug abuse warning network study revealed that drug related emergencies increased by 17 % (McCaig, 1995). Not only is the physical health perceived as a negative consequence but also the user’s mental health. Adolescent illegal drug use causes problems involving healthy psychological growth and functioning for a healthy lifestyle (Brook et al., 1998a).

Substance abusers frequently leads to depression, developmental lags, apathy, withdrawal and psychosocial dysfunctions (Bureau of Justice Statistics, 1992).Substance abusers can also develop a wide cluster of personality disorders. One personality disorder that is associated with adolescent substance abuse is conduct disorder (Stratton, 1998). Conduct disorder consist of behavior and emotional problems in adolescents. Adolescents with this disorder are viewed as bad or delinquents. They have a difficult time following the basic social and cultural norms and rules in which they behave in ways that are considered socially unacceptable. (Bureau of Justice Statistics, 1992)

Another consequence that is related to adolescent substance abuse has to do with the performance in academics. Hawkins, Catalano, and Miller (1998) cited research revealing that low levels of commitment to education and high truancy rates are related to an adolescent substance abuse. Truancies rates are also know as inexcusable absences. Low commitment to school and inexcusable absents set up bigger problems for education in the future. These bigger problems include users producing low standings compared to their class and even dropping out of school. The school consequences are very important to consider in the development of adolescents. Education is one aspect that dictates ones present and future quality of life. School dropout rates are highly correlated with adolescents that have substance abuse problems (Crowe, 1998). It is important to understand the different causes of the negative effects from a substance abuse. The more knowledge we know the better chance we have to prevent it.

Cause:

One cause that can make an adolescent vulnerable to start abusing substances at an early age could be due to social influences. Instead of only looking at the individual for explanations of the cause/origin of adolescent substance abuse it is also important to consider the social influences in which adolescents are surrounded by as an important causal contribution. Chau-Kiu Cheung and John Wing-Ling (2008) had conducted a study concerning the impact of social influences of adolescent substance abuse. Their study was directed to demonstrate how social influences, such as social encouragement and support are relevant to a cause of a substance abuse (Cheung and Ling, 2003). An adolescent is more likely or at greater risk of substance abuse when the adolescent is helpless due to “contextual unhappiness” (Patterson, 1999). From the results of Cheung and Ling’s study (2003), found a main interaction between social influences and “contextual unhappiness. When external social influences engage in an adolescent while they are unhappy, can create a vulnerability to abuse a substance (Cheung and Ling, 2003). Adolescents being stressed combined with an external social influence (encouragement & support) also creates a vulnerability to cause a substance abuse (Cheung and Ling, 2003). The overall findings from Chau-Kiu Cheung and John Wing-Ling’s study (2008) shows that external forces play an important role in an adolescent substance abuse. These external forces lay in lines of our environment (peers, family members, and others) and are a huge contributor to the cause of a substance abuse.

The findings from the previous study suggested that our environment is a causal factor to substance abuse. To better understand why our environment possess causality to substance abuse, we need to determine what aspects, domains, or settings put adolescents at risk for becoming substances abusers. Settings that include risk factor can include families, peer groups, schools, and your community. The more risk factors that adolescents are exposed to, the more likely the child will abuse a substances. (Hawkins and Spoth, 2001)

Risk factors that appear in a family setting converse around the parents. Furthermore the risk factors revolve around parental active roles of supervision and appear in family situation (Kumpfer, Olds, Zucker,1998). For example, if there is a lack of attachment or nurturing between the parent/caregiver while that adolescent is developing. A number of investigators have shown that a close and mutually warm bond between the parent and the child is associated with less adolescent abusing drugs (Brook et al., 1993;Schmidt et al., 1996). Also drug use by a parent or sibling has been found to cause a substance abuse (Conger and Rueter, 1996; Duncan et al., 1995; Kandel, 1990; Kazdin, 1987; Loeber and Dishion, 1983; Patterson et al., 1989). If a family member is or has abused a substance and if there is a poor relationship between the child and the parent will put adolescents at risk of a substance abuser (Brook et al., 1990, 1998b). Children that have used drugs were compared to kids that have not and were found to be three times more likely to have a family member who is or has abused a substance (Brooks, La Rosa,Whiteman, Johnson, Montoya, 2000).

In a study done by Brooks, La Rosa,Whieman, Johnson and Montoya (2000) did research examining family drug use, parent and child relationship, and environmental factors that contribute to a cause of a substance abuse. Strong parent and child relationships were found to decrease the chances of a substance abuse. In this study, parent-child relationship were described by support, identification, and non-conflict relationships. Results from the study (200) about parental identification suggest for a better internal representation of the father will decrease the chances of a substance abuse. This means not only the mother but the father has to spend more time with the child engaging in his or her life. This creates a close mutual relationship that will allow the child to admire his or her parental figure as a role model according to Brooks, La Rosa,Whieman, Johnson and Montoya (2002). Another aspect of the parent-child relationship was found to decreased a substance abuse was the amount of time the parent spends with his or her child. Furthermore by parents not having a close mutual relationship and not engaging with the child will create a risk factors for a substance abuse. Overall this research presented by Brooks, La Rosa,Whieman, Johnson and Montoya (2000) demonstrated that parental drug use and poor parent child relationships are key risk components to developing a substance abuse. (Brooks, La Rosa,Whieman, Johnson and Montoya, 2002)

Environmental causes outside of the family home setting can decrease the chances of a substance abuse (Brooks, La Rosa,Whieman, Johnson and Montoya, 2002). For instance, by having children attend to church regularly. Church can teach morals, values, and give guidance about life. Brooks, La Rosa,Whieman, Johnson and Montoya (2000) also hit on the importance of neighborhoods being a component of an environmental cause. Neighborhoods that are found to have violence, drug availability, low familism and non regular attendance to church will increase the chance of causality of a substance abuse.

Like I mentioned previously there is more than one domain or setting that can cause an adolescent being involved in substance abuse. Not only can the family play apart in the causality of developing a substance abuse but also schools. Instead of blaming the victim we can put blame on our school systems. For example, the classrooms adolescents are attending to might not be conducting good classroom behavior or good social skills. These skills play a big role in the developmental process of an adolescent. This leaves kids very vulnerable to external forces from the classroom. Not only can the classroom be the problem but the school itself. Schools offer a lot of social activity and interactions. While being at school adolescent are at risk of associate and becoming involved with adolescent that have a substance abuse problem. This also opens up new doors for the availability of getting a hold of drugs; quantity and variety. (NIDA, 2001)

Pervious intervention:

Although there are a variety of types of treatments that show positive effects for a substance abuse. I want to focus on preventing a substance abuse and not blame the victim. Some adolescent substance abuse programs have attempted school based approaches, community approaches, and family based approaches.

Pervious school based drug prevention programs have focused on protective factors of social influences on drug abuse. Some have been successful by delaying the use of tobacco, alcohol and illicit drugs for adolescents in middle school. Programs that have been targeted toward middle school have been found to miss the importance of the transition phase from middle school to high school. It is important to set prevention programs to gear in to adolescents that are making this transition phase. (Lynskeyet al., 2003)

Another problem with previous prevention programs (ALERT) found that their programs affect boys more that girls. The cause of this problem still remains unknown (Longshore, Ellickson, McCaffrey, Clair, 2007).

The Project ALERT program was focused on middle school students. This programmed aimed its principles to motivate youth against using drugs and develop skills for resistance behavior. Project ALERT used small group activities and used techniques to examine questions and answers. These are important components to an effective program (Tobler, 1992). Pervious trials of the ALERT program have produced positive results, but they found room for improvement. Their new program called “ALERT PLUS” is based off the same fundamental principles of their old program; however, they have made changes to address problems. The ALERT PLUS added changes to focus on developmental changes during the transition phase of middle school to high school. Developmental changes can affect opportunities and motivation to drug use (Longshore, Ellickson, McCaffrey, Clair, 2007). These developmental changes include friendship networks and dating opportunities. Overall, the new program goals were to strengthen norms against drug use, help students cope with drug situation, and learn ways to quit. Furthermore they wanted to have a better educational system for teaching students consequences of drug and cope with emotional stress. (Longshore, Ellickson, McCaffrey, Clair, 2007)

Pervious results from their old program were able to prevent and reduce marijuana and tobacco in 8th grade students. However the program was not able to help students how have already smoked cigarettes. Also the old program only affected alcohol use in the short-run and not long-run. Therefore the PLUS program strengthened their lessons to improve education on alcohol use and was designed to help those who have already smoked more than one cigarette. (Longshore, Ellickson, McCaffrey, Clair, 2007)

The results of the ALERT PLUS program showed significant improvements. Girls in the PLUS program reported lower rates of weekly alcohol use. Girls in the plus program were compared to girls in the original program showing a reduction of alcohol by 32%. Reductions were also found in marijuana use by 49%. Another important finding that contributed to the new program was the scores of alcohol consequences and high risk alcohol use all showing improvements. (Longshore, Ellickson, McCaffrey, Clair, 2007).

Other programs mostly rely on school teachers and police officers to educate the youth during school time. In my opinion they never left enough time that adolescents need to be well educated/rounded on substance abuse.

This next prevention program created by Abbey, Pilgrim, Hendrickson, Buresh, (2002) set its principles on family based substance abuse prevention. This program offers skills that are directed toward parents. These skills are designed to increase family communication and bonding. Skills in this direction will decrease the chances of an adolescent substance abuse. The “families in Action” (FIA), includes techniques for a stronger parent-child communication, positive behavior management, ways of interacting among the family, factors for school achievements, and education on substance abuse. These were designed to create a better overall relationship. (Abbey, Pilgrim, Hendrickson, Buresh, 2002)

The FIA programs goal was to increase resiliency and protective factors within the family. The program was aimed toward children who are entering middle school. This prevention took place between 1994 to1995. It involved 37 children and 38 parents. The program involved once a week sessions for six consecutive weeks. The session went no longer than 2.5hrs. (Abbey, Pilgrim, Hendrickson, Buresh, 2002)

Families were measured on three different accounts for pre and post data. They were measured on family cohesion, family communication, and family fights. Cohesion was measured by the family environment scale on a nine point rating. Family communication was also measured on a nine point scale by participants indications the number of times they had different behavioral patterns. (Abbey, Pilgrim, Hendrickson, Buresh, 2002)

There were no significant finding presented between children in the FIA program when compared to a baseline group. However, the parents produced an important finding when compared to the comparison group. Parents in the FIA program had lower scores on attitudes toward tobacco, an appropriate age to drink at, and family cohesion. (Abbey, Pilgrim, Hendrickson, Buresh, 2002)

Program Description:

Because substance abuse is becoming active at earlier and earlier ages as the time goes on, it is important to start prevention early in a child’s life. What is needed is more consistent and long term adolescent substance abuse prevention that stays associated and involved with children during their courses of development. The program needs to be consistent by reaching out to where adolescent spend most of their time. This adolescent substance abuse program includes educations and developmental skills across the family and school settings.

Because substance abuse can affect ones academics, physical and mental health and ones future, it is important to start prevention as early as 8 years old. For prevention to start this early prevention needs to be focused on families and more so on parents. One leading cause to a substance abuse is having a family history or a parent who was chemically dependent. Family members who were chemically dependent put their child to be genetically vulnerable to a substance abuse (Kumpfer, 1999). The first step of prevention is to get the parents to be well rounded and educated on drugs and substance abuse. Parents need to become aware of the origins of substance abuse. Meaning they need to know the causes and effects of a substance abuse. A great way for parents to become educated is to take part in neighborhood leader groups. Leader groups offer a great opportunity for getting and giving input and output. This also leads to another important prevention aspect in the family setting. Getting involved and paying attention to the child is important. Parents need to become very active when it comes to supervising. Staying involved with your child will heighten protective factors to outweigh the risk factors. Parental involvement is a crucial ingredient to preventing a substances abuse. Involvement doesn’t just mean being around the kid when he/she is at home. Parents need to reach out past the home setting. A great skill for prevention is to get involved with your children’s interest. This can include friends, activities and their fantasies like a hero/role model. This is why it is important to take part in neighborhood leader groups. It gives the chance to know your child’s friends and their families. Becoming aware of who their friends are, where they come from, and getting to know the parents makes for a very strong and effective way for staying involved and having a tight relationship. Getting to know your child’s interest can really make a positive impact on the child and is a great skill for prevention. For example, take your child’s favorite superhero/role model and exemplify a new anti drug message once a week that has consequence toward that hero or role model. Parents being educated, staying involved with the child’s interest and having good supervising skills offers a big part in keeping this prevention program consistent and long-term.

Because it is important to keep the program consistent and long term in the development of the child, education and skills need to be implemented at school settings. At this point schools offer more risk factors than protective factors for substance abuse. Because of this window of risk factors and because schools take part in a big section of development of children; prevention needs to be enforced. Most school systems do not seem to be aware of the severity of negative effects of a substance abuse. This is apparent because of how high dropout rates are correlated to substance abuse in which rates are only going up. Instead of school systems only setting aside 15-20 minutes for drug awareness assemblies, school need to set aside more time for children just as their parents. In doing so the school systems have to change their academic system. They need to implement a full education class three days a week. Instead of the children just sitting in the class room and listening to the teacher, the class is going to involve a lot of participation. This participation will not only involve inside the classroom but will also take part as an extracurricular active outside of the school. By giving children extra actives to do outside and inside of school, will lessen the chance of them becoming involved with children that already have a substance abuse problem and take away from the availability of drugs. Inside the classroom teachers will be instructed to keep kids well rounded on types of drugs, health effects, academic affect, behavior affects and what a substance abuse can lead you to, like in the juvenile system. Activities inside the class room will be meant for participation toward learning coping skills, emotional control skills and social skills. Because this program is constructed to be long term and consistent, inside school classes and the extracurricular activities need to be practiced and implemented into school academic circular systems and not just as a brief assembly or an announcement.

The extracurricular actives outside of school are going to involve children reaching out into their communities beyond the school and family settings. This component to the program will stay active throughout the whole year and the summer so transition phases are not in effect. These activities will involve children from schools giving educational seminars in public place around their community. They will take what they have learned from inside the classroom and propose anti drug messages consistently across their community. Seminars will include places such as libraries, parks, beaches, neighborhoods, churches and shopping centers. Unlike other program this program needs to stay consistent and long-term through the stage of development. That is why this program is implemented into the family, school and beyond.

In summary, this educational and skills substance abuse prevention program will strengthen the protective factors and weaken the risk factors of a substance abuse. For this program to be affective it has to take place in our families and school staying consistent and long term. All the aspects of family and school settings combine to create a chance of involvement of socializing creating strong relationship in a positive manner for being substance free. By having the protective factors outweigh the risk factors we can stop this continual pattern of adolescent substance abuse.

Dual diagnosis between drug abuse and mental illness is very common. The two problems affect and interact with each other. The number of people diagnosed with a mental illness and substance went from 210,000 to 800,000 between the years of 1998-2003. (Druss MD, Bornemann, Fry-Johnson MD, McCombs PhD, Politzer, & Rust MD, 2006) Substance abuse is the most common and clinically important dual disorder among adults with severe mental illness. Studies show that fifty percent of people with mental illness also have a substance abuse problem. (Saisan, Smith, & Segal, 2010) And more than half the persons with a substance abuse diagnosis also have a diagnosable mental illness. (Saisan, Smith, & Segal, 2010)

Clinicians believe that mental illness and substance abuse are biologically and physiologically based. “Although substance abuse and mental health disorders like depression and anxiety are closely linked, one does not directly cause the other.” (Saisan, Smith, & Segal, 2010) Both conditions can mirror each.

PROBLEM STATEMENT:

More and more people are suffering from a combination of substance abuse and mental health problems. Alcohol and/or drugs are often used to relieve the symptoms of a mental illness, side effects from their medications or just to cure symptoms they are having at the time. Alcohol and drug abuse can increase original risk for mental disorders and can make symptoms of a mental health problem worse. Substance abuse and mental illness commonly co-occur due to genetic factors, environmental factors, a brain disorder and/or a development disorders. “Co-occurring disorders, two disorders or illnesses occur simultaneously in the same person, they are called dual diagnosis or co morbidity.” (Topics in Brief, 2007) Treatment for this dual diagnosis has not been well designed. Clients have to go a treatment facility for mental health treatment and a different facility for substance abuse treatment. This kind of treat is not successful because this leaves the client trying to cope/manger a disorder on their own. It is almost impossible for them to manger the other disorder because if they could quit on their own they would not need treatment.

It can be hard to diagnose a person with a dual diagnosis of mental illness and substance abuse. One of the things that makes diagnose hard is denial by the patient. “Substance abuse and mental disorders commonly co-occur because of overlapping genetic vulnerabilities, overlapping environmental triggers like stress, involvement of similar brain regions, and drug abuse and mental illness are developmental disorders.” (Topics in Brief, 2007) Having a dual diagnosis put a person at greater risk for relapse. Violence and suicide attempts are also more prevalent among the dually diagnosed population.

BACKGROUND:

The problem of dual diagnosis became clinically clear in the early 1980s. (Drake R. P., 2001) Substance abuse and mental illness hinders your ability to function, handle life and have a healthy social life.

Mental illnesses are mental conditions that disrupt a person’s thinking, feeling, mood, ability to relate to others and daily functioning. “The World Health Organization has reported that four of the 10 leading causes of disability in the US are mental disorders.” (National Alliance on Mental Illness, 2010) Some of the major and the most common mental illness that occur with substance abuse are manic depression, schizophrenia, bipolar disorder, attention deficit hyperactivity disorder, obsessive compulsive disorder, panic disorder, post traumatic stress disorder, generalize anxiety disorder and antisocial personality disorder. It is reported that about 57.7 million Americans experience a mental health disorder in a given year. (National Alliance on Mental Illness, 2010)

Substance abuse, also known as drug abuse, refers to a maladaptive pattern of use of a substance that is not need to sustain life or to make it better. “One in four US deaths can be attributed to alcohol, tobacco, or illicit drug use.” (Innovatory Combating Substance Abuse, 2010) The commonly abused drugs by people with a mental illness are alcohol, cocaine and/or marijuana. Substance abuse complicates some aspect of care for a person with a mental disorder. It provides challenges for the counselor to engage the individual in treatment.

About “50% of individuals with severe mental disorders are affected by substance abuse.” (Saisan, Smith, & Segal, 2010) “Thirty-seven percent of alcohol abusers and 53% of drug abusers also have at least on serious mental illness.” (Saisan, Smith, & Segal, 2010) See the chart below. The risk of developing a drug abuse problem while having a disorder goes as high as 15.5% for antisocial personality disorder and as low as 02.1% for phobias. “The mental health problems that most commonly co-occur with substance abuse are depression, anxiety disorders, and bipolar disorder.” (Saisan, Smith, & Segal, 2010) When a person has a dual diagnosis of substance abuse and mental illness the clinician has to determine what are the symptoms/signs of the substance abuse and what are the symptoms/signs are from the mental illness.

Disorders with Increased Risk of Drug Abuse
Disorder
Risk

Antisocial personality disorder

15.5%

Manic episode

14.5%

Schizophrenia

10.1%

Panic disorder

04. 3%

Major depressive episode

04.1%

Obsessive-compulsive disorder

03.4%

Phobias

02.1%

Source: National Institute of Mental Health.

(Drug Abuse and Mental Illness Fast Facts, 2006)

At least 60% of people fighting substance abuse or mental illness are fighting both at the same time. (Bouchex, 2007) Patients with mood, anxiety or drug disorders are about twice as likely to be diagnosed with the other as well. Figure 1 (Topics in Brief, 2007) The prevalence of these dual diagnoses does not mean that one condition caused the other, even if one appeared first. The high rates show the need for better treatment and treatment centers able to deal with both at the same time.

WORKING DIAGNOSIS:

Substance abuse can cause mental disorders due to the fact that,

“drug abuse can cause a mental illness,”

“mental illness can lead to drug abuse,”

“drug abuse and mental disorders are both caused by other common risk factors”

all three can contribute to the establishment of specific dual diagnosis of mental disorders and addiction. (Topics in Brief, 2007)

FRAMEWORK/METHOD OF ANALYSIS:

I began my search using Google and searched using the terms “Substance abuse and Mental Illness”. This resulted in nine articles that were relevant to my topic all of which I used as references.

I then went to the Pub Med Central database and searched using the term “substance abuse and mental illness” and found many articles. I used four of those articles as references. The other references were found on website such as National Institute on Drug Abuse and the National Drug Intelligence Center.

ADDITIONAL INFORMATION (LITERATURE REVIEW):

This review looks at progress made in understanding the relation between drug abuse and mental illness. Volkow found that the relationship between substance abuse and mental illness “is likely to reflect common contributing factors and brain substrates.” (Volkow, 2001) One of the main factors substance abuse and mental illness have in common is stress. A question that still remains is the role that drug abuse has on causing psychosis in individuals with no previous psychiatric histories. Stimulant drugs induce psychosis because they increase extracellular dopamine concentration in the brain. However it does not explain why psychosis can continue after the stimulant drug is no longer present in the brain.

Regier, et al, broke his study down into specific mental disorders. This review found that of people with schizophrenia forty-seven percent has some form of substance abuse problem. People diagnosed with schizophrenia have a 4 times as likely then people who do not have schizophrenia to have a substance abuse problem. (Regier, et al., 1990) The odds for people diagnosed with anxiety disorders to have a substance abuse proplem were more than fourteen percent.

It is believe that substance abuse may trigger mental illness in vulnerable individuals. Evidence show a “complex explanation in which well-known risk factors- such as poor cognitive function, anxiety, deficient interpersonal skills, social isolation, poverty, and lack of structured activities combined to render people with mental illnesses particularly vulnerable to alcohol and drug abuse.” (Drake, 2009) People that already have a mental disorder probably appear to be extremely sensitive to the effects of alcohol and other drugs, due to having a form of brain disorder.

Drake, et al, explains the term dual diagnosis as misleading because people with a dual diagnosis are diverse and tend to have multiple illnesses rather than just two illnesses. Drake discusses how researchers have established some identical finding. First, co-occurrence is common. “Second, dual diagnosis is associated with a variety of negative outcomes, including higher rates of relapse, hospitalization, violence, incarceration, homeless and serious infections such as HIV and hepatitis.” (Drake R. P., 2001) Third, the mental health and substance abuse treatment system delivers fragmented and ineffective care.

RESTATEMENT OF WORKING DIAGNOSIS (Hypothesis):

There is evidence that substance abuse can lead to a mental disorder but also a mental disorder can also lead to a substance abuse, it is not known which comes first. Like the saying which comes first the chicken or the egg. It is said that having one of the diagnosis makes you vulnerable to the other.

MANAGERIAL/POLICY RECOMMENDATIONS:

Why people who are having a mental disorder are so prone to drug abuse raises a lot of questions due to the limited research done on the topic. The research so far is inconsistent and has failed to address a number of issues. There is a need for more research as well as more treatment center that are equipped to deal with dual diagnosis. The patient has two brain diseases that influence one another, and which both need treatment, at the same time. This is when dual diagnosis treatment is need. It is an approach used by clinicians to treat individuals affected by two co-occurring or coexisting conditions simultaneously. Dual diagnosis affects a person physically, mentally, spiritually, emotionally and socially. There is a need for an all-inclusive approach that identifies both disorders, evaluates both disorders, and at the same time treats both disorders. Many treatment centers now only treat one or the other. Substance abuse treatment are not recommended or designed to handle a mental illness and vice versa. Awareness about the problem needs to be made public, so that people know the signs to look for and how to approach the person about their disorder correctly. Patients also need to be aware of the help that is available to them and support groups like Dual recovery Anonymous. There also needs to be better training for the counselors and physicians so that they will be able to better and accurately diagnosis patients. For recovery to be successful you must treats a client’s addiction and mental health problem.

Introduction

Mr X is a 78 years old gentleman who has been admitted to a busy dementia unit six months ago. He was admitted from home following increasing lethargy, depression and reduced mobility. Prior to the admission he was diagnosed inter alia with Vascular Dementia. He communicates verbally with no difficulties, using very wide vocabulary however can mix up words and situations. He was assessed as lacking capacity to make informed decisions. Mr X has one daughter who is of the opinion that her father lacks insight into the difficulties he was having at home believing that he was managing fine. Mr X’s wife (Eva) died few months ago, in a hospital suffering from breast cancer. Mr X was very involved into her care throughout the illness and cannot accept the loss.

Problem assessment

Mr X, does appear to have an understanding of the sourroundings albeit he is very quiet most of the times almost like having no intrest of what is happening around him. He appears unable to generate any enthusiasm.

Mr X remains independent in terms of personal care, use of facilities, eating and drinking and requires minimum assistance and maximum encouragement and prompting. He is able to mobilize with a zimmer frame, though seem to feel best sitting in a chair in his room, even at “meals or activities times”.

In relation to the above three main problems that interlock have been identified

1. Depression and its effects

Mr X cannot reconcile yourself to the loss of his wife, changes in life his physical and mental health resulting in depression and progress in dementia. He appears isolated, lost a lot of weight; apathy and withdrawal are present affecting seriously his ability to perform everyday tasks.

According to him, to his daughter and to the information gained on assessment using Initial Dementia Assessment (IDA) he used to enjoy reading books, travelling and had an outgoing personality. The IDA indicated that the dramatic change and deterioration in his condition was noted when his wife passed away and he was told that he is having dementia. On the Mini-Mental State Examination (MMSE) Mr X scored 20/30 which could suggest that his dementia is not severe and that there may be other reasons for his withowal. His score could have been slightly inflated because well educated people like Mr X find thequestions “easy” to answer (Marshal at al 1983) but he could be described as “ mildly confused”.

One of the MMSE questions related to language skills was about writing a sentence about anything. Mr X wrote a short statement “Eva is not here and I have dementia”.

Research show that coping and getting along with the diagnosis of dementia is a time-consuming process often related to a range of emotions such as: fear, shame, guilt, sadness, bitterness, isolation and helplessnes. (Alzheimer Europe, 2009) Mr. X appeared to feel overwhelmed by those emotions.

Paying attention to non verbal signs of Mr X bevaiour helped staff to investigate his case further. He often avoided eye contact, showed no inattentiveness his appetite decreased and his posture expressed “tiredness of living”. Studies of nonverbal behaviour indicators in show that this type of signs are often related to post traumatic stess disorder ( PTDS) and that men are more likely to show depression in a form of isolation and withrowal (Stratou at al, n.d.).

2. Upset family relationships

Assessment tools demonstrated that family was very important to Mr X.

When communicating with the daughter lack of understanding dementia, depression and PTDS were identified as an important factor contributing to Mr X situation. Evidence show that above named health issues have an impact on family members; relationship difficulties are common and it it not easy to understand the “loved one”. ( Alzheimer’s Society, 2013). The main concern was no communication with the father and unwillingness to spend time with him to enable him to accept his chalanging situalion. She could not imagine that her normally happy and sociable father was so depressed, and in addition diagnosed with dementia which meant he became “a stranger” to her.

3. Challenging behaviour

Whilst staff members were doing their best trying to motivate and encourage Mr X to get more involved into his care and the care home life, Mr. X refused everything or simply ignored them. The efforts had a negative impact on him and caused reactions such as pretending to be dependent and irritating staff. These types of reaction have been identified by Wallbridge as types of aggression called “ active resistance” ( Wallbridge, n.d.). Staff then presented negative attidude and disaffection towards Mr X. Evidence suggests that behaviours, including uncooperativeness, staff find difficult to cope can lead psychological stess amongst staff and discourage them to deepen knowledge related to the health problem of the patient. ( Brodaty at al, 2003)

Planning

From the above assessment a list o goals have been created in order to improve the quality of life for mr X which is aimed to be archived through:

creating an environment where Mr X could feel emotionally safe, supported and understood
helping him understand, manage and accept his condition .
Lowering the level of lethargy and depression and stimulate functional ability, social contact and activity by encouraging him to talk and listen to what he is saying
Stimulating and motivating Mr X to create new habits related to maintain his physical independence, eating and help him use his potential
involving Mr X’s daughter into care and help her understand the complexity of her father’s condition to make the psychosocial interventions better and improve Mr X behaviour and mood as well as increase his acceptability of the care home settings. Encourage her to let Mr X know that she cares about him and to stay in contact with him by visiting him, taking him out, calling etc to minimise the isolating experience
training for staff in relation to challenging behaviour and dementia awareness, communication, behaviour and work related stress management

The desired outcome is partially based on the outcomes from the research done amongst people with mild dementia and suffering on depression that have successfully managed to improve their lives, that was done was done by the social work department of University of Stirling for the Scottish Executive. (Scottish Executive Social Research 2005)

Implementation

In relation to problem 1

Assessment using IDA and MMSE indicated that Mr X condition is affected by depression. Further investigation has been done. GP and the Liason Psychiatric Nurse have been contacted and involved.

Mr X scored 23/30 in the Geriatric Depression Scale (GDS) indicating severe depression. (Yesavage et al, 1982)

It has been decided that his depression should be addressed first because it was the major factor preventing Mr X from enjoying life similarly to like he used to. It is known that the effects of depression go far beyond the mood ( Smith at el. 2014).

In Mr X case this had an impact not only on his energy, appetite, and physical activity but also on his relations with family and staff.

In relation to the weight loss Malnutrition Universal Screening Too (MUST) (BAPEN, n.d.) has been used. Initial MUST score was 0 with healthy BMI but due to his poor appetite the score rose to 1 within 3 months. Therefore his dietary intake was documented in a form of Food and Fluids Record Chat ( Care NHS UK, n.d) and his weight was monitored every two weeks.

In relation to diet intake Mrs X was offered meals according to his likes suggested by his daughter and accepted by himself which significantly increased the likehood of an “ consumed meal” .

After 2 months his weight stabilised. He remains “ poor eater” and therefore his meals contain more calories. His weight is currently monitored once a month and is not a concern anymore. Changes are documented in his care plan that is evaluated every month.

Studies show an association between depression and increased mortality in older adults. Factors identified in Mr X case included poor adherence , lack of physical activity, cognitive impairment. ( Gallo et al 3013)

From the point of his medication, a rviewd was requested by the GP and and it has been suggested to discontinue Paroxetine(Seroxat) and commence on Amitriptyline. Both belong to antidepressants but vary in side effects. ( NHS Choice, 2013). In addition it has been requested to commence Mr X on regular laxatives as episode of constipation have been noted. Currently Mr X bowels are monitored and documented on bowels chart on daily basis. No concerns have been noted.

In relation to problem 2

Reduced sense of purpose was identified as the main co-existing factor

To help Mr X overcome this problem (which he expressed clearly during the MMSE mentioning the loss of his spouse and dementia diagnosis) his daughter was asked to participate and although she was initially sceptical she brought meaningful memoralia and small pieces of furniture to help him feel like home. Staff gave her assistance and explanation in relation to dementia and depression. She was also offered help and given reassurance in a form of Family Support Meetings organised by the home. The initial scepticism disappeared with gaining awareness of the illness. She became Mr X advocate and currently holds medical and financial power of attorney for him. ( Office of the Public Guardian, Scotland, n.d.) Furthermore her two sons come regularly to visit Mr. X, they often take him out for a meal or call him to find out how he is.

Staff has also managed to discuss one the most sensitive matters related to Mr. X’s End of Life such as DNACPR certificate that is present in Mr X file in the event of need. Mr. X’s relationship with his daughter and grandsons appears happy. The daughter stated that this helped also her to resolve personal problems she feels acknowledged by her father and therefore valued. There is a Family/Relatives Communication part in Mr X care plan and a book in Mr X room where any suggestions, complaints or comments can be made by staff members or by the family .(U.S National Library of Medicine, 2011)

The relation with staff can be defined as very good. A person’s family is often the most important, long-standing connection in their life. Therefore, the ability of staff to work positively and inclusively with families and carers is a core staff skill.

In relation to problem 3

Most of the staff required training to help them understand the nature of behaviour that challenges. The importance of the training this became so vital that it is now one of the mandatory trainings every member of staff has to attend. Skills that were aimed to be improved included addressing challenging behaviour, person centred approach and communication skills (Skills for Care, 2013) Many staff showed the need to be trained in related to stress management (Wallbridge, n.d.) The future aim is to create a team that focuses on people’s assets and life outcomes. A team that is confident of their roles and impact on Mr X and any other client, willing to contribute and encouraging new members of staff to learn.

Evaluation

Summarising, Mr. X case has been an example of mostly successful process of assessment and implementation of the planned actions. There was and so called “multi agency” approach to Mr X needs. Assessment tools helped in the identification and articulation of the needs and contributed to positive changes leading to holistic, personalised approach to them. Recent changes to the social care management and the need to comply with the Public Services Reform Scotland Act 2010 contributed to the awareness in relation to staff due to the accent on the importance of systematic and sensitive assessment.

Mr X’s continuing care did not require up to now any specific nursing interventions.

The difficulty consisted of identifying the roles and the division of work.

Mr X’s case proved that there are different functions staffs have to complete that contribute to the optimum health and overall wellbeing of older people such as:

psychosocial and emotional support enabling life review – where the family support was crucial but required time to function
work aimed at maintaining his independence and functional ability that continues to be improved through the aspiration of a well functioning team work.
educative – teaching self-care activities by encouraging physical activity
managerial- directions in terms of who and when undertakes the administrative and supervisory responsibilities could have been improved.

All the above reduces to good knowledge, awareness, and experience, will power to change things for the better and to a well functioning team work. Many things would have been done sooner or could have been dealt with better if we were aware of the need and knew how. This is why it would be recommended to pay more attention to training needs in relation to new regulations, staff assessments, achieving and evidencing outcomes, person-centred care planning.

References

Office of the Public Guardian( Scotland)( n.d.) http://www.publicguardian-scotland.gov.uk/whatwedo/power_of_attorney.asp

Care NHS UK ( n.d.) Food and Fluid Record Chart http://www.glos-care.nhs.uk/images/Food_and_Fluid_chart_-_attachment_31_copy_copy_copy.pdf

(BAPEN, n.d.) Malnutrition Universal Screening Tool http://www.bapen.org.uk/pdfs/must/must_full.pdf

Skills for Care (2013) Supporting staff working with people who challenge services Guidance for employers http://www.skillsforcare.org.uk/Document-library/Skills/People-whose-behaviour-challenges/Supporting-staff-working-with-challenging-behaviour-(Guide-for-employers)vfw-(June-2013).pdf

U.S National Library of Medicine (2011) no author Communicating with families of dementia patients Can Fam Physician Joulrnal Vol 57(7): 801–802 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3135450/

NHS Choice ( 2013) Antidepressantshttp://www.nhs.uk/conditions/Antidepressant-drugs/Pages/Introduction.aspx

Melinda Smith, M.A., Lawrence Robinson, and Jeanne Segal, Ph.D. Last updated: February 2014. Depression in Older Adults & the Elderly http://www.helpguide.org/mental/depression_elderly.htm

Gallo, J., Morales, K.H.,Bogner, H.R, Raue, J.P, Zee,J, Bruce M.L and Reynolds C.F(2013) BMJ Helping doctors making better decisions Long term effect of depression care management on mortality in older adults: follow-up of cluster randomized clinical trial in primary care http://www.bmj.com/content/346/bmj.f2570

Scottish Executive Social Research (2005) Effective Social Work with Older People http://www.scotland.gov.uk/Resource/Doc/47121/0020809.pdf

Wallbridge, H. ( n.d.) When pushed to the limit:Moving beyond a difficult situation http://www.alzheimer.mb.ca/handouts/When%20Pushed%20to%20the%20Limit…Moving%20Beyond%20a%20Difficult%20Situation.pdf

Alzheimer Society (2013) Understanding and respecting the person with dementia file:///C:/Users/GEORGE/Downloads/Understanding_and_respecting_the_person_with_dementia_factsheet.pdf

Stratou,G., Scherer,S., Gratch,J. and Morency, L.P. (n.d) University of Southern California, Institute for Creative Technologies, Los Angeles Automatic Nonverbal Behavior Indicators ofDepression and PTSD: Exploring Gender Differences http://ict.usc.edu/pubs/Automatic%20Nonverbal%20Behavior%20Indicators%20of%20Depression%20and%20PTSD-%20Exploring%20Gender%20Differences.pdf

Alzheimer Europe (2009) no author Facing the diagnosis Diagnosis of dementia http://www.alzheimer-europe.org/Living-with-dementia/After-diagnosis-What-next/Diagnosis-of-dementia/Facing-the-diagnosis

Marshal F. Folstein, MD; Lee N. Robins, PhD; John E. Helzer, MD (1983) The Mini-Mental State Examination JAMA Network Journal Archives of General Psychiatry Vol 40, No. 7 http://archpsyc.jamanetwork.com/article.aspx?articleid=493108

National Chronic Care Consortium and the Alzheimer’s Association (2003) Tools for Early Identification,Assessment, and Treatment for People with Alzheimer’s Disease and Dementia http://www.alz.org/national/documents/brochure_toolsforidassesstreat.pdf

Introduction

Every society in the human history confronted the question of how disputes should be resolved. Independence of the judiciary is the principle that the judiciary should be politically insulated from the legislative and the executive power. Courts should not be influenced by the other branches of government. Different nations deal with the idea of judicial independence through different means of judicial selection. An independent judicial branch is one of the main guarantees of democratic system of government and it ensures the rule of law so that it is free from outside influences and judges can render cases only due to the law and facts.

The importance of the independent judicial system in England were established in the beginning of 11th century, when William The Conqueror come to throne in 1066 and had started settling new laws in the whole England (today is known as Common Law) and also had fixed by The doctrine of the “separation of powers”. Whereas, In Kazakhstan legal system the Judicial power as the legal category is rather new. On 30th August 1995 on the basis of the Declaration of Independence the Constitution of The Republic of Kazakhstan had been accepted and it covered the initial principles and appointments of independence of judges (The Constitution of The Republic of Kazakhstan, 1995).

Firstly, I would like to return to the past of the UK to observe the formation way of the power structure, which we have today.

The ideas based on a modern principle of division of the authorities, for the first time was expressed by Aristotle, in his fourth book named, “Politician”. He formulated the idea of separating the power in the state on three parts: legislative, official, judicial; each of the authorities should be represented by the separate ‘body’.

The further development of the theory of division of the authorities is bound to John Lock and Charles Louis Montesquieu, who have carried out the most thorough working out of this principle. Later on, by the end of 18th and the beginning 19th century, the principle of division of the authorities was recognised in many states.

Next paragraph separately exposes the origin ways of each power branch in the UK.

The Parliament

The British Parliament is one of the oldest parliaments in the world. It is often named “foremother”, but in my opinion it would be more exactly to call it “forefather” of all parliament systems in the world, and it continues to function throughout the whole political history of the country since the second half of 13th century.

Formation and development of The British Parliament occurred during XII and XV centuries. Considerable value of this long process traditionally was attracted by a crown of the higher nobility to the decision of the state, affairs monarchy going back to its origin. Meetings of the King’s vassals, from the middle of XII century, became an obligatory part of the state life and they were the historical beginning of the class representations.

The ancestor of legislative system of England was the Curia Regis (the council of tenants-in-chief) it was created by William The Conqueror, who brought to England the feudal system from his native Normandy after the Norman conquest in 1066, and was granting land to his most important military supporters, further the supporters were granting that land to their own supporters thereby creating feudal hierarchy of England. Eventually this council has developed into the Parliament of England, and now includes the head of the state (monarch), chamber of lords (historically – chamber of the nobility and the higher clergy) and the House of Commons (historically – chamber of commoners).

The Monarch and Government

Formation of strong English government begun in the beginning of 12th century when English people were victims of intestine wars and feudal anarchy. This severe historical experience had definitively convinced English people that nothing but the strong central power and the wide state organisation can serve for them against those harms.

Reducer of the reeled English state order was Henry II Plantagenet (years of board 1154-1189). During Henry’s reformatory activities people against feudal lords joined him and it can be said that absolute monarchy formation in England begun with him.

The restrictions of the monarchs’ power began being introduced in the beginning of the 13th century, when the English nobility forced King John to recognize the certain document named, Magna Carta. The constitutional monarchy in that way we see it today, has developed and has become stronger in 18th and 19th centuries when function to administer the affairs of the state has passed to the Cabinet which were appointed from elective parliament.

The Cabinet has arisen before the bourgeois revolution of 17th century on the basis of secret council, as the narrow board helping the king to quickly solve the important problems of the government.

At first this body completely depended on the monarchy. Further, by the end of 18th century and the beginning of 19th century, it was ceased to be a subsidiary organ of the Royal management and should lean against Parliament support. As the result by that time it started being recognised that the Cabinet should have the majority of voices in Parliament and the head of it should be the Prime minister.

The Legislative

If the legislative and executive powers are assigned on the exactly higher state body then the judicial power is much more difficult. It is assigned to set of judicial bodies from the local Supreme. Each judicial body is independent and it has own place in the system, resolving concrete affairs absolutely independently.

The today’s judicial power of England has arises from 1178, when Henry II appointed five members of his personal household “to hear all the complaints of the realm and to do right”, however the role of the Lord Chancellor was still formal and judgements were a prerogative of the King. Such situation had been existing till “Glorious Revolution”, the acceptance of the Bill of Rights in 1689 and the Act of Settlement in 1701. After those changes the power of the monarch was essentially limited and courts received independence and leadership of the law.

The doctrine traditionally demands “separate of powers”, that the state system of the power must be divided into three branches and each branch is not only supplemented by two others, but also could be balance.

As I said above, the judicial power became independent from executive, legislative and Royal powers when The Bill of Rights 1689 was introduced. According to the Bill the monarch was deprived to a duty to support and supervise judicial system, and the right of the Queen was only to dismiss judges on ministerial council. However, until recent time the principle of “separate of powers” in the Great Britain was not completely observed. So that the Lord Chancellor being the head of the judicial power in the Great Britain simultaneously was the member of the Cabinet and a member of Lords’ chambers. Moreover, the Lord Chancellor was appointed to the post by the Queen on representation of the Prime Minister.

In July 2003, Tony Blair’s government tried to make radical changes to a judicial branch of the power and declared plans to cancel a post of the Lord Chancellor to abolish the system of Law Lords and to replace it with separate Supreme Court. These plans caused considerable contradictions, and finally, Prime Minister decided to change, instead of cancelling an ancient role of the Lord Chancellor. Reform of the role of the Lord Chancellor has started the process of separating his various duties making clear distinction between the government, Parliament and the judicial power.

Kazakhstan

16 December 1991, the Parliament of the on the Republic declared the independence of the Republic of Kazakhstan and the Republic Kazakhstan was formed.

During the period 1991-1995, the political system and Constitutional legislation of the Republic were formed. The first Constitution of sovereign Kazakhstan was adopted in January 1993. Being to some extent a compromise between the old and new political systems, reflecting attempts to introduce into the post-Soviet context a western democratic model, this Constitution initially contained some contradiction which occasionally took the form of unnatural opposition and resistance of power.

As a result of the Referendum held on 30 August 1995, a new Constitution of the Republic of Kazakhstan was adopted, eliminating the shortcomings of the former constitution. The new Constitution established a Presidential Republic, and solved rationally the problem of divided responsibilities among different branches of power, while also welcoming changes to the market system.

According to Article 3 of the Constitution states that the state power in the Republic of Kazakhstan is unified and executed on the basis of the Constitution and laws in accordance with the principle of its division into the legislative, executive and judicial branches and a system of checks and balances that governs their interaction.

The legislative branch comprises Parliament of the Republic of Kazakhstan (the Senate and the Majilis).
The executive branch comprises the Cabinet of Ministers, state committees, others central and local executive bodies of the Republic.
The judicial branch comprises the Supreme Court and Constitutional Council and local courts (regional, district and others).

The President of the Republic of Kazakhstan is the head of state, its highest official determining the main directions of the domestic and foreign policy of the state and representing Kazakhstan within the country and in international relations. He shall ensure by his arbitration concerted functioning of all branches of state power and responsibility of the institutions of power before the people. (Art. 40 of the Constitution). The President is elected every seven years on the basis of universal suffrage. One and the same person may not be elected the President of the Republic more than two times in a row.

Nursultan Nazarbaev has been the President of the Republic of Kazakhstan since 1 December 1991.

Parliament

The highest representative body of the Republic of Kazakhstan is the bicameral Parliament. According to the President’s Decree having force of Constitutional Law «On elections in the Republic of Kazakhstan» (1995) the parliament will consist of two chambers the Senate and the Majilis and work on professional base.

Parliament at a joint session of the Chambers: introduces amendments and makes additions to the Constitution; adopts constitutional laws, approves the republican budget, the reports of the Government, and the Accounts Committee about its implementation, and introduces changes into the budget; conducts a second round of discussion and voting on the laws or articles of the law; hears the report of the Prime Minister on the Government’s program and approves or rejects the program and annual messages of the Constitutional Council of the Republic on the state of the constitutional legality in the Republic or reports on the activity of the commissions; decides issues of war and peace; adopts a decision concerning the use of the Armed Forces of the Republic to fulfill international obligations in support of peace and security at the proposal of the President of the Republic; puts forward an initiative calling for an all-nation referendum; exercises other powers assigned to Parliament by the Constitution.

The Government

The Government is appointed by the President and accountable to the Parliament. It implements the executive power in Kazakhstan, heads the system of executive bodies and exercise supervision of their activity.

Judicial Authority

Justice in the Republic of Kazakhstan is exercised only by the court. The judicial system in the Republic consists of the Supreme Court Republic of Kazakhstan, the highest judicial body, and regional, district, town, and city courts. (Art.75)

The Supreme Court of the Republic of Kazakhstan shall be the highest judicial body for civil, criminal and other cases which are under the courts of general jurisdiction; exercises the supervision over their activities in the forms of juridical procedure stipulated by law, and provide interpretation on the issues of judicial practice.

The chairman of the Supreme Court is the judge and is appointed to the post by the President with the consent of the Senate of Parliament of the Republic of Kazakhstan.

Independence of the judicial power in Kazakhstan completely based on the Constitution and the Constitutional Law named, “About courts and the status of judges”, and the guarantor of the constitution is the President. However, the theory of division of the authorities does not assume creation of “the Chinese wall” between various branches of the power. That is also impossible, as their interaction and interdependence are the questions of uniform institutes and the government shall be necessarily differentiated from its branches, generating an interlacing of some elements.

The general meaning of the modern legal doctrine are the connection of ideas of unity and division of the authorities, their interactions and system of controls and counterbalances. Such understandings are reflected in the newest constitutions. The most distinctive expression is the point 4 of article 3 of the Constitution of Republic Kazakhstan of 1995 which says: “the Government in Republic Kazakhstan is uniform, is carried out on the basis of the Constitution and laws according to a principle of its division into legislative, executive and judicial branches and their interactions among themselves with use of system of controls and counterbalances”.

Basically the Kazakhstan’s and English models of the judicial power are very difficult to compare moreover they are based on various legal foundations. English system of the Right is based on judicial precedent and actually courts of England create laws. In Kazakhstan the system is based on the code system of the right, such as the constitution, the constitutional laws, codes etc., and the Kazakhstan courts in contrast to English courts do not have the legislative initiative.

It is believed that the judicial power is the weakest branch and it does not lean against wish of voters as the legislature, has no power for compulsion as the Executive. The force of the judicial power is in respect from the civilised society to the right and court. Here again we can see considerable distinctions. In that number, and in relations of other branches of the power both judicial in England and Kazakhstan.

The execution institute of court decisions in England is so accurate also punishment for default so serious, that the practical excludes concept «default of the decision of court» and communication with what, the authority of the judicial power is indisputable.

Since independence Kazakhstan has undertaken huge efforts for a raising of courts authority, however corruption and a principle of “the telephone right” create for this purpose very big obstacles.

Also I would like to stop in detail on the status English of judges put in English statutes. According to this statutes judge are appointed for life. In Kazakhstan the similar norm of the law does not exist. And although the legal judge is appointed to the post and dismissed by the President of Republic, the nonflexible system of estimations of activity of the judges allow to the chairman of courts easily release the judges who was not undesirable to him.

Although the term empowerment is frequently used, the availability of high-quality research which demonstrates its success for improving the wellbeing of communities is fairly minimal (Woodall et al. 2010). There is, however, some evidence that shows that empowerment programs can lead to improve outcomes for participants. For example, in examining the effectiveness of interventions using community development approach, the Migrant Resource Centre of South Australia, which provides programs that targets particular community groups, including women, younger people, has recorded some promising ability to impact the lives of young refugees (MRCSA Annual Report, 2009). In fact, this essay argues that while community development interventions are difficult to measure, the migrant Resource Centre of South Australia has registered significant gains in the area of youth empowerment.

This essay will highlight the various intervention programs implemented by the Migrant Resource Centre of South Australia (MRCSA). However, case study will focus on its youth empowerment component and to evaluate the overall effectiveness of community development approach of the organisation. To achieve this task, the essay is partitioned as follows. The first part will examine the definitions of empowerment. The next section will discuss about community development as a strategy and a model of practice by the Migrant Resource Centre of South Australia (MRCSA). The third section discusses the impact and challenges of this intervention. The final part of the essay will evaluate the impact of MRCSA’s youth empowerment program among a number of interventions.

Background and definition of the Concept of Empowerment

In the 1990s the term empowerment began to replace community participation (Rifkin, 2003). Empowerment according to Rifkin has conceptually evolved from the idea of lay participation in technical activities to a broader concern of improving life situations of the poor. This evolution can be traced historically in the areas of policy and in community activities. In the policy area, Rifkin proposes that three theoretical constructs can be identified to trace the changing view of participatory approaches from consensus building to empowerment. These Rafkin stated correspond to the political and political environment of the time.

The historical development of the concept of empowerment helps explain why there is no universally accepted definition of empowerment (Rifkin, 2003). However a number of scholars defined it as a process (McArdle, 1989; Laverack, 2005; Werner, 1988; Kilby, 2002). McArdle (1989) defines empowerment as a process whereby decisions are made by the people who will wear the consequences of those decisions. Similarly Werner (1988) and Laverack (2005) describe the concept of empowerment as a process by which people are able to gain or seize power to control over decisions and resources that determine their lives. Moreover, Kilby (2002) describe a process by which disadvantaged people work together to increase control over events that determine their lives. Expansion of individual’s choices and actions, primarily in relation to others aˆ¦ fundamentally a shift of power to those who are disempowered.

From a public health perspective, empowerment involves acting with communities to achieve their goals (Talbot & Verrinder, 2005). This implies working with disadvantaged individuals or groups to challenge structural disadvantaged (on the basis of class, gender, ethnicity or ability) and influence their health in a positive way. The application of the concept into the field of health promotion as outline by Laverack and Labonte (2000) is categorized in two folds; the bottom-up programming and the top-down programming. The former more associated with the concept of community empowerment begins on issues of concern to particular groups or individuals and regards some improvement in their overall power or capacity as the important health outcome. The later more associated with disease prevention efforts begin by seeking to involve particular groups or individuals in issues and activities largely defined by health agencies and regards improvement in particular behaviours as the important health outcome. Laverack and Labonte (2000) thus viewed community empowerment more instrumentally as a means to the end of health behaviour change. They argue that community empowerment which is defined as a shift towards greater equality in the social relations of power is an unavoidable feature of any health promotion efforts.

On a much broader scale empowerment promotes participation of people, organisations and communities towards the goals of increased individual and community control, political efficacy, improved quality of community life, and social justice (Wallerstein, 1992). The next section is a case example of how this approach is applied by an agency in dealing with question of social inclusion.

Community Development: A case of Migrant Resource Centre of South Australia (MRCSA)

By reviewing the previous definitions of empowerment and examining MRCSA’s framework, It is clear that the worker in (MRCSA) understand and adopt empowerment concept similar to which all of McArdle (1989); Laverack (2005); Werner (1988); Kilby (2002) and WHO (1986) do understand and adopt where empowerment is a matter of giving people the right and the opportunity to exercise power and control regarding making decisions that affect their health promoting.

In addition, in order to empower migrant people and communities, the (MRCSA) provide and still providing number of interventions based on community development model of practice. According to Tesoriero (2010), community development is the use of a set of ongoing structures and processes which enable the community to meet its own needs. Similar to Tesoriero (2010), Community Development is understood and implemented by the (MRCSA) as a multifaceted program of activities that concentrated on supporting the need of new arrivals and their new and emerging communities to understand their rights and obligations, to link into training and employment pathways and to develop networks of support within their local and in the broader community (www.mrcsa.com.au). In fact, The MRCSA has adopted Laverack and Labonte’s (2000) bottom-up approach in implementing their programs by consult sing and working closely with leaders and key representatives of new and emerging communities, including women and young people, to support them in gaining the knowledge and skills that they need to further their independence as well as their capacity to support and provide assistance to their members. Moreover, beside community development programs, MRCSA is providing number of women’s advocacy programs, youth leadership and participation and employment advocacy programs, As well. The programs also include Refugee Men’s Talk, an initiative supporting men to adapt to their new social environment.

To ensure and facilitate the participation of new and emerging communities in their local areas and in regional areas where they settle, or resettle, the program includes local government and regional initiatives. MRCSA believes that new and emerging communities require a place in which to implement their own activities. The organisation provides these through its own community centres and through linkages with other community facilities.

Also, Given that community development as an approach require working across divergent spheres, the Migrant Resource Centre of South Australia (MRCSA) maintain link with a number of stakeholders. These include the Commonwealth Government, the state of South Australia and the NGO community.(www.mrcsa.com.au). At the level of the Commonwealth Government, the links include; Department of Immigration and Citizenship, Centrelink, Employee Advocate, Department of Families, Housing, Community Services and Indigenous Affairs and Australia Council for the Arts. At the level of the State Government the links are; Multicultural SA, Department of Health, Department of Families and Communities, Department of Education and Children’s Services, Skills SA, English Language Services – TAFE SA, Arts SA, Office for Women, Women’s Information Service, Women’s Health State Wide, Local Government Association of SA and Be Active. The links within the Non-Government Sector includes; Settlement Council of Australia (SCoA), Refugee Council of Australia, Federation of Ethnic Communities’ Councils of Australia (FECCA) LM Training Specialists, SA Council of Social Service (SACOSS), Service to Youth Council (SYC), Working Women’s Centre, Migrant Women’s Support and Accommodation Service, Youth Affairs Council of SA (YACSA), Anglicare SA, African Communities Council (ACCSA), Middle Eastern Communities Council (MECCSA), Volunteering SA and Northern Territory. Analysing this web of networks from Labonte’s, (1992) community development continuum, the MRCSA’s programs deal with individuals which transcend to small groups, community organisations, coalition advocacy and political action. With this wide array of networks, the organization has been facilitated to maintains a huge amount of social capital and through careful co-ordination, it stands a lot to gain in achieving its primary objectives (Butter et al. 1966)

The next section will focus on one of its many programs in the area of youth enhancement.

Youth Empowerment Program

The Migrant Resource Centre of South Australia (MRCSA) works closely with the leadership and key representatives of its client communities, including women and young people to support them in acquiring the knowledge and skills that they need to further their independence and self-determination, as well as their capacity to assist their members with their settlement and participation (www.mrcsa.com.au)). These goals are achieved through a number of programs including ethnic leaders’ forum, adult migrant education, community management and leadership forum by way of funding and leadership training. This section focuses on its youth empowerment program with emphasis on the Newly Arrived Youth Settlement Services (NAYS). The primary objective of this program as outlined in the MRCSA Annual Report (2008-2009) is to empower young people to develop their own programs and to become advocates for themselves, their families and communities.

In partnership with TAFE SA, the MRCSA conducted a number of training programs for young people who were not engaged in school or work. Specific training includes Certificate II in Information Technology, Productively Places Program Certificate II, Volunteering, work experience capacity building, apprentiships and traineeships (MRCSA Annual Report (2008-2009).

Through its new arrival humanitarian settlement program, the MRCSA has been an advocate and a voice for the inclusion and participation of young people of refugee background (www.mrcsa.com.au). According to the 2010 MRCSA Youth Empowerment Program Annual Report, the program has since 1998 addressed the needs of young people from new and emerging communities in South Australia through a multi-faceted program. The program provides young people with a range of services that aim to further their resilience, leadership skills and pathways to employment and independence. The MRCSA Youth Empowerment Program for 2008-2009 provided assistance to five hundred and twenty-nine (529) young people of refugee background, most of them recent arrivals to South Australia, to achieve some of their goals (Annual Report 2009-2010). These achievements were based on strong foundations upon which MRCSA operate. The next section will discuss the guiding principles which form the basis of MRCSA’s operations.

MRCSA Guiding Principles

The Migrant Resource Centre of South Australia’s philosophy and approach in working with young people from refugee backgrounds outline a number of guiding principles (Annual Report, 2008-2009). The principles discussed below indicate that MRCSA operates Laverack and Labonte’s (2000) bottom-up approach of community development. The guiding principles include the following:

Firstly, any youth programs, initiatives or activities are shaped and driven by the young people themselves through consultation with their peers. Secondly, young people are encouraged and supported to speak for themselves to drive their own development; the role of the MRCSA is that of mentor and advisor only. Thirdly, the importance of young people’s connection to family and community is recognized, valued and supported. Fourthly, the ethnic, religious and cultural identity and heritage of young people is affirmed and respected. Fifthly, respect for gender differences and how these impact on the planning and delivery of the youth program. Also, young people are active decision makers. Finally, an action research approach informs continuous service improvement and best practice.

These guiding principles are based on the premise that empowerment strategies focus on what people can do to empower themselves and so deflect attention from social issues (Keleher et al. 2007; Keleher, and Murphy, 2004) . However, Labonte (1990) warns that unless national and international trends are taken into account, the decentralization of decision-making may shift from victim blaming of individuals to victimizing powerless communities. In view of such warnings, Wilson et al (1999) suggest that effective primary health care as in the case of public health functions depends on efforts to link local issues to broader social issues. Intersectoral action can be used to promote and achieve shared goals in a number of other areas, for example policy, research, planning, practice and funding. It may be implemented through a myriad of activities including advocacy, legislation, community projects, and policy and programme action. It may take different forms such as cooperative initiatives, alliances, coalitions or partnerships (Health Canada http://www.hc-sc.gc.ca)

What are the Barriers?

In achieving their goal of empowering communities, the Migrant Resource Centre of South Australia (MRCSA) faces a number of challenging issues.

When young refugees arrive in Australia they face a number of challenges. They need to begin a new life, establish new friends and networks and find pathways that link them into mainstream community (MRCSA Annual Report, 2008-2009).

Some young people may also be at risk and need to deal with issues around language, religious identity, grief and loss, the justice system, consumer culture and intergenerational tension (MRCSA Annual Report, 2008-2009). Young people also need ways of dealing with race, racism and their identity (MRCSA Annual Report, 2008-2009).

There are fewer opportunities for young women from new and emerging communities to participate in sport due to the barriers they experience from within sporting environments and their own communities (MRCSA Annual Report, 2009). These barriers can be based on cultural, religious, and gender expectations of young women and their roles in their community. The report (MRCSA, 2009) also highlighted other factors affecting young women participation in sports. These include; lack of parental support, perceived fear of racism, lack of knowledge about the structure of sport in Adelaide and high cost of membership and registration fees.

On the other hand, community development approach can pose barriers to Public Health Practitioners in a number of ways. Epidemiological, sociological, and psychological evidence of the relationship between influence, control, and health, provide a rationale for a community empowerment approach to health education. For example, studies show an association between powerlessness (or similarly, learned helplessness, alienation, exploitation) and mental and physical health status. Examining the application of community empowerment approach to health education, Israel (1994) identified a number of limitations and barriers to this approach. Firstly, situations where community members’ past experiences and normative beliefs result in feelings that they do not have influence within the system (powerlessness, quiescence) and hence, they may feel that getting involved in an empowerment intervention would not be worthwhile. Secondly, differences in, for example, social class, race, ethnicity, that often exist between community members and health educators that may impede trust, communication, and collaborative work. Thirdly, role-related tensions and differences that may arise between community members and health educators around the issues of values and interests, resources and skills, control, political realities, and rewards. Fourthly, difficulty in assessing/measuring community empowerment and being able to show that change has occurred. Fifthly, the health education profession does not widely understand and value this Approach. Next, risks involved with and potential resistance encountered when challenging the status quo, for the individual, organizations, and community as well as the health educator. Seventhly, the short time-frame expectations of some health educators, their employers, and community members are inconsistent with the sustained effort that this approach requires in terms of long-time commitment of financial and personal resources. Finally, the collection and analysis of extensive amounts of both qualitative and quantitative data to be used for action as well as evaluation purposes may be perceived as slowing down the process.

Inspire of these barriers, community development is still relevant to Public Health Practitioners. Epidemiological, sociological, and psychological evidence of the relationship between influence, control, and health, provide a rationale for a community development approach to health education (Israel, 1994). For example, studies show an association between powerlessness (or similarly, learned helplessness, alienation, exploitation) and mental and physical health status (Israel, 1994).

The challenges posed by community development approach also extend to the wider arena of state level. The demand on government and competition for resources by professionals is a major obstacle. Similarly, Inter-professional distrust and reluctance to share information also remains a major obstacle. The way in which governments fund departments can be an obstacle to collaboration (Baum, 1993). It is therefore argued that Stability of an organisation and its staff is important for interagency agreements and establishing trust (Walker et al. 2000). Walker (2002) further argued that Competition for resources can affect trust and intergroup conflict can occur when there is a lack of adversaries. However, insecurity brought on by political and economic uncertainty can facilitate political coalitions (Weisner, 1983).

Overcoming the barriers

Overcoming the barriers will require a concerted effort from communities, concerned organisations and government. The Proceedings of 2008 the Conference on Social Inclusion for New and Emerging Communities, outline some of the areas that need urgent interventions are discussed below.

Racism and discrimination

Identified as a major area of concern, combating discrimination requires coordinated and targeted social inclusion and human right measures. The focus should not be limited to what occurs in a social context (e.g. schoolyard, public places etc.) but also the systemic racism that supports discrimination, the perpetuation of racial stereotypes, and institutional inclusion e.g. within the justice system, the employment sector and in the blocks to the recognition of overseas qualifications and experience as well as the registration and utilization of these.

Women and safety

Women should have the right to feel safe in their homes as well as the broader community, to access culturally appropriate services for themselves and their families (e.g. health, childcare, education etc ), to learn English without it compromising their chances at finding a job and to undertake training that prepares them for work and improve their employment potential.

Empowering young people

The voices of the diversity of young people rather than a token representative from new and emerging communities must be listened to and give strong credence in the advance of a national or state framework for social inclusion. Supporting the empowerment and participation of young people as future citizens and leaders of Australia will serve the country culturally, socially and economically.

Base on the above discussion in the case of challenges to MRCSA operations, solutions to barriers could be summarized therein; Barriers can be overcome through integrated structures, developing responsibility – within structures

Support of local leaders, developing leadership skills for negotiation and collaboration. Enhancing Regional networks/structures, established processes and relationships are important for collaboration.

Conclusion

From the case studies, it was found that the Migrant Resource Centre of South Australia (MRCSA) utilize community mobilization approaches to improve equity of services, reduce institutional barriers within the society, enhance participation in new and emerging communities, strengthen civil society associations and create healthy social policies. The programs demonstrated that opportunities for community ‘voices’ to be heard had been increased and this had raised community capacity to maximise their needs and create change.

This study also found that empowerment can have a positive impact on participants’ self-efficacy, self-esteem, sense of community and sense of control and, in some cases, empowerment can increase individuals’ knowledge and awareness and lead to behaviour change. These findings were particularly apparent on youth empowerment approaches and those programmes concerning young women.

A theory of service delivery that focuses on the individual strengths instead of weaknesses.

This model is based on the understanding of the individuals’ deep internal resources and ability. The purpose of this model is to help survivors identify this strength and build life upon them. During the treatment, the clients must participate in the process of their recovery which controls the direction and pace of healing efforts. Each client helps his or her own plan for personal wellness. The plan is based on the client’s psychological, medical, or legal needs. Together, the client and case manager regularly review the progress, discuss achievements and changes, and modify goals based on the client’s evolving situation and needs. When a client is granted asylum, the case manager continues to provide assistance to satisfy the client’s needs. This may include helping the client find information on educational or employment opportunities.

Assessment:

The strength based model focus mainly on developing and finding the client’s strengths and abilities and makes a plan based on this. As this model considers the wellbeing of the clients, so the participation of the client in the treatment is very important. The client must figure out their needs of any aspects and give feedbacks of the current treatment. According to this point, the model is very adaptable to individuals as the diversity of their different situations. But this kind of model just encourage the client to live life as what they want and they can so the disability part has been left over which is very important in making progress.

Planning:

The strength based model needs a very detail and flexible service plan at the beginning which carried out mainly depends on the client’s own abilities and needs because the client will live a life based on the plan. And the plan will be change over time because during the treatment the client and the case manager have to review the changes and progress that the client has met so the goals will be modified based on the reality and the process of achievement.

Coordinating:

The strength based models require a high standard of the coordinating between the client and the case manager. The case manager will give the client professional suggestions and make plans according to the client’s condition which maybe not very consistent with the client’s imagination and needs. But the client should be considerate since the accessibility and the efficiency. And the case manager should also have a regular contact with the client and be ready to make any changes to make sure the plan is always suitable and updated.

Strengths and weaknesses of the strength based model:

The strength of the strength based model is that it is easy to be carried out because it is based on the client’s needs and ability so the client will be very cooperative during the treatment. And the psychological needs of the client are easily to be met so the confidence will be built to the client. It is very good to the client’s mental health. Besides, the client’s strengths are well maintained and developed. But the weaknesses of this kind of model are also obvious. It is because this kind of model only concerns about the strength so the weakness of the client has been ignored. But at many times the weakness plays the main role of whether the treatment is successful or not so the weaknesses can’t be improved.

Perspectives of the disability people:

The strength based model is very practical for the disabled. Client empowerment is a central theme to this approach. To empower a client, the evaluation must be made to the disabled person and thus the achievable goals will be made along with the evaluation so a well-organized plan will be carried out to achieve the goals and the possibility of the success will hopefully be very high. Critics of the strength perspective suggest this is simply reframing problems in a better light. No one will succeed while being convinced that they will fail.

Summary of the expected outcomes for the disabled:

For the strength based model, the expected outcomes is that the mental health of the client is strengthened and many the disabled can joint well to the society like the normal people without much mental barriers. In addition, the client may develop certain advantages to a high level and gain some achievement better than normal person. But the disabled part can’t be improved.

Case management Model

A collaborative process of assessment, planning, facilitation and advocacy for options and services which is aim to meet an individual’s holistic needs through communication and available resources to promote quality cost-effective outcomes.Case Management has been used to a wide range of issues including community care for the aged, and people with disability and mental health issues; acute health settings; injury management and insurance related areas; correctional services; court systems; in the management of chronic health conditions; child and youth welfare; at risk populations in schools; managed care and employment programs. The case management model requires the organization deliver a range of services based on the comprehensive assessment that is used to develop a case or service plan. The plan is developed in collaboration with the client and reflects their choices and preferences. Case Managers provide the coordinating and specialist activities that flow from the particular setting, program and client population. However it is usual to identify the following process as core to Case Management: screening, assessment/risk management, care planning, implementing service arrangement, monitoring/evaluation and advocacy.

Assessment:

However the case management model is a bit similar to the strength based models as they both respect the needs of the clients. But the case management model focus on the hobbies of the client and encourage them to attend relative activities so that the purpose of treatment is achieved during the community time. So that this model is also based on the client’s abilities in some degrees and can maintain the client’s past lifestyle and an active mind and body as much as they can. But there will be many potential barriers hidden behind like the decrease of the client’s health condition or the bad weather. So there will be many uncertain situations so the achieving of certain goals will require a long time and patience.

Planning:

Comparing with the strength based model, the case management model plan is relatively fixed because the client’s hobbies and preference are stable. Based on this a long term plan is worked out and the plan will be seldom changed. But the plan is not very detail because it’s just an optional orientation.

Coordinating:

The case management requires coordination between the activity coordinator and the client as well as the relationships among different clients who participate in the activities. And the coordinator also has to consider the clients’ physical ability and other element like the economy and the climate and so on make sure the arrangement is made in advance.

Strengths and weaknesses of the case management model:

Like the strength based model, the case management model is also very easy to be executed since it is based on the priority of the client’s to the activities according to their interests. This model is good for both the mental and physical development of the clients. But the weakness is that it is easy to be influenced by the uncertainty elements like the natural disasters and the client’s health conditions and any personal issues of each part. Also this model can’t be updated with the time going on along with the aging and the decrease of the client’s health. So at the end, the client does maybe have no ability to participate or the quality of the participation is going down.

Perspectives of the disability people:

The strength based model is very practical for the disabled. Client empowerment is a central theme to this approach. To empower a client, the evaluation must be made to the disabled person and thus the achievable goals will be made along with the evaluation so a well-organized plan will be carried out to achieve the goals and the possibility of the success will hopefully be very high. Critics of the strength perspective suggest this is simply reframing problems in a better light. No one will succeed while being convinced that they will fail.

Perspectives of the disability people:

The case management model is widely used in our lives and it’s easy to be carried out. The perspective is that this model will be continuingly development and improved during the practice in reality. It will play a main role in the recovery or dealing with the disability problems. The potential ability and interests will be found during the process of the treatment so there will be a bright future of this model.

Summary of the expected outcomes for the disabled:

For the case management model, the client’s life is fulfilled and interesting than before. Also this is very good for the psychological development like the strength based model. And it will be a big contribution to the arrangement of the arrangements of the physical therapy. But this model is not good for finding an occupation for the client and it is easy to make the client depend on others.

Comparisons of the two models

The strength based model focus mainly on developing and finding the client’s strengths and abilities and makes a plan based on this. However the case management model is a bit similar to the strength based models as they both respect the needs of the clients. But the case management model focus on the hobbies of the client and encourage them to attend relative activities so that the purpose of treatment is achieved during the community time. Comparing with the strength based model, the case management model plan is relatively fixed because the client’s hobbies and preference are stable but the strength based model is very flexible and keep changing with the client’s condition. The two models also have difference with the coordinating part. The strength based models need a high level of coordinating between the client and the case management however the case management model requires a good relationship between the activity coordinator and the client as well as the relationship among clients. If the clients have mental goals we suggest that they choose the strength based model but if the client has the needs of physically requirement then we’d better use the case management model for her.

Review of databases on social care, psychiatry, and psychology revealed various strategies for preventing sexual abuse in people with intellectual disabilities. These procedures generally seem to fall into one of three broad categories: therapeutic measures, designed to minimise the effects of abuse; education and training for staff, victims and/or family members (e.g. parents); and multi-agency information sharing.

Kroese and Thomas (2006) tested the value of Imagery Rehearsal Therapy (IRT) for treating sexual abuse trauma in learning disabled people experiencing recurring nightmares. The intervention produced a statistically significant reduction in distress. Furthermore, these positive effects seemed to endure even when participants were awake. Several studies have evaluated the merits of ‘support groups’ for victims of abuse (e.g. Singer, 1996; Barber et al, 2000). For example Singer (1996) organised ‘group work’ for adults living in a residential home. The aim was to teach these individuals how to respond assertively in situations of abuse. Assertiveness is an essential skill for victims who often fail to challenge authority, due to low self-esteem, fear, dependency and lack of awareness of their rights (MENCAP, 2001). Participants learned to respond more assertively when role-playing situations that involved sexual abuse. However, role-play scenarios often lack the stressful conditions of real-life that may prevent an individual from speaking out. Nevertheless, support groups may provide a valuable therapeutic resource for victims of abuse (Barber et al, 2000).

The National Association for the Protection from Sexual Abuse of Adults and Children with Learning Disabilities (NAPSAC^[1]) identifies the sharing of information between protection agencies as a valuable prevention strategy (Ellis & Hendry, 1998). Based on data from a survey of individuals and organisations involved in social care, Ellis and Hendry (1998, p.362) emphasised the need for a “foundation level of awareness” between specialists in learning disability and those involved with child protection. Lesseliers and Madden (2005) report the establishment of a ‘knowledge centre’ to encourage systematic exchange of sexual abuse information, which is accessible to both victims and specialists (also see Stein, 1995). The problem with information sharing schemes is that they primarily benefit service providers (e.g. expanding their knowledge of available therapies), rather than the victims themselves. Finally, several studies have tested the efficacy of education and training programmes, targeted at staff, victims, and/or family members (e.g. Martorella & Portugues, 1998; Tichon, 1998; Bruder & Kroese, 2005). Bruder and Kroese (2005) reviewed clinical studies that evaluated the value of teaching protection skills to learning disabled adults and children. Findings revealed that adults could be successfully taught such skills, although the generality and longevity of these abilities was questionable. Martorella and Portugues (1998) conducted workshops with parents, based on the premise that prevention is best achieved by making family members aware of sexual issues concerning their children. Parents were provided with printed materials and videos on puberty, childhood sexual fantasies, and other related topics. Following these sessions many parents re-evaluated their children, and demonstrated a renewed urge to support and protect their children. Overall, training and education schemes seem to have immediate albeit short-lived psychological benefits, for both the victim and their families.

Discuss the Similarities in “Vulnerable Adult Sexual Abuse” and “Child Sexual Abuse”

There are similarities in terms of the reasons why disabled people are susceptible to abuse (MENCAP, 2001), psychopathological and social effects of abuse (Sequeira & Hollins, 2003), consent issues, and protection requirements (DOH, 2002a, 2002b). The MENCAP (2001) report identifies seven reasons for increased vulnerability in adults, most of which may equally apply to children; they include low self-esteem, long-term dependency on carers, lack of awareness, fear to challenge authority, powerlessness to consent to sexual relationships, inability to recognise abuse when it occurs, and fear of reporting incidents of abuse. These concerns are compatible with factors the National Society for the Prevention of Cruelty to Children (NSPCC, 2002) implicates in child vulnerability. They include: children’s lack of awareness and education; a learned reluctance to complain; dependency on carers, which can make it difficult for a child to avoid abuse; and general disempowerment. Whereas factors such as fear of authority and low self-esteem may be ambiguous, and hence difficult to detect, long-term dependency on a care giver is a much more tangible characteristic that increases susceptibility to abuse, in both adults and children. The risk may be higher in children because their level of dependence is usually more extreme. However, severely impaired adults may also be highly dependent on another person for their day-to-day care (MENCAP, 2001).

In their review of the literature on the clinical effects of sexual abuse in intellectually disabled people, Sequeira and Hollins (2003) found that both children and adults exhibited behavioural problems, sexually inappropriate behaviours, and various forms of psychopathology. However, some evidence suggests that children may be more ‘overwhelmed’ by the experience of sexual abuse, often with long-term and harmful consequences for mental health (Green, 1995). Moreover the damaging effects of sexual abuse may be compounded in both adults and children when the abuser is known to the victim (e.g. family member). However, Sequeira and Hollins (2003) warn against drawing conclusive inferences regarding the clinical impact of abuse on disabled populations. Firstly many studies rely on ‘informants’ (e.g. family members) for their data, many of whom may be ignorant of the internal psychiatric and cognitive trauma that a disabled person might be experiencing. Thus, any apparent similarities between children and adults in how they respond to sexual abuse may not reflect less obvious discrepancies in psychopathology. Sequeira and Hollins (2003) emphasise the need for more reliable diagnostic criteria.

The MENCAP (2001) report stresses the issue of consent. Both children and adults often lack the ability to give consent albeit for different reasons. Children may simply not have any understanding of sexual activity, its consequences, and how to distinguish sexual behaviour from other forms of physical contact (e.g. hugging) and personal care (e.g. bathing). Although most adults will have a better grasp of sexuality, some may be unable to give consent if their learning disability is extremely severe. Regardless, adult and child sexual abuse denotes a lack of consent. Furthermore, both forms of abuse may require similar safeguards. There is a mutual need to create more awareness amongst the general public about the vulnerability of people with learning disabilities (NSPCC, 2002). Community building, staff training, and other protective measures will benefit both children and adults (Ellis & Hendry, 1998; Barter, 2001; Davies, 2004).

Can the “Keeping Safe” Child Protection Strategy Work with Adults with Learning Disabilities?

The Department of Health has made various recommendations for “keeping children safe” (DOH, 2002a). These include: having a sound statutory framework; encouraging professionals from different specialities/agencies to work together; assessing children’s needs and the range of support services provided by organisations and community groups; considering the impact of strategies designed for vulnerable adults on children; involving both children and family members in making decisions about what services the child needs; monitoring how well councils are delivering the system; and recruiting, training, and supervising adequate care staff. These proposals are a direct response to the Victoria Climbie Inquiry report. Overall they emphasise risk assessment, recognition of abuse, and information sharing, consistent with other published literature (e.g. Ellis & Hendry, 1998; Lesseliers & Madden, 2005). By contrast, the Department of Health prescribes a different set of guidelines for adults, referred to as the Protection of Vulnerable Adults Scheme, or POVA (DOH, 2004). Central to the scheme is the POVA list: “Through referrals to, and checks against the list, care workers who have harmed a vulnerable adult, or placed a vulnerable adult at risk of harm, (whether or not in the course of their employment) will be banned from working in a care position with vulnerable adults. As a result, the POVA scheme will significantly enhance the level of protection for vulnerable adults” (DOH, 2004, p.5). The POVA system is supposed to complement other schemes, such as MENCAPS “behind closed doors” plan (MENCAPS, 2001).

The child protection scheme can be adapted to work with adults. Many child safety measures focus on staff performance (e.g. working together, recruitment, training). For example, it is a requirement that staff are trained sufficiently to recognise “whether a child’s injury or illness might be the result of abuse or neglect” (DOH, 2004, p.7). By implication, it should be possible to modify training protocol so that staff can also identify sexual abuse in vulnerable adults. For example, Lunsky and Benson (2000) identify some issues to be considered when interviewing developmentally disabled adults about sexual abuse, notably the appropriateness of using detailed drawings and dolls used in assessing children (Martorella & Portugues, 1998). Proposals designed to help identify the need for protection and facilitate information sharing, such as community “neighbourhood watch” arrangements, can be extended to adults. What modifications would be required? MENCAPS (2001) highlights the need for a suitable mechanism for establishing consent between adults. Vulnerable adults have the same sexual rights and privileges as the general population, and these rights have to be accommodated within any protection strategy. Staff training on child protection can include guidelines for identifying adults who are able to give consent to sexual relations (e.g. suggesting appropriate tests to use), and protecting those who can’t. Additionally, MENCAPS (2001) emphasises the need to “tighten standards for people who work with adults” (p.16). The POVA scheme is set up precisely to address this issue, albeit retrospectively, after abuse has occurred (DOH, 2003). Improvements in staff recruitment, training, and monitoring can be implemented that benefit both children and adults.

Bibliography

Barber, M., Jenkins, R. & Jones, C. (2000) A survivor’s group for women who have a learning disability. British Journal of Developmental Studies, 46, pp.31-41.

Barter, K. (2001) Building community: a conceptual framework for child protection. Child Abuse Review. 10, pp.262-278.

Bruder, C. & Kroese, B.S. (2005) The efficacy of interventions designed to prevent and protect people with intellectual disabilities from sexual abuse: a review of the literature. Journal of Adult Protection, 7, pp.13-27.

Davies, L. (2004) The difference between child abuse and child protection could be you: creating a community network of protective adults. Child Abuse Review. 13, pp.426-432.

DOH (2002a) Safeguarding Children: A Joint Chief Inspectors’ Report on Arrangements to Safeguard Children. London. DOH.

DOH (2002b) No secrets: The Protection of Vulnerable Adults from Abuse: Local Codes of Practice. London. DOH.

DOH (2004) Protection of Vulnerable Adults (POVA) scheme in England and Wales for care homes and domiciliary care agencies: A Practical Guide. London. DOH.

Ellis, R. & Hendry, E.B. (1998) Do we all know the score? Child Abuse Review. 7, pp.360-363.

Green, A.H. (1995) Comparing child victims and adult survivors: Clues to the pathogenesis of child sexual abuse. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry. 23, pp.655-670.

Kroese, B.S. & Thomas, G. (2006) Treating chronic nightmares of sexual assault survivors with an intellectual disability – two descriptive case studies. Journal of Applied Research in Intellectual Disabilities, 19, pp.75-80.

Lesseliers, J. & Madden, P. (2005) European Knowledge Centre for the Prevention of and Response to Sexual Abuse of People with a Learning Disability. Learning Disability Review, 10, pp.18-21.

Lunsky, Y. & Benson, B.A. (2000) Are anatomically detailed dolls and drawings appropriate tools for use with adults with developmental disabilities? A preliminary investigation. Journal-on-Developmental-Disabilities. 7, pp.66-76.

Martorella, A.M. & Portugues, A.M. (1998) Prevention of sexual abuse in children with learning disabilities. Child Abuse Review, 7, pp.355-359.

MENCAP (2001) Behined Closed Doors: Preventing Sexual Abuse Against Adults with a Learning Disability. London. MENCAP

NSPCC (2002) Disabled children and abuse [online]. London, NSPCC. Available from: [Accessed 10 March 2006].

Sequeira, H. & Hollins, S. (2003) Clinical effects of sexual abuse on people with learning disability: Critical literature review. The British Journal of Psychiatry, 82, pp.13-19.

Singer, N. (1996) Evaluation of a self-protection group for clients living in a residential group home. British-Journal-of-Developmental-Disabilities. 42, pp.54-62.

Tichon, J. (1998) Abuse of adults with an intellectual disability by family caregivers: the need for a family-centred intervention. Australian Social Work, 51, pp.55-59.

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