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Demonstrate your understanding of the main principles of TASK CENTRED PRACTICE. Consider the strengths and weaknesses of the theory in its application to anti discriminatory practice.
Introduction

The International Federation of Social Work states that:

“The social work profession promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance well-being. Utilising theories of human behaviour and social systems, social work intervenes at the points where people interact with their environments. Principles of human rights and social justice are fundamental to social work”^[1].

The best kind of social work is that which places the client or service user at the centre of everything it does. This is a core principle of task based social work, rather than working with a set of preconceived ideas the social worker has to negotiate the legal framework within which she/he is obliged to operate in order to achieve the best results for the service user. Task based social work is therefore first and foremost ethical and anti-oppressive social work which takes as its foundation the Human Rights Act of 1998 that each person should be dealt with in terms of the concept of the inherent worth of the individual.

This assignment will first give some definition of the role and responsibilities of the social worker. From within this framework it will then look at the main principles of task centred practice and will use imaginary scenarios to consider the strengths and weaknesses of the theory and its application to anti-discriminatory practice.

Social Work

People looking for a career as a social worker usually have more luck if they have had some experience of dealing with individuals in the community. This could involve work placements or being involved with voluntary work, both of which seen as good practice and background to engage in social work practice. Prior community involvement is seen as a valuable asset for anyone wishing to become a social worker. Social services is set against a background of voluntary charity work in the late nineteenth century and people who get involved in community work are seen to have the right kind of spirit, or an interest in social justice that is a valuable part of social work (Moore, 2002).

Tasks and Roles Within the Legal Framework

The social worker’s role is outlined by what was the personal social services. The overall aim of social workers is a concern with individuals and the care they may need. Under Government legislation and the Code of Practice, social workers have to act in accordance with the 1998 Human Rights Act, the 1990 NHS and Care in the Community Act (a result of the 1988 Griffiths Report), the Chronically Sick and Disabled Person’s Act of 1970 and the 1995 Disability Discrimination Act. More recently social workers are legally required to be involved in partnership working with other agencies (ref) and this has been extended to include the service user/service provider relationship. There is, arguably, some truth in the fact that this takes what is at heart a charitable search for social justice and puts it on a par with businesses and at the mercy of market forces.

The primary work behind task centred practice is the identification of social systems, what they might be and what they do. Thus the properly qualified social worker needs a good deal of sociological knowledge with regard to things like class, gender, race and religion. He/she would also need to be aware of Parson’s work on social systems and socialisation because this gives an insight into the boundaries from which a service user may be operating (Payne, 1991). Once social workers are aware of social systems and how they operate then it is possible to be able to define any imbalances within a working relationship (Payne ibid). This last is a necessary part of anti-oppressive and anti-discriminatory practice, however, we shall see that task centred practice can be a two edged sword for the social worker.

Payne’s (1991) systems analysis is essential to task centred practice because it provides the social worker with a conceptual basis to start breaking a problem and its solution into manageable pieces.Task centred practice is based on the idea that people learn by doing and that when they have a success this then improves their performance (Hanvey, 1994). Task centred theory is further premised on the view that tasks are a series of steps that a professional would take in order to help a service user achieve a goal. This goal would need to take into account the rights and responsibilities of others as well as those of the service user.

There are three key parts of task centred practice the first part of this process focuses on the problem or situation that the social worker is faced with, for example a young mother who has been hospitalised with mental health problems and now wishes to look after her child herself. In this situation the social worker would have to break the problem down for example what might the risks to the child be if it was left unsupervised with a mother from a difficult client group? The social worker would begin by looking at the whole picture and then focus on particular aspects of the situation that could be problematic. Added to this as the social worker investigates the problem further he/she may find the shape and scope of the problem changing (Hanvey, ibid). Thus the social worker has to establish certain parameters e.g. the urgency of the problem and the chances of failure or success as well as any support the service user may have. In the case of a young mother with mental health issues for example the following problem might occur:

If the social worker needs to make a visit and the service user refuses to allow entry this could cause problems with regards to any future assessment, something which is required by the legal framework. According to the terms of the Community Care Act of 1990 (circular LAC (92) 12, any needs assessment would have to take into account that persons current living situation, any help or support from friends and relatives and what she herself hopes to gain from the assessment. Because of mental health needs this client would be entitled to a specific type of assessment.^[2]

A task centred approach involves looking at what the service user wants (in this case to have parental rights and control of her child), what the problems might be. If an earlier assessment has shown that family and friends would be able to offer little in the way of help and a young child is involved then the social worker has a duty to search for alternatives. If the mother’s care of the child is erratic and she is posing a problem for other people around then it would be the social worker’s duty to call in the medical officer of health who then has to obtain an order from the magistrates’ court. This would allow the social worker to gain entry and to assess the situation and the needs of the child, however, this could bring the social worker into a value conflict situation (this, I think is one of the problems with the task centred approach).

Task centred social work means that once the social worker has defined the problem and the hoped for outcome, he/she then has to decide whether the outcome is really attainable and what the consequences might be if it were achieved. With the imagined scenario used here achieving what the client wants could involve the social worker in a variety of problematic situations.

Ethically speaking the interests of the service user should take priority. However the social worker has a duty to bear in mind the BASW guidelines on ethical practice, Boulton (2003) has said of this:

In exceptional circumstances where the priority of the service user’s interest is outweighed by the need to protect others or by legal requirements, make service users aware that their interests may be overridden (Boulton, 2003 p.10).^[3]

Where it has been estimated that a child may be at risk then a social worker has a duty of care under the 1989 Children’s Act. At the same time there is a requirement to act within a framework that is informed by the Human Rights Act of 1998 and the rights of the mother have to be taken into consideration. There is a dilemma here for the social worker because a wrong decision could result in harm occasioned either to the child or to the mother as a result of her own actions. In such circumstances a social worker is bound to make an assessment of risk, and also probable harm. If harm is occasioned then the social worker could be held to account.

The (system we are in now is almost ready to treat every death as chargeable to someone’s account, every accident as caused by someone’s criminal negligence, every sickness a threatened prosecution. Whose fault? Is the first question (Douglas, 1992:15-16).^[4]

Clearly this situation needs a multi-agency approach including the social worker, his/her immediate superior, someone from the child protection scheme, the mother’s GP, the health visitor and the mother. Putting the child on the child protection register with regular reviews may help alleviate the situation and is in line with the requirements of the 1989 Children’s Act. This could therefore become a case where the service user’s rights will be overridden because the primary duty is to the child. This is where a social worker would be faced with a conflict of ethics and values which may lead to a practice situation where, as a practitioner, the social worker cannot be right. The final part of a task centred approach is to define just how long a social worker can give to a particular case and this is almost impossible to define, particularly in the imagined scenario above. A case like this could go on for years with different levels of professional involvement.

Conclusion

Task centred theory, I believe is a good starting point for social workers as it provides some sort of framework for dealing with some of the problems service users may present. While the theory is meant to support anti-oppressive and anti-discriminatory practice, this relies on a thorough understanding of social systems and how they operate. On the other hand there are some situations where a social worker has to weigh the needs of one person against another and this can result in apparent oppression and neglect of a service user’s human rights. The fact of the matter is that there will always be cases where someone is the loser and this is a sad fact of social work experience.

Bibliography

http://www.gscc.org.uk/NR/rdonlyres/30BC32F2-20B2-4D90-ABAB-3666D5BB44EB/0/Rolesandtasksconsultationpaper.pdf accessed 31st March 2007

Boulton, J 2003 Code of Ethics for Social Work available at http://www.basw.co.uk/articles.php?articleId=2&page=14

Hanvey, C and Philpot, T. 1994 Practicing Social Work New York, Routledge

Kemshall, 2002 Kemshall, H. 2002. Risk, Social Policy and Welfare Buckingham, Open University Press p.9

Payne, M. 1991 Modern Social Work Theory. A Critical Introduction, London: Macmillan.

The Care Programme Approach Policy: towards integrated care programme approach and care management (2000) South London and Maudsley NHS Trust

1

Select a social work intervention, evaluate its theoretical roots and influences and compare it to at least one other approach. Describe briefly how you would apply your chosen approach in work with a service user or carer group and evaluate its effectiveness. Use at least one piece of research to inform your evaluation. You will need to demonstrate the ability to detect, understand and evaluate potential for discrimination generally with particular emphasis on two specific areas.

This paper will evaluate the theoretical roots and influences of two psychological social work intervention theories – task-centred and crisis intervention. They will be applied to practice with a children and family setting. The potential for each intervention to discriminate on the grounds of age and race will be demonstrated and evaluated. Both theories will be contrasted and evaluated in terms of their strengths, weaknesses and effectiveness, by use of informed literature and research.

Theories can provide social workers with a safe base to explore situations and understand complex human behaviour (Coulshed and Orme 2006). Used wisely, they can promote effective, anti-oppressive practice (Wilson 2008). Theory underpins the social work degree (Coulshed and Orme) and the growing emphasis on evidence-based practice ensures theory is at the heart of the profession (Corby 2006).

The most significant theory within social work is Freud’s psychodynamic theory (Daniel 2008). Payne (2007:80) goes say far as to suggest that “psychodynamic work is social work”. It was the original theory social workers drew upon to understand complex human behaviour (Coulshed and Orme 2006). It is also the theory from which many others have been developed or as Payne (2005) suggests, opposed. For these reasons, it can be difficult to understand other theories without knowledge of psychodynamic (QUOTE, QUOTE).

Psychodynamic is a major underpinning base of crisis intervention, more specifically, ego psychology, developmental psychology, and cognitive behavioural approaches and systems theory (McGinnis 2009). These theories provide an understanding of the “particular psychological characteristic of people in such situations” (Beckett 2006, p110).

By contrast, task-centred was established within social work. Stemming specifically, from Reid and Shyne’s (1969) research into the profession (McColgan (Lindsay ed.) 2010). Reid and Shyne claim the roots and influences of task-centred were not derived or borrowed from any other discipline (Parker and Bradley, 2010; Watson and West, 2006). Therefore, Trevithick (2005) suggests task-centred should be referred to as a “work or practice”, rather than an approach. However, many writers contest this, including Doel (2009) and Marsh (2008) who assert association lies with behavioural and problem-solving approaches to social work. On reflection there are stark similarities between problem-solving tool and behavioural.

Crisis intervention was developed by Caplan from Lindeman and Caplan’s work into loss and grief (QUOTE). It “is not a single model in the way that task-centred casework is a single model, but rather a group of models for short-term work with people at points of acute crisis” (Beckett 2006, p110).

A crisis is a “precipitating hazardous event” which is “meaningful or threatening” to oneself (Payne 2005:104). Crises are often caused by “sudden loss or change” (McGinnis 2010:39). However, it is not the event that defines a crisis, but rather the service user’s perception and emotional interpretation (Parker and Bradley 2010). What may present a crisis for one may be considered a challenge for another because people have different life experiences, cultural backgrounds, coping strategies and levels of resilience. Crises can be predicable, as in Erikson’s psychosocial model (which views developmental conflicts as part of the life course), or unpredictable crises which cannot be foreseen for instance, a natural disaster, ill health and poverty or even a burglary (Hamer 2006) (ONLINE).

Crises reduce the psychological coping ability by challenging the homeostasis (normal equilibrium) (Thompson 1991). When one’s usual coping resources are unsuccessful in responding to their problem and they cannot adopt alternative internal strategies or find another way to cope, they are likely to find themselves in crisis (Hamer 2006).

Caplan argued, that “people act as self-regulating systems” (Trevithick 2005:267), in that they strive to retain homeostasis. He believed that “in addition to the occasional crises caused by unpredicted events” people experience developmental crisis throughout the life course. He further argued that “preventative work, offered at the time of such developmental crises, might be effective in reducing symptoms of psychiatric illness” (Wilson et al. 2008: 361). Unsuccessfully resolved crises can lead to psychologically incapacitating experiences such as “regression, mental illness, feelings of hopefulness and inadequacy, or destructive action” (Wilson et al. 2008:362).

Equally, crises can stir up repressed feelings (Coulshed and Orme 2006). For example, a marriage breakdown may reactivate repressed feelings of rejection and loss from being taken into care as a child. This can add “to the sense of feeling overwhelmed and overburdened (a double dose)” (Coulshed and Orme 2006:135). While this may provide the opportunity to address a repressed event, the more unresolved crises one has, the more vulnerable they are to future crises (Hamer 2006). Similarly, if unhelpful coping mechanisms are employed during a crisis, this has the potential to create another crisis (Watson and West 2006).

Crises produce “biological stress responses” whereby the “fight or flight mechanism is activated”. CHINESE MODEL This energy can be fuelled into developing new coping strategies and resilience for now and the future (Thompson 1991, p20).

Thompson (1991:10 citing Caplan 1961) uses to his three stage model to understand the characteristics of a crisis. “The impact stage” is short-lived and “characterised by stress and confusion” where the event can appear unreal. The second is the “recoil stage”. This is “characterised by disorganisation and intensity of emotion”. For example, emotions can be directed externally (anger), internally (guilt) or both concurrently. There may be psychical symptoms as well such as, “fatigue, headaches (and) stomach disorder”. The final stage is “adjustment and adaption”. Crises take on average four to eight weeks to resolve and it is during this final period that a crisis can be resolved as a “breakthrough or breakdown” (Thompson 1991:10). If unhelpful coping mechanisms are used during this stage, they have the potential to create another crisis (Watson and West 2006). As such, skilled crisis intervention during this time can lead to a “breakthrough” (Thompson 1991:10).

For application to practice, Roberts 2000 cited in Wilson et al 2008:366

Uses a seven stage model:

Assess risk & safety of service user
Establish rapport and appropriate communication
Identify and define major problems
Deal with feelings and provide support
Explore possible alternative responses
Formulate action plan
Provide follow up service

IN APP:

Try to find trigger – but don’t get lost in it
What is happening to them?
How do they normally cope internally/externally?
Do they use just psychological or social and community resources to good effect?
Opp to help back to homeo but also to improve
Min danger enhance risk
Mobilise support system – advocate
Calm, reassure, rapport, interest
Develop new techs of coping thro counselling
Remember person open for limited period
Get SU to set goals – give beginning and sense of control
Short term incremental to build confidence and new learning
Don’t set up for failure

If using the example given above, the situation does not constitute a crisis, but rather a series of/or large problem, task-centred can be utilised to address these. Task-centred practice involves five structured steps which are essential to its effectiveness (HOWE BOOK):

The first step is for the social worker to understand the problems faced, the methods used to respond to the problem and the preferred situation. These are defined and expressed by the service user (Thompson, 2005). Anna expresses she is feeling low since the recent birth of her son, she is worried she does not have the natural mothering ability and cannot remember the last time she last had an adult conversation. She doesn’t know where to turn for help. The social worker explores cultural and structural XXXXX it becomes clear that Anna cannot tell her family how she is feeling because it is frowned upon by her culture. She would love to feel happy and in control again. Using feminist perspectiveaˆ¦.. Her cultureaˆ¦.. Ageaˆ¦..

During the next stage the social worker encourages Anna to prioritise which parts of the problems she would like to work on first. With support she breaks the problem down in manageable chunks. This process helps Anna to see that her problem is not insurmountable; it gives her hope and a focus. It is essential during this time that the social worker remains empathetic and builds Anna hopes.

The following stage is based upon negotiation in partnership. Together, Anna and social worker agree a maximum of three problems for desired change. Each goal must be “specific, measurable, achievable, realistic and time-bound” (Doel AND WHO YEAR p36) to ensure Anna is not set for failure. The first of task might be for Anna will visit the local Children’s Centre next week to find out what services they offer. The second step could be attending a session as the Children’s Centre. A timeline for the tasks (usually 12 weekly sessions), together with agreement of who will complete which tasks will form a written contract, signed by both parties.

The agreed contract is implemented and monitored until evaluation or termination. This allows for flexibility should this be required (such as extension of time or reorganisation of problems).

Anti-oppressive practice lies at its core of task-centred and the values of social work practice are integrated.

Partnership working promotes social justice and seeks to reduce the power imbalance between worker and service user. Thompson (2007, p50) agrees stating “user involvement and partnership working are part of a political commitment to promoting social justice, social inclusion and equality.” These aspects are further supported by the British Association of Codes of Practice, Codes of Ethics for Social Work (DATE) (24 October 2010).

The promotion of choice for service users by their own identification of the problem and prioritisation of their goals empowers. It also views the service as an expert in their situation. The nature of breaking down problems (often considered insurmountable) builds a sense of hope for service users to overcome them (QUOTE)

The simplicity of the model means it is easy to understand and apply and enables service user to use it for future problem solving (Doel and Marsh 1995). This builds resilience and empowers service users.

The model recognises and builds upon service users strengths because it considers they have the personal resources to solve their problems with limited support. This empowers by enabling service users to take control and ownership (McColgan, (Lindsay ed.) 2010).

A contract provides transparency and clarity. It places the focus on the problem, rather than the individual. It also allows for flexibility for the level or duration of support to be increased or goals to be reorganised.

Because the model is time-limited it decreases the risk of dependency and creates motivation to respond to tasks (Doel AND WHO, DATE, p36).

The successful completion of tasks, lead to personal growth of the service user, in terms of confidence and self-esteem for now and for the future.

For the worker and agency it offers a time and cost effective intervention. It also saves on future resources by building service users to solve their own problems in the future.

A note of caution is that it would be oppressive and ineffective if used with service users with limited cognitive functioning (such as poor mental health, learning disability or dementia). The model is also incompatible where there are complex underlying issues because it cannot address them. Additionally, it may not consider structural oppression such as class, poverty, ill health, gender or racial oppression.

Because of the nature of partnership, service users need to be willing to participate for the model to be effective (Trevithick 2005).

A written, signed contract may encourage a power imbalance between social worker and service user, placing the social worker as the expert.

Marsh (Davies ed. 2008) warns that while task-centred practice may be the most popular theory among social work students, perhaps owing to its simplicity. The quality of its application is often undermined. Many believing they are carrying out task-centred practice work, when actually they are not. PAGE 121

BBB

In applying crisis intervention the social worker must establish a rapport with Anna using skills of empathy and active listening, while also assessing the risk of harm to Anna and her child (Mc Ginnis 2010). Importance should also be given to the non-verbal communication of the service user.

Anna should be supported in exploring the problem (the objective facts) and her emotional response to the problem (the subjective) (Beckett 2006). The social worker can assist by asking sensitive open questions (to ensure it remains Anna’s story) and responding by showing acceptance. McGinnis (2010, p45) claims “showing acceptance is key to effective relationship building”. It can also promote anti-oppressive practice and social justice by not judging the service user. The information collected should focus upon the here and now, although the past should be acknowledged.

The social worker should find out the attempts Anna has made to respond to her problem, while at the same time reassuring Anna. McGinnis (2010:45) suggests achieving reassurance by “gently reframe(ing) the client’s perception of self and events into a more realistic understanding of the situation”. Therefore, the social worker could say ‘I imagine you feel isolated’; ‘It sounds as if you have had a lot to cope with one you own’. Empathy should be shown the entire intervention by the social worker, by use of lexis and non-verbal communication.

If the service user is assessed as being in crisis the social worker can explain the concept of crisis intervention and agree the nature of the work to be carried out.

Arguably crisis intervention is also anti-oppressive. It seeks to effect positive change in behaviour now and for the future, through the building of resilience and coping mechanisms. It can also release service users from their past by addressing repressed issues. All of which results in empowerment of service user.

Integrates with codes of practice – WHAT CODES – Active listening and empathy

Crisis intervention provides a safe structure of intervention for social worker, service user and use by voluntary agencies in addition to statutory. QUOTE

The time limited nature is anti-oppressive because it reduces the risk of dependency for the service user. Additionally, it provides an economical intervention for the social worker and agency. This is supported by research undertaken by the NCHaˆ¦. (QUOTE)

Factors such as individual culture, values, gender, race, class and age can be taken into account because the service user is the expert and defines their own experience. (QUOTE)

Crisis intervention can be applied to many situations, namely, predictable crises in line with Erikson’s ego psychology model and unpredictable crises. (QUOTE)

Conversely, there are many criticisms.

The service user must be committed to working with the social worker to effect change (QUOTE)

The very nature of the word ‘crisis’ can lead to the theory being used inappropriatelyaˆ¦.. sw may assume su in crisis due to event

There is an imbalance in the power dynamic between social worker and service user because of the vulnerable nature of the service due to the crises. Moreover, the social work is considered the expert. This can leave room for unethical behaviour on the social workers part (QUOTE)

As crisis is short-lived, many social work agencies may not be able to respond fast enough to take full advantage of this window (Wilson et al. 2008). KEYWORD the brevity of the intervention may not be long enough to resolve a service users issues fully (QUOTE)

Research suggests that people respond to crises differently and at varying speeds, due to age, culture and cognitive impairments. Thus the model may need to be adapted to suit the service user and the situation, although, adaptation may render it unsafe for practice (Wilson et al 2008).

The theory involves active listening and empathy on behalf of the social worker. As the intervention involves use of active listening and empathy on behalf of the social worker, this may provoke many emotions. The social worker must remain empathetic and professional with an awareness of self.

Crisis intervention is also criticised as being Eurocentric. Ignoring different traditions and cultures and being concerned simply with fixing the problem as quickly as possible (Wilson et al. 2008). This can lead to oppressive practice.

In conclusion

Psychodynamic as discussed, was the theory of the day. It provided according to Howe (2009), complex, inefficient, open-ended intervention. In comparison, task-centred offered an effective, simply structured, easy to understand, time-limited approach, which dealt with the here and now (Howe, 2009). Reid and Shyne’s concluded through their research, that short-term intervention was effective (Trevithick 2005), and that problem-solving was more likely to be successful if a deadline was in place (Marsh Davies ed. 2008).

SUMMARY

While both interventions are suitable for differing situations, there are several similarities. Both are individualistic-reformist in that neither truly addresses social change.

Both have the potential to oppress and discriminate, but this can be overcome if assessments are sensitive to anti-oppressive practice (Wilson et al. 2008:366).

They are both time-limited.

Payne (2005:105) quoting James and Gilliland (2001) purports there are three crisis intervention models: “The equilibrium model – Caplan’s (1965) original approach.” Individuals are seen as experiencing disequilibrium.

The focus is upon return them to equilibrium enabling them to respond effectively to their problems.

Secondly, “The cognitive model – Associated with Roberts (2000)”

Ego psychology developed by Erikson, views the course of life as a series milestones through which conflicts occur. Developmental psychology considers early experiences shape personalities in adulthood.

(Daniel ed-Davies 2008); “cognitive behavioural approaches and systems theory” (McGinnis 2009:37).

3.3 Strengths (pay attention to AOP and values)

Time limited – reduces risk of dependency

In line with codes of practice – WHAT CODES

SU more open to help and change at a time of crisis (for a limited period)

The Application Of Systems Theory

To a Case Study

Introduction

The following case study will detail an intervention with a 32-year old service user who was referred with a range of presenting issues and needs. It was apparent that a complex array of family, social and agency networks existed, indicating that the focus of any intervention would necessitate the addressing of these various components and their role in the service user’s functioning. It was decided that employing systems theory would be the most efficacious approach in managing the service user’s needs.

General systems theory was first proposed by von Bertalanffy (1968) as a universal theory of the organisation of parts into wholes. A system was defined as “a complex of interacting elements”. Although this paradigm was initially applied to the physical world (mathematics, biochemistry, etc), it was adopted by the therapeutic community in order to formulate an understanding of systems comprising individuals and organisations. Some of the ideas and concepts systems theory has brought to the field include:

Families and other social groups are systems having properties which are more than the sum of the properties of their parts.
Every system has a boundary, the properties of which are important in understanding how the system works.
Changes within systems can occur, or be stimulated, in various ways.
Communication and feedback mechanisms between the parts of a system are important in the functioning of the system.
Events such as the behaviour of individuals in a family are better understood as examples of circular causality, rather than as being based on linear causality.
Systems are made up of subsystems (e.g. parental, marital, siblings) which are themselves parts of larger suprasystems (e.g. extended family, the neighbourhood, hospital).

(Beckett, 1973).

The service user was a 32-year old male of Afro-Caribbean origins, with a diagnosis of schizoaffective disorder dating back to his early teens. He had been residing in a semi-secure forensic unit for more than two years and was detained under Section 3 of the Mental Health Act. In terms of family history, he had been conceived through rape and fostered by distant relatives in Trinidad. Upon the death of his foster mother, his natural mother arranged for him to leave Trinidad and enter the UK. Shortly after this, he became involved with the mental health system and the criminal justice system. Subsequently, his mother had refused all contact with him and would not engage with any of his care. The sole family contact had been his maternal grandmother.

A genogram is a useful adjunct within assessment and treatment when utilising systems theory (e.g. Guerin and Pendagast, 1976), in that it gives a concise graphic summary of the composition of the systems surrounding an individual. A genogram depicting DE’s particular systems was prepared and is illustrated in Figure 1.

Within the genogram, DE’s familial relationships are illustrated, showing the existing subsystem with his maternal grandmother. Other subsystems include, DE’s relationships with the criminal justice system, mental health services and with myself, his social worker.

With regard to using systems theory in my assessment and intervention of DE, this would encompass developing a hypothesis concerning the nature of the relationships DE has with aspects of his system and how this impacts upon his functioning. In addition, circular questioning would be employed to test this hypothesis and promote change (e.g. Selvini Palazzoli, Cechin, Prata and Boscolo, 1980a). Each of DE’s presenting needs will be explored within the context of his wider system and the methodology inherent to systems theory employed in my intervention.

Figure 1: A genogram of DE’s case.

The Referral

DE was a statutory referral which was accompanied by a challenge from his legal representatives to the local authority, claiming that they had failed in their duties towards DE as he was medically fit for discharge and did not need to be detained under Section 3 of the Mental Health Act. Although discharge from Section 3 was agreed, no plans were presented to the mental health tribunal by the local authority regarding the arrangement of appropriate accommodation. From the perspective of the social worker, plans were therefore required to implement Section 117 and organise appropriate after care and accommodation. In order to do this, it was necessary to identify DE’s wishes and preferences as far as possible, in addition to managing any risk perceived by the multidisciplinary team and the mental health tribunal. A transfer CPA to the community team was organised in order to maintain DE in the community and facilitate his recovery. Adhering to the notion of “goodness of fit”, inherent to systems theory (Payne, 2002), that is enhancing the match between the individual and their environment, ways of developing, maintaining or strengthening supportive interventions and reducing, challenging or replacing stressful systems were explored.

Assessment

An assessment of DE’s presenting needs was conducted in order to formulate a hypothesis based upon the information available which would then provide a starting point and guide to subsequent interventions. According to Selvini Palazzoli et al. (1980a), a hypothesis is “neither true, nor false, but more or less useful”. Therefore, it was important to maintain this stance when considering the circumstances surrounding DE’s case. By seeking information from DE and others within his system, I was able to obtain as many perspectives as possible and construct an understanding, or story, as to how he had come to be “stuck” and enable him to move in a more helpful direction.

Both DE and the multidisciplinary team involved in his care agreed that he required 24 hour residential care, as previous supported accommodation had not been able to facilitate his needs and he had relapsed, leading to his admission to hospital under section. Additional presenting concerns reported by DE included an impoverished family support network and poor finances. Drug and alcohol misuse were also evident, acknowledged by DE and verified by a positive test for cocaine. DE’s keyworker recounted how DE frequently disengaged with him and displayed challenging behaviour, including breaking rules of the care home and absconding. Indicators of relapse described by staff included a preoccupation with insect infestation, delusions of the devil attacking him and homophobic fears of male staff sexually assaulting him. In addition, non-compliance with his care plan was recognised as a precursor to relapse.

Using circular questions to derive new information about DE’s situation and the interconnectedness of the system’s components, a pattern emerged which suggested possible indicators of relapse. A principal feature of circularity is the capacity of the therapist to consider feedback from the systems involved and to invite each part of the system to relate their perspectives of other subsystems, thereby metacommunicating (Selvini Palazzoli et al. 1980a; Byng-Hall, 1988; Cecchin, 1987). Further crucial principles of circularity are asking about specific behaviours that occur, rather than feelings or interpretations and ranking behaviours in order to highlight differences (Barker, 1998; Dallos and Draper, 2000). So, for example, DE’s keyworker was asked: “what does DE do when he breaks the rules in the house”, “when you believe DE is relapsing, how do you know? What does he say or do?”, “who is most worried about DE using drugs/alcohol?”. Similarly, DE was asked such questions as: “when you abscond from the care home, who is most concerned? … and then who?”, “when you are worried about the devil attacking you, what do you do?”, “what would your keyworker say was most important for you to get sorted out?”.

A specific use of circular questioning is to define the problem (Bentovim and Bingley Miller, 2002). Hence, members of DE’s system, including his key worker, other multidisciplinary team workers, available family members and DE himself were questioned as to “what is the problem? What do you think DE/keyworker/etc would say is the problem? Who agrees with DE? Who disagrees? Who is it most a problem for?…” etc. Such information served to enrich the hypothesis that was being formulated of DE’s needs.

Over time, a systemic hypothesis evolved which incorporated the role of impaired family functioning and an early sense of abandonment by DE’s natural mother combined with the loss of his secondary, foster mother contributing to the development of a schizoaffective disorder. A further contributing factor may have been DE’s move to the UK following his bereavement and the sense of confusion and alienation this may have instilled. A pre-existing vulnerability to his mental health problems may have been activated by DE’s use of drugs and alcohol, possibly his coping mechanism to manage the previously described stressors.

In terms of DE’s behaviour within his care home, it would be important to consider physiological factors many of the concerns reported. The literature associated with schizoaffective disorders has suggested that the onset of the illness can produce cognitive deficits, including memory impairment, planning, social judgement and insight (Randolph, Goldberg and Weinberger, in Heilman & Valenstein, 1993; James and Murray, 1991). These deficits, combined with the lack of family support and underlying psychological issues, could have resulted in the issues with compliance and rule-breaking reported by the professionals involved in DE’s care.

However, within a systemic approach, it is important to consider the dynamic interplay between the individual and the various components of their system when conceptualising the problem. In DE’s case, it appeared that the effects of his drug and alcohol use and of rejection issues had not been fully considered by staff at the care home and therefore the consequences of these had been able to escalate into relapse. Furthermore, it may have been that an over-critical attitude towards DE prevailed within his care home, as has been described in the concept of expressed emotion (Leff, 1994). This has generally been reported as existing within the families of those with schizoaffective disorders and is thought to represent deficits in communication and overinvolvement.

The function of the problem is also a vital element within a systemic formulation (Reder and Fredman, 1996; Bilson and Ross, 1999) and in DE’s case his presenting issues appeared to represent both a communication of internal conflicts (loss, abandonment, etc) and as a solution to the problem perceived by him as inappropriate accommodation. Thus, his behaviour could be conceptualised as an attempt to resolve both internal and external discordance. However, clearly DE’s perceived solution only served to escalate and maintain the essential difficulty, that of his lack of engagement with help and disruptive behaviour.

Intervention

There were various strands to my intervention with DE, within which I attempted to address the issues outlined in the above hypotheses. Initially, the issue of accommodation was addressed. In concordance with a systemic approach, DE’s needs and preferences, as well as opinions derived from members of the multi-disciplinary team, were matched with available accommodation. Three suitable placements were identified which were concomitant with the needs identified in DE’s care plan, that is: 24 hour residential accommodation with staff to supervise his medication, encourage independent living skills and monitor his activities and behaviour to identify relapse indicators. DE’s opinions on the three potential placements were sought and a decision reached on the most suitable. In view of DE’s history of lack of engagement with keyworkers, it was felt that regular meetings with his care co-ordinator would be vital in exploring his concerns and potential barriers to compliance with his care plan. The use of circular questioning could be usefully extended in such meetings, in reframing DE’s perception of his concerns and enabling him to recognising the effects of his behaviour on himself and others.

Specific aspects of DE’s presenting problems were managed by referral to appropriate agencies, thus widening his system of support. For the substance misuse reported he was referred to a drug and alcohol worker. A referral to psychological services was made to address his rejection and bereavement issues. The involvement of DE’s grandmother and uncle was also an integral part of discussing his difficulties and it was postulated that at some point in the future, systemic family therapy might be helpful in providing some cohesion to DE’s family structure and enabling communication with this part of his system.

Once the initial concerns had been addressed, my role turned towards care management and a reasonable price for the accommodation was negotiated, along with the development of a comprehensive care plan which was presented to the agency’s funding panel. The funding was agreed and a discharge and transfer of care CPA was arranged. Throughout the ensuing discussions of plans, DE’s opinions were sought. In order to best meet the needs identified and ensure an optimal rehabilitation programme, DE’s care plan incorporated day care activities, psychological and community forensic input.

In accordance with the principles of a systems intervention, a non-judgemental stance was maintained throughout (Goldenberg and Goldenberg, 2004) and the notion of partnership was promoted (Dallos and Draper, 2000). Additionally, the strategy of facilitating sustained change whilst not being an expert about the system was adopted (Fleurida, 1986), although this presented certain challenges as will be discussed in the following sections.

In terms of implementing DE’s placement, it was agreed that a gradual transfer which allowed him to adjust to the new setting would ameliorate his opportunities for rehabilitation. Therefore, overnight stays and extended stays for a week prior to discharge were arranged. Initially, difficulties were experienced with DE’s compliance with some house rules and I arranged a meeting with DE and the house manager in order to discuss and negotiate these in order to prevent a breakdown of the placement. Once more, circular questions were used to elucidate the problem and identify possible routes for change. For example, DE was asked, “when you don’t comply with this rule, who is most upset?” and “what prevents you sticking to the rules?”. The house manager was asked questions such as, “What does DE do instead of sticking to the rules?” and “what reasons do you think he has for not complying?”. Consequently, specific barriers and obstacles were identified and it was possible to negotiate a way in which DE could assert his individuality within the placement setting, whilst behaving in ways which were acceptable to staff and other residents. Thus, the “fit” between DE and this particular system was enhanced.

Review and Ending

During my work with DE a dynamic, fluid hypothesis was formed which was based on systemic principles, in that it was circular, addressed relationships, was expressed in terms of what people do and believe rather than what they are and included all members of the system (Reder, 1983). The hypothesis was continually monitored and reframed during the intervention phase, which facilitated change and enabled new perspectives and solutions to be considered.

Other parts of DE’s system were also modified by posing circular questions as they allowed the various professionals and agencies involved to consider how helpful or unhelpful the strategies they employed to manage the exigencies of DE’s case were and to gain different perspectives. It is important to note that this approach is distinct from merely providing instruction or information, in that it facilitates change through the process of thinking and reasoning.

The initial focus of intervention – to provide appropriate accommodation – was successfully completed. This was rendered smoother by the gradual transition to his new setting. By the end of the intervention, I believe that DE was able to engage in a more useful way with the various components of his system and was more settled in his placement as a result. Reports from the house manager and other professionals also indicated that this was the case.

Referrals to other agencies (psychology and drug and alcohol services) which comprised a vital component of the intervention, enabled an expansion of DE’s systems and the meeting of previously unconsidered needs. His progress with these agencies was ongoing. DE’s engagement with community forensic services was valuable in gaining further perspectives into his care.

Discussion

Within systems theory, the questions themselves form a substantial part of the intervention (Tomm, 1988), as they are believed to lead towards a constructive change in the problematic experiences and behaviours of service users. In addition, questions constitute a much stronger invitation for users to become engaged in a conversation and process than do statements, instructions of information and provides stimulation to think through problems alone, thus promoting autonomy and a sense of personal achievement (Payne, 2002).

In continually seeking the views of DE and perspectives from other parts of his system, it was possible to create a clearer picture of the characteristics of the problem and to foster a sense of ownership on the part of DE. That is, because he felt part of the process of change, he would be more likely to feel comfortable with its parameters. A further part of promoting DE’s compliance with his care plan was to use positive connotation, another important principle of systems theory (O’Brian and Bruggen, 1985). Positively connoting DE’s behaviour consisted not only in reinforcing and praising his attempts to change, but also in acknowledging that his problem behaviour was serving to express his dissatisfaction with the situation he was in. An important aspect of intervention therefore was to communicate an understanding of how things had come to be the way they were. Only through doing this was it possible to challenge the existing belief system, suggesting new and different definitions of relationships. Therefore, by acknowledging the pain of DE’s abandonment by his mother with a referral to a psychologist, it enabled him to explore a different way of interacting with this part of his system. Similarly, by considering the role of drugs and alcohol in mediating his distress and enabling him to cope with his situation, other means of coping were explored.

The use of systems theory was congruent with mental health policy guidance for CPA in that it was person focused, involved all relevant agencies and required a recognition of needs in order to facilitate the movement of service users through CPA. The identification of unmet needs in DE’s case, as well as involving multiple agencies was crucial in managing his care effectively. As DE was on enhanced CPA, it was important to consider multiple care needs and to recognise that he was more likely to disengage with care. Once more, a holistic assessment and a comprehensive, multi-disciplinary, multi-agency plan which encapsulated his wider system was necessary.

Systems theory requires strategic thinking about the possibilities and limitations for change in the different systems affecting the user’s environment, as well as an understanding of the possibilities for intervention in each system (deShazer, 1982; Penn, 1982), therefore considering DE’s behaviour in specific settings and with specific individuals and agencies was a useful strategy. In addition, possessing an understanding of the possibilities for intervention within each system enabled me to think creatively about different courses of action and potential outcomes (Byng_Hall, 1988).

Review and Evaluation

In general, systems theory was a useful tool in working with DE, in that its principles guided many aspects of the assessment and intervention towards a beneficial outcome. The basic tenets of systems theory, of being respectful of all perspectives and attempting to empower the service user to implement change, are congruent with the CPA model of working. However, the principle of maintaining neutrality (i.e. forging an alignment with all parts of the system) and a non-judgemental, non expert stance (Selvini Palazzoli et al. 1980a; Fleurida, 1986) proved to be more challenging. As DE’s care co-ordinator it could be expected that a greater alliance would be formed with him and also that I would possess, in this role, information and knowledge pertaining to a variety of issues, such as financial assistance available to him. Clearly in this case, I was unable to maintain a non-expert stance. Furthermore, being non-judgemental in relation to all DE’s presenting needs (for example, his drug and alcohol misuse) was very difficult and whilst my approach could encompass the evolution of a shared understanding of this behaviour, ultimately the negative impact on DE’s mental health and stability of his placement would need to be acknowledged. Therefore, it could be said that there was a juxtaposition between CPA care management and using systems theory. However, it was possible to separate the two aspects of my role with DE and apply systems theory accordingly.

In terms of what I would do differently, I believe that a greater involvement of DE’s family would have been beneficial in order to assist him in constructing a different story or narrative around his history, which would have enriched his and perhaps others’ understanding of why problems were presenting themselves.

Applying systems theory to a service user such as DE, who may have the cognitive deficits previously described, raises some important ethical issues. Firstly, regarding the ability to give consent to such an approach being employed and to the seeking of perspectives from other parts of the system, such as family members and other workers. The potentially harmful influence of labels has been described in the literature of systems theory (e.g. Benson, Long and Sporakowski), however the use of labels such as “schizoaffective” and “enhanced CPA” would seem unavoidable when working within a multidisciplinary team which necessitates communicating with equivalent language. However, the use of systems theory creates space for thinking about the meaning and impact of these labels and is, therefore, at the very least a valuable and functional adjunct to the repertoire of strategies for managing complex cases.

Summary and Conclusion

The work carried out with DE attempted to illustrate how individuals function as a part of many systems – they are affected by these systems and they, in turn, affect the systems. I believe that the circular nature of DE’s presenting issues and needs was highlighted effectively and the intervention took into consideration this dynamic interchange and the consequences that changes in one part of a system will have for other parts. Fundamentally, I have learned that many problems arise due to a mismatch between individuals and the systems of which they are a part and the role of a social worker is to enhance the fit between the individual and the systems affecting them.

References

Barker, P., 1998. Basic Family Therapy, 4^th Edition. Oxford: Oxford University Press.

Beckett, J.A., 1973. General Systems theory, psychiatry and psychotherapy. International Journal of Group Psychotherapy, 23, pp. 292-305.

Benson, M.J; Long, J.K. and Sporakowski, M.J., 1992. Teaching psychopathology and the DSM-III R from a family systems therapy perspective. Family Relations, 41 (2), pp. 135-140.

Bentovim, A. and Bingley Miller, L., 2002. The Assessment of Family Competence, Strengths and Difficulties. London: Pavillion.

Bertalanffy, L. von, 1968. General Systems Theory: Foundations, Development, Application. New York: Braziller.

Bilson, A. and Ross, S., 1999. A history of systems ideas in social work. In, Social Work Management and Practice. London: Jessica Kingsley, 2^nd Edition.

Byng-Hall, J., 1988. Scripts and legends in families and family therapy. Family Process, 27, pp. 167-179.

Cecchin, G., 1987. Hypothesizing, circularity and neutrality revisited: an invitation to curiosity. Family Process, 26, pp. 405-413.

Dallos, R. and Draper, R., 2000. An Introduction to Family Therapy. Buckingham: Open University Press.

de Shazer, I., 1982. Patterns of Brief Family Therapy: An Ecosystemic Approach. New York: Guildford Press.

Fleurida, C. et al., 1986. The evolution of circular questions. Journal of Marital and Family Therapy, 12 (2), pp. 112-127.

Goldenberg, I. and Goldenberg, H. , 2004. Family Therapy: An Overview, 6^th Edition. London: Brooks/Cole.

Guerin, P.J. and Pendagast, E.G., 1976. Evaluation of family system and genogram. In, P.J. Guerin, ed. Family Therapy. New York: Gardner Press.

James, P. and Murray, R.M., 1991. The genetics of schizophrenia is the genetics of neurodevelopment. British Journal of Psychiatry, 158, pp. 615-623.

Leff, J., 1994. Working with the families of schizophrenic patients. British Journal of Psychiatry, 164 (suppl. 23), pp. 71-76.

O’Brian, C. and Bruggen, P., 1985. Our personal and professional lives: learning positive connotation and circular questioning. Family Prcess, 24, pp. 311-322.

Payne, M., 2002. Systems and Ecological Perspectives. In, Modern Social Work Theory, 3^rd Edition. Basingstoke: Palgrave MacMillan.

Penn, P., 1982. Circular questioning. Family Process, 21, pp. 267-280.

Randolph, C., Goldberg, T.E. and Weinberger, D.R., 1993. The neuropsychology of schizophrenia. In, K.M. Heilman and E. Valenstein, eds. Clinical Neuropsychology, 3^rd Edition. Oxford: Oxford University Press.

Reder, P., 1983. Disorganised families and the helping professions: “Who’s in charge of what?”. Journal of Family Therapy, 5, pp. 23-36.

Reder, P. and Fredman, G., 1996. The relationship to help: interacting beliefs about the treatment process. Clinical Child Psychology and Psychiatry, 1 (3), pp. 457-467.

Selvini Palazzoli, M.S., Cechin, G., Prata, G. and Boscolo, L., 1980a. Hypothesising-Circularity-Neutrality. Three guidelines for the conductor of the session. Family Process, 19 (1), pp. 3-12.

Selvini Palazzoli, M., Boscolo, L., Cecchin, G. and Prata, G., 1980b. The problem of the referring person. Journal of Marital and Family Therapy, 6, pp. 3-9.

Tomm, K., 1988. Interventive interviewing: part III. Intending to ask lineal, circular, strategic or reflexive questions. Family Process, 27, pp. 1-15.

Reflective Diary Analysis

I applied the theory of psychoanalysis to the practice situation in order to explore underlying issues which had made ME so dependent upon her partner, JM. This appeared appropriate as it would provide an opportunity to gain information about any past experiences which had contributed to her present state, in particular, the nature and origin of her anxieties and fears. Uncovering this information would then inform my practice with ME and JM and provide structure to any intervention.

The overall purpose of psychoanalysis derives from the Freudian assumption that psychopathology develops when people remain unaware of their true motivations and fears and they can be restored to healthy functioning only by becoming conscious of what has been repressed (Bower, 2005). Freud believed that the unconscious conflicts he uncovered – in dreams, in memory lapses, in neurotic symptoms – always referred to certain critical events in the individual’s early life. His observations of his patients led him to conclude that all human beings experience a largely similar sequence of significant emotional events in their early lives and that it is this childhood past that shapes their present (Freud, 1905).

Although Freud cautioned against the use of psychoanalysis in schizophrenia, as he believed that sufferers of schizophrenia had regressed to a state of “primary narcissism”, a phase early in the oral stage before the ego has differentiated from the id (Freud, 1905), more contemporary psychoanalysts have adopted a different approach. Primarily followers of Melanie Klein, they have taken the position that the schizoid position, or splitting between “good” and “bad” objects, was a normal stage of development and that schizophrenia was the late consequence of not negotiating this stage properly (Salzberger-Wittenberg, 1970). Thus, the flow of unconscious material (e.g. delusions, hallucinations and thought disorder) were actively encouraged, explored and participated in.

In ME’s case, a formulation of her presenting issues included the role of specific anxieties and fears. Anxiety has been conceptualised psychodynamically as a state of helplessness and “psychic pain”, which results from the perceived discrepancies between one’s ideal self (or ego ideal) and one’s actual self (Freud, 1926, cited in Brown and Pedder, 1991). These painful discrepancies cannot then be easily assimilated into our conscious view of ourselves and the world because of the anxiety they arouse and the consequence is a “defence mechanism” activated to subdue this psychic pain.

Using open-ended questions with ME, such as “how are you feeling?” and allowing her to respond freely revealed a little of her state of mind, ie. “very low, always tired and very sad”. It was interesting to note ME’s partner, JM’s, explanation of ME’s low mood, “the weather”, a subject he had mentioned at the outset of the encounter. This may indicate an attempt to avoid, or defend against, speaking of difficult issues and furthermore, may represent his own coping strategy. Further questions to elicit ME’s emotional state included “has it made a difference?” (regarding the use of anti-depressants) and “how do you feel about quitting smoking?”

An inherent principle of psychoanalysis is the use of transference and countertransference within any clinical encounter (Casement, 1985; Salzberger-Wittenberg, 1970). Transference is the conveyance of past feelings, conflicts and beliefs into present relationships and situations, spe

Discussion Paper on Quality Service and Impacts on Poor Service Quality in terms of reputation, Accountabilities of private and public sector and Stakeholders

Written by:

Eva Michelle S. Baculi
Shela Mae Sabanpan
Gynievel Ondasan
Epifanio Jr. Montajes
Elangkovan Balakrishnan

INTRODUCTION

Kindly Residential Care Rest Home had experienced problems regarding the quality of care of its services, in so doing, as a Geriatric Healthcare Specialist; I am tasked to organize a group of caregivers in order to produce a paper that discusses Quality Management Approaches and Techniques. Such research work will be disseminated to all health staff so that it will be implemented and eventually will improve the services of the rest home in serving our geriatric clients.

As we all know, New Zealand, like all other countries, faces the same challenge in the rapid increase in the ageing population. With this, health sector is greatly affected as it provides greater services to varieties of conditions, such as arthritis, heart disease, and even dementia, thereby health facilities, such as hospitals and rest homes have also increase their workload. Being in the health sector, it is our vital role to ensure that all our clients are given the best quality care. But then, how do we define quality service? What will be the impact if we give poor quality service in the organization with regards to reputation? What will happen to the stakeholders? And lastly, what are private and public accountabilities with regards to poor quality service? As mentioned above, it is then necessary to answer these questions to have better clarity on what it means to give quality care so that we, ourselves, could give the best quality service to those people suffering from dementia and other geriatric conditions.

What is Quality Service?

Service quality is viewed as “the degree and direction of discrepancy of the client’s perception and expectations and are influenced by five gaps” (Parasuraman et al, 1985):

Tangibles as seen on the facilities, equipment, health care workers and some communication materials such as patient’s folders, prescription forms and requests forms
Reliability or the hospital’s ability to perform the promised service accurately and dependably.
Responsiveness or health care workers willingness to aid the patient and give prompt service
Assurance or the competency, knowledge and courtesy of the health care workers and their ability to inspire patient’s trust and confidence towards the hospital services
Empathy or the caring, undivided attention given to patients by the health care workers.

Therefore, the quality of health care depends upon on the how the patient perceives. Patient perception of quality ranges from their desired health outcome, relationship with health care workers, health care workers qualifications and performances and healthcare access and choice.

To provide service quality among the clients the aim of the organization must be achieved while service performance and client’s satisfaction must be met. As we talk about service quality in health care there are many questions that would pop-up in our minds. Everyone deserves a good service quality especially in a healthcare setting or any residential care where mentally impaired clients are being taken care of. Sometimes understanding the opposite concept of good service quality will enhance your knowledge to do well on the services you provide to your clients. Especially if you are a healthcare provider, you must do your very best to provide the proper care that your client needs.

Poor service quality has a big impact towards any organization. It is because it could affect the internal and external aspects of your business. Client satisfaction must be a priority at all times. Giving poor quality service to clients could pull any business or organization down. It could negatively impact the stakeholders and shareholders because they are the ones who would be affected by poor service quality. For example in the hospital or any home care, if the doctors, nurses and other medical teams who are involved in the care are showing poor quality service to the clients, it could affect not just the hospital and the employees themselves but the organization as a whole.

IMPACTS OF POOR SERVICE QUALITY IN TERMS OF REPUTATION:

The reputation of any business or organization will be affected if poor service quality is practice. Reputation is how your organization is being perceived through the eyes and judgment of your clients, suppliers, employees and other parties that are included in your organization. An organization engages in various activities such as rendering proper quality care, responding to the needs not just to the clients but also to the significant others and their families, attending to queries and complaints if there is any in an appropriate approach, and by taking any feedback or concerns in a positive way. Through these things a strong reputation can be built by the organization which could attract and retain our clients. The organization’s reputation is the biggest and most important determining factor in the long term success of your efforts. Your reputation is recreated each day with each client that you are taking care of. In reality, however, you are not only dealing with the organization’s reputation in general but also other considerations that arise from the minds of the clients or to significant others who deal with you during the organization’s activities. Therefore, reputation is very much important because this is a key factor that determines the trust and confidence that clients will have on us. We must keep in mind that our clients will talk about us about the services we give them. If we provide poor service quality they can negatively influence the public’s perception on what our company is all about through word of mouth.

ACCOUNTABILITIES OF THE PUBLIC SECTOR:

PUBLIC SECTOR

The declining quality of service of Kindly Residential Care Rest Home led to a negative impact that resulted to a liability to the public sectors accountability and the results are the following:

Low client patronage. Because of the poor quality service, client’s family members opt to avail services of other health facilities instead of Kindly Rest Home.

Jeopardize the Rest Homes reputation. Public perception would be sour due to the above mentioned infarction, and it will taint the reputation of the health services of New Zealand. Some might think or generalize the idea that other health facilities in the area have similar problems. That is why, the District Health Board have continuously monitoring the services of all its health institutions to ensure that standardized health practices will be adhered.

Increase in staff turn-out. Since patronage of the public will be minimized of the Kindly Residential Care Rest Home, low income earning of the rest home will affect the increases in wages/ other benefits to the employees. As a result, employees will opt to transfer to other work to seek a much better wage offer and equally, recruitment will be affected considering that Kindly rest home can no longer afford to pay additional workers.

Loss of profit. With few client patronage and tainted reputation, obviously, will result to decrease in profit, not to mention that the facilities operational funding allocation will be greatly affected.

Under scrutiny of government health organization. As mentioned earlier, the District Health Board ensures that health facilities under its jurisdiction will adhere according to the standardized health practices formulated by the board. Any health institution that will violate health standards set will be sanctioned by the DHB. Possible measures will be imposed such as fines, withdrawal of public funding support, closures, reprimand and other government actions.

Leads to poor services. Poor quality of care will result to accidents due to equipment malfunction such as defective bed side rails and wheelchairs and legal actions against facility personnel will be made as a result of such negligence. Another is possibility of infection outbreak resulted from lack of disinfection materials or even poor hygiene practices and finally, contamination will affect not just to other residents, visiting family member and also to home staff.

ACCOUNTABILITIES OF THE PRIVATE SECTOR:

It is always expected that if the management is poor the quality of service to be rendered is also poor. In New Zealand there are private sectors who are also handling the health care of patients with dementia and the other common geriatric diseases. If this private sectors are not well-prepared to assist these patients, there will be a great impact on the kind of institutions they have and because of poor service quality, the patients will be affected so much. The medical staff of these private sectors should attend training on health care program. So as to widen their knowledge, skills and attitudes on the health care program. The government should not permit private sectors to start giving assistance to patients with dementia and other common geriatric diseases if not ready because they are adding more problems to the patient and to the health care program in general. It is advisable that all the medical staff of this private sector should be well informed of all the best practices in the health care program. The New Zealanders also want their country to have the best health care program. The patients need special care and attention, likewise, it is needed for this home care private sector to know well the cause and effect of the ailment of this individual patient, so the management will be able to give them the proper assistance needed, thus, giving the patient the feeling of belongingness and acceptance. That is they are accepted as individual in the society where they live. These patients with dementia will not feel insecure because of their illness or personality, but instead, have that feeling of joy and happiness. So this kind of behavior will be enjoyed by the patient with dementia if the medical staff in private sectors are well trained and are ready to assist patients with dementia and other common geriatric diseases.

There is really a need for a thorough screening of medical staff for private sectors so as to avoid poor service to their clients. These dementia patients need to be understood so it is the management to make adjustments so as to understand each other. They need a loving assistance so as to give them a comfortable life despite of their ailment. The better quality of service the better will be the result. You will lessen the stress of the patient and helping the individual a wholesome member of the community. The New Zealanders are health conscious. Therefore, private sectors should work hand in hand with the health care program of the government. There is a need for the private sectors to establish the best practice quality management health care for the benefit of the individual with dementia and other common geriatric diseases.

STAKEHOLDERS:

Stakeholders are individuals or group of individuals who are afflicted by or can control a company or product throughout its life. Without the continuing participation of these stakeholders, it would find it difficult for a company to get through, because a company and the stakeholders are mutually co-dependent. Their involvements are vital in company’s expression of values, execute its mission, establish strategies and enhance relationships continuously. Also, they are also important for involvement in performance-based sense. If the company establishes long term relationships with these stakeholders, it runs smoothly and has a better chance of earning profits, can increase production and harvest the word-of mouth benefits. However the stakes are high once a company establishes the long-term relationship with them. In this section, we will categorize these stakeholders into two:

Internal Stake Holders:

These internal stakeholders include

Clients

Clients are categorized as the consumers and patients. Since they are the final user and the payer of the health care system, they become the most valuable stakeholder; thereby, they also must be participative in their own care. They have to be informed about their illness, the kind of medical treatment and as well, be accountable of their health. They also have the right to voice out any concerns of the company.

Family Members

Family members are often said to be partners, joining forces with the health care staff in ensuring the best health care needs of the client/patient. They have the right to question any misdemeanors or wrong choice of treatments and even medications that are prescribed to the patients. It has become a common knowledge that many of this establishment face lawsuit mainly because of miscommunication between the family and the establishment. This can be reduced and corrected by giving the right information, discuss better recommendations to the patients and inform of the establishment’s policy rules and regulations. This will give a better understanding to both parties concerned and there will be a connection between them to work together for the benefit of the patient admitted there.

Care providers

Who knows the patients suffering dementia better than the care providers? Hence, the importance of the care giver is of vital importance to the patients and more so to the establishment. Nurses, aides, medical staffs, dietitians, pharmacist are all part of the category. Each and every employee takes their positions seriously as any cause of carelessness would affect the lives of the patients. It is not only essential to attain good quality care givers but they must also be protected by the establishment. There are many numerations that can be given to the care providers as incentives to take their job more seriously and also give them the aspiration that they can depend on the establishment if any crisis arises. The establishment can also furnish the care providers with better trainings and information on how to deal with the dementia patients at every level and treat the Geriatric patients with using the latest skills and equipment’s to make the treatment less stressful for the patient.

External Stakeholders:

Medical equipment supplier

Medical equipment suppliers may seem insignificant but indirectly they hold a major stronghold in the establishment. Medical equipment comes in all shape, size and functions and is one of the factors the patients depend on heavily. In this case, medical supplier has to be prompt in delivering their stock according to their records. Any equipment malfunctions must be reported immediately to the suppliers to be replaced or repaired so there will not be any disruption to the patient’s physiotherapy or exercises. It is also their role to explain the benefits of equipment and how it will benefit them in the long run. Any new products in the markets are introduced to the Health care and proper and detailed information must be given to the patients and also the therapists

Food supplier

Food is equally important factor in this establishment as it is a basic human necessity. Not only that, patients need their food on time so they can consume their medication on time therefore, the food chain cannot be broken or interrupted in any time or else dire consequences will happen. If the food supplier is not a reliable one or produces poor in quality or not in the dietary list should be terminated and a reliable one should be tendered in immediately. The establishment should check the timing and quality (freshness) of the food items at all times. This also means it has to be under the Food Act.

Care Home Building maintenance supplier

The building material supplier is also one of the many major factors that need constant reviewing. Especially in the Kindly Residential Rest Care home it is vital that all building structure is secure, safe and durable in any case of natural disasters. Safety of the patients must be the first priority. Many criteria must be given attention to, including proper and good lightings at the home, hand rails for support, and many more. Injuries and damaged grounds of the building will bring a questionable reason to the safety of the patients as well as the establishment. It is advisable always to keep in check of building maintenance and cleanliness at all times. Other stakeholders like the patient’s families are sure to note of this.

D.H.B ( District Health Board )

Every Health care facility is automatically registered under the District Health Board which is a requirement bonded by the Government to ensure the delivery of quality health care services. This procedure is done so that any legal complaint against the Home can be done through the District Health Board. The Kindly Residential Rest Care home is for the benefit of the elderly patients, patients going through Dementia and Alzheimer and other Generics illness. So the environment and the premises must always be in good conditions and abiding all the rules and regulations that will encourage more patronage to the health care. If any faults are filed against the care home, warning letters will be issued by the D.H.B. to make the changes according to the rules and regulations. If the warning letters are neglected, the D.H.B. has the right to cancel the license to run the rest home care. This will affect the entire Rest Home business and image in the health care business will be tarnished.

CONCLUSION:

In today’s world where there is an outgrowing number of ageing population and the advances in sciences that increases the life expectancy of people, the demand of health care increases. Therefore, there is a need for continuous improvement so as to satisfy the ever-increasing market. To be able to do this, it needs good quality management. If a certain organization exhibits poor quality management, it can lead to negative impacts affecting both the internal and the external aspects of the business. The company’s reputation is damaged and many would be greatly affected, the clients, the employee, caregivers, employees and worse, its existence. To avoid this from happening, it is then important that we render good service particularly to the clients, family members. Not only that, we should also need to work as a team that can lead to a long lasting improvements. We should also ensure that we adhere to the policies and procedures. With this, the result would be good quality, efficiency and profitability.

This report reflects on the care needs of 67 year old Kingsley, at 55 he was diagnosed with Type 2 Diabetes then at 65 Kingsley suffered a stroke. After a lengthy stay in hospital he was moved to a nursing home where he currently lives, he is not happy in the nursing home and wishes to be discharged and return home to the care of his wife. He displays his unhappiness to care staff with bouts of anger and frustration. He has a social worker assigned to his case who is currently undecided if Kingsley should return home to his wife, he questions the layout of the home and his wife’s ability to cope with Kingsley’s care needs. Kingsley and his wife have some difficult decisions to make and should be able to discuss these with the social worker as these will have a fundamental impact on where he lives as this will be instrumental to his wellbeing.

Living with a long term health condition can have its challenges when receiving health care, its paramount that a care user receives the correct level of support and information available. A psycho sociological perspective offers a holistic approach which addresses an individual’s needs and an anthropological perspective which offers a biological study of the human being.

A psycho sociological perspective addresses an individual’s psychological health and wellbeing needs which are individual to functioning within human society. This perspective highlights that factors such as age, gender, environmental living conditions and the individual differences that people face are to be considered in health needs and care issues.

A psycho-social approach to public health aims to incorporate the environment which will address the health of groups of people by social context, social class, location and how accessible they are to local resources. In the past this has been referred to as the social model of health (K217, Learning Guide 2, p43).

The structure of the social model of health aims to make health services more affective, accessible and acceptable to individuals. The components are as follows (K217, Learning Guide 2, p43).

To acknowledge the influence that health has on political, economic, social, psychological, cultural and environmental factors and also biological factors.

To improve health a focus must be placed on the socio-economic environment.

To achieve community participation with shared decision making between lay people and practitioners.

Health services to collaborate with other government agencies and sectors.

Commitment to equity and accountability in health.

The use of evidence which is qualitative and quantitative.

The concept of this perspective is that the focus of social causes are linked to illness rather genetics. If the social causes which are causing a detrimental effect on health are addressed then a better quality of life and sense of wellbeing are to be achieved. In Kingsley case he is not socially active because of the environment he is currently living in, which is restricting him from participating in any social networks, which gives the practitioners power over him so he is then not part of the decision making regarding his wellbeing.

Holism perspective

The practice of holism is to recognise that each person’s needs are unique to one’s own identity. It acknowledges that focus is to be given to lifestyles and choices which have an impact on health and illness. The approach links all aspects of a person’s physical, mental and emotional state to create a composition of a state of health and illness.

The approach of a biomedical perspective will address medical conditions with a biological, anatomy, and a physiology view but ignores an individual’s needs, as a holism approach would address the individual’s needs which would have an effect on lifestyles and choices.

So a Biomedical perspective has a place in some health conditions such as Diabetes which will address the medical needs such as insulin. But a holistic approach will identify the whole person combining their mind, body and spirit. This can be helpful for practitioners to understand how a Diabetic may be feeling with effects of injecting insulin, are they coping with self management of the condition. The whole person approach to care is to give service users the ability to move on from the professional dominance in the doctor centred model and to achieve the self care model which is to encourage independence. (K217, Learning Guide 2, p42).

Discussion.

The contribution of theory.

Do theories have a place in health and social care services and how can they help people like Kingsley who is suffering from a long term health condition.

Theories in health and social care are developed from two perspectives

Good research and medical engagements which results in theories from evidence.

Generalised practice and an understanding of experience within a profession, these theorises are developed from practical experiences.

Theories in understanding long term health conditions can be found in two perspectives bio medical and the social model of health. The bio medical approach is that the body functions normally but when things go wrong a specialist can repair the body; its focus is that biological problems can be addressed with medicine. The social model of health recognises biological factors but also includes the recognition of the influence of health being a matter of psychological and social addressing the wellbeing of an individual.

If just a bio medical approach to theory was taken of Kingsley’s situation he would have been diagnosed with two long term health conditions a stroke and type two diabetes by a practitioner then undergone biological treatment in hospital, were tests were taken and symptoms were controlled with medication. He is now living with two conditions controlled by medication. Bio medical may adapt mechanical metaphors which presume that a practitioners approach is to be an engineer and to fix what is malfunctioning with medication (K219, leaning guide 1, p36). The N.H.S. point out that a stroke is a medical emergency and should be diagnosed as soon as possible this would be in a bio medical environment. A bio medical view would be taken to determine the emergency treatment needed and also for after care with medication, therapists, physiotherapist and G.Ps. The N.H.S also highlight that the social model of health should be incorporated into a patients social care needs social workers would assess a patient and their carers needs and offer services such as meals on wheels and home care services (N.H.S. 2011).

A purely social view of theory to long term health conditions would offer Kingsley and his with sociological support in dealing with his conditions addressing needs for his wellbeing. Kingsley has experienced a change to his identity, because of his illness he feels he can no longer contribute in society. Kingsley’s illness has made it impossible for him to work so he now relies on the welfare benefit system so his identity has changed from a working man providing for his family to the sick role. The sick role can be identified when an ill person becomes exempt from a social role of responsibilities examples are because of illness, a sick person will not get better without being taken care of and the sick person will want to overcome illness and should be obligated to seek the correct professional help to deal with an illness (Parsons, 1951, p.294). This theory of the sick role has an element of social care and bio medical, society will address an ill persons needs with benefits and care issues and a biological factor will be present with medication.

What can be learnt from research and practice guidelines?

Research show that suffers from a long term health condition such as a stroke may face physical disabilities and suffer from social exclusion which can lead to spoiled identities. The Stroke Association commits approximately two and a half million pounds per year in to research of stroke prevention and treatment .Two key achievements are (The Stroke Association 2011).

Staying physically fit after 40 cuts risk of a stroke. People who are physically fit after the age of 40 can lower their risk of stroke by as much as 50 percent, ‘compared to people who aren’t as physically fit’ (The Stroke Association 2011).

The benefit of occupational therapy for stroke care home residents. A recent study funded by the Stroke Association has shown how beneficial even a small amount of occupational therapy can be to residents in care homes who have had a stroke. The study, carried out is extremely significant as the care home population is an understudied and extremely vulnerable group (The stroke Association 2011).

The research suggests that prevention can reduce the risk of a stroke and that life style changes and rehabilitation will help with the recovery process, learning to deal with the effects that the stroke has had on them and learning to adapt to the limitations caused by stroke. Rehabilitation would also address the need for any support in dealing with social, emotional and practical issues.

A government report on long term health conditions and self care (Your health, your way, 2009) is aimed at promoting discussion between health and social care professionals and people with long term health conditions, it addresses what options, support and information are available for health care users who wish to self care. The N.H.S. and social services want to encourage people with long term health conditions to self care, its shared aims and values for the transformation are to ensure that service users and their carers are not discriminated because of illness or disability and are supported to be able to:

Live independently and be able to sustain a family unit, which will avoid children taken on inappropriate caring roles.

To stay healthy and to be able to recover quickly from illness.

The ability to exercise control over their own life and if appropriate the lives of family members.

To participate economically and socially as active and equal citizens.

Have the best quality of life, irrespective of illness or disability and retaining respect and dignity.

(Your health, your way, 2009, p.4)

Self care is build around a holistic process that places the service user at the centre of their own care but also recognising that different issues can impact on an individual’s health and wellbeing so the process is supportive, individual, flexible and non-judgemental, the focus is solely on enabling the individual to achieve the outcomes that they want for themselves.

People who use services completed a survey prior the transition to self care and after the changes had occurred the findings are.

(Your health, your way, 2009)

(Your health, your way, 2009)

The results show how being empowered to take a more active role in health and well-being can improve quality of life. People who are living with a long term condition can benefit enormously from being supported to self care. They can live longer, have less pain, anxiety, depression and fatigue, have a better quality of life and be more active and independent (Your health, your way, 2009, p.6).

Theory and practice.

The social model of disability (K217, Learning Guide 6, p43) plays a significant part in a care service user’s life, such as Kingsley. This theory accepts that people will experience differences in life because of health issues such as stroke and diabetes, but questions that the difference is the problem when society does not adapt to such differences. The theory was introduced in the 1970’s when disabled activists debated that society is the problem that faced disabled people not the individual’s disability. This approach has a commitment to improving the lives of disabled people, by promoting social inclusion and removing the barriers which oppress disabled people (Tom Shakespeare, 2006, p 9).

The biomedical paradigm ignores the differences between individuals and is criticised for overlooking social influences which have an effect to health care (K217, Learning Guide 2, p40). This is clear in the case of Kingsley; he has received biomedical treatment in the past for type 2 diabetes and now for a stroke from medical practitioners. Kingsley is now experiencing differences in life to an able bodied person as well as a change to his identity to being disabled because he cannot walk or use his right hand without being aided. The nursing home were Kingsley now lives accepts his disabilities and provides care for him such as assistance to walk and use his right hand. Two people assist Kingsley to get out of bed, shower and dress him. The environment is restricting his independence and making him disabled relying on assistance and there are no aids he can use himself which would give him control of his care.

Empowering people who use services (K217, Learning Guide 10, pp28-34) is a theory which would allow Kingsley to become involved in his health care needs. The focus of the theory is the concern regarding the need for people to participate in their health care needs, and that empowerment will encourage them to use services and empower them to participate within them. People need to be encouraged to use health care services but also need to empower themselves to participate within a service. Health and social care services encourage users to become empowered; this can be with support groups with people who share similar experiences (Diabetes NHS, 2011). Key factors of the theory are that power and control should be equally divided between service provider and user, several options will be available to the user which there will have knowledge on, information supplied to assist in making decisions and if the user is dissatisfied with the system has the option to decline any further use of the system and make a complaint. Involving people who use health and social care services with empowerment gives them achievement by (K217, Learning Guide 10, p30).

Having control and being engaged with services.

Equal share of power with practitioners.

The contribution of planning individual services and the development of good practice.

Including all members of society.

Empowerments goal is to involve participation at all levels in care services allowing users to have a say and to be engaged in their care needs working with practitioners to satisfy care needs. Empowerment is a ‘way of equalising the distribution of power between users of services and practitioners’ (Tuner, MacKian, Woodthorpe, 2010, quoted in Learning guide 10, p.30).

Kingsley’s care needs are being dictated to him by the care home and his social worker if he was to be empowered to use care services and was to empower to participate in services he may be more actively contented with his care needs.

Conclusions and recommendations

Who cares for Kingsley and where he receives care are now important decisions to make. The decisions will influence his care needs and his future wellbeing. This report highlights the concerns that people who have long term health conditions face with care needs and the services that provide care.

Clearly when a person suffers from an illness such as a stroke or diabetes an emergency response for care is received from a medical practitioner who will offer a biomedical diagnoses and if needed medical treatment and medication. As was the treatment Kingsley received, the next phase in the care process is how after care support and treatment is provided for people with a long term health condition.

Kingsley’s individual care needs have not been addressed; he may be adequately receiving biomedical care in the nursing home and his basic fundamental needs for living such as shelter, food and warmth are being provided his individual needs are not being considered.

Kingsley wishes to return home to the care of his wife, a psycho sociological perspective will identify that his individual psychological health and wellbeing in society is not being fulfilled. The care home environment is restricting him from participating in main stream society; he cannot be active within society because he has no access to social networks. This will be a fundamental reason for his bouts of anger and frustration as before his illness he was social active and provided for his family. Kingsley’s care needs are unique to his new identity as a disabled person with a long term health condition, along with a psycho sociological perspective a holistic approach will help to identify the impact this is having on his health, lifestyle and wellbeing.

The social worker assigned to Kingsley is concerned that his wife would not be able to cope with his care needs, one option is to recognise what difficulties in society will be restricting Kingsley because of his disability (The social model of disability). The care home is disabling Kingsley because of its lack of practices and environment.

If the social worker was to work with Kingsley and his wife to identify the support needed to provide a self care package such as direct payments (K217, Learning Guide 10, p29) this would allow them to be independently in control over which services they use. Allowing them to live independently as a family and able to participate economically within society.

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
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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.
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Jacques Duff. (2005). Grief and the grieving process. Available http://www.adhd.com.au/grief.htm. Last accessed 04/10/09
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(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.