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Working with young people: A profile of projects funded by the Partnership Drugs Initiative
Chapter 5: Case Management
This chapter discusses the ways in which the projects managed their cases. The central issues for the projects were assessment, goal setting, case closure and the maintenance of client confidentiality.
Goal setting and assessment
The assessment of clients' needs on initial contact and the subsequent setting of goals for their interventions were common to all projects. Assessment and planning were regarded as vital in individual cases in order to maintain focus and promote progress towards closure. Most projects sought to involve clients in this process and stressed the importance of working with them towards the achievement of agreed goals. There was a strong belief among project workers that meaningful and substantial involvement of the client was an essential component of effective intervention.
It was evident that, across the projects, staff were using a variety of assessment tools depending on the client group involved and the nature of the work to be undertaken. The time taken to conduct the assessment also varied enormously across projects. Some assessments took less than an hour to complete while others such as the EuroADAD which was used by the Tayside projects or POSIT (Positive Screening Instrument for Teenagers) used by the Reiver project could involve 4-6 hours of face-to-face work. Both of these instruments are designed for use with young people and involve lengthy questionnaires. EuroADAD is a European version of an American assessment tool for adolescents, consisting of a large number of questionnaire items covering several areas of a young person's life such as school, social life, family health and substance use. The POSIT, also developed in the USA, consists of a questionnaire of 139 items which are rated by a young person to give a view of ten different areas of risk in a young person's life, including substance misuse, school, peer interaction, or mental health. Staff in the projects which were using these tools reported finding them highly accurate in assessing the needs of young people and extremely useful as devices for monitoring their progress.
Another assessment tool in common use with young people was the Rickter Scale. Also from the USA, this is less comprehensive than the instruments described above but is simpler to administer. It takes the form of a plastic board of sliding scales (from one to ten) held by the young person. These scales are used as positive/negative dimensions to indicate where the young people see themselves in different areas of their lives. Repeated administrations of the scale during the intervention, possibly on a weekly basis, allows progress to be monitored: "It is a tool that gives you a bit of insight. You say ok you said seven there. What would you like that to be? And they will maybe say nine or something like that. You can either then - it depends on how you want to do it - you can say how do you think you could improve that? And then you go into goal setting and stuff like that or getting them to see what the problems are. It is important to know what they are meaning when they go nine. What is happening at school? Is it that they are getting bullied? It could be anything. Then you can say, well what can we do? And then you
can go back and review it". |
A different set of assessment instruments was used for families in which adult drug misuse was impacting upon the children. The most popular assessment tools used in these projects were the SCODA (Standing Council on Drugs and Alcohol) assessment instrument and the Parenting Hassle Scale. The SCODA instrument was used both to assess a family's intervention needs and to monitor its progress. The three categories of risk employed by SCODA provided a basis for monitoring interventions. For example, if clients started at stage 3 (chaotic use and lifestyle) they might be brought to stage 2 (stability) by harm reduction information and support and ultimately to stage 1 (control) through counselling. The Parent Hassle Scale provides a list of problematic child behaviours and home conditions and asks parents to rate them, where appropriate, for frequency of occurrence and the extent of the 'hassle' they create. This assessment is then used to determine need and target interventions. Repeated administration of the instrument can be used to monitor the progress of the family. Other instruments employed by the family orientated projects included the Department of Health's Assessment Framework for Children in Need and the Thomas-Kilmann Conflict Mode Instrument for assessing the relationship between parents. Time 4 U had devised their own assessment tool to suit their own particular needs.
Case closure
While project staff were reasonably comfortable with the process of assessment and goal setting and reported their procedures to be both efficient and effective, the issue of case closure was much more problematic. There were three problems here. First, on most projects case closure tended to be slow because of the intensive and necessarily protracted nature of the work. In several projects, very few clients or families had exited the programme during the first year or so of their operation. Workers in some of the family projects described how it could take nine months to a year before the service felt able to disengage from them. In other words, part of the difficulty in achieving case closure is inherent to the nature of the work which these projects undertake with families and individuals. Effective and, hopefully, enduring outcomes take time to achieve.
A second problem as far as case closure was concerned was that project workers experienced difficulty in moving cases on because of a claimed shortage of services for onward referral. Although their own intervention may have reached a conclusion, their clients might still be in need of other forms of assistance and the absence of this facility could sometimes make it difficult for projects to discontinue their contact with them. This could lead to the development of backlogs of cases for which the project had exhausted its intervention but for which other forms of support were now required.
The third problem with case closure was the difficulty experienced by some projects in identifying clear criteria for defining a case as having been satisfactorily completed. Some projects had clearly tried very hard, and with some success, to devise a set of clear exit procedures and criteria. For example, with the Families First project intervention is viewed as complete when the client's action plan is empty. This is monitored through team reviews at 12-week intervals. With most projects regular reviews of progress were built into the programme of intervention. However, several projects gave the impression of having criteria for case closure that were much less precise or easy to implement. For example, in one project families were discharged 'once the worker feels that the family are on their feet.'
Confidentiality
Confidentiality was an important issue for all of the projects. There were a number of aspects to this. First, projects reported making strenuous efforts to ensure client confidentiality by keeping any written records under secure conditions and by being guarded in relation to the sharing of information with workers from other projects or agencies. Project staff were all acutely aware that any breaches of confidentiality could be highly damaging to their entire enterprise. Second, all prospective clients were assured that information on them would not be divulged to another agency without their permission, except where child protection issues were involved. However, project staff were very sensitive to the fact that this latter qualification had the potential to undermine the project's relationship with clients:
"So the first few appointments are quite tricky, really, they're quite tense as far as I'm concerned. Because you're hoping to give that client a sense that they can trust you, but at the same time you're having a boundary. You know 'if you're going to tell that to me, that you're going to harm yourself, or harm someone else, I will have to take this further'".
Child protection issues could also create a difficult working environment as far as intervening in drug using families was concerned but project staff were unequivocal that, in circumstances in which a child was at risk, it was the needs of the child that had to take priority:
"Our stance would be that you always have to take the part of the child because they're the most vulnerable. Even if you have every sympathy for the parents".
Projects also sought permission from clients and from the parents of young people to share relevant information with other involved agencies. Where a child did not want his or her parents to be informed of their referral to a project, this would be respected by the project staff.
While confidentiality regarding the nature and content of a client's involvement with a project could be preserved relatively easily, an individual's contact with a project could be more difficult to conceal. Maintaining this sort of confidentiality was partly about ensuring that the project's premises were such that a client's very attendance did not compromise their privacy. However, this could sometimes be difficult, especially in small communities or rural areas where people's movements were more visible and where workers and clients might be known to each other. Where this potential existed, projects dealt with it by ensuring that a worker was not assigned to a case in which the client's family was known to them.
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