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Care planning, case management and counselling

As a case manager in a drug and alcohol setting you are not expected to provide all the necessary services to support a person's needs, but you are expected to work with staff from appropriate agencies to provide holistic care.

Care planning and case management

Many drug and alcohol and community services use a variation of case management or care planning approaches. These approaches allow for "a process that coordinates the acquisition and delivery of services to meet individual client needs" (Marsh et al 2007a:55).

Care planning and case management is an effective approach to working with clients with complex needs. Case management may at times require a high level of coordination with external services depending on the individual's needs. Having close partnerships with relevant service providers will assist you in facilitating this process.

Your case management approach when working with clients with complex needs may require a more proactive or assertive approach to maintain client engagement. Both approaches draw significantly from the strength-based model of care and have been shown to be highly beneficial in mental health service provision.

A proactive style of case management promotes strong client engagement and close follow-up of new or fragile clients (Mental Health Services 2008). This includes people who have complex needs and people who shift between the stages of change in alcohol or drug treatment.

An assertive approach to case management focuses on ensuring the person doesn't 'fall through the cracks' by providing service support but knowing when to stand back and give support when invited. The assertive approach supports not intervening so as to abuse a person's human rights, but not passively neglecting them either. This approach requires a good and often long-term relationship with the client that fosters engagement and collaboration (Mental Health Services 2008).

There are advantages and disadvantages to these approaches in terms of accountability, coordination of services and funding models for providing services. Whatever the approach your organisation uses, the following considerations, developed to inform case management for working with people with FASD (Gelb & Rutman 2011), are a useful guide for working with all clients:

  • Establish a trusting relationship with the person.
  • Establish close and frequent communication with them (e.g. check-ins and regularly scheduled meetings).
  • Develop a care plan based on their goals, strengths and needs.
  • Facilitate transportation for important appointments.
  • Liaise with other service providers.
  • Assist the development of life skills and/or the person's participation in healthy, safe activities.
  • Establish close communication with supportive significant others in the person's life.
  • Advocate for improved communication among service providers, continuity of care and access to care/services.

For further guidance on case management and case planning see:

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Case management for people with FASD

People with FASD learn and behave differently. They are usually expected to change and adapt to the world, when in fact they can't change. Changes to the environment (both physical and social) should be considered to better support a person with FASD. Additionally, a change to more appropriate assumptions and expectations will create a better working/living/learning environment and produce successes instead of failures (Sood et al 2001).

If FASD is referenced or suspected, then treatment planning needs to reflect the adjustments, strategies and interventions that might be made in support of the person, examples of which are provided in the table below. Similar adjustments may be useful for a person with another form of mild cognitive impairment.

Examples of adjustments for FASD-related problems

ProblemReason for problemAdjustments
Not remembering to attend appointments

Poor short-term memory.

Easily distracted.

Provide reminders via SMS, phone, email.

Enlist friends and family members as reminders.

Facilitate transport and/or accompany the client to appointments.

Issues when participating in programs

People with FASD think differently and have usually felt like 'failures' at school and in previous programs. Because of this they'll often have difficulty participating in a program where it's likely these issues will crop up again.

Provide programs that are suitable for a client with a cognitive impairment.

Nothing is making a difference

Inappropriate strategies, communication and/or intervention model for a person with an organic brain-based disability.

Strategies must be appropriate for a cognitive impairment. Workers need to consider that the person may be unable to work independently as planning and organising can be very difficult for a person with FASD.

Therapeutic interventions such as cognitive behaviour therapy may be effective.

Spoken communication: Make sure language is concrete - don't use idioms or jargon (e.g. 'bitten off more than you can chew' may be interpreted literally).

Written communication: Make sure any documents, reading material or resources have lots of white space and contain only one point at a time.

Source: rffada.

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Counsellors in drug and alcohol settings work from a variety of models. When counselling people with cognitive impairment, it's essential you have strategies to tailor sessions to their needs. A person requires numerous cognitive functions (verbal skills, memory, attention, problem-solving and abstract reasoning) to benefit from the many strategies used in drug and alcohol counselling (Teichner et al 2002 in Marsh et al 2007b).

If the person's level of cognitive functioning is not taken into account, they'll experience poorer treatment outcomes. For people with attention/concentration difficulties, Aharonovich et al (2003) recommend shortening the length of sessions and frequently rehearsing session content and feedback with the client (Marsh et al 2007b). Modifying content to include more concrete language and offering greater counselling support to assist the person in identifying and changing problematic beliefs and thought patterns are essential.

Similarly, narrative techniques that require a high degree of verbal competency and comprehension will need to be modified to include simplified language and diagrams or pictorial representations. Motivational interviewing has been highlighted by a number of authors as a particularly useful technique in working with people with complex needs (Taggart et al 2008; Gelb & Rutman 2011).

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"... it is important for counsellors to consider the impact of cognitive deficits upon client engagement behaviours (e.g. irregular attendance, non-compliance with homework completion) rather than automatically assuming these behaviours are the consequence of more typically salient explanations (e.g. resistance, ambivalence to change etc)" (Marsh et al 2007b:45).

Cognitive behaviour therapy and cognitive impairment

Evidence suggests that people with ABI or another cognitive impairment are more likely to display maladaptive coping styles due to impaired executive functioning (Arundine 2009). Cognitive behaviour therapy (CBT) has been suggested as an appropriate therapeutic intervention for people with ABI or other cognitive impairment because of its structured format, flexibility and extensive range of therapeutic techniques that can be employed and potentially adapted (Arundine 2009; Kahn-Bourne & Brown 2003).

The following list of techniques, as described by Kahn-Bourne and Brown 2003, may help in delivering CBT to people with an ABI or cognitive impairment:

  • Use memory aids such as written notes, cue cards, digital recorders or audiotapes
  • Shorten the length of individual sessions
  • Increase the frequency of sessions
  • Involve a family member or support person to help remind /or reinforce therapy strategies and to assist with work out of the counselling session
  • Use techniques such as summarising, or even agreeing on hand signals, to refocus clients.

Consider talking to a specialist service such as Synapse about how to adapt CBT when a cognitive impairment has been identified or is suspected.

No matter what counselling technique you use, it's important to remember that non-compliance with homework, being late or not attending sessions does not automatically translate into a person being ambivalent or unmotivated. Rather, this may be due the impact of their cognitive deficits.

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