In this essay I am going to attempt to explain and describe an intervention I carried out with service user A in my time that I spent at placement, I want to note that all people in this essay are anonymised. Firstly I will give an overall view of what the agency is and what it offers; explain how the service user came to use the service and how he met the criteria for the service. I then discuss how I approached the assessment, what models and theories I planned to use and if they went how I expected, I then explain what my conclusions were from this intervention and how I dealt and reviewed this with service user A and finally I explain how I prepared the service user for the termination of my involvement in his care needs.
The agency I did my placement at is a 10 bed roomed residential rehabilitation service for people with drug and alcohol misuse issues, it’s a voluntary organisation. To enter the service you have to have been abstinent from drugs or alcohol. The service is a tier 4 service which is the highest intensity treatment from which the framework for commissioning services sets out, which was developed by the National Treatment Agency through the National Health Service in 2002 and updated in 2006. Its objective is to provide integrated care pathways that are person centred; this service allows service users to maintain their abstinence through the agencies program with the goal of integrating back into society and living independently free from addiction (NTA, 2006).
The service provides a structured environment including group therapy, one to one key working sessions, professional counselling and various activities such as art therapy and workshops on certain topics such as relapse prevention. The group therapy which is carried out at the treatment centre can fall into a number of different theoretical frameworks including Person-centred, Motivational interviewing or Task centred to name a few. An example is when the individuals are leading the group it could be described as Client centred whereas on the other hand if it was Counsellor led the use of Motivational interviewing may be more appropriate to guide the individual to a positive outcome. I feel that it has not always been evidence based practice that has been used, as some of the workers have no background knowledge of this. This has resulted in the range of provisions altering as staff member’s change which has detrimental effects to the service users in term of consistency. I realise that this isn’t solely the worker fault as they are doing what they feel is right in terms of their own skills and values but I have concerns for the service users who have needs and expectations of the service.
The work carried out at the treatment centre is long term and it’s beneficial to have access to long periods of time to be able to achieve the positive long term outcomes, (Rosenburg, 2009) this can be difficult as funding is sparse. Rosenburg finds that substance abuse treatment is generally funded for the greater number of people for less time, this approach doesn’t account for the length of time that it takes to engage with service users as this can be a long and slow process (Rosenberg, 2009). This is beneficial as the service user and the worker needs to de-construct what has been constructed throughout their addiction which takes time (Stephney and Ford, 2000).
Service user A came into the agency a few weeks into my placement, I was asked in a team meeting if I was happy to support and key work A during his time in the treatment service. I asked what my role was to be with this A and what the agencies requirements were. It’s my role as A’s key worker to have weekly one to one key working sessions with A, through these sessions it’s my role to formulate with A his care plan. It’s also my role to assist with registering him with the local GP and dentist.
In preparation for meeting A, I contacted his care manager to find out further information. This was done as multidisciplinary team working is crucial to bring together a rounded description of circumstances and by working in partnership it gives the ability to engage with colleagues and discuss outcomes either by compromise or confrontation (Coulshed & Orme, 2006). It’s essential to gather as much information prior to contact to gain a holistic overview of the service user. I asked if A had any previous convictions as I would need to know this prior to A coming into the service as this enables me to risk assess the situation and decide what measures need to be in place before contact.
A’s primary addiction is alcohol. He’s had four previous alcohol detoxes – one at home and three in hospital, but has not previously had residential rehabilitation treatment. He had been assessed by his care manager at his local alcohol service under the National Health Service and Community Care Act, 1990 (Brammer,2007), he had assessed that his needs met the criteria and he was granted funding.
It’s important to plan what you are going to do and what you want to achieve before any assessment is undertaken as assessment is a key task in social work practice (Milner & O’bryne, 2002). It’s important to have a balanced approach which involves many skills that will enable me to gather accurate information from the service user, to make an analysis of what I have been told and to enable me to develop a hypothesis to explain what is happening and what may be able to be achieved. It’s also important to reflect prior to practice as this emphasises on a thoughtful and planned approach which help’s to make what my aims are clear to the service user and also more open to review (Parker, 2009).
When engaging with A I used the exchange model. According to Smale, Tuson and Stratham (2000) the underlying principles of the exchange model are that the service user is an expert in his own problems / situation and this approach enables him to identify and articulate his own needs. Whilst I accept that I as the worker has to have their own expertise, it is imperative that I do not lead the exchange of information but that it is led by the information given. This should lead to practice which is more likely to be anti-discriminatory, I will be approaching the assessment with an open mind and not a preconceived idea of the problem / solution etc (Smale, Tuson, & Statham, 2000).
The reason I chose this approach is because I believe it’s the most empowering of the 3 models of assessment which Smale et al discuss; it allows A to identify his own issues and hopefully resolutions, thereby impacting positively on his self- esteem (Smale,Tuson, & Statham, 2000). Having said that, Milner and O’Byrne (1998) believe that the questioning model is necessary in some instances which I believe is the case when I will be completing some of the agencies requirements, however Smale et al., (1993) (as cited in Coulshed and Orme) state that there are limitations on the questioning model as the worker can sometimes be seen as the expert and can be seen as oppressive and disempowering (Coulshed and Orme, 2006). I believe that to make this model work and not be oppressive is down to me as the worker and how I approach and address A and the questions.
I propose to use a task centred approach as this is designed to assist in the resolution of difficulties that people experience (Stephney & Ford, 2000). I also use person centred approach, as a person-centred approach to planning means that planning should start with the individual (not with service), and take account of their wishes and aspirations. Person-centred-planning is a mechanism for reflecting the needs and preferences of a person (Doh, 2010) and assists in working in an anti-oppressive manner by supporting A to enable him to gain more power (Dalrymple & Burke, cited in Howe, 2009). This is achieved through process of assessment, care planning and review in a person centred approach. It enables me to look at A’s coping skills, interactions, quality of environment he lives in and weigh up the resources and support that are in place and also look at the barriers he has been facing.
When reflecting on meeting A for the first time it’s important as his worker not to fall into the labelling of him as for many people the stereotype of substance misusers is a person who lives in a twilight world and isn’t a very nice person (Goodman, 2009), I had my own preconceived ideas of what I believed an addict would act like, I was aware of this so I had to ensure that I had dealt with these thoughts and feelings before meeting A. I was aware that A was anxious so I found a quiet room for us to talk in, I spoke in an even and calm manner and explained what my role was as his key worker, I told A that I understood how difficult it must be for him being in a new environment with lots of strange people and if at any point he needed a break or didn’t understand anything to let me know. I explained what I was going to do as this is part of the process of the task centred model which emphasises on helping people to help themselves (Doel & Marsh, 1992). Trevithick states that in assessment you must have a purpose and a plan (Martin, 2010) and the purpose of this first meeting was to complete the agencies paperwork and to gain relevant information to enable me to gain some valuable knowledge about A, and to jointly formulate his care plan which I wanted to ensure that he had participation throughout the process.
It’s important to show empathy when A discusses his feelings, and attempt to understand the distress he is going through (Thompson, 1993). Jaspers suggests that an empathic rapport may not always be successful but can create a sense of feeling valued and understood by the service user; it will enable us workers to understand service user’s diverse and problematic experiences (Stephney & Ford, 2000), more recent evidence from users of services (SCIE, 2004a and c) found that service users valued both warmth and empathy highly (Lishman, 2009). Research has also shown that substance misusers need support to gain or regain control of their lives which will require me as his worker to explore (Goodman, 2009).
In using my observation skills I noted that A was having fidgeting and becoming agittated, I asked if he was ok and he said that he needed a cigarette, I acknowledged this and agreed. When we returned to the room, I reminded him that he could take break at any time if he needed to do so, I recognised from his body language that he was able to focus more on what was being said because his anxiety level had reduced.
In order to make an analysis of A circumstances a holistic approach is needed as understanding someone’s behaviour is essential, this means taking to account every aspect of the A’s life. In other words, building an understanding of his life presently and past and not only physical or psychological but also social, cultural, historical factors that may have influence his life by discussing the structures and microsystems in his experiences (Barber, 2002). When looking at human behaviour it also gives a wider perspective, and it takes the social worker beyond his own particular life experience giving a ‘bigger picture’ and an understanding of people’s behaviour. However, it’s important again to be careful to not stereotyping or labelling people. (Trevithick, 2009). This is in line with General Care Council Codes of Practice, 2010, by treating the person as an individual and supporting him throughout with respect (GSCC, 2010).
When working with a person centred approach and Carl Roger (1961) put forward three personal qualities essential to a person centred approach (Martin, 2010) which I used in my key working sessions:-
The first is empathy which I used throughout all my key working sessions, I did this by checking that I understood what A had said by paraphrasing it back and reflecting. I was showing that I was attempting to understand his situation and in some of the sessions A seemed helpless and lost in his emotions and I showed empathy by saying “you sound as if you feel totally helpless” which then lead to A confirming this and it enabled him to take the lead in the conversation and continue on (Martin, 2010).
Then second is unconditional positive regard, when A talked about his past and his relationship with his ex-wife, it became clear that he had received very limited unconditional positive regard and struggled with how to accept this. It took a number of sessions for A to gain my trust and feel confident in sharing his deepest difficult thoughts and memories which have made him feel oppressed and powerless and still continued to do so. Throughout our sessions I shown empathy and listened with respect to what he had been through, I did this in a non-judgemental way so that A could gain more confidence to increase his feelings of self -worth and to also give him that feeling of unconditional positive regard, as when I listened I did it without imposing any conditions on him (Maslowski & Morgan, 1973).
The third is self- congruence, I did this by being genuine and honest with A throughout our sessions, it became apparent that A had been hurt and suffered a significant amount of loss in a short period. We discussed this in many sessions and I was honest with A by telling him this which he states he now has come to realise this and that he needs to allow himself to grieve so and in time he will come to accept what has happened and find in himself the confidence and power to hopefully achieve self-actualisation (Martin, 2010).
In our first couple of sessions we discussed A’s health needs both physically and mentally, as there is a strong link between substance misuse and mental health issues (Rosenberg, 2009). A had said that he would like to improve his physical health as he said that he had not been eating balanced meals, when discussing A’s mental health I could see from his responses that this was a difficult area for him to discuss. He said that he wanted to address the feeling of loss which were impacting on his mental health, but wasn’t sure if he was capable. I showed encouragement to A by telling him that it will take time and that he can give himself that opportunity to work through his feeling of loss, through tasks and goals that he can set himself, by motivating him to see that he has the potential to do it (Goodman, 2009).Task centred practice works well with motivational interviewing as it can be used as a method to assist the service user for change (Goodman, 2009).
He talked about his relationship with his family he said that he had put them through a lot and wanted to make sure that he put everything into his recovery this time around as he felt that he didn’t last time. Phillip Bean (2004) cited research from the biggest study of treatment for substance misuses in Britain which states that it is essential to get people into recovery however ‘Most substance misuses require several attempts at treatment before noticeable success occurs’ (Bean, 2008). We discussed the causes of his relapse and he talked about going back to his old haunts when things became tough for instance if he wasn’t working. Frisher and Beckett (2006) indicate that the evidence against problematic misuse is linked to structural problems like poor education and unemployment. Substance misuse places individuals outside of society and leave them in a very vulnerable situation (Goodman, 2009).
We discussed issues around his goals and where he wanted to be in his life, what his future aspirations were, I asked A if he found this difficult to do and we talked about ways in which we can work on changing his thinking and behaviour patterns to deal with everyday problems and triggers. I did this as I wanted A to give A encouragement towards this goal so that in time with confidence he will see that he is capable of change and when he sets himself important goals this will motivate him to change. I explained that he should attempt to provide solutions to problems that he feels he’s facing which will give him choices and make him responsible for how he wants to achieve this (Goodman, 2009).
After gathering all the information in these first couple of session the analysis I had made is that A wants to improve his physical health which can be achieved by eating a balanced diet as he had previously neglected his self-care needs. A also has issues around his health which I assisted him with registering with the local GP so that he can address these issues with him. When looking at his family structure and his past and where he feels he fits in has been a difficult task, I wanted to maximise A’s potential which I knew was going to be a difficult and challenging task and I am aware that within society substance abuse places individuals outside of society and leave them feeling vulnerable (Goodman, 2009). Davey states that substance misuses are seriously disadvantaged in society and they rarely have one problem, they are usually a multitude of problems and suffer a ‘cycle of change’ and empowerment must address all the problems if it’s to be significant (Davey, 1999: 31).
I used an ecological approach to A’s life structure as Bronfenbrenner (1979) saw how people’s lives were effected not only by their immediate surroundings but by the wider society (Howe, 2009). This approach will enable me to understand how the wider and socioeconomic of society have affected him throughout his life as it can help identify the structural causes of oppression. It’s clear from our discussions that A’s parents and the quality of their parenting have affected him throughout his childhood and through his adult life, both of A’s parents were alcoholics and he describes his childhood as miserable and belong there as they didn’t want him, he believes that he doesn’t deserve to be loved and doesn’t feel that he fits in within society.
Margolis and Zweben (1998) state that substance misusers can used as a form of self- medication to manage shortage of love arising from early deprivation and a lack of parental infant relationships (Margolis & Zweben, 1998). Also when looking at the psychoanalytical view children who have been emotional neglected or rejected can become emotional trapped as children and then carry this on through their adult life and emotional conflicts can cause their behaviour to become disadvantaged and their minds are not at rest which can lead to them having an over dependency on something which in A’s case is the alcohol which then masks his feeling (Howe, 2009).
Once I had completed A’s care plan I asked my team leader to review the content as I wanted to ensure I had followed the agencies requirement as this was my first care plan and I wanted to ensure I could receive feedback in regards to an honest exchange of views as this will then reduce the risk of biased views or value from myself (Coulshed & Orme, 2006). I then shared the completed plan with A to ensure that I had fully understood what his needs and wishes are.
I continued to review A’s needs and goals through his weekly key working sessions it’s my role to work with A to give him the encouragement and opportunity to change and encourage him that he has the potential to do it (Goodman, 2009). If A is seen as capable of change which I found that A strengths were his motivation to change in my role I researched the agencies internal system and files and work sheets that are used in attempting to change the persons thought processes and through these it will teach A how to recognise the triggers and situations that cause him stress and have caused the relapses in the past. Working through these work sheets and using his other group therapies he will enable him to develop and use coping strategies that he can take with him throughout the rest of his life (Goodman, 2009).
In each session A came to the session with an agenda that he wanted to discuss in line with his requirements identified in his plan and in one session I had given A his life story to complete when he felt that he was able to do so, this is similar to a road map it’s a pictorial representation of a person’s life history and completing this confirms the perception of A as he is the one writing these experiences down and the significance of these (Parker, 2010). This activity raised painful memories and I was struggling to understand the significance of events and why they were so painful to A. When looking at A and his life experiences and comparing them to my own they are both very different and his views on his experiences are different. I discussed this in supervision and my team leader who said that it is common with people with addictions to struggle to face painful memories and it’s about giving him time and showing him empathy, this is in line with key role 6 of the GSCC Codes of Practice (GSCC, 2010). I have found that working with service users who can be ambivalent about themselves and with changeable motivation can lead to feelings of being de-skilled (Goodman, 2009). I found that by taking small steps and showing him empathy worked, and by asking him how these memories made him feel now and how he wants to move forward, we discussed issues together and weighed up the significance of these together. I feel that by taking this approach and the time I was able to gain a fuller understanding of A’s life and gain his trust.
It has to be noted that the aspect of time is a major part in the recovery process however my attitude is also a key element in the approaches used and there has to be a good foundation with a trusting and appropriate relationship for the service user to gain what is needed from the intervention. This is particularly relevant for myself when working with the A as I need to form a positive relationship, one that develops and finds the equal balance between myself and A. I ensured that A was informed of changes and ensured his opinions are valued and taken into account, which enabled him to feel empowered and also hands the responsibility back to him for him to make decisions about what he wanted to gain from his own treatment for his own recovery (Parrott, 2010).
When my placement was coming to an end I wanted to ensure that A was aware of the time scale in my leaving and who his new key worker was going to be and how he felt about this, we had many discussions around this and we discussed how much of his personal life experiences he wanted to share at that point. It did take a few session of talking over his feelings around this but he did make the decision to share everything which I shown encouragement towards him regarding this as I feel that this was a major step forward in terms of his confidence and self -esteem. Upon reflection I feel that even through the difficulties I managed to achieve what I had planned to do as Rogers outlined four characteristics which, if achieved give an indication that the therapeutic process has been a successful one. These characteristics are:
· An openness to experience.
· A trust in themselves.
· An internal source of evaluation.
· A willingness to continue growing.
Each of these characteristics are appropriate to the work that I have carried out with A For example “A willingness to continue growing” is especially significant due to recovery being a life-long factor in the individual’s life. A’s addiction will never be cured and it will need him to continue growing and developing and working on his addiction through his group work and key working sessions and we know from research that maintaining contact with services and the length of time in treatment are important indicators of good outcomes (Pycroft, 2010).
When reflected on my intervention with A I have at times faced many struggles but I feel that my strengths are that I have been able to recognise my values and biases and I have addressed them when needed, I feel that I researched my service user and the methods and models I decided to use worked well. I do feel that there are limitations in this service which is lack of funding and time constraints.
When reflecting on my placement and my intervention with A it has had huge impact on my practice and on me personally and I feel more equipped with the skills necessary. I feel more assertive and competent in decision making and in working as part of a team making decisions that will impact on individuals and hopefully improve their well-being. It has given me an insight into group work and being able to diffuse difficult situations which will be an important asset to me in the future.
I have throughout this placement become more aware of my own belief system, what I believe to be right and wrong, my opinions, thoughts and feelings and how this would affect my practice as a Social worker. It’s important to me that I have a good understanding of my morality because I can be aware of not using that in a negative way when working with service users and “understanding feelings and emotions is essential, if we are to understand the complicated, often messy, emotionally charged situations which social workers are faced with”. (Knott, C., & Scragg, T., 2008: 34).
The understanding of my personal belief system also links in with ethical issues in social work and how being a reflective practitioner can minimise this. “The reflective practitioner has an awareness of ethical issues or value conflicts and the potential, as there is in any relationship or process, for oppression”. At the central part of social work is empowerment of service users and to provide support free of discriminatory or oppressive attitudes, behaviours and opinions and if reflection helps to minimise or eradicate this then that demonstrates the importance of reflection. (Knott, C., & Scragg, T., 2008: 11).
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