Tc-310
DEVELOPING A NEW CLIENT CENTRED - ASSERTIVE SUPPORT MODEL WITH DEAFBLIND PEOPLE


INTRODUCTION: 
Today I would like to explore ways of working with clients that are flexible, meaningful and constructive, and not alienating for clients. I will do this by looking at the Community Services Program where I work in Victoria from a theoretical framework, which has been developed based on our experiences. The impetus came from a government review of CSP and resulted in a joint collaboration between Mary Tass and myself in developing this model.
OVERHEAD ONE
I would like to explore this through the following areas:
* Deafblindness
* The Community Services Program
* The Mechanistic Model
* The Client Centred Assertive Support Model
* Conclusions. 
What can a worker do when a client refuses to be assessed? How can a client "play the game" in order to receive services? What happens if a client is emotionally immobilised and finds it difficult to make an informed decision? What if a client's culture and life experiences are fundamentally different and at odds with western cultures? Many of you as clients, carers and workers may have come across these sorts of dilemmas where there are problems that are not easily dealt with. 
Many organisations in welfare use what is called the mechanistic model when working with clients. This provides a framework for sequential task focused interventions through assessments, setting goals, implementation, monitoring and review, and focuses on the problem rather than the client. This model does not always deal with dilemmas confronted by deafblind people effectively. So we are trying to look for better ways. 

DEAFBLINDNESS:
A current accepted definition of deafblindness is:-
	"a person who has a significant degree of combined visual and 	auditory impairment. It is a separate disability, which requires special 	methods of :	* communication
			* orientation and mobility
			* adjustments to functions of everyday life."
Deafblindness affects fundamentally every aspect of a person's life: functional, mental, emotional, physical, environmental, social, financial and spiritual. 
Communication
In a sighted, hearing world, overcoming barriers to normal communication is crucial. People with deafblindness use a range and combination of communication methods to suit individual needs. These include sign language (ie. auslan, signed English, tactile signing, makaton), large print, gestures, compic, smell, touch, fingerspelling. Sign language and other communication methods are conceptually and grammatically different from spoken english. It is a visual, gestural language with different literacy requirements.
Frequently people with deafblindness are in situations where it is extremely difficult or impossible to be assertive. As a result of the communication barriers their needs are often unmet, and they can appear passive or aggressive. People in the deafblind community are aware that they are often misunderstood by the general public and providers of generic services, and consequently their needs are misinterpreted.
Orientation and Mobility
Some people with deafblindness travel independently or with the assistance of a guide dog or cane. Others require a sighted guide to access the community. They are vulnerable to exploitation and abuse when using public transport, and encounter a myriad of obstacles in negotiating a transport system constructed for the sighted hearing world, eg. trains changing platforms.
Living in a World of Limited Information
Without support, people with deafblindness miss out on cues of what is happening around them. They can give up on trying alone and, over time, become passive in day to day situations, and increasingly isolated. 
As such there is a greater need for workers to spend time ensuring clients are in a position to make informed decisions as they have different experiences of living in a world of limited information. Clients at times may not know what they want or be confused with information about resources and services.
Clients place an extremely high level of trust in workers to physically negotiate an often perceived hostile outside world (eg. sighted guide to travel to appointments). Clients also place a high degree of trust emotionally in workers who often interpret and explain foreign situations and events encountered on a daily basis. Thus the coaching and modelling roles of workers takes on special significance and purpose.

Assessments with Deafblind People
Most conventional assessment tools have not been designed or have the capacity to comprehensively assess clients with dual sensory loss and multiple disabilities. With deafblindness people are unable to see and hear instructions adequately, and assessment tools often have jargonistic language, and are not always understood. As such a more flexible approach is needed with assessments. A range of clinical assessment tools partially adapted to suit people with deafblindness, in combination with observation and qualitative and quantitative data gathered over an extended time period is required.

THE DEAF-BLIND ASSOCIATION - COMMUNITY SERVICES PROGRAM
The Community Services Program (CSP) aims to improve the quality of life of people with deafblindness or a combined vision-hearing impairment by reducing isolation and enabling them to live as independently as possible in their local community. 
OVERHEAD 2
It is an outreach service to clients and their families with a team of specialist workers who provide:-
		* communication skills development
		* counselling
		* case management
		* respite
		* behaviour management
		* advocacy
		* practical support to access appointments, shopping etc.
		* recreation activities
		* volunteer support
		* information provision
		* specialist advice to other organisations.
Practice Approaches
A practice approach based on respect, empowerment and taking into account the person as a whole, reflects the working partnership with the client as the first and foremost priority, over and above organisational or wider political agendas.
The team endeavours to balance between the pivotal roles of professional judgement, standardised work procedures, and the development of trusting, relationships with clients. Within this balance, engaging and motivating clients is a crucial part of the intervention process.
Formal and Informal Approaches
With a multi-disciplinary team, interventions are both formal (eg. written personal plans) and informal (eg. flexible worker role encouraging trust and engagement with clients). The informal style of practice is underpinned by structured purposeful ways of working. Work practice relies both on communication between team members and clients, and the skills and responsibilities of workers to ensure quality service delivery.
The value of the team approach is that there is additional cross fertilisation of ideas with verbal sharing of information with the relevant team members (eg. impressions, brainstorming), which would otherwise be missed with the limitations of written mostly fact based file notes from a single key worker.
Language
Objectifying language can distance and disassociate clients from participation in the running of the service, especially when auslan sign language is the native language. Therefore the team finds it important when working directly with clients to avoid terminology that is not user friendly such as 'screening' and 'case closure', and argues that it undermines the capacity for clients and workers to feel valued.
OVERHEAD 3a&b
THE MECHANISTIC MODEL - A CRITIQUE:
With the development of case management, care co-ordination and purchasing of services in the disability sector in Victoria, the mechanistic model has been widely utilised.
OVERHEAD 4 
The mechanistic model relies upon the professionalism of the case manager with client needs being satisfied by matching available resources to those needs. 
It is a lineal throughput process with clear beginning and end points. It is task oriented and has a logical sequential problem solving focus through assessments, setting goals, implementation, monitoring and review. Generally there are statistical targets to be achieved.
Being task oriented it offers a process of finding solutions for many deafblind clients who are looking for practical action. However the model does not fit well with clients who refuse to be assessed and fall between the gaps. Some clients say 'no' to being assessed but in the context of the interaction the message from the client is "I need and want help". Applying the model can result in a disservice to some clients who in effect challenge the mechanistic model as the access point to a fixed service delivery system.
In practice the model runs the danger of commodifying and treating the symptoms of the disability through a focus on problem solving, and can minimise the value and focus on working directly with the person. Crises which are unrelated to established goals can become obstacles to outcomes. Therapy and Case Management can become overly symptom focused and less client centred, not taking into account the cognitive and emotional components of the whole person.
An overly professional approach can actually disempower clients (eg. by reinforcing an initial dominant position of power), and mystify emotional support with the professional's imperative on goal setting and problem solving. 
Case management using the mechanistic model can inadvertently be used as a way of actually avoiding involvement with clients and disengaging from a meaningful interaction with clients by focussing on the service system and forcing a fit between available services and perceived problems. This results in a superficial system which has the appearance of problems being addressed, but may not necessarily produce lasting positive changes.
Individual interpretations by case managers of the model can reinforce inflexible structures especially when setting and implementing general service plans and individual program plans.
Service delivery in the deafblind field needs to be tailored to the client group, where generic standardised procedures have somewhat limited usage especially when applied rigidly.

THE CLIENT CENTRED ASSERTIVE SUPPORT MODEL:
OVERHEAD 5
Description 
Consistent with other models, the process involves the initial inquiry, needs identification, eligibility assessment, and follow up and referral to other agencies if required.
 Eligible clients then enter the service when a worker or workers are allocated, and undertake a more detailed assessment. Allocation (internal referral) changes within a multi disciplinary team as needs change, and include referrals to other services. Re-assessment, goal setting, implementation, monitoring, and review are part of an on going process, reflecting clients changing needs, until services are no longer required.
This model accommodates clients with deteriorating conditions requiring services on a long term basis. However the client can exit the service at any time.
The model is not intrusive in the sense that information is obtained according to the problem at hand and respects the wishes of the client. The model focuses on checking with the client in the context of a positive working relationship.
OVERHEAD 6
Assumptions
The  model is based on the following assumptions:-
* People who have a desire to change and become more independent do not always have the capacity to take action.
* People do not normally take risks to change unless they have some trust in themselves and others.
* People who are vulnerable may not link into mainstream community supports and services without 'stepping stone' strategies in the first place.
* Development of a trusting relationship is the basis for the quality of the interaction between the worker and the client and is a part of service provision.
* Clients make decisions and choices, and exercise empowerment and self-determination as part of the process.
* Environmental factors are a necessary consideration when setting goals and implementing strategies with clients.
* Assessment and planning tools are used flexibly in the context of constant change.
Continuous Assessment.
Many assessments and standard procedures such as I.Q. tests are static, and clients' intellectual capacity does not usually change. It has been the experience of the Community Services team that conventional forms of assessment have their limitations. Some clients refuse or are reluctant to be assessed, or challenging behaviours prevent comprehensive assessments being made.
Some clients are embroiled in chaotic life situations, and problems are multi-faceted, complex and interlinked.
With these dilemmas in mind the model focuses on assessments and reassessments which take place as needed from initial presenting problem through to dealing with underlying problems over time. 
OVERHEAD 7
Hepwoth and Larson  support this view with the following: -

	"It is important to differentiate between assessment as an on going 	process and as a product. Practitioners engage in the process of 	assessment from the time of an initial contact with clients to the 	terminal contact, which may be weeks, months or even years later. 	Assessment thus is a fluid and dynamic process that involves 	receiving, analyzing, and synthesising new information as it emerges 	during the entire course of a given case." (P. 194)

Given that clinical measures of outcomes is an emerging science, which has limitations in capturing qualitative outcomes, this approach integrates other measures and checks which involve participation by the client. As such the model provides a way of working with clients when assessments are inadequate or unable to be administered comprehensively, and still work towards productive outcomes.

CONCLUSION
The client centred assertive support model builds upon the positive aspects of the mechanistic model and uses it as a tool in a different framework.
It complements and allows for multi-dimensional assessments across welfare/ disability sectors, and in the case of the Community Support Program, builds 
on a continuous specialist assessment from a multi-disciplinary team. 
The model integrates psycho-social rehabilitation principles, the client centred systemic model, and the mechanistic model to enhance flexible service delivery, through a holistic approach of continuous assessment, goal setting, implementation, monitoring and review.
A central aspect of the model is the development of trust with clients. This helps prevent a danger that the assessment and planning phases become the goal, instead of the service to the client as the goal.
The client centred assertive support model can be considered for use in other programs and services within the disability sector.
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