Client-centred care involves tailoring interventions to fit with the unique needs and experiences of each client, and beginning work from ‘where the client is at’. Although all of our clients share many experiences and issues, they also differ from each other along many socio-demographic variables such as cultural background, religion, age, gender, sexuality, and particular sub-cultural affiliations. There is also wide variability among our clients according to developmental stage or maturity, and the strengths and other resources that they bring with them. Our staff do their best to ensure that the care young people receive is appropriately nuanced according to these variables.
Holistic care involves recognition that a wide range of biological, psychological and social factors impact upon the client and the issues they bring to a particular service, recognising that these factors and issues are connected with each other, and ensuring that these factors are taken into consideration in the design and implementation of the client’s care.
In the context of working with young people with multiple and complex needs, client-centred care must of necessity be holistic, because issues such as alcohol and drug use problems, mental health problems, experiences of neglect and abuse, homelessness, social marginalisation, and involvement in the criminal justice system, are integrally connected with each other, and their unique configuration is a key determinant of ‘where the client is at’ and what their unique needs are.
Many writers on the topic of treatment and support for young people with AOD problems and other complex needs strongly endorse the principle of client-centred care (Bell, 2006; Bruun, 2008; Clark, 2001a, 2001b; Miller & Duncan, 2000; Moos, 2007; Pichot, 2001; Schuetz & Berry, 2009; Ungar, 2005a). Other terms that are widely used in the literature include ‘individualised’ or ‘needs-led’ care. The most basic definitions of this construct involve a ‘focus on meeting the individual needs of each youth’ or ‘assessment and treatment matching’. The latter is one of the key elements of effective adolescent drug treatment practices identified by expert consensus processes as reported in the various publications from this work (Austin et al., 2005; Brannigan et al., 2004; Henderson et al., 2007; Mark et al., 2006). Assessment and treatment matching involves selecting, and then also tailoring interventions to the individual needs of the client. Comprehensive assessment, individualised treatment plans, and regular case review are widely regarded as key technical requirements for individualised treatment (Marsh, Dale, & Willis, 2007).
Pichot (2001) points out that while many AOD treatment agencies profess that their services are individualised according to client need, the content of the program has usually already been determined before the client seeks admission. In contrast to this genuine client-centred care involves ensuring that interventions (i.e. the contents) are selected, adapted, and delivered in ways that are consistent with the individual needs of the client (Bell, 2006; Bruun, 2008; Clark, 2001a, 2001b; Miller & Duncan, 2000; Pichot, 2001; Schuetz & Berry, 2009; Ungar, 2005a). Barry et al (2002) recommend an orientation that “responds to what our patients require from us rather than our deciding what they need in advance” and “incorporat[ing] the services of the program into their lives rather than having them adjust to us” (p147).
Practitioners in many health and welfare services espouse a commitment to client-centred care and to holistic care, and strive to deliver this to the best of their abilities. However, the structural characteristics of many services and health care programs place constraints on the ability to realise these aspirations.
Illness- or problem-centred care focuses on the treatment of particular illnesses or problems. For example, public acute mental health services focus exclusively on the treatment of a narrow range of mental illnesses. Similarly many drug and alcohol services focus exclusively on the treatment of alcohol and drug problems. The proliferation of specialist services within the health and welfare sectors is an indication of an increasing trend towards illness or problem-centred care and away from client-centred care. The development of ‘dual-diagnosis’ services for clients with drug and alcohol problems and other mental disorders is essentially an extension of the illness-centred approach to the organisation of health care.
Youth AOD services respond to the issues that are of the most pressing concern to clients at the time, and / or those offer the most potential benefit to the protection and improvement of the health and wellbeing of the young person in the medium to long term. Drug and alcohol issues may not be the most direct focus of attention, but due to the interrelated nature of the issues, they are highly likely to be impacted in long run.
Intervention-centred care focuses on the development and application of particular interventions or types of interventions. Thus a practitioner or team of practitioners may specialise in pharmacotherapy or family therapy interventions for mental health, drug and alcohol, and other related behavioural health problems. Similarly, programs of service development or clinical research will often focus on applying and evaluating particular evidence-based practices such as cognitive behaviour therapy (CBT) in particular settings such as drug and alcohol services or primary health care. In these exercises variability between clients is minimised through application of strict selection criteria or controlled experimentally. The question of how a particular type of intervention may need to be adjusted to suit the variability among clients that is ubiquitous in most real-life practice settings is rarely considered in service development from an intervention-centred perspective.
In contrast to this, a client-centred and holistic approach is concerned with understanding the variety of different interventions that may be appropriate to the range of issues experienced by a particular client (including their problems and their strengths), and when and how these different interventions can be most profitably introduced and configured. Being holistic does not require the practitioner to deliver all the necessary interventions. Rather the essence is to be aware of the issues and take them into account in designing a program of care.
Client-centred care rests on a youth AOD service’s commitment to acceptance and respect for the person, self-determination, and empowerment. The values of acceptance and respect for the client demand that clients are understood more as more than mere collections of illnesses and problems, and more than passive receptacles for professional interventions. A person is someone who authors the subjective meaning of their experiences, and who exerts agency in the design and execution of their responses.
Numerous writers, particularly those from a youth work or social work perspective, argue that in order to genuinely understand what clients’ need, more emphasis must be placed upon eliciting and validating the subjective experience of the client, and securing their active participation in formulating their treatment or care plan. At the very least, most advocates of client-centred care recommend that the client be consulted in the design of the treatment plan. Others advocate an approach that seeks to maximise client agency to the extent of driving the treatment process.
Moos argues that grounding the intervention in the clients’ perspective, affirming the client’s strengths, and eliciting the client’s ideas about change, all support the client’s responsibility and self-efficacy for change (Moos, 2007). This is viewed as essential to the effectiveness of efforts to motivate and engage clients in addressing their issues. Similarly other writers argue that practitioners need to understand the subjective experience of young people, especially their understandings of ‘problem behaviours’ before attempting to create change or intervening to reduce any harm associated with them (Munford & Sanders, 2008; Ungar, 2006). This understanding is viewed as necessary for drawing the client into an active and collaborative process of solution-finding (Munford & Sanders, 2008; Pichot, 2001; Ungar, 2006).
It is important to recognise that client-centred care necessarily takes place within service settings that are funded to help meet certain policy goals, which are limited in the range of interventions that can be provided, and which require a certain amount of planning at an organisational level to ensure good governance. Some pre-planning of services is also necessary if services are to have the capacity to respond rapidly to identified needs. However, pre-planning introduces a tension for client-centred care if it overly narrows the variety of responses that are possible, or constrains the ability of practitioners to respond to unusual and rapidly emerging needs. The challenge for client-centred practitioners is to find ways of maximising client agency, self-determination and empowerment within these constraints. At the very least the client must have input into decisions about which, when and how services are provided. This requires that a range of choices are available and that practitioners are willing to enter into a genuine dialogue with clients about the interpretation of their problems, strengths, resources and needs. Thus client-centred and holistic practice involves a partnership in a journey.