When is the practice elements approach appropriate?
A modular practice elements approach is designed to deliver evidence-based therapeutic interventions for clients who have multiple and complex needs that cannot be fully met through traditional case work or manualised treatment programs that focus on narrow types of problems. It is also particularly well suited to working in service modalities such as outreach, residential settings and day programs that do not easily accommodate structured, one-on-one counselling sessions of fixed duration. These conditions are common in specialist youth AOD services in Australia.
However, this does not mean that that whole therapeutic approaches such as Motivational Interviewing or Dialectical Behaviour Therapy or manual-based treatment programs have no place. Combining elements within sophisticated and integrated interventions that are much more than the sum of their parts has a place within youth-focused services. Rather, the practice elements approach responds to the reality that at any point in time, most young people engaged with youth-focused services do not need or want to commit to a whole course of a particular kind of therapy. Some young people will never need or want such therapy, while others will be at different levels of readiness to engage with it. Others still may have received such therapy in the past and can benefit from reinforcement of gains made previously.
How are practice elements used?
The practice elements described in this resource are intended to be used within the context of a modular approach to intervention design. The range of modules to be used within a particular service setting should ideally be chosen and constructed in a carefully considered process that is guided by a comprehensive therapeutic practice framework.
Individual youth-focused services have their own practice frameworks that are developed according to the unique history and culture of the organisation, the particular client populations served, and evolving understandings of client needs.
A resource designed to strengthen therapeutic practice frameworks in youth AOD services in the context of the state of Victoria was published in April 2012 (Bruun & Mitchell, 2012). The practice elements described here can be used in conjunction with information in this resource to guide the design of modules.
Who can use practice elements?
A key premise underpinning the practice elements approach is that by breaking down complex therapeutic procedures into discrete elements, and defining these elements precisely, workers without specialist training in particular therapeutic models may be empowered to make the use of relevant elements as an achievable part of their everyday practice.
This premise does not mean that all practitioners in youth-focused services should be expected to use, or be competent in, all the practice elements endorsed by the organisation. Nor does it mean that specialist training has no place, or that practice elements and modules are of little use for specialists.
Practice elements and modules can be used by practitioners working at various levels in service settings.
The role of specialists versus generalists
Teams of practitioners must have the shared capability to apply a wide variety of therapeutic elements to meet a diversity of needs that change over time. Most practitioners in youth-focused services need to be generalists. There is also a need for specialists who develop expertise in particular therapeutic approaches. Roles of specialists include providing focused and sustained therapeutic interventions based on particular approaches when the assessed needs of a client indicate their use, and to provide consultation support or supervision to generalist staff so that they use relevant elements correctly, in the right situations, and improve their skills continuously.
Between the functional poles of complete generalist and expert specialist, the practice elements approach is highly amenable to the challenge of responding to different levels of client need and the variable levels of difficulty involved in addressing particular types of therapeutic challenges.
Principle of application and implementation
Several key principles that need to guide the use of a modular practice elements approach within youth-focused services are:
Embeddedness – Practice elements are embedded upon a foundation of:
- casework and basic counselling skills,
- the values and principles that run through all of our work (e.g. human rights, acceptance and respect, client-centred, relationship-based, building on strengths etc) and
- the common elements of all effective therapeutic approaches (e.g. relationship factors and client factors).
Therapeutic practice elements supplement and build upon these foundations of practice. They do not replace them.
Choice – Both services and individual practitioners can choose which elements or modules to use. Procedures need to be developed to ensure choices are made carefully and systematically.
Realism – Practitioners do not need to be experts in any particular therapeutic models. Workers with varying levels of expertise can engage with new practice elements incrementally according to their existing strengths, interests, and comfort zone.
Flexibility – The modular practice elements approach is designed to maximise flexibility in responding to the needs of individual clients, individual practitioners, teams and organisations.
Support – Practitioners need to be adequately supported to make appropriate choices about the use of practice elements. A comprehensive set of resources need to be developed, training and supervision provided, and a wide variety of tools made available.
Defining a set of clinical governance processes
The modular practice elements approach enables practitioners in real-world service settings to pursue an eclectic practice approach that respects their professional judgement about the needs of their clients and facilitates genuine response to client preferences.
However, ensuring that practice is intentional, of high quality, and continually improving requires that decisions are made carefully and systematically. A clinical governance framework is needed to guide decision-making and provide adequate support to practitioners, especially those with less formal training and experience.
There are at least six mechanisms that support high quality clinical decision making.
Assessment - Making appropriate choices about interventions begins with assessment involving comprehensive data collection about a client and their social ecology.
Case formulation – Data collected during assessment guides the selection of interventions via a process of case formulation. This requires theoretically informed analysis of assessment data, collaboration with the client, and where appropriate, consultation with other informants. The aims are to: (i) generate a plausible definition of the problem in terms that point towards effective interventions, (ii) clarify the psychosocial processes that are amenable to intervention, and (iii) set goals for intervention. Case formulation is particularly critical to the modular practice elements approach because it captures and documents an understanding of the client’s individual needs.
Care planning – Building on case formulation, care planning requires further close collaboration with the client to design a strategy for systematically working towards the client’s goals. Other providers may need to be consulted to clarify what interventions they are providing and to facilitate coordination and collaboration where necessary. Care planning is the stage at which modules (or practice elements within modules) are chosen and these choices documented. Computerised tools can be developed to support the choice of modules and practice elements appropriate to the needs.
Case notes - A systematic approach to recording case notes enables the practitioner to critically reflect upon progress, review the strategy, and ensure that the care process is transparent and accountable.
Supervision – Regular supervision is necessary to ensure that practitioners are adequately supported; to ensure that assessment, case formulation, care planning and case notes are conducted appropriately; to help solve problems that arise in the therapeutic project, and to detect and address emerging risks that may not be apparent to the practitioner. The modular practice elements approach provides a comprehensive framework for exploring the range of interventions that may be appropriate for a particular client, reviewing what has been tried so far, and identifying new strategies.
Case review – Review of all cases at regular intervals is necessary to realise accountability, monitor quality, and provide ongoing professional development.