Stage 3 - Deciding what to do
- Kristina identifies problems of social transition - from dependent
to independent adult. The social worker discusses with Kristina
what she thinks her problems are, itemising them in more detail:
prioritising them, breaking them down into small stages; making
a written agreement and allocating the tasks; taking a stage at
a time and achieving small successes incrementally in a limited,
specified time period of a month at a time.
- Care needs to be taken to ensure that the assessment of the situations
of Marta, Jan and Kristina is not agency centred but is user and
carer centred. The assessment should be needs led rather than service
led. It should be multi-disciplinary and should involve them integrally
in the process.
- Team members identify a danger of assumptions made due to knowledge
gaps about the culture of the family. This may lead to discrimination.
- The team adopt a holistic approach. They decide to work with
all three members of the family in different ways to improve their
quality of life, individually and collectively. Three practitioners
are allocated to work with the three family members, individually
- The social worker intends to work with Kristina to meet her emotional,
personal health and educational and social needs. This is an ambitious
goal. Kristina has identified all of these as her own ideals for
herself. The social worker develops these with Kristina as part
of the person centred approach to planning.
- As part of her immediate goals, Kristina wants to go to work.
She wants skills and she wants to go out socially, with girlfriends
and eventually with men. These are her problems, her goals prioritised
by her. The social worker enables her to apply for a job. She secures
a job as waitress in a local hotel in Fenton.
- Kristina has heard the local Further Education college runs GNVQ
and NVQ courses in catering for people with disabilities. She wants
to go to college. She needs help in learning the route, via a bus
before she can travel it herself. It takes many times. The social
worker employs a volunteer to help Kristina practise. Kristina has
found out that the college runs courses specifically to meet the
needs of disabled people and has facilities to enable carers and
personal assistants to attend. At the local further education college,
Kristina could choose to join a course to learn skills in Information
Technology and social interaction. She enrols on a numeracy course.
This enables her to cope with guests in the dining room at the hotel.
- Following a task-based approach, Kristina's tasks are broken
into sub-tasks so they don't become too demanding and too stressful,
and so unattainable. At the same time, the advantage of her applying
to be a waitress is that the hotel work can be varied and demanding
in the dining room, with many tasks to be performed such as interacting
with guests, rather than in the kitchen or as a chamber maid. Perceiving
this, the worker avoids stigmatising Kristina and discriminate against
her. She enables Kristina to find work which brings her into contact
with people rather than perpetuating her isolation.
- With Marta, freedom from Kristina relieved Marta of the task
of carer for that time. Marta returns to considering her goals.
She joins a choir at the local further education college.
- On the negative side, Kristina's actions over the following few
weeks later cause concern by Marta. Kristina fails to return home
one night. the police trace her, after she is seen in the Fenton
shopping arcade. She is accompanied by a young man known to the
police. She later tells the social worker she was approached by
a young man aged 19. He asked her to have sex with him. She refused
but gave him details of where she was at work. He called on her
at work several times over the next two or three days. On the last
occasion she went to his flat with him and had sex. His friends
were there. She did not want to have sex with them and escaped.
She accused him of raping her but later withdrew the allegation.
- Although Kristina is over 18, there is still a concern for her
safety. This triggers the Vulnerable Adults policy, based on No
Secrets (DoH/Home Office, 2003). Some practitioners in the team
have argued this should have happened earlier. The activation of
the Vulnerable Adults policy leads to a Strategy Meeting followed
by a Case Conference. As part of this, it is necessary to resolve
issues concerning the involvement of Jan and Marta as carers and
Kristina as the client.
- Even though Kristina withdrew the allegation, some practitioners
in the team argue the agency is still statutorily bound to pursue
the investigation of the alleged rape with the police. Members of
the Vulnerable Adults Steering Group includes police and people
with experience of rape counselling, who can advise practitioners
in the team about practice dilemmas and related issues at this point.
The duty of care, local risk procedure in the context of statutory
Vulnerable Adults policies and the risks to Kristina have to be
balanced against her stated wish to resume her plans for independent
living and work without delay.
- There is another incident. This time Kristina apparently cat-called
a man outside work. He hung around. She kept displaying and making
suggestive comments to him. he followed her after work and, according
to her, raped her. She tells her parents on arriving home. Her father
rejects her and tries to throw her out. She runs down the road in
a very distressed state.
- Kristina is very upset her father hasn't believed her allegation
of rape. She takes some pills and collapses at the bus station.
A bus inspector finds her slumped on a bench and calls an ambulance.
She has muttered about trying to kill herself. The para-medical
staff assume she has taken an overdose. She is admitted to a psychiatric
ward in the local general hospital, voluntarily. She stays there
two days and nights.
- The hospital staff, led by the consultant psychiatrist's assessment,
are preparing to discharge Kristina on the second day. There is
a meeting at the hospital involving the multi-disciplinary team
and Kristina. This is a Pre-Discharge Planning Meeting and it follows
health trust policy, through the hospital discharge procedure. The
psychiatrist's assessment is the incident has been exaggerated.
The pills were identified as vitamin pills and were non-lethal.
She has said she did not intend to kill herself. As an aside, the
nurse’s report to the social worker she has talked about sex
a lot to staff and other patients while on the ward. The psychiatrist
considers this matter can be referred back to the practitioners
already working with Kristina and her family. There is deemed to
be no need for formal psychiatric involvement in following up Kristina.
- Kristina's parents are very anxious about what is happening to
her. They need much reassurance. The other practitioners working
with Jan and Marta check out with them whether they wish to change
their minds and request a separate carers' assessment. The social
worker is trying to understand Kristina's bizarre and contradictory
behaviour, which is making her increasingly vulnerable, in terms
of her life skills and the strategies she develops to cope with
her new, challenging and somewhat intimidating lifestyle. She finds
it exciting and stimulating. But she feels lonely and insecure and
easily rejected as well. The social worker hypothesises Kristina
is overcompensating for this by trying to ensure young men like
her and are attracted to her.
- A plan is devised in the work with her to enable Kristina to
extend her repertoire of social skills of interaction with other
young people, so as to give her a range of techniques, so she doesn't
resort to the extreme of offering to go to bed with every young
man she wants to meet and chat with further.
- For a time, after Kristina exposes her breasts in the canteen
at college, the care manager discusses this with college staff and
the key worker and decides she should stop attending for a while
and return to attending the day centre for a while.
- This has some success. After a month, Kristina rejoins the college
- At a subsequent review, it is stated Kristina no longer deals
with change, novelty and the fear of rejection by becoming seductive,
outwardly aggressive, or directing her aggression inwards and harming
herself. Her key worker considers this could be attention seeking
behaviour, a cry for help. Again, strategies are devised to give
her alternative ways of seeking help, which don't leave her increasingly
vulnerable and at risk of harm.
- There are cultural and generational aspects to the practical
problems of dealing with diversity within the family. How do Kristina's
parents equip themselves as carers? For instance, what do they believe
and feel about their daughter's sexuality? Do they believe she has
the right to have a sexually active lifestyle? They may say they
don't want Kristina as their disabled child to learn about sexuality.
But this is oppressive and a denial of rights. Kristina's confidence
may be undermined by this attitude. This raises questions about
what and how each family member been taught, how she/he learns and
what training is available.
- The social worker persuades Kristina of the benefits of joining
a self-help group for young women and to her surprise Kristina readily
agrees to attend a meeting on a trial basis.
- The overall care coordinator for the family needs to check to
ascertain if any family member is, as it were, be losing out in
this household? How should the somewhat marginal situation of Jan,
as father in the family, be acknowledged and his needs tackled?
Jan is losing his job. His wife is becoming independent. What can
the agency offer? Is there a briefing service or Polish Club which
can help Jan in particular? Jan's care coordinator discusses this
with him, finds out there is and, of his own volition, Jan starts
to attend a fortnightly luncheon club.
- How will practitioners work with Jan, Marta and Kristina to prepare
the task centred plan?
- How will practitioners prioritise the risk and vulnerability
of Kristina which has emerged from recent events in her life?
- Will Kristina, in particular, accept help?
- What implications does Kristina's behaviour have for the assumptions
practitioners have made about her Down's Syndrome being mild?
- What objectives do practitioners need to set?
- Given that no specific legislation can protect Kristina, as a
vulnerable adult, what policies and procedures can protect her?
- Will Kristina be on the Care Programme Approach (CPA) now (See
note under Relevant Knowledge below), given she may have had a diagnosis
of reactive depressive episodes, from the consultant psychiatrist,
even though the risk is not considered high and she is likely only
to be on the standard level of CPA?
- If Kristina has been put on the CPA, how can good practice be
ensured, through her having a risk, crisis and contingency plan,
as legally required?
- Over what period of time should the work extend?
- Who will do the work?
- What will the work cost?
- Are resources available for the plan?
Research Focused Questions
- What evidence is available about the effectiveness of what is
- What is the evidence of the consequences of doing nothing?
Kristina would be on the CPA only if the hospital had
not discharged her. otherwise, she would remain with the learning disability
Empowering Kristina so she is confident enough to
complain if the service falls short of standards may lead to her being
labelled as a nuisance. This creates a dilemma for the practitioner
but is a basic practice principle.
The publication Valuing People (DoH, 2001)
requires that the National Service Framework (NSF) for Mental Health
is applied to learning disability. This implies it includes the CPA.
There is a risk that the mental health needs of clients with learning
disabilities may be neglected. This aspect needs careful monitoring.
Direct payments can be made to Kristina so that she
can buy directly services for which she has been assessed. This is carried
out under the Direct Payments Act 1996. If Kristina is to live independently
in a flat in town, she can employ a worker to come and help her with
the cleaning and shopping, checking on her if she is not well.
Kristina is in priority need when wandering around
Fenton, under Section 189, Part vii of the Housing Act (1996). This
states people vulnerable through age, disability or illness are entitled
to special accommodation. Young people considered at risk of physical
or sexual abuse may be considered vulnerable, according to the Code
of Practice on Homelessness.
In the first place, the practitioner and the client
make what Reid (1978) calls a contract and what Doel and Marsh (1992)
call an agreement. Reid finds verbal contracts less intimidating for
clients. Doel and Marsh prefer written ones because they are clearer.
Kristina is happier with a verbal arrangement.