I am a student of the HNC in Social Care and I work with an organisation that promotes social inclusion of Adults with Learning Disabilities with social support through group work and one to one befriending. Throughout this paper I shall also refer to our service participant as Dan and our service as the Group. This is not the real name of our client or our group. By doing this I am complying with our organisations policy of confidentiality. This policy was designed to conform to the (ref 1) Data Protection Act of 1998. This Act ensures client confidentiality, that any information written about a client is accurate, truthful and any opinions are objective, substantiated by factual evidence. The Act also allows the individual to make a formal application to see the information held on them by the Group.
To complete this piece of work I have assessed Dan`s needs and planned out a piece of work which has addressed an identified need.
I read his existing activity plan as a starting point as it had his medical information included, this allowed me to update the information at Dan`s assessment. This first assessment had been done by my manager a few months ago and so I discussed Dan`s case with her before I met with him. Our activity plans are flexible allowing for the changing needs of our clients. The task undertaken also complied with our organisations constitution which concentrates on social inclusion of adults with learning disabilities.
The assessment of needs is the first stage in the care planning process. Our organisation takes a person centred planning approach. A person centred care plan is devised to ’empower’ people, to support their social inclusion, and to ensure people are not devalued within society.
It was necessary for me to listen to what my client needed, to differentiate his needs from his wants and to ensure that I could take action to deliver a positive outcome. A need is something he has to have as opposed to a want which is something he would like to have. Assessing a person for needs is the method of collecting information, recording the information and interpreting the information.
The assessment took place at our office just after his one to one art session as he was comfortable and felt safe here. Under (Ref 2) the Regulation of Care (Scotland) Act 2001 Dan has a right to feel safe and secure. I did a Risk Assessment of our areas which complied with the (Ref 3)Health and Safety at work Act 1974. It was important for me to continue gaining his trust and use good communication skills. I used the SOLER technique which had us both sitting squarely facing one another showing that I was being involved, I had an open posture implying that I was non defensive, I leaned forward slightly showing a personal interest, I had regular eye contact also conveying an interest in Dan and I had a relaxed manner. I used active listening which involved me trying to understand the real issues affecting Dan and had a meaningful conversation with him.
Our meeting was timed to last no longer than twenty minutes as his attention span can be short if he is bored. I ensured that board maker signs and visual aids where available, to direct his attention if he did get bored.
I used both open and closed questions which allowed me to get factual answers from the closed questions and his opinions and feelings from open questions.
I observed his behaviour at all times and I spoke to him in a way he understood. I wrote the information collected in a concise manner in the form stated in our organisations policy and procedures. As we do not supply a care service, we are not required to register with the Care Commission, but we ensure all our policies and procedures meet their standards.
As all clients under these standards are legally allowed an assessment of needs and an individualised care plan, the form I used was called the Activity Plan.
The Care commission was set up under the Regulation of Care (Scotland) Act 2001. This Act came about to regulate the care and social work force and set out the principals of good care practice. During our meeting I was conscious that I had to explain the care planning process to Dan, and I used the visual aids when necessary.
Dan was born in 1949 into a society that had introduced the IQ test in 1930, whereby those scoring low had been considered “mentally defective”. By 1946 and the introduction of the NHS, this term was changed to mentally handicapped and so required “treatment” in institutions. Dan was considered as being in this category.
There is no generally acknowledged definition of a learning disability and there is a continued argument of the definition. However, there are certain features that are agreed upon.
Those with a learning disability have difficulties with educational success and growth.
An uneven pattern of their human development is noticeable i.e. physical, perceptual, educational and language developments..(Ref 4)
The (Ref5)NHS and Community Care Act of 1990 implemented in 1993 and (Ref6)the Human Rights Act of 1998., saw the closure of these institutions. This saw the movement of adults with learning disabilities out of institutions into being cared for in the community, either by their own families or in small supported housing being cared for by the voluntary sector.
“The Same as You” strategy of 2000(Ref 7) by the Scottish executive is committed to providing fairness, equality and social inclusion for adults with learning disabilities. As a result of this strategy the local community set up the “Group” to provide socialisation to help with social inclusion of adults with learning disabilities through one to one befriending and group activities.
Dan lived within a nuclear family unit where he was given the basic human requirements of food, shelter, clothing, love and socialisation to live until the age of 6. He was born into a society where it was common for young children with learning disabilities especially those with Downs Syndrome to be institutionalised. There was also a social stigma assigned to those with learning and physical disabilities.
Dan’s family insisted in caring for him at home until school age, but his educational needs where not met. He also suffers from “anxiety attacks” which his father says he developed at the age if six, when taken into the car for the first time. He reacted by lashing out and pulling hair. The “anxiety attacks” were given by his father as an excuse for Dan`s disruptive behaviour. His behaviour was tempered by his mother, who had to be consistently by his side cuddling him and holding his hand during his anxious moments. His parents did everything for him, until he was institutionalised. Here, he grew up where privacy, choice, dignity where lacking and he was not allowed to take risks. Life skills, education and road work where not given. More often than not in the past, these “patients” where drugged if they showed any signs of disruptive behaviour. Being “locked up” living in Nightingale wards with communal living and toilets may have also contributed to his “anxiety attacks”.
These “anxiety attacks” still causes Dan to behave in a challenging manner if he feels hemmed in, especially in crowded places with no obvious means of escape. After 1995, when government strategies of closing large institutions were implemented through the(Ref8) Disability Discrimination Act 1995 and its amendments of 2003 Dan was given a home within supported accommodation as his father was elderly.
Dan did not like to go out unless his father was with him and tended not to interact with anyone when introduced. His “anxiety attacks” causes him to be agitated when his routines change.
He finds it difficult to make choices unless they are limited and is not keen on trying anything new. He is unable to read or write, he has no life skills e.g unable to make a cup of tea, make a slice of toast, shop or clean his home, he is unable to cross the road without help. The physical developmental stage Dan has reached is that of an adult but the emotional stage is that of childhood between 2-12 years of age, probably nearer the age of seven or eight. He has been living out with the large institution for six years now but has not learned to change his behaviour accordingly. This may be as a result of being told by his support workers that he cannot do certain things as they deem certain activities to be a risk. Staffing problems also contribute to the lack of his change in behaviour as time constraints in helping Dan learn new skills are often given as an excuse for staff not being able to assist Dan attempt new things.
So, I believe he is still institutionalised although he lives in smaller community shared accommodation. He was given no choice as to where he would live, who he would be sharing with or who would be supporting him.
With the help of his family, before being institutionalised he was able to meet the bottom three stages as seen in Maslow`s hierarchy of needs pyramid. (Ref9) Abraham Maslow was a humanist psychologist who developed this model between the 1940s and 1950`s. He stated that human needs can be arranged in a step ladder pyramid and that the lower level needs must be satisfied before higher levels can be met.
This model consisted of eight stages. He stated that we are all motivated by need as evolved over thousands of years. He stated that we must satisfy these needs in turn, starting with the first. The first need is the physiological need which is e.g having food, oxygen, water, etc, the needs to allow our bodies to survive. The second need is that of physiological and physical security, whereby there is protection from possible hazardous circumstances and objects. The third need is belonging and love, which is being part of a group of family and friends in a loving situation with trust acceptance and affection. The fourth need is esteem which is respect of self and others. The fifth need is self actualisation which is realising personal potential. The fifth need is Cognitive needs with knowledge and understanding. The sixth need is Aesthetic needs which is the appreciation of symmetry, beauty, order and form. The seventh need is self- actulisation which is realising ones full potential and the eighth need is transcendence which is helping others to fulfil their potential. Dan, as functionalist sociologist (Ref10) Talcott Parsons (1902-1979) argued, will have gained his primary socialisation and emotional stability within a nuclear family of two parents, a mother and father, plus his siblings. Primary socialisation can be defined as a means by which the norms and values of society are taught to children and they learn to accept these values within the family. The functionalist sociologists believe that society can be compared to a living body, with different organs (institutions) having different functions yet all working together to keep the body (society) alive.They consider the family to be a small version of society which operates as a social, economic and emotional unit.
The conflict theorist believe that society is separated into two classes, with the bourgeoisie and the proletariat who are at odds with one another. The family, conflict theorists state is just another social institutions which contribute to the acceptance of social inequality. Every member takes difference roles at certain times in the family life cycle and conflict happens within the family when a person challenges those roles, e.g teenagers challenging parental authority.
Dan lived in an institution from the age of six so his secondary socialisation was to learn to live within the confines of the institution. This socialisation would have been radically different from a family situation. (ref11) Research showed that concerns grew about the care given by institutions “quality of care provided by these institutions in terms of gross physical deprivation
(overcrowding, poor food, clothing and environment), abuse (ill-treatment, theft of
possessions and over-use of medication and restraint) and neglect and inactivity (lack
of care, lack of contact and stimulation and extensive periods of disengagement and
isolation” staff and client interaction and engagement in meaningful activities would have been poor . As a result, no chances where available to allow Dan to move to the next level of Maslows Pyramid of Needs of self esteem.
(Ref 12) Dan was the youngest member of the family and so according to Alfred Adler this would have affected the type of personality that he would develop later on in life. The youngest are known to get their own way and to have a stronger parent bond, which Dan did
Have as he was overprotected and indulged before hospitalisation. But, this cocooning can also be claustrophobic. But, by being institutionalised, according to Erikson, his environment would also have affected Dan`s development and have had an impact on his behaviour .
The behaviour Dan often displays can be explained by the behaviourist theory, which was named (Ref 13)”Learned Helplessness”. While experimenting on dogs using Pavlov`s theory of Classical Conditioning, which shows links between the stimulus and the response. Seligman discovered that learned behaviour is a results of the belief that the person`s actions are futile. People who have lived in Institutions have learned not to expect to have any control over their lives. Behaviourist theorists believe that if behaviour is learned, then it can be unlearned. Lev Vygotsky and Russian cognitive psychologist believed that development was guided by culture and interpersonal communication with significant adults. Being institutionalised will have reduced Dan`s chances of having regular important communication with a significant adult. Vygotsky stated that to learn a range of tasks that are too difficult on their own, a child must be shown or guided by someone who is more knowledgeable. This became known as the “Zone of proximal development”. This assumes that the child has the ability to memorise and the capacity to recall the learned experience. This is not always possible in some with a learning disability. In the care setting where Dan spent his life, the chances of a child being challenged to learn new skills would have been diminished or non- existent. Vygotsky was the first to observe that social isolation caused a delay in both social and cognitive development.
The “anxiety attacks” Dan suffers from can also be explained via Operant Conditioning suggested by B.F.Skinner (1953). Operant Conditioning is where behaviour is followed by a consequence.
His behaviour of lashing out when he is anxious is a result of positive reinforcement where initially this bad behaviour was rewarded by receiving physical and emotional contact from his mother before institutionalisation and later attention from nursing staff in the institution.
Positive reinforcement is where the consequence is a positive outcome. Now, Dan`s support staff try to ensure that Dan does not come into a situation that may make him anxious.
After the death of his elderly mother Dan relied totally on his elderly father for any continued socialisation, as his siblings had long left home to set up their own family life. (stats to be put in)
His father feared Dan would become isolated, especially as his father was becoming less able to take Dan out. Dan was introduced to join the Group by his father in an attempt to introduce him to new friends, increase his confidence and improve his self esteem. His time at the group has seen his confidence increase. After moving out into the community, Dan was rather introverted and shy and would only go out in the company of his father. This concerned his ninety year old father greatly, and so his father came to our organisation in the hope that we could increase Dan`s social circle. Dan was assessed by being asked a number of questions using PIES to establish what his Physical, Intellectual, Emotional, and Social needs were. This information was put into his activity plan which we use instead of a Care Plan. As under the NHS and Community Care (Scotland) Act 1990 everyone is entitled to a care plan. Dan will have such a plan set up by the social work department.
To increase his social circle as requested by his father, we included him in a number of activities which has expanded his scope of social activity and made him less isolated. Dan`s physical needs are met by social services, but his intellectual needs of mental stimulation, his emotional needs of needing to increase his self esteem and his social needs of social interaction require attention.
Dan has already improved his social skills through art by now communicating well with our staff and is keen to take his work home to show to his family and carers. His father has commented on how the communication skills of Dan have improved and his confidence has increased. Remembering Maslow`s Hierarchy of Needs, I had assessed that Dan would benefit from reaching the fourth stage – Esteem Needs. I felt an activity that would help to improve his confidence, his communication skills and make him less anxious in a large group situation would be beneficial. I spoke to him and observed him answer my questions .One of my questions gave him a choice of activities to try, I found that the activity he was most interested in was art. I mentor both at the art group and on an individual basis, which helps adults with learning disabilities gain new skills, gain confidence, improve self esteem, socialisation and self
actualisation through creativity. Carl Gustav Jung a Swiss psychiatrist B.1875 to D. 1961 encouraged patients to use art to convey their unconscious emotions. He stated that (Ref14) “drawing, painting, and modeling can be used to bring unconscious material to light. Once a series has become dramatic, it can easily pass over into the auditive or linguistic sphere and give rise to dialogues and the like.” (1941)
My aim was to try to put coping mechanisms in place to allow him to be able to take part in the graded unit activity which was to allow him to create a work of art and to exhibit at our Malawi Awareness Evening, which we expected to be busy.
This activity is to take place some weeks away so it was important for me to arrange new art activities over a period of time, to allow him to gain confidence in being part of a large group. My goal through these activities was to allow Dan the chance to increase his confidence and communication skills and to develop coping mechanisms to allow him to deal with his fear of large groups. I have used the (Ref 7) task-centred model in planning this exercise; this is a short-term problem solving approach over a short period. This had five phases- Problem Identification (assessment), Agreement, Planning goals, Achieving Tasks and Evaluation. Here, the client takes concrete action to solve the problem. The Initial interview or phase allowed Dan to express his need to have more confidence when in a room with more people in order to be able to enjoy more activities. He wanted to complete a painting and to be present at its exhibition. To achieve these goals, we agreed on the steps and tasks that allowed Dan to attain his goal. We emphasised the tasks that were required to be completed to allow Dan to exhibit his work of art and agree on timescales for the tasks.
Other interviews will took place to ensure that we were on track and that Dan felt safe and confident doing the agreed tasks.
With Dan`s agreement we decided to have an hourly one to one befriending art session of three one hour sessions per week over four weeks and to increase these sessions to become a group session. To do this I needed to slowly introduce more and more people to the group. These were other service users, staff and volunteers. With agreement of everyone involved I brought people in one at a time each session. I did this by giving each individual a date and time to join us at the “Group” premises.
I hoped that by the end of the four weeks he would be able to sit in a room happily with at least twelve noisy people. He had to have a positive experience and to have a positive association with the group. Dan enjoyed a regular cup of tea and a chocolate biscuit, so I introduced this positive experience to him in the group setting while he was painting.
I ensured he sat facing the door and informed him that he was able to leave the room at any time. I sat him at the end of the table to ensure that he did not feel hemmed in.