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10 Things To Consider When Working with Vulnerable Clients

 

  1. What do we mean by ‘vulnerable’? Here’s the official definition –

The term ‘adult at risk’ replaces the term ‘vulnerable adult’ within national Safeguarding Adult Partnership multi-agency procedures, as it is thought to be more respectful to those to whom it refers.

An adult at risk is described as an individual, aged 18 years or over, and is:

  • A person who is, or may be, in need of community care services by reason of mental or other disability, age, or illness; and
  • who is or may be unable to take care of him or herself, or unable to protect him or herself against… harm or exploitation (No Secrets, 2000)

Also included are people with a mental illness, dementia or other memory impairments and people who misuse substances or alcohol.

The definition also includes carers (family and friends who provide personal assistance and care to adults on an unpaid basis).

  1. When considering the best ways to support, guide and develop effective front-line practitioners there are 3 broad areas to be accounted for:
  • Clients: Needs and challenges as well as resources
  • Practitioners: Skills, experience, needs and challenges
  • Employers/commissioners: Expectations and agreed outcomes.

 

  1. The foundation of this for commissioners of services, employers and practitioners is a good understanding of the client group, their needs, the challenges they present and the resources they have, so that support and interventions are appropriate and effective, and expectations relating to outcomes are reasonable, and everyone gets set up to succeed, rather than fail.

 

  1. This group of people are often living in poor conditions, sofa-surfing or even homeless. They can be at, or close to the very bottom of Maslow’s hierarchy of need
  2. In order to help them to re-connect with their communities in a functional and healthy way, and begin to engage in behaviours at the love/belonging and esteem levels, the physiological and safety levels need to have been achieved by them.
  3. The problem is that in order for people who are in these circumstances to achieve those basic levels to move on, from they have to believe that they are worthy, believe that it is possible for them, trust ‘others’ who may have previously harmed and exploited them, and give up a well-known and well-trodden path for something they maybe can’t imagine.

 

  1. It is crucial that front-line practitioners have an understanding of the psychological make-up of their clients, as this will enable them to tailor their approach in order to give the best conditions for engagement and the development of a relationship/working alliance. It is well-documented in research evidence that the relationship is the crucible for change in work between practitioner and client. When a connection develops there is the potential for trust, and when there is trust people begin to believe they can risk making changes etc, etc. There are many pitfalls to this process with very vulnerable clients who sit low down on the hierarchy of need, and it can become so difficult that they disengage or are disengaged with, and the hoped for (and paid for) outcomes do not materialise.

 

 

  1. Transactional Analysis (TA) provides a brilliant set of tools to work with this client group. It is a well-known, well-evidenced approach used in education, organisations, psychotherapy and counselling, that offers a theory of how we become who we become, believe what we believe and behave as we behave in relation to self, others and the world at large. TA can be used to as a model to train, support, guide and develop effective front line practitioners through clear and understandable theory, focussed training using simple, sensible and very user-friendly tools and ongoing reflective practice supervision. All of these elements come together to provide a very ‘holding’, effective and resilient model which wraps around the practitioner and their clients to help both to build effective relationships and develop healthy ways of relating to self, others and the world.

 

  1. The approach:
  • Teaching the emotional and psychological make-up of people who have become very fragmented, chaotic and vulnerable and who make harmful choices that mean they pose a risk to themselves and/or others. This puts context to and ‘normalises’ the extreme behaviours the practitioners are often faced with, and de-personalises it.
  • Teaching, using TA to explain how and why the experience of being in relationship with a positive, caring, resilient, emotionally healthy other who is interested and consistent is the key to emotional and psychological change.
  • Experiential training for practitioners where they will learn about themselves and how they relate – with the knowledge that the relationship is the vessel for change, and when all we have as practitioners when we are with our clients is ourselves, it is crucial that we know and understand what we take into those relationships so that we recognise what is helpful and what is potentially unhelpful.
  • Teaching the core models of TA to give a range of ways of understanding and working with their clients in order to help clients move towards healthy, safe behaviours.
  • Ongoing reflective practice supervision (RPS) using TA to consolidate, deepen and develop the skills of the practitioners through self-reflection using TA, presentation and reflection on case work, reflection on practical application of TA, adding in learning new pieces of theory. Could be group or individual or both.

As well as providing comprehensive staff support and development for effective working, using TA to provide this ongoing wrap around approach builds in safeguarding, ethical thinking, self-reflection, self-knowledge, critical thinking, solution-focussed approach, ability to evaluate and improve outcomes.

The following describes my approach to reflective practice supervision and the frameworks I put TA thinking into. TA lends itself extremely well to reflective practice and I currently use it very successfully with many front line practitioners working in very challenging schools clusters and a community mental health team:

 

Reflective practice supervision involves ‘A working alliance wherein the practitioner can offer an account or recording of her or his work, reflect on it, and receive feedback and, where appropriate, guidance. The object of the alliance is to enable the practitioner to gain in ethical competence, compassion and creativity so as to give the best possible service to clients.’ (Charlotte Sills)

Three central tasks emerge from this definition:

  • The sharing of responsibility between practitioner and supervisor for monitoring the practitioner’s competent and ethical practice
  • The sharing of responsibility for the professional development of the practitioner
  • Reminding the practitioner to take care of her/himself and to support the continuing renewal of energy and faith in his/her work

 

“Reflection is an important human activity in which people recapture their experience, think about it, mull over & evaluate it. It is this working with experience that is important in learning”. Boud, D., Keogh, R. & Walker, D. (1985) p 43 Reflection: Turning Experience into Learning. London: Kogan Page.

 

“We learn through critical reflection by putting ourselves into the experience & exploring personal & theoretical knowledge to understand it & view it in different ways.” Tate, S. & Sills, M. (eds) (2004) p 126 The Development of Critical Reflection in the Health Professions. London; Higher Education Authority

 

 

 

Reflective Practice Models

 

Williams and Rutter (2007) based on Gibbs

 

Description:        What happened?

Feelings:              What were you thinking and feeling?

Evaluation:          What was good and bad about the experience?

Analysis:              What sense can you make of the situation?

Conclusion:         What else could you have done?

Action Plan:        What was learnt?  If it arose again, what would you do?

 

 

Barton (1976)

What? – What happened?

What did I do?

What did others do?

What was I trying to achieve?

What was actually achieved?

So What? –

Now What?