Module 6: Existing Resources and Case Management

Transcription

1 Module 6: Existing Resources and Case Management Jordans, M.J.D., Tol, W.A., Komproe, I.H., Lasuba, A.C., Ntamutumba, P., Susanty, D., Vallipuram, A. & de Jong, J.T.V.M. (2008). Module 6: Existing resources and case-management. In: Children in areas affected by political violence: a resource package for a comprehensive psychosocial care approach. Amsterdam: HealthNet TPO/ PLAN Netherlands. 1. Rationale As mentioned in module 2 this resource package follows a multi-leveled preventive approach focusing on both curative and preventative interventions, which entails targeting symptoms reduction as well as targeting strengths and healing. Two concepts that underlie the latter focus are (1) ecological resilience, and (2) existing community resources. One of the strategies to strengthen ecological resilience is to assess and work with existing resources, which is the focus of this module. First, ecological resilience is defined as those assets and processes existent on all social-ecological levels that have shown to have a relationship with good developmental outcomes after exposure to situations of armed conflict. We see ecological resilience as a reservoir of factors at different socialecological levels that can enhance psychosocial wellbeing. Children under strain can seek out and utilize resources from this reservoir to enhance their chances of retaining or obtaining psychosocial wellbeing (Tol, Jordans, Reis & de Jong, 2007). Second, these are core reasons for strengthening resilience through existing resources; (1) Cross-sectional non-vertical care systems are preferred for reasons of applicability and feasibility; (2) Linkage with both formal and informal existing resources are preferred for reasons of availability, sustainability and relevance of service provision; (3) Active community involvement is preferred to reach children out of school and to tap into responsibility of the community to support, reducing dependability on external service/resources. Moreover, working with contextual community activities, traditional healing and religious practices, availing norms and coping, will increase cultural relevance of a combined (i.e. traditional and novel interventions) care system (see chapters 3 and 4 in: Tolfree, 2006). The critical question that underlies this module is; To what extent are existing resources and resilience sufficient to restore the balance between present risk and protective factors or to Module 5: Case-management and Utilization of Existing Resources 1

2 what extent can external mental health care or psychosocial services support and integrate this balance? 2. Implementation steps Assessment of existing healing practices and community services It is through careful participatory assessment that resources available at different social-ecological levels can be identified and the interaction between them observed. Moreover, it has been our observation that damage to the social fabric and resources available at different social-ecological levels is variable, depending amongst others on pre-conflict family and community characteristics and the type of conflict situation (Tol et al, 2007). Furthermore, as is shown in figure 1 in module 2, any psychosocial interventions should be embedded in, and linked to, initiatives and services focused on peace-building, poverty reduction, education and health care. Box 1: Examples of community resources What are existing resources? Religious practices Health care Normalization through education and recreation Traditional healing Family systems Purification ritual Rites de passage Economic support programs Micro-crediting schemes Youth groups Community conflict mediation and reconciliation efforts Existing child care and protection structures Locally relevant activities such as story telling, songs and dances 2.2 Resource maps Practically, assessment should include identification of resources. A possible tool to synthesize information collected is a drawing of nested circles on a large sheet of paper, representing the child embedded in the family, peer setting, school, and community. With the use of +, -, and symbols, the resources, needs and transactions between the social ecological levels can be summarized for discussion (Tol et al, 2007). 1 The family of children is one of the main available resources when dealing with problems or when increasing existing community resilience. This will not be discussed within this module, but rather in the module on parental support. Module 5: Case-management and Utilization of Existing Resources 2

3 Figure 1: Resource maps Community School Peer Family 2.3 Negotiation and involvement of social agents Based on the results from the needs assessment discussions should be held with community social agents, especially those involved in the care of children, to develop a framework for utilization of resources. Such negotiation entails discussing which types of available services and interventions might be appropriate for the problems identified in the needs assessment. Additionally, the active involvement of these social agents needs to be discussed. Involvement has a dual function, (i) it ensures sustainability and responsibility of community members, and (ii) it is also a strategy to improve psychosocial wellbeing. An example of the former is to ask community members to contribute to sustain interventions or to support individual families in need of material support. An example of the latter is to include children in pro-social activities as volunteers doing community services or to include adolescents in peace-building activities. 2.4 Collaboration and referral to existing care and healing services Collaboration with existing services (informal and formal), such as schools, health care and traditional healing, should be actively sought. Additionally, psychosocial care services should link with non-mental health care, such as religious practices, nutrition project, micro-finance schemes, youth and child clubs, etc. The aim of such linkages is to provide the most needed services to indicated children and their families and, in turn, such services will improve the psychosocial well-being. Practically, this means referral from the program s services to external services. 2.5 Case management Case-management is the process in which the above steps come together and are integrated with other clinical and non-clinical services. A counsellor as a case-manager coordinates services to individuals, families, and communities, Module 5: Case-management and Utilization of Existing Resources 3

4 based upon assessment and planning. Case management is a client-centred, goal-oriented process for assessing the need of an individual for particular services and assisting him/her to obtain those services, often across institutional boundaries. Tasks: Develop, support, maintain clients' treatment process Target and improve conditions which obstruct client progress or the maintenance of their progress Develop & maintain partnerships (individual/agencies/community) Asset-based community and resource assessment Comprehensive, collaborative, systemic planning & coordination Activities Guide and support child through different steps of a treatment process Link the child and/or family to existing services in the community that are requited for the treatment process Follow-up on the external services provided, both with the third party as well as with the child/family itself Case management is intended to help patients take advantage of community services that have the potential to enhance their treatment experience. Psychosocial problems, especially in low-income and conflict settings, are mostly not singular and often go alongside a set of larger problems, related to (mental) health-, economic-, educational-problems. Often the non-mental health problems are overriding in severity and importance from the perception of the clients and are often causes for increased distress and accumulated burden. Linkage with services other-then psychosocial counseling, can therefore become in essential in supporting those children with identified problems as well as increasing the effectiveness of the counseling service. Moreover, case management has the tendency to increase treatment maintenance. Figure 1: Case management Service Delivery System - TPO Sudan Existing Care System Counselor as Case-Manager Module 5: Case-management and Utilization of Existing Resources 4

5 2.6 Integration of steps: Case management plan In the following cases it is crucial to have a case-management plan at hand and have that case-management plan form the basis of the treatment or follow-up: (1) Mental retardation The essential feature of mental retardation is significantly sub-average general intellectual functioning. It is accompanied by significant limitations in adaptive functioning such as; self care, communication, social/ interpersonal skills, use of community resources, functional academic skills. When mental retardation is detected case management involves the following activities: the counselor should raise the level of understanding of the adults close to the child to prevent maltreatment and stigmatization. Secondly, when it concern mild retardation case management should focus on integration of the child within the peer group and within the school setting. When it concerns severe retardation referral to more specialized services need to be arranged, if available, where learning daily functioning and life skills are encouraged. (2) Epileptic children When children have recurrent fits a medical check-up should be arranged to assess the nature of the fits. Case management therefore entails a medical consultation. If epilepsy is diagnosed effective medication is available. Once medication is started case management further entails ensuring treatment compliance, making sure that the child is receiving the medication as per indication. (3) Families with chronic child abuse, neglect and parental mental illness Home visitation programs are indicated when child abuse and/or neglect is suspected or reported. Many direct therapeutic interventions are not beneficial or not contra-indicated when abuse is present. Home visitation program, combined with discussion about the child s well-being, is mainly a case-management task and might form the start of a longer family interventions strategy. (4) Crisis care Especially in crises situations the counsellor core task is to reduce risk and to ensure basic safety and needs. Case management has the potential to help patients access the community support they need to stabilize their lives so they are able to focus on treatment. In case of suicidal tendencies this includes reducing direct risks of suicide. 3. Suggested points of attention and lessons learned Module 5: Case-management and Utilization of Existing Resources 5

6 3.1 Planning and harmonization of services; At time of project development and planning of intervention, assessment and integration of existing resources should be taken into account, as outlined above. Commonly, these aspects are either overseen or integrated once the program and its services have started. 3.2 Case management integrated; Especially when working with counsellors as service providers, case management should be integrated in the training course, services and skills. Case-management becomes the hinge pin in linking new interventions with those already available. Job descriptions and training courses should clearly focus on the role and tasks as a casemanagers. 4. Examples from four-country CTP projectp 4.1Across countries: Besides the presence of social networks at the neighborhood and community-level, which were helpful in providing direct assistance (including material assistance, assistance in performing rituals) and linkages to other resources, we found a host of other resources available in our qualitative study in Burundi, Indonesia, and Sri Lanka. Faith healing (Christian, Hindu, and Muslim) and traditional healing practices (massage herbalists in Central Sulawesi and spirit healers) were generally consulted in all three settings to deal with children s problems such as spirit-related problems, fears, concentration problems, behavioral problems, relational problems and bodily complaints. Moreover, churches, mosques and affiliated educational institutions were felt to provide healing opportunities and moral clarity in a climate of felt moral decline. We found that peers were supporting each other in several ways. Besides assistance in basic needs (e.g. where pupils in Northwestern Burundi would ask their parents to feed classmates), peers would for instance support each other through play, through support in education, and individual emotional support (e.g. advice-giving and encouragement) (Tol et al, 2007). 4.2 Sudan: Through mother groups attention can be given to the well-being on the children s core caregiver. Encouraging mother groups can reduce the general distress of the participants (following normal group support logic), which generally has a positive impact on child rearing practices. Secondly, the groups can be a forum to discuss topics related to the psychosocial well being of children. 4.3 Indonesia: Child reading centres aim to provide educational activities. In the child reading centre children and parents are able to lend books, but also join discussion groups and study group. Reading centre activities and resources have helped mother support groups develop their microbusiness to improve their livelihood. Module 5: Case-management and Utilization of Existing Resources 6

7 4.4 Sri Lanka: Multi disciplinary teams are employed to facilitate collaboration between mental health services. 4.5 Burundi: Peer Groups Children can play an important and active part in social healing processes and primary psychosocial prevention. The objectives of this initiative are; (1) involvement of children in a positive providing a sense of meaning, increasing pro-social behaviour and a sense of empowerment; and in turn (2) supporting vulnerable children and families; (3) support the community at large through small community development projects; and (4) raise awareness about the plight of children in war situations. People in affected communities still need to understand the impact of psychosocial problems on the daily functioning of children. Through cooperation and community projects, awareness raising by children can take place. This is also a strategy to develop children s resilience as it contributes to making their environment increasingly careful for them through a network of children helping children (i.e. help some children living alone in doing some domestic tasks). At the same time such efforts can mobilize other community structures to support vulnerable children. For children whose families are extremely poor advocacy and assistance can be provided through peer support groups that help peers. Involve children and especially adolescents in peace building and reconciliation efforts by working together for community reconstruction. In Burundi para-professional service providers create a peer-group identified through the school-based psychosocial program. These peer groups carry out several activities. First, identifying children and families in their respective communities that are in need of support. Together with the children or families they identify their needs in terms of domestic tasks and organise the rest of children at school to help those children. Teachers and community leaders are also invited to join (e.g. fire wood gathering, cultivating, harvesting, house building, fetching water). See small VIDEO link. Second, peer-groups are involved in the organization of children and staff to advocate for material needs of vulnerable families: clothes, soap, food, school material, etc. Everyone can bring from his family what they can contribute. Subsequently, the collected stock is distributed to very vulnerable or orphans children. Third, children are sensitized for helping other children in crisis for example when one of their peers is very sick, or has lost a dear one, a visit is organized to provide for emotional support. Fourth, the peer groups are involved in arranging sport days, cultural activities, and recreational activities at schools. Module 5: Case-management and Utilization of Existing Resources 7

8 These peer-groups activities have been highly appreciated by local leaders, children and the community at large. The activities look especially exciting for children and do not require any external resources. Internal Links See publications: Tol, W.A., Jordans, M.J.D., Reis, R. & De Jong, J.T.V.M. (under review) Ecological resilience: working with child-related psychosocial resources in war-affected communities. Forthcoming in: D. Brom, R. Pat-Horenczyk & J. Ford (Eds.) Treating Traumatized Children: Risk, Resilience, and Recovery External Links Wessels, M., & Monteiro, C. (2006). Psychosocial assistance for youth: Towards reconstruction for peace in Angola. Journal of Social Issues, 62, References Mikus-Kos, A. Activating Community Resources for the Well Being of Children and Stability. In: Friedman, M.J. & Mikus-Kos, A. (2005). Promoting the Psychosocial Well Being of Children Following War and Terrorism. Amsterdam: IOS press. Tolfree, D. (1996). Restoring Playfulness. Different approaches to assisting children who are psychologically affected by war or displacement. Falun: Radda Barnen. Module 5: Case-management and Utilization of Existing Resources 8