Needs-led treatment planning

At the level of the individual client a prerequisite for appropriate treatment and care is an expert diagnosis and a treatment plan based on this. Questions on ad-diction diagnoses cannot be gone into further detail within this context. Men-tioned here are just the ICD-10, the DSM-IV¹⁰² as well as the Addiction Severity Index described above (4.2.4).

In addition to the diagnosis, the subjective needs of the client must be included in the treatment planning. This is in order to be able to meet the frequently formu-lated general need for an individual approach in supporting and recognising in-dividual achievements. These days the assessment of clients’ needs should be both an integral part of routine clinical practice and a component of service evaluation.

In the field of treatment and care of drug abusers there has been until now a lack of instruments for systematically assessing the needs from the perspective of the individual clients. In community mental health care, however, the importance of a needs-led approach towards the individual care of those with severe mental ill-ness has been widely recognised. One established needs assessment tool in the mental health field is the Camberwell Assessment of Need (CAN). This is an

102Diagnostic and Statistical Manual of Mental Disorders, edited by the American Psychiatric Association.

strument for assessing a wide spectrum of met and unmet needs from the per-spective of the clients, the personnel and the relatives. A further instrument which is currently being developed is the WHODAS II. Besides the standardised survey instruments, there are also methods for individual treatment planning as part of the case management. Two examples are these from the Czech Republic will be presented here.

4.3.3.1. Camberwell Assessment of Need (CAN)

The Camberwell Assessment of Need (CAN) is a new instrument which has been designed to assess both met and unmet needs of people with severe mental ill-ness. The CAN is based on the principle that need is a subjective concept and that there will frequently be differing but equally valid perceptions about the presence or absence of a specific need. The CAN therefore records the views of staff and users separately. A priority of the CAN is to identify, rather than describe in detail, serious social and health needs. Specialist assessments can be con-ducted in specific areas if required, once the need is identified. Three versions of the CAN are available: a clinical version (CAN-C), a research version (CAN-R) and a short version (CANSAS).

Target population:

Clients of mental health services with severe mental health problems.

Dimensions:

The CAN assesses problems during the last month in 22 domains of health and social needs:

1. Accommodation 12. Alcohol

2. Food 13. Drugs

3. Looking after the home 14. Company

4. Self-care 15. Intimate relationships

5. Daytime activities 16. Sexual expression

6. Physical health 17. Child care

7. Psychotic symptoms 18. Basic education

8. Information on condition and treatment 19. Telephone

9. Psychological distress 20. Transport

10. Safety to self 21. Money

11. Safety to others 22. Benefits

103The following description of the CAN is based on the work book from Mike Slade et al. (1999), which in-cludes a manual, questionnaires, score sheets, training programme, case vignettes, worked examples and answers to frequently asked questions. (Slade, M., Thornicroft, G., Loftus, L., Phelan, M. & Wykes, T.

(1999). Camberwell Assessment of Need. London: Gaskell.)

Administration of the CAN:

An assessment using the CAN involves an interviewer asking an interviewee questions about each of the 22 domains. The interviewee may be the client, the carer (e.g. friend or family member) or a member of staff who knows the user suf-ficiently well. If the client or the carer is being interviewed, administration involves the interviewer going through the CAN, asking about each domain in turn. If a member of staff is the interviewee, this member of staff himself/herself fills in the CAN.

Description of questions:

Questions are asked about each domain to identify:

- whether a need or problem is present in that domain, - whether the need is met or unmet

- how much help the user is currently receiving from informal (friends, family) or formal sources, and how much help he or she needs,

- what the client’s views about his or her needs are and

- whether users are getting the right type of help for their problems and (in the user interview only) whether they are satisfied with the amount of help that they are receiving).

CANSAS: Only questions of the type (1) and (2) are asked. The answer catego-ries are: "0=no problem", "1=met need", "2=unmet need"

CAN-C: Questions of the type (1), (2), (3) and (4) and CAN-R: (1), (2), (3) and (5) are asked. The answer categories for CAN-C and CAN-R are: Section (1): "0=no problem", "1=no/moderate problem due to help given", "2=serious problem" and sections (2) and (3): "0=none", "1=low help", "2=moderate help" and "3=high help".

Necessary time for assessment:

CANSAS: approx.. 5 minutes; CAN-C / Can-R: approx. 15 minutes.

Validity and Reliability:

The studies of Phelan et al. (1995)¹⁰⁴ and Slade et al. (1996)¹⁰⁵ suggest that the CAN is a valid instrument, which when used under research conditions has ade-quate reliability.

104Phelan, M., Slade, M., Thornicroft, G., Dunn, G., Holloway, F., Wykes, T,. Strathdee, G., Loftus, L., McCrone, P. & Hayward, P. (1995). The Camberwell Assessment of Need: The validity and reliability of an instrument to assess the needs of people with severe mental illness. British Journal of Psychiatry, 167, 589-595.

105Slade, M., Phelan, M., Thornicroft, G. & Parkman, S. (1996). The Camberwell Assessment of Need (CAN):

Comparison of assessments by staff and patients of the needs of the severely mentally ill. Social Psychia-try and Psychiatric Epidemiology, 31(3), 109-13

Publications using the instrument:

Owing to the large number of publications only a small selection can be provided here. A complete list can be obtained from PRiSM (see address below).

Burns, T., Creed, F., Fahy, T., Thompson, S., Tyrer, P., & White, I. (1999). Intensive versus stan-dard case management for severe psychotic illness: A randomised trial. Lancet, 353, 2185-2189.

Slade, M. & Thornicroft, G. (1999). User friendly assessment of need. Nursing Times, 95, 52-53.

UK 700 Group. (1999). Predictors of quality of life in people with severe mental illness. British Jour-nal of Psychiatry, 175, 426-432.

Van Os, J., Gilvarry, C., Bale, R., van Horn, E., Tattan, T., White, I. & Murrey, R. (1999). To what ex-tent does symptomatic improvement result in better outcome in psychotic illness? UK700 Group. Psychological Medicine, 29(5), 1183-1195.

Languages:

Cross-culturally validated versions of the CAN exist in English, Dutch, Danish, Italian and Spanish. Non-validated translations exist in French, German, Greek, Swedish and Turkish. All versions can be obtained from PRiSM (see address below).

Comment:

The CAN can basically also be deployed in the treatment and care of drug abus-ers. However, several adaptations are conceivable. For instance, the field "drugs"

could be expanded whilst questions such "Do you know how to use a tele-phone?" or "How do you find using the bus, tube or train?" could be left out.

Copyright / address / further information:

Section of Community Psychiatry (PRiSM) Institute of Psychiatry

De Crespigny Park Denmark Hill London SE5 8AF England

Tel: +44 (0) 20 7919 2610 Fax: +44 (0) 20 7277 1462

4.3.3.2. Disability Assessment Schedule WHODAS II

Another important instrument that can be used to help identify individual needs is the World Health Organization Disability Assessment Schedule II (WHODAS II). It assesses the activity limitations and participation restrictions experienced by an individual irrespective of medical diagnosis. Results provide a profile of func-tioning across the domains as well as an overall disability score. Whilst in CAN needs are directly assessed, in WHODAS II these must be determined from the limitations which are established..

WHODAS II is currently under development and not yet available for general re-lease and distribution. Further information on the WHODAS II can be obtained from: http://www.who.int/icidh/whodas/generalinfo.html .

4.3.3.3. Individual Treatment Planning

The Czech Republic reports on the following procedure to promote adequate in-dividual treatment planning (see country reports, Cost-Effectiveness):

Individual Treatment Plan or Client Contract

Individual treatment plans are a kind of contract which is concluded when a client is admitted to the programme. During treatment the contract is regularly up-dated in consultation with the client. It includes the client’s main problems together with the steps defined to change the situation which is unsatisfying to the client. The problem area as well as the steps to be taken are defined by the client supported by his/her personal counsellor (staff member). Such contracts include the fol-lowing items:

- client data (name, birth, address, education/profession, brief drug career) - relevant persons (basic information, contacts)

- definition of main client’s problem

- the main (long-term) aim which the client wants to reach - partial (short-term) aims which the client wants to reach - steps - how to get to the targets set

- date of the next contract revision (up-date)

- signature of client, personal counsellor, supervisor of contract Programme effectiveness evaluation protocol:

The programme effectiveness evaluation protocol is completed by the client, a staff member and/or by the client’s relative (mostly parents). It is completed (1) at the admission of the client to the programme, (2) periodically while in treatment/

care, (3) at the completion of the programme (at orderly completion, or when dropping out), and (4) approx. one year after completion of the programme (or after dropping out). The following evaluation scales are used:

- Client’s life satisfaction: client is unsatisfied; more unsatisfied than satisfied;

more satisfied than unsatisfied; client is satisfied, everything is OK.

- Abstinence: client uses regularly; tries to be abstinent, uses safely, tries a

"controlled use"; client relapses, he/she works with staff; client does not use

- Relation to the family (parents, significant persons): negative; more bad than good; more good than bad; regular contact with relatives valued positively by the client

- Contacts with other users: client has no other contacts than with DUs; client has mostly contacts with DUs; client has mostly contacts with no users; client has no contacts with DUs

- Education and/or working position: client is unemployed and does not study;

client is employed or studying, but has serious problems (drop-out is very likely); client is working or studying; client is working or studying, he/she is satisfied with this situation.

Goal attainment is documented according to the following grid:

Evaluated by Evaluated area At admis-sion

At comple-tion

1 year after completion

1.Life satisfaction 0 - 3 0 - 3 0 - 3

2.Abstinence 0 - 3 0 - 3 0 - 3

CLIENT 3.Relations 0 - 3 0 - 3 0 - 3

4.Contact with users 0 - 3 0 - 3 0 - 3

5.Work/Education 0 - 3 0 - 3 0 - 3

1.Life satisfaction 0 - 3 0 - 3 0 - 3

2.Abstinence 0 - 3 0 - 3 0 - 3

RELATIVES 3.Relations 0 - 3 0 - 3 0 - 3

4.Contact with users 0 - 3 0 - 3 0 - 3

5.Work/Education 0 - 3 0 - 3 0 - 3

1.Life satisfaction 0 - 3 0 - 3 0 - 3

2.Abstinence 0 - 3 0 - 3 0 - 3

STAFF 3.Relations 0 - 3 0 - 3 0 - 3

4.Contact with users 0 - 3 0 - 3 0 - 3

5.Work/Education 0 - 3 0 - 3 0 - 3

4.3.4. Identifying unmet needs within and outside the