Defining features of client centered care
Four overarching themes emerged from the staff interviews that captured the defining features of the client centered model: flexible, comprehensive, open-minded and inclusive. The themes are not mutually exclusive, but rather are complementary and interdependent.
Flexible. All staff described care as being conscientiously tailored to the clients’ individual needs – in other words “making all the decisions around, and always taking into consideration, the needs of the client and doing what’s best for them” (S1). Staff explained that decision-making and treatment planning are directly shaped from client needs and adapted over time as necessary. S1 added:
It’s not that one size fits all treatment, like what we traditionally thought about rehabbing in the past. It’s from the get go, you know, these are all your options, what do you actually need out of treatment? Is it outpatient? Is it residential? If it’s residential, what is it going to look like? How long do you need? And constantly assessing that as you go through the program with the client.
Providing flexible care was described as being dependent upon transparency between staff and clients and an open mindset. Most staff explained that they have needed to help clients adjust to the intensity of flexibility or tailoring offered at Kedesh by regularly questioning clients about their needs and reminding them of their options. As S5 observed, “I think there’s a lot more discussions and involvement with the client in terms of what their time here looks like”. Staff identified significant components of this flexibility as the adaptable treatment and program structure, unlimited extension, accessible re-entry, and graduated and negotiable leave.
Comprehensive. All staff emphasised the importance of looking at the holistic, individualized needs of a client and that in doing so the care naturally becomes more comprehensive and in-depth. For S2:
The way I describe it is that we look at the needs of the client so we try and look at the overall context of the client not just at Kedesh but their context in their life, we look at their context in relation to their mental and physical health and we try to work with them as much as possible with that in mind.
Staff described there being a greater spirit of authenticity to care by acknowledging the client from a whole person perspective with consideration to the family and community systems that they ultimately need to re-integrate into. Staff identified a vital part of this approach as negotiating leave with clients, in which clients typically take progressively more leave throughout the program and return to the service where they process any issues that arise. As S3 explained:
Clients weren’t accessing things that they really needed to, that were important for their recovery and rehabilitating them back into their own life outside of rehab life wasn’t working quite as well as where it may have in our client centered model that we’re providing them a lot of time outside of here to integrate back into their normal life.
Open-minded. All staff described the need to hold a curious and open-minded attitude to the possibilities in care. This appeared to take the form of setting aside ideas of a standard protocol (e.g. treatment program, service rules) and instead routinely questioning, challenging and discussing the best approach indicated for the client. S1 explained that adjusting to this mindset took time and teamwork:
When we first started moving towards it, it was a bit like, “Can we do this?” Like, “What are we allowed to do?”. We were still in that old rehab model around being allowed to do certain things, being not allowed to do certain things. But now it’s kind of more of a conversation of, “Why or why not?” Rather than, like a, “Yes or no you can or can’t do it.” So, I think it’s created a lot more discussion.
Inclusive. Client centered care was experienced as a more compassionate approach by all staff participants. This meant actively acknowledging the autonomy of clients in managing their care and making room for client mistakes in order to provide the care that they need. S1 said:
We’re actually considering the client, rather than just being very clinical and going through the procedures and ticking boxes and you know, making these huge decisions that really affect peoples’ lives without really considering the impact that’s going to have on them and just going based on the procedure.
In order to show more leniency and flexibility around rules staff frequently identified, “using our clinical judgment a lot more” (S3). Most staff explained that a natural consequence of this approach is that the needs of the client are prioritised over the needs of the house.
Benefits and challenges of client centered care
There was significant overlap between client and staff participants regarding the benefits and challenges they identified in the client centered care model at Kedesh. The benefits and challenges could be grouped as subthemes within each of the identified overarching themes of flexible, comprehensive, open-minded and inclusive. The exception was the inability to capture a client identified challenge for flexibility, which did not emerge from the data.
Staff perceived benefits and challenges.
Flexible. Staff identified the benefit of individualized care and the challenge of consistency. All staff reported that there is a great deal of room for flexibility and creativity in tailoring the program to individual clients. S6 observed that, “There’s no set, “this is what we provide”. It’s always essentially what they need and the amount of support required”. Consequently, staff described nurturing reciprocity and collaboration between staff and clients and reported the belief that this directly promotes client autonomy. As S4 explained:
Often when they’ve come from addiction where there’s been a lack of boundaries, sometimes I think for them there can be safety in very strict boundaries. But then yeah, the strict boundaries doesn’t necessarily foster for them what we or they would hope to get out of it.
However, all staff noted that metering flexibility on a case-by-case basis inevitably leads to some inconsistency in approaches and confusion about what to do. S5 stated:
It’s sometimes difficult to make a decision because you don’t know what the boundaries and limitations actually are and what framework or what sort of expectation are you working with. So again, one person might think this is a really good idea because of this, but then this person might think, well actually, no because what about these things as well.
Hence, the majority reported that finding a middle ground where all staff can agree about a particular action can be challenging.
On other occasions staff noted that clients may observe inconsistency in an approach that in fact arose from a considered rationale. For example, staff may provide different treatment to individual clients because circumstances indicated a different approach was needed at the time. S8 commented that clients approach staff with complaints of “I want what this bloke got” and “You let him stay because he had a slip, why aren’t you letting him stay because he’s had a slip?”. Staff explained the need to adroitly communicate their decision-making to clients.
Comprehensive. Staff identified the benefit of holistic care and the challenge of logistical complexity. All staff reported a focus on thoroughly considering clients’ needs beyond drug and alcohol issues. S5 explained:
Because we’re dual diagnosis, we look at more than just drug and alcohol, we look at all the other things that are going in their life, mental health and we look at creating a treatment plan that doesn’t just fit being in rehab, but more so, what their problems are in general, what they want to work on.
This holistic standpoint was viewed by all staff as instrumental to the successful reintegration of clients into their family and community systems and thus sustained change. As S3 identified:
A couple of weeks in a program feels great, but when you’re on the outside of Kedesh, it could really hit home. So I think we’re addressing things now that probably weren’t addressed before and I feel like it’s a quite important part of recovery for these clients.
At the same time, all staff explained that providing this depth of care complicates decision-making and therefore more logistical work. They noted challenges of communication and coordination between staff in individualising treatment as opposed to one-size-fits-all. S7 commented that, “because it is client-centered and we’re changing the way we’re doing things all the time – we talk about it, but I don’t know how well that often translates to the whole team.”
Staff also noted the difficulty in determining their capacity to provide individualized support in the residential environment. S3 commented that, “it is difficult to manage a bigger group of clients when you’re trying to focus on their individual needs” and S4 explained that while they may want to endorse timely re-entry of a discharged client, “it can get a bit tricky sometimes because it depends on the needs of the people on the waitlist as well”.
Staff also identified a notable logistical difficulty in providing support to family and friends of clients and opportunities and treatment for reconciliation. They noted the key issues within this particular domain as feeling underskilled in family liaison, the broad catchment area of their service, and varied levels of willingness of clients and their families to be involved. So, while meeting individual needs was a strength, a challenge was having the requisite skills or resources to meet diverse needs.
Open-minded. Staff identified the benefit of being enterprising and the challenge of resource intensive service. All staff described the client centered model as highly collaborative and supportive. As S1 explained, “it’s never one person making these decisions. It’s constant discussion and questioning and you share the load as a team”. All staff consistently reported a questioning as opposed to conclusive undercurrent to their decision-making.
Inherent within this approach is a respect that “everyone’s opinions are valid” (S3). This inclusivity was described as for the benefit of the client because “when you have a team of people that are giving input and saying, “How about we try this or how about we do that?” it actually is for the advantage to the client because you’ve got all of that different input coming in” (S2). As a consequence, staff described becoming closer and more respectful as a team.
However, the majority of staff also noted that delivering this model inevitably involves much more time and effort spent in discussions and critically thinking about courses of action. As S3 expressed:
If we worked by a book, it’d be very easy to make decisions. That person used, they get discharged, there’s nothing to talk about. As opposed to, “This person used, okay. What was the situation? How did they respond when they came back? Were they honest about it?” All that turns into an hour-long conversation, which is time consuming.
Staff reported that this issue can be significantly exacerbated by staffing availability.
Inclusive. Staff identified the benefit of satisfying work and the challenge of anxiety provoking responsibility. Staff were highly positive about client centered care being more satisfying to deliver. They reported showing a more compassionate approach to care in which, “staff get that genuine sense of doing what’s best for the individual … that sense of we’re doing what we can” (S6). They described feeling more like critically thinking clinicians and coming to have greater confidence in their skills and one another’s. S4 found that, “when we started the client centered care it boosted my confidence so much because it was kind of that, okay, it might be scary doing this new approach, but I do have good judgment”. S2 summarised the benefits of being inclusive for staff as:
… autonomy and variety and creativity and learning to respect each other’s professionalism but also having their professionalism respected, feeling that they are making a difference and that they’re an active participant in this as well, seeing some pretty cool ideas come to fruition with a client and seeing the impact that that has on the client.
Conversely, all staff spoke about there being greater room for uncertainty and doubt when leniency and flexibility are introduced. They explained that there is safety in hard and fast rules and procedures while in client centered care it is the team’s decision-making under the spotlight. As S5 explained:
We also sometimes feel there’s a lot of pressure to make the right decision and before sometimes it was like decisions were made for us, but now it’s like, well do we, don’t we. If we do, this is what’s going to happen, if we don’t this is what’s going to happen. So, for me personally, there is that, sort of, ongoing pressure in that you’re always having to make a decision and you’re not always going to know if that’s going to be the best or the right decision at that time.
Client benefits and challenges.
Flexible. Clients identified the benefit of individualized care. A corresponding challenge did not emerge from the data. The majority of clients identified that staff showed an open-minded and adaptable consideration of their unique needs and how best to “customise certain things to what we need” (P3, Group 1). Clients expressed appreciation for being provided with options and choice in their treatment planning and the sense that staff were being thoughtful of their needs. For example, P5 in Group 1 commented:
My counsellor’s given me time through the week to give me the iPad so I can go in a room by myself and do some mindfulness. So she’s taken out – she’s organised some time for my illness, I guess, and, like, actually considered it, which I haven’t gotten from any other residential rehab before.
Comprehensive. Clients identified the benefit of holistic care and the challenge of confronting personal work. Most clients reported that staff developed an in-depth and sophisticated formulation of their presentation that took into consideration the context of the whole person. P1 of Group 1 explained, “when you’ve got the case manager, the counsellor and all the other staff you’re really forced to focus on yourself as an individual. So you can’t just fit in with the herd and just fly under the radar …”. P4 of Group 4 expressed appreciation for staff being able to “pinpoint” specific emotional struggles “because then I’m able to work on it”. As a result, clients expressed the belief that “You get more help in the end” (P3, Group 1). P6 of Group 4 commented that “you can tell the times when they are doing the client-focused stuff because that feels totally more effective”.
At the same time, some clients advised that this depth of care can be confronting or experienced as overwhelming. They described times of processing a lot of information and working through insights of intense personal significance. Nonetheless, clients frequently viewed this work as a necessary part to their recovery and reported being able to manage it with support and guidance from staff. As P5 of Group 1 explained:
I mean therapy is more challenging because I think we’re getting more done. So it’s not happening – I mean it’s hard because I think they’re getting down to the nitty-gritty and we’re actually getting – it can get worse before it you get better but not in a bad way.
Open-minded. Clients identified the benefit of having agency and the challenge of uncertainty in taking ownership of their care. The majority of clients reported being invited into an open-ended consideration of their care and having a say in what they do. P4 of Group 2 stated that staff teach clients “accountability” and “responsibility” and “give you tools that allow you to learn for yourself”. Thus most clients reported adopting a more reflective stance to how they approach decisions and life challenges. P1 of Group 1 commented:
I think staff can feel like we’re making meaningful change because the change is coming from within, rather than just doing what is told and doing it just to exist and we’re getting told in the house – because it’s client based therefore a lot of decisions are coming from within us.
All clients endorsed the benefit of gaining “freedom” with the graduated leave so that “you can go out a bit more and more and you can test yourself” (P3, Group 4). Clients reported that this provided opportunities to review these experiences with staff upon their return from leave.
On the other hand, some clients also expressed anxiety and frustration with this independence due to feeling like they did not have the knowledge or skills to know what is best for them or how to go about it. This led to client concerns about the availability and willingness of staff to be able to see them through their care journey. P5 of Group 2 identified as having “a lot of self-responsibility with my care here” and that they were “the one that’s brought a lot of it out and said what my needs are”.
Clients discussed the need for a balance between being guided and challenged – a “two-way street” (P5, Group 2). P4 of Group 4 described the approach at Kedesh as “pushing you a little bit and letting you do it at your time”.
Inclusive. Clients identified the benefit of compassionate care and the challenge of times when treatment seemed unfair. All clients endorsed that staff provided authentic and empathic care. After leaving a rehabilitation service with “more of a group approach”, P2 of Group 4 explained “I went and had one counselling session and I already feel like I’m human again”. P2 of Group 3 identified authenticity in “funny” things like being able to have a bike on the premises because if it were denied you would feel like, “Oh God, I wish I had my bike”.
Clients reported that staff showed respect and responsiveness to their boundaries by regularly checking in and emphasising their availability for support while also allowing space for clients to move at their own pace. P2 of Group 3 reported:
If something has been a little bit close to home or triggered and I've got a bit teary or emotional about it towards the end of the group, "Are you okay?" So when the group finishes you've pretty much been asked if you want to speak about it, explore the feelings anymore, that sort of thing”.
However, some clients also noted the potential for clients to take advantage of the leniency and flexibility given by staff. P1 of Group 1 commented:
Because it’s not like a boot camp, a military school and it is meant to be that staff encourage feedback, there is an option if that power is given to the clients to be used. Because if somebody already comes in with a – the universe revolves around me, sort of, mentality, they could really come in from the door and be like, “All right, that means I can just whinge and complain about every little thing and staff are going to be at my beck and call”, sort of thing”.
Some clients expressed frustration when witnessing other clients “get away” with misdemeanours or not do their share of the house tasks, especially when they feel such clients are not genuinely and actively seeking recovery.