Section 1: An introduction to Individualised Plan and Support

An individualised plan is a generic term used to describe a support or service provision plan developed specifically for an individual client. It is likely to have different names depending on the organisation; some examples include individual support plan, care plan, coping plan, recovery plan, personal support plan, or service delivery plan. Individualised plans are commonly used in disability, aged care, and mental health settings because there is typically a greater need for personalised care and to document information of the individuals that relates to the care they need. Of course, these are not the only contexts in which individualised plans may be used. A case manager may also develop individualised plans as part of a client’s case management processes.

Whilst the name and the format of an individual support plan will vary in different contexts, it generally includes information such as:

• personal details, emergency and important contact persons (e.g., carers, family)
• the individual's profile, e.g.,
  • What do people appreciate about me or who I am?
  • What is important to me? (For example, things I like and things I am good at.)
  • What is most important to know to support me? What do I need?
  • My goals/ values: What is important for me? What do I want?
• key contacts, including people who will be involved in the care of and making decisions in relation to the individual
• support services/plan, including actions, time frame, the person responsible, and the level of support they require.

Like case management plans, individualised plans are more often used with clients who have complex needs and are engaged with a range of support services. Often, it is more like a document that travels with the client (e.g., a client may share it with different services they engage with) instead of being bound to a specific service or organisation. It helps reduce the need for clients to repeat their information across services while highlighting the strengths, values, and preferences of the individual clients.

Let’s consider the following case study (Government of Western Australia, 2018, p. 8):

Case Study

Paul

Paul is 55 years of age and lives in a country town with his partner. Paul has a teenage son who lives nearby with his maternal aunt. Paul has a mild spinal injury and psychosocial disability, which have both impacted his ability to maintain regular employment. Paul experiences periods of social isolation, often remaining indoors for days as he becomes overwhelmed and anxious. He visits a clinical psychologist every six weeks to help him develop coping strategies. Paul also attends monthly physiotherapy sessions for his spinal rehabilitation but does not exercise regularly. Paul’s partner has a mild cognitive disability as a result of an accident – this is sometimes difficult for Paul to cope with and causes strain on their relationship.

[…] Paul has been assisted to effectively identify his goals and a number of strategies that will enable him to reach these. Paul identified that he has difficulty managing his in-home routines and maintaining a tidy home and garden. He also wants to spend more time with his son and would like to develop his computer skills so he can manage his bills independently, as well as expand his skills in other areas so he is able to return to work.

In Paul’s case, he is likely to have ongoing needs from a range of professionals, such as a psychologist, physiotherapist, in-home support worker and employment services. It is also likely that his needs will change over time as his physical and mental health status progress and new abilities are being developed. Engaging Paul in an individualised support planning process enables Paul (and his family) to remain at the core of these services so that the information and support he receives are tailored to his unique circumstances and meet his goals.

From a counsellor’s perspective, if you were one of the practitioners providing support to Paul and his family, his individualised plan is likely to provide you with key information that helps you work effectively with Paul and his significant others within this larger support network, including who he is, what he hopes to achieve, his strengths and abilities, the role of services they are engaged with, as well as important considerations for service delivery (e.g., potential risk issues, language needs and cultural engagement). This is not only a great starting point for establishing rapport with Paul but also supports a person-centred service approach that seeks to surround clients with appropriate services instead of making clients fit in with the existing human services systems.

What is an individualised care plan?

The presenters in this video discuss what an individualised plan is. 

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On a broader level, providing individualised support that is tailored to the clients reflects a recent shift in paradigm within the human services sector in Australia. It has been recognised that some users of human services “will have multiple and complex needs and require access to several coordinated services, potentially for long periods” (Productivity Commission, 2016, p. 52). Unfortunately, these users often face barriers in accessing the services they need, which is further complicated by the challenges associated with navigating a fragmented and complex service system:

This leads to a call for greater integration both within and across human services, particularly for people with complex needs and requiring multiple services. Providing more individualised services is one of the main strategies to achieve service integration:

As a counsellor, you will likely be working within the great scheme of the human services sector and providing support to a variety of clients, including those who have complex needs. It is therefore important that you learn how to provide individualised support to clients and work effectively as part of an integrated service.

Principles of Individualised Support

Essentially, the rationale of individual support planning and delivery lies within the following principles: person-centred practice, strengths-based practice and active support.

Person-centred practice

All planning is focused on the individual client and their specific goals. Clients are viewed as experts in their own lives and engaged as a collaborating partner throughout service planning and delivery.

Strengths-based practice

Planning is based on what the client can do and seeks to draw from and build upon the client’s skills and abilities to help them achieve their goals.

Active support

Planning should facilitate the client to remain an active participant in the community and engage in tasks and activities that develop and maintain their skills.

These principles are at the heart of individualised support planning – this means that counsellors should support clients to achieve their goals and increase their independence and participation as valued, active members of the community. Supporting and empowering the client to make decisions about how to achieve the goals outlined in their individualised plan will help ensure that any counselling goals and activities developed reflect the client’s individual needs and preferences as well as promote their rights and autonomy.

In order to effectively implement these principles in practice, all practitioners and services involved in supporting the client will need to make sure that they have appropriate processes – communication, documentation and reporting – in place that enable individualised support planning and delivery within an integrated service approach. This is particularly important because each service provider will have different protocols and guidelines and working with clients who have complex needs requires the whole team to operate holistically within agreed-established guidelines. If, as a counsellor, you are working with a client who has several needs that are being addressed in collaboration with several services, you will need to organise, provide, and monitor your counselling support services within the limits established by the client’s individualised plan. You will also need to engage in active communication with other stakeholders, including the client (and their carers and family where appropriate), and record your work with the client following organisational protocols. We will look closely into some of these protocols later in the module.

Now that you have some understanding of what individualised support provision entails and how it relates to your role as a counsellor, let’s turn to some key practice considerations that will assist you in providing individualised support to clients with complex needs.

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Benefits of Doing Group Therapy vs. Individual Counseling Sessions

The presenters in this video discuss the differences between group therapy and individual sessions. 

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Counsellors’ work must be guided by a sound understanding of legal, ethical and practice considerations. Particularly when working with clients who have complex needs, making sure that you are following established guidelines and protocols is important for clients to experience safe, consistent service delivery and reduce barriers to access. We will begin with a review of the broader legal and ethical frameworks that underpin helping services, moving on to different service delivery models in the sector. Then we will turn our focus to practice considerations for direct client work, including roles and responsibilities of stakeholders, factors affecting clients, and risk management.

Relevant Legal, Ethical, and Organisational Considerations

As always, a counsellor must work in accordance with legal and ethical requirements relating to their role. Whilst these responsibilities may vary depending on the jurisdiction in which you practice, and your specific area of expertise, all counsellors must meet requirements relating to human rights, discrimination, privacy, confidentiality and disclosure, duty of care, dignity of risk, mandatory reporting and work role boundaries.

Human rights

Client rights are protected by both legal and ethical frameworks as well as a range of typical organisational policies and procedures. An overarching framework that informs and underpins these legislation, requirements and policies is the United Nations’ Universal Declaration of Human Rights. Throughout your studies, and in the work that follows, what counsellors (and other helping professionals) do is guided by human rights, including children’s rights, the right to be free from discrimination, the right to be informed and the right to privacy. Providing individualised support is likely to support clients’ rights to access services they need as well as reduce barriers that clients with complex needs often face. Human rights considerations are also important for organisations when it comes to designing service processes, making sure that all service procedures do not violate the human rights of clients and workers involved. Human rights form the foundation upon which the following legal and ethical requirements are based upon.

Discrimination

There are a range of anti-discrimination laws in place that aim to protect people from certain kinds of discrimination in public life and from breaches of their human rights. Examples of anti-discriminatory legislation that operates at a federal level include the Age Discrimination Act 2004, Racial Discrimination Act 1975, Sex Discrimination Act 1984 and Disability Discrimination Act 1992. At the same time, you must comply with anti-discriminatory legislation that applies to your specific state or territory.

For instance, the Disability Discrimination Act 1992 is important for individualised service planning when supporting a client who has a disability. It is important that you make sure they are not discriminated from access to services, such as by making sure your service is adaptable for accessibility. This is not limited to physical accessibility but also whether the information provided is accessible. Moreover, disability discrimination also covers situations when “people are treated less fairly because they are relatives, friends, carers, co-workers or associates of a person with a disability” (Australian Human Rights Commission, n.d.).

You will also find anti-discriminatory requirements in codes of practice and practice standards that guide the conduct of counsellors. For example, the ACA Code of Ethics and Practice states that you must “offer a non-judgmental professional service, free from discrimination, honouring the individuality of the client.” (2019, p. 7). Providing individualised support enables counsellors to tailor services to individual clients’ needs and circumstances, making sure that they are not in any way being discriminated against for needing multiple services and integrated support.

Privacy, confidentiality, and disclosure

A client's right to privacy must be upheld at all times during service delivery. They must also be informed of the confidential nature of counselling as well as the exceptional circumstances in which confidentiality may be overridden (e.g., scenarios such as a client at risk of harming themselves or others, or there is child abuse, or when required by law). It is the responsibility of a community services organisation to provide secure storage for client information and ensure there are appropriate policies and guidelines to guide staff in maintaining client privacy and managing confidential information. Counsellors must ensure they strictly follow these guidelines, particularly when client information may need to be shared with the case manager and/or other service providers to facilitate integrated service delivery.

Duty of care

As you have learned, counsellors have a legal responsibility to take reasonable steps to avoid clients coming to harm either through their actions or lack of actions. Your client’s individualised plan typically includes information about the client, including risk factors that service providers must take into consideration. As such, reviewing and confirming the details of the plan with your client is an important step in fulfilling your duty of care.

Importantly, your duty of care also extends to those who are not directly involved in the service, such as families and children of clients, staff in the building, and yourself. This means that you must always assess for potential risk issues, and make sure that you address potential or identified issues in a timely manner, following your organisational policy and procedures.

Dignity of risk

Counsellors must treat clients with dignity and respect, including acknowledging their dignity of risk whereby they are given the right to make the choice of taking some risks in order to fully engage in life experiences. At times, it can be a challenge to support client decisions that we feel are too risky. However, unless there are serious concerns about the client’s safety and present state of mind, clients should be respected for their rights to take the level of risk they are comfortable with. It might be appropriate to work collaboratively with the client in identifying potential risks and developing strategies that can minimise risk, however, it would not be appropriate to restrict the client from taking their chosen action. In some cases, there may not be a clear line between your duty to protect clients from harm and their dignity of risk, thus you should always seek consultation with your supervisor, manager, or experienced colleagues in order to determine the most appropriate actions.

Mandatory reporting

While mandatory reporting legislation does differ between jurisdictions, a child’s right to safety is considered paramount in all states and territories, and most helping professionals have a legal and/or ethical obligation to act where they have reason to believe a child has been abused, is being abused, or is at risk of abuse. It is important that clients are informed of this exceptional circumstance for when confidentiality may be overridden. Typically, your organisation would have developed clear policies and guidelines to support staff in complying with mandatory reporting requirements, which are applicable to those who work directly and indirectly with children and young people.

Work role boundaries

As mentioned before, each practitioner working with the client must be very clear about their role and responsibilities in supporting the client, as documented in the individualised support plan. It is important to maintain these boundaries and acknowledge that there are limitations to your role. If clients raise issues or needs that are not within your work role, referral to appropriate services or raising such matters with their case manager may be more appropriate. At times, it may be appropriate to renegotiate your role in supporting the client, however, this must be done in collaboration with the client and/or other relevant stakeholders (e.g., case manager, other service providers or family/carers) to make sure that proposed changes are in the client’s best interests and not hindering their engagement with other services.

Your organisation or practice will have its own policies, protocols, and procedures in place that guide the planning and preparation of counselling services and support activities. It is essential that you understand and apply these guidelines correctly when implementing individualised plans.

Policies, protocols and procedures may reflect industry service standards, as well as legislative or regulatory requirements, and may relate to the following:

• Access and equity
• Clinical supervision
• Duty of care
• Eligibility criteria
• Ethical standards
• Evaluation of services
• Documentation requirements
• Intake procedures
• Privacy and confidentiality requirements
• Professional boundaries
• Referrals to other services
• Reporting requirements
• Risk management
• Service provision
• The rights of the person
• Use of specialist equipment or aids
• Use of interpreters
• Waiting lists
• Work health and safety.

Essentially, all of the standard counsellor responsibilities continue to apply when working with clients with individualised plans. However, additional considerations will be required in aspects relating to managing co-occurring client needs, communication between stakeholders, documentation, and where adjustments to service processes are made.

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Service Delivery Models

Each service provider will have their own service delivery model, which is typically influenced by their vision, philosophy, and funding. For instance, some services focus on providing support for specific issues (e.g., homelessness specialist support) or clientele (e.g., youth service); whilst others may be multidisciplinary in nature (e.g., a community-based health service that offers health services, counselling, support groups, and home visits). Traditionally, clients are required to attend service locations to access support services face-to-face. However, it is becoming more common now that services are adapting their service delivery approach to suit client needs and circumstances, to make services more accessible and less costly. Some alternative service delivery approaches include community outreach, in-home and residential support, phone and online services.

Community outreach

Common forms of outreach include a bus or van that travels to communities to offer information and services, or a car with counsellors or community services workers that goes into communities to conduct home visits with clients and their families. This model of service delivery is often used to offer mobile services to targeted communities (e.g., Aboriginal and Torres Strait Islanders or young people in specific geographical areas) where service access is minimal and/or stigmatised.

In-home support

This generally refers to when support is delivered at the client’s home instead of at the service venue. For example, clients may have support workers attending their home on a regular or short-term basis to assist with household activities or support skill development. This mode of service delivery can be flexible and tailored to the client’s lifestyle while supporting them to restore or maintain independence. It also enables clients to apply and practice their skills in their home environment.

Residential support

Some clients with complex needs may require more intense care and support, such as in a residential or rehabilitative facility. For instance, a client may attend a residential facility to undertake a ten-week drug rehabilitation program, in which they also receive counselling support. Once completed, they are then transitioned into in-home support, where a worker would attend every week to follow-up and support relapse prevention.

Phone and online services

With the advancement of technology, service provision through phone, online or virtual platforms has become more common and is particularly beneficial for those with complex needs. Clients with complex needs often have fewer resources (such as time and budget) to allocate for the range of services they require. They also may face higher barriers to accessing services, such as social or cultural prejudices, stigma or geographical obstacles. With interventions delivered over the phone or electronically, clients are able to overcome difficulties associated with traditional face-to-face treatments, including the delivery of effective treatments that are costly when conducted traditionally.

Roles and Responsibilities of Stakeholders

When a client is supported by multiple people (e.g., carers, family) and services, it is important that each stakeholder is clear about their roles and responsibilities and how they will be liaising in relation to the client. As part of the supporting team, a counsellor is likely to work with the client, the client's carers and family, as well as one or more health professionals, other support workers and their supervisor. 

The client

The client should always be at the core of planning and delivery; hence it is important to collaborate with them throughout the processes. For instance, the client should be informed of all relevant information that they require to make decisions about their care. They should be consulted during service planning and supported to make their own decisions where practicable. Of course, clients will need to take responsibility for the decisions and actions they make to help progress towards their goals.

The client’s carers and family

The client’s carers and family may be actively engaged in their day-to-day care as well as decision-making. If so, they can often offer valuable information about the client that can assist service providers in tailoring the service on offer. It will also be important to make sure they are informed and supportive of the client’s support plan particularly if they are involved in its implementation (e.g., transportation, meals). You are also likely to see their contact details included on the client’s individualised support plan. However, overinvolvement of carers and family can be unhelpful at times (e.g., becoming overprotective or hindering the client’s autonomy), so it is important to check with the client as to whether and to what extent carers and family should be involved, and have that clearly documented.

Health professionals

Health professionals are commonly involved when clients have complex needs. They typically have their own specialty and provide specific support in addressing client needs, for example, psychologists, psychiatrists, general practitioners, nurses, physiotherapists, speech pathologists and occupational therapists.  

• Psychologists aim to improve client outcomes through the provision of psychological services within a case management practice or via specific referrals. Most clinical psychologists develop expertise in specific areas of practice in sub-specialities.
• Psychiatrists treat all kinds of mental illnesses, emotional disturbance, and abnormal behaviour from mild or episodic conditions to those that are severe, persistent and life-threatening. They work with people of all ages and from all ethnicities and backgrounds, assessing and treating patients with mental health problems.
• General practitioners treat all common medical conditions and refer patients to hospital and other medical services for urgent and specialist treatment. They combine physical, psychological, and social aspects of care by focusing on the health of the whole person.
• Nurses play an integral role in the healthcare system and work in a variety of contexts, such as hospitals, general surgeries, aged care facilities, or in a person’s home. Nurses play various roles concurrently depending on the unique needs of a patient at the time.
• Physiotherapists help people with physical difficulties resulting from illness, injury, disability, or ageing to improve their movement. Physiotherapists assess, diagnose, treat and prevent a wide range of health conditions and movement disorders and support people to repair damage, increase mobility, and improve quality of life.
• Speech pathologists have expertise in the assessment and management of communication, feeding, and swallowing disorders. They often work as part of a multidisciplinary team including other health care professionals to ensure the maximisation of the client’s abilities by using skills a client has and working to develop or improve areas of deficit. Speech pathologists support people with difficulties that may be due to known or unknown conditions such as cerebral palsy and developmental delay, or with acquired difficulties due to accident or illness.
• Occupational therapists enable people to participate in the activities of everyday life. They partner with people and communities to improve their ability to engage in the occupations they want to, need to, or are expected to do, or by modifying the occupation or the environment to better suit their individual needs.

Depending on the client’s situation, health professionals may only be engaged for a limited period, or at different times of the process (e.g., a client may be recovering from a trauma injury). Clear documentation such as progress reports and referral letters can be useful to make sure their work is communicated appropriately to other stakeholders in the support team.

Other support workers

Apart from health professionals, clients may also be engaged with workers from a variety of support services, such as employment agencies, housing, domestic and family violence, child and family services, mental health, alcohol and other drugs services, and of course, counsellors. These workers tend to offer support with more practical issues that help the client manage and improve their independent living towards how the client envisages. For instance, as a counsellor, you may be providing loss and grief support to a client who is in rehabilitation after a severe motor vehicle accident. Where there is a case manager involved, you are also likely to communicate with them about the client’s progress and engagement.

Your supervisor

Although your supervisor (or manager) may not be directly involved in working with your clients, it is important that you make sure they are aware of who you are working with and the support you may require in taking out your responsibilities. For counsellors, regular supervision is a common ethical requirement, and even more important when working with clients who have complex needs, to support reflective and ethical practice. In an organisational setting, you will most likely need to consult your supervisor/manager to make sure you are working within your organisational guidelines (e.g., when adapting service processes to suit client needs) and that resources are provided to manage potential or identified risks.

How communication takes place between the above stakeholders will vary depending on the nature of their roles. Typically, all stakeholders will be communicating directly with the client (and carers/family). Specific client information may also be shared with relevant stakeholders, verbally or in writing, with permission from the client. If there is a case manager involved, part of their role is to make sure information about the client is effectively communicated to and between all stakeholders, through case management meetings, case management plans or other agreed channels. Nevertheless, it is important that you always conduct and document communication with any of these stakeholders in line with the privacy, confidentiality, and disclosure requirements in your organisation.

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Factors that Affect People Requiring Support

Clients whom you work with will have a range of different needs, and they may have come to you from a variety of backgrounds. Whilst counsellors typically focus on providing mental health and psychosocial support to clients, it is important that you take a holistic approach when addressing client’s needs – that is, to acknowledge that the client can experience a wide range of needs/issues that may be interrelated.

Let’s consider an example: Henry has been referred to you for stress management. Since becoming unemployed twelve months ago, he has been exhibiting symptoms of depression and taking medication to help with his sleep. He is also using alcohol to excess to cope with his stress which consequently contributed to the deterioration of his mental health. He is working with an employment service provider to secure a job but is also under the stress of being evicted from his rental property. As Henry’s counsellor, you will be focusing on supporting Henry with stress management, but it is obvious that his stress is interrelated with other issues and needs. It is important that these issues and needs are being considered.

The Hidden Forces that Shape Behaviour

In this video, Jonah Berger explains some of the basic concepts of invisible influences on behaviour. 

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Whilst it is impossible to discuss every possible factor here, there are a few experiences and issues that are known to have a wide range of impacts on a person’s living, often resulting in complex needs situation and engagement with multiple services:

While the holistic approach recognises the broad range of needs the client may have and that the needs are interrelated, it does not necessarily mean you as the counsellor have to deliver interventions to address every single need. However, you should keep in mind that the client has different co-existing needs, and take these into consideration – such as how these needs interact, what needs to be incorporated into the counselling plan, and how to understand certain “challenging” behaviours of the client. You should also monitor for changes in client needs or circumstances so as to refer the client to the appropriate service whenever required.

Patient-Centered Care Systems: A View From Chronic Illness 

The presenter in this video discusses some important considerations around patient-centred care. 

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Risk Management

Risk management is always an important consideration in client work. This is relevant not only to your client’s safety and well-being but also to the safety and well-being of your own and other people who may be supporting the client. Typically, your organisation will have set out protocols to help you identify and manage potential risks relevant to the nature of your role – for example, if you visit clients at home, you may need to complete a home safety checklist to check for potential hazards in this ‘work’ environment. Some organisations would provide staff with training in first-aid, de-escalation strategies, suicide response, or work health and safety, in addition to appropriate tools and resources, to make sure staff are equipped to manage potential risks at work.

Risk Assessments: Key Factors in Mental Health

This video provides relevant information on risk assessments for mental health patients. 

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As part of your duty of care, it is also important to make sure you have considered and prepared to manage any identified or potential risks relevant to your clients. This will obviously vary for each client, and an individualised support plan is likely to provide some basis as to where you begin. There is usually information on the client’s plan that indicates potential or existing risk issues; for example, a client has been experiencing domestic and family violence and chooses to remain in an abusive relationship. When working with the client, you must incorporate appropriate responses – such as, continuously assessing their safety, reviewing, and updating their safety plan, making sure counselling takes place in a safe space (particularly if you are doing home visits) and supporting the client to develop skills in maintaining their own safety.

Where there have been experiences of trauma, you should also incorporate recognition of the impact of trauma in the development or implementation of an individual support plan, such as identifying potential triggers, risks, and strategies to mitigate the risks. For instance, you may engage clients in learning skills and strategies to help manage symptoms of trauma responses (e.g., irritability, aggression), and make sure these strategies are included in their individualised plan. You may also work collaboratively with clients to adapt current procedures so as to defuse and de-escalate potential incidents.

Suicide Risk Assessment in Youth

This video provides an example of a suicide risk assessment. Answer the questions that follow. 

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As each client’s situations will vary, make sure you follow risk management protocols and guidelines from your organisation and always consult with your supervisor/manager to make sure you are conducting work safely and appropriately. Remember that the range of work health and safety policies and procedures developed by your organisation can be a useful starting point, however, they may not cover all possible risks and it is important that you actively monitor for risks and seek assistance in a timely manner.

Assessing someone who is potentially psychotic and dangerous in the community

This video provides an example of a risk assessment of a client with mental health issues. Answer the questions that follow. 

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Breaking the Stigma and Shame of Mental Illness

The presenter in this video uses heartbreaking true stories and scientific facts to help the audience understand ways to challenge their thinking and join the fight to reduce stigma and shame around mental illness. 

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In this section of the module, you were introduced to individualised planning and support, which is commonly used in a case management context to support clients with complex needs. You also learned about some key considerations relating to providing individualised support as a counsellor, including legal and ethical requirements, service delivery models, roles and responsibilities of various stakeholders, and risk management. These considerations are important to ensure you can work safely and appropriately with clients as you learn to do so in the following section.

1. Australian Counselling Association (2019). Code of ethics and practice of the association for counsellors in Australia. https://www.theaca.net.au/documents/ACA%20Code%20of%20Ethics%20and%20Practice%20Ver15.pdf
2. Australian Human Rights Commission. (n.d.). DDA guide: What’s it all about. Retrieved June 24, 2022, from https://humanrights.gov.au/our-work/disability-rights/dda-guide-whats-it-all-about
3. Australian Institute of Health and Welfare. (2021). Health of people experiencing homelessness. https://www.aihw.gov.au/reports/australias-health/health-of-people-experiencing-homelessness
4. Government of Western Australia. (2018). National Disability Insurance Scheme: A guide to planning in the NDIS. https://www.disability.wa.gov.au/Global/Publications/WA%20NDIS/Guides/Individualised%20planning_A%20Guide%20to%20Planning%20in%20the%20NDIS.pdf
5. Productivity Commission. (2016). Introducing competition and informed user choice into human services: Identifying sectors for reform. Commonwealth of Australia. https://www.pc.gov.au/inquiries/completed/human-services/identifying-reform/report/human-services-identifying-reform.pdf