Working with different client groups

As we saw earlier, alcohol and other drugs support workers are guided by the national policy framework, namely the National Drugs Strategy 2017-2026.

This framework helps us to target our actions and interventions in areas where they are most needed and may have the most positive impact. The National Drugs Strategy has three priority areas that determine where action and funds are focused. These areas are: priority actions, priority populations, and priority substances. As an AOD support worker, you will be engaged in a top priority action, by ‘enhancing access to evidence-informed, effective and affordable treatment services and support.’

Priority Actions

• Enhance access to evidence-informed, effective and affordable treatment
• Develop and share data and research, measure performance and outcomes
• Develop new and innovative responses to prevent uptake, delay first use and reduce alcohol, tobacco and other drug problems
• Increase participatory processes
• Reduce adverse consequences
• Restrict and/or regulate availability
• Improve national coordination

Priority Populations

• Aboriginal and Torres Strait Islander people
• People with mental health conditions
• Young people
• Older people
• People in contact with the criminal justice system
• Culturally and linguistically diverse populations
• People identifying as lesbian, gay, bisexual, transgender, and/or intersex

Priority Substances

• Methamphetamines and other stimulants
• Alcohol
• Tobacco
• Cannabis
• Non-medical use of pharmaceuticals
• Opioids
• New psychoactive substances

Source: National Drug Strategy p. 18 available at: National Drug Strategy 2017-2026

You will also be focusing your interventions on target populations identified in the National Drugs Strategy, namely:

• Aboriginal and Torres Strait Islander people
• People with mental health issues
• Young people (aged 10-24)
• Older people (aged 60 and over)
• People who are engaged with the criminal justice system
• Culturally and linguistically diverse populations
• People who identify as being gay, lesbian, bisexual, transgender, intersex, gender non-binary, or otherwise part of the rainbow

According to the National Drugs Strategy, ‘Policy responses designed to prevent and minimize the harms of alcohol, tobacco, and other drugs should have particular reference to these priority populations, to ensure that new efforts will benefit those most at risk of harm, marginalization, and disadvantage. [However,] this does not diminish the importance of providing appropriate and effective responses for any community members who may not fit within one of these particular population groups.’

Let’s look at the priority population groups one by one.

Aboriginal and Torres Strait Islander People

Aboriginal and Torres Strait Islander people suffer more harm from alcohol and other drugs than any other population group. The many aspects of harm (health, social, and economic) are felt profoundly in Aboriginal and Torres Strait Islander families and communities. The reasons for the disproportionate impact of alcohol and other drugs among First Nations populations include:

• Dispossession from land and from the spiritual and cultural life that thrives in connection with country
• Intergenerational trauma resulting from colonization, frontier wars, and government policies such as the Stolen Generations
• Poverty
• Lack of access to opportunity and social inclusion due to racism
• Lack of access to culturally appropriate, First Nations-led services to reduce supply and harm of alcohol and other drugs.

Support services for Aboriginal and Torres Strait Islander people need to be:

• Culturally competent, sensitive, and inclusive
• Located in and engaged with Aboriginal and Torres Strait Islander communities
• Wherever possible, led and designed by Aboriginal and Torres Strait Islander people
• Informed by specific evidence about what works for Aboriginal Torres Strait Islander people, families, and communities.

People With Mental Health Conditions

Mental health issues are a common comorbidity of alcohol and other drug issues. This means, they frequently occur together. In some cases, alcohol and other drugs may exacerbate underlying propensity to mental health issues. In other cases, people with mental health issues may use alcohol and other drugs as a way to manage or numb symptoms of the underlying mental health condition. Either way, the presence of both mental health issues and alcohol and other drug use can complicate support and treatment. This requires strong collaboration between support and other health workers to provide responsive and non-judgemental treatment strategies that empower optimal mental health while supporting reduction of substance use.

Youth

Young populations face a unique combination of propensity and risk. Firstly, young populations are more likely to engage in risky behaviours than other age groups, which may result from curiosity, boredom, peer pressure, exposure to abuse, vulnerability and lack of agency. At the same time, young populations face more risk due to substance use, because of the vulnerability of the brain and body during this phase of growth and development. Support for young populations needs to focus on offering approachable, non-judgemental spaces and strategies. Support workers working with young populations need to be particularly aware of identifying factors such as abuse and know how to exercise duty of care through mandatory reporting.

Older People

Statistics suggest that alcohol and other drug issues are becoming increasingly prevalent in older populations (over the age of 60). Common issues include abuse of alcohol, prescription pain medications, and tobacco. Older populations may be vulnerable to alcohol and other drug issues due to exposure to prescription opiates, difficulty transitioning to older age, and vulnerability due to social isolation and illness.

People Engaged With the Criminal Justice System

People who are in prison very commonly experience multiple harms from alcohol and other drugs. Firstly, rates of current or previous substance use are much higher among prisoners than the general population, with the majority of prisoners having used illicit drugs, including methamphetamine in the year before they were incarcerated. According to the National Drug Strategy, in 45% of cases, prisoners stated that their drug use was a contributing factor in their imprisonment.

Culturally and Linguistically Diverse Populations

A number of factors contribute to problematic substance use in culturally and linguistically diverse populations.

A number of factors contribute to problematic substance use in culturally and linguistically diverse populations. These include:

• Experience of trauma, poverty, social isolation, and marginalization
• Lack of experience with substances that are unavailable in the home setting but widely available in Australia (e.g., alcohol)
• Cultural acceptability of some substances (e.g., cannabis, tobacco, kava, and khat have a long history of use in some cultures and are considered socially acceptable)

Gender Diverse Populations

According to the National Drug Strategy, statistics suggest that people who are gay, lesbian or bisexual are more likely to have issues with alcohol and other drugs than heterosexual populations. Many factors may explain this correlation, including social marginalisation, discrimination, family rejection and feelings of confusion or exclusion. These issues may coexist at higher rates with sexually transmitted diseases (STDs) and blood-borne viruses (BBVs) in these population groups.

In providing AOD support services, you will work with:

• Youth
• Men, women, and gender-diverse people
• Parents of clients
• Voluntary migrants and forced migrants
• Aboriginal and Torres Strait Islander people
• Older people

Communication Strategies for Different Client Types

Youth are still growing physically, emotionally, and psychosocially. Their voices and bodies are changing; they are starting to menstruate or have erections, and are becoming sexually aware. They may be experiencing acne and are very selfconscious about it. They are learning emotions, insecurities and independence (e.g. learning to drive and getting a job).

They are developing impulse control and awareness around things like actions and consequences, and are developing personal identity and self-esteem. They may not yet have the words for the trauma they have experienced, and they often have a high need for social acceptance.

Parents may or may not be involved when their child is being treated for AOD use disorders. Some parents will genuinely want to assist in the recovery process and be eager to learn strategies that can be implemented at home. However, some young people will not have parents, or have parents who are substance users or who are abusive. The young person’s situation will be clarified during the assessment. Generally, supportive parental involvement is going to benefit a young person’s recovery. Where parental love and safety is lacking, there may be other older relatives or siblings who can serve as a safe harbour. With young people, always keep in mind your responsibilities around mandatory reporting.

Older people will often have other health conditions and take prescription medications. Potential interactions between illegal drugs and prescription drugs need to be considered, as well as interactions between existing medications and future medications related to AOD treatment.

Female clients may be more at risk of agreeing to referrals or suggestions they are unsure about; or may simply not say what they really think, feel or have experienced, because culturally women are often taught to be agreeable, not to speak up and not to make a fuss or cause drama.

Mandated Clients

Clients who have been mandated to attend appointments may be unwilling or not ready to change and may be mistrustful (though this can also be true of clients who have not been mandated). Communication strategies that can be helpful include making sure your mandated clients understand why they are there, letting them know their rights and responsibilities, explaining the scope of your role and the client-support-worker relationship, and highlighting the benefits for the client in getting support.

As an AOD support worker, you will meet clients who identify as Aboriginal and Torres Strait Islander people and who have experienced intergenerational trauma. You will also meet clients from an array of countries and different religious backgrounds. Some of these clients will have voluntarily migrated to Australia; others will have experienced forced migration. These factors can affect the client-support-worker relationship and how support is provided.

Intergenerational Trauma

Intergenerational trauma is a psychological theory that trauma can be passed down through generations and impact those who did not directly experience the original traumatic experiences.

Globally, intergenerational trauma is recognised as being a consequence of atrocities, such as the African slave trade and the Holocaust. Here in Australia, intergenerational trauma affects all Indigenous Australians and has its roots in colonisation, loss of land and culture, the Stolen Generation (forced removal of children), and loss of rights, freedom, safety, and dignity.

Trauma is known to change the function of the nervous system, so it affects people right down to the cellular level.

Results of intergenerational trauma can include significantly higher rates of:

• Self-destructive behaviours
• Family violence
• Attachment disorders, mental health problems
• Addiction
• Lifestyle disease (e.g. obesity, type 2 diabetes)
• Suicide

In the AOD support work context, this can mean that Aboriginal and Torres Strait Islander clients may struggle more with trusting healthcare workers and the health system in general, even more so if they have been mandated to attend AOD services.

Watch

This short animated film highlights the impacts of colonisation and the Stolen Generations for Aboriginal and Torres Strait Islander people: ‘Intergenerational trauma animation’ from The Healing Foundation

Voluntary Migration vs. Forced Migration

Australia has a large migrant and refugee population. As an AOD support worker, it is important that you understand some of the issues affecting these groups.

Voluntary Migration

• An exciting event that is planned for
• Big adjustment to new culture lifestyle and climate
• Qualifications may not be recognized, and retraining may be required
• Possibility of returning home if desired

Forced Migration

• Often a result of war, genocide, or persecution
• A very stressful move that is not planned and which the participants do not have full control over
• People have to adjust to a new culture, lifestyle, and climate while already traumatized
• People may feel isolated and unsure of how to access support - language is often a barrier

As you can see, there are risk factors for both migrant groups, but more so for those who have experienced forced migration. Forced migrants may have lost family members in traumatic circumstances, as well as their home and all their possessions. Translation services are likely to be needed by both groups but more so by those forced to migrate. Both groups may experience racism and discrimination, but forced migrants may feel less able to speak up about it. Both groups are under increased stress, which can increase the risk of substance misuse.

Once again, as a support worker, you are in a privileged position to be the person who listens, who cares, who is non-judgemental and who uses their skills to help the person access the help they need. A huge part of your role in supporting voluntary migrants and forced migrants will be making them aware of the supports available to them and how they can access these supports.

Case Study

Supporting CALD People

A young South Sudanese refugee client comes in alone to a Sydney clinic. Her name is Aaliyah, and her English is limited.

She manages to get across that she wants her unemployed and unhappy boyfriend to get help for his drinking, and she thinks she might be pregnant.

Dani, a support worker, immediately realizes she cannot refer the boyfriend owing to his lack of involvement and consent, but that she can pass on information about where he might find support from other males and in his preferred language.

Dani is also concerned about the possibility of domestic violence and wants to convey this to her client. Dani also worries about whether Aaliyah has experienced female genital mutilation (FGM), given Aaliyah’s cultural background. If so, Dani knows Aaliyah will need to see an obstetrician experienced in working with FGM.

However, language is a barrier in all of this. Dani knows that Family Planning NSW offers a multicultural service, so she decides to give them a call and see what help is available for a Juba Arabic speaker from Sudan.

She also checks with one of her peers regarding telephone support in Juba Arabic for people who may be misusing alcohol. Her colleague suggests she contact the Drug and Alcohol Multicultural Education Centre (DAMEC), which offers free interpreter services.

Aaliyah looks very happy when Dani writes down and explains that she has scheduled two initial phone appointments – one for Aaliyah (with Family Planning NSW), and one for Aaliyah or her boyfriend to inquire about help for him (via DAMEC) – and tells her that an interpreter who speaks Juba Arabic will be available for both calls.

There will be times when you encounter clients who are angry, threatening, or who express that they are feeling suicidal or say things such as ‘I would kill myself if…’ It is important to have guidelines to follow if such a situation occurs.
Additionally, make sure your at-risk clients know that Lifeline Australia, as well as Beyond Blue, offers 24/7 crisis support by telephone, text and online chat.

Case Study

Assessing an At-Risk Client

John is 21 and has been legally mandated to come in to an AOD support centre for assessment. He uses alcohol and, more recently, meth. He tells Shiko, a support worker, upfront he has ‘no interest in being here.’

He is angry, refuses to answer questions and mocks Shiko for being Asian. He then says he is leaving, but instead, he gets up, punches the wall and starts yelling at no one in particular. Then he walks to a table and leans over it with his head down, while breathing fast.

In this situation, Shiko should:

• Assess whether she is safe and whether John is safe (He has not threatened to harm her; he punched the wall but did not touch anything else. However, he seems highly agitated.)
• Look for anything in the room John could use to harm himself or her
• Keep communication simple and brief
• Not raise her voice – speak softly
• Let John know she is there to listen to him
• Not take any insults personally, as becoming defensive or angry will inflame the situation
• Not panic
• Try to understand what has made him so angry
• Allow for reasonable verbal expression of anger
• Call Triple Zero (000) and request police if John is an immediate risk to her or property
• Call Triple Zero (000) and request an ambulance if John is a risk to her or himself.

Later in the session, John tells Shiko that his brother and best friend committed suicide last year. Not long after, he was fired from his job as an apprentice builder due to his habitual lateness. He says his brother was his only real family, his dad has never been around, and his mother is a drinker.

John tells Shiko that, with all that has happened, he has been thinking it might be better if he was dead too. He says he was lying awake last night thinking about how he would do it. He mentions pills but then becomes vague. He says he never felt like this before.

John’s behavior would be classed as suicide ideation (i.e. thoughts of suicide but no action taken). However, Shiko can identify several risk factors for suicide:

• Current drug and alcohol misuse
• Lack of family and social support
• Loss and grief
• Loss of hope
• Potential access to lethal means

Shiko puts a safety plan in place, which includes:

• Making an urgent appointment for John to see a grief counsellor experienced in loss to suicide for later that day
• Giving John the Suicide Call Back 24/7 crisis number (1300 659 457) on a card he can keep in his wallet
• Asking him to come back and see her in a few days, to which he agrees.

Shiko also advises John on coping strategies, such as looking after himself by walking his dog on the beach (a way to check the surf conditions too – something he used to have a passion for with his brother) and eating three meals a day (even if it is just toast, cereal, a sandwich, or a takeaway).

Visit this link to learn about the counselling services provided by the Suicide Call Back Service: 'Phone and online counselling' from the Suicide Call Back Service

No-suicide Agreements

• No-suicide contracts
• No-suicide promises
• No-suicide commitments
• Suicide contracts
• Suicide agreements
• Suicide prevention contracts
• Suicide prevention agreements
• No-harm contracts
• No-harm agreements
• No-harm promises
• No-harm commitments

Regardless of what they are called, no-suicide agreements have been found to be useful tools and strategies in suicide prevention. They are not legal documents, are not enforceable and, in many cases, rely on the strength of the relationship between the clinician and the client.

While traditional agreements can be long, complex and often confusing, no-suicide agreements are written in plain English and are very clear. They may not always require a signature if the client is not comfortable doing so and can be agreed to verbally. The agreement can include many things, but the most important element is that the client agrees to not attempt suicide or to harm themselves. It will also outline what a person needs to do or should do if they become suicidal. It should also include a list of people they would contact in such an event, such as friends, family, emergency services, or other professional services.

Be aware that some research suggests there is a lack of evidence that these agreements work.

The National Drug Strategy recognises that different substances have different impacts on individuals, their communities, and society more broadly. Different strategies for minimising the harm of each substance are necessary. It is important for alcohol and other drug support workers to understand the patterns of use, impacts, harms, levels of addiction, and withdrawal of a range of substances, both in isolation and in combination.

According to the National Drug Strategy, ‘the relative impact of strategies implemented under demand reduction, supply reduction, and harm reduction varies for alcohol, tobacco, and other drugs, due to differences in legality and regulation, prevalence of demand, and usage behaviours. Strategies are also more effective in combination than separately and should be tailored to meet the varied needs of individuals, families, communities, and specific population groups.’ Drugs may be legal (e.g. alcohol and tobacco), illicit (e.g. cannabis, cocaine, meth, heroin, LSD, and MDMA), or prescription (i.e. medicines). Two well-researched early intervention or prevention strategies for drug use are screening for mental health conditions, with referral to appropriate support and removing the taboo of talking about drug use to begin with in schools, families, and communities.

Priority Substances

As we saw earlier, the National Drug Strategy focuses on seven priority substances. They are:

• Methamphetamine and other stimulants
• Alcohol
• Tobacco
• Cannabis
• Non-medical use of pharmaceuticals
• Opioids
• New psychoactive substances

According to the National Drug Strategy, ‘these priorities are not just as a result of prevalence among the population, but also the increased harms that these substances bring to an individual and/or the community... Poly-drug use is also a significant concern, and strategies that address this can be very effective at reducing harm.’

Let’s now refer to the National Drug Strategy for more information about each of the priority substances.

Methamphetamine and Other Stimulants

According to surveys, around 1.4% of Australians aged over 14 have used methamphetamines in the past 12 months. Methamphetamines are a class of synthetic stimulants. The effect depends on the substance and may include alertness, euphoria, increased energy, stamina, and libido, loss of inhibition, and anxiety. Methamphetamines may be taken in different forms, including powder, paste, liquid, tablets, and crystalline. Repeated use of methamphetamines is highly addictive and highly correlated with paranoia, violent tendencies, mental imbalance, psychosis, dental decay, and skin lesions.

Some of the health risks caused by methamphetamines include:

• Mental illness
• Cognitive impairment (brain damage)
• Cardiovascular problems
• Overdose

A major problem with methamphetamines is their highly addictive quality. This has become more of a problem since the arrival of crystal meth in Australia in the early 2000s. This is a growing problem. Between 2010 and 2016, for example, use of crystal meth among amphetamine users increased from 21.7% to 57.3%. The number of people using daily or weekly also increased from 9.3% in 2010 to 20.4% in 2016.

Alcohol

According to the National Drug Strategy, ‘alcohol consumption has resulted in significant fiscal and health costs in Australia. In 2010, the cost of alcohol-related harm (including harm to others) was reported to be $36 billion. Alcohol is also associated with over 5,000 deaths and more than 150,000 hospitalisations every year. Alcohol-related harm has a significant impact on Australian society with almost 250,000 Australians estimated to have been the victims of an alcohol-related physical assault in 2015-16.’

Alcohol causes chronic diseases including liver failure. It is strongly correlated with mental illnesses, particularly depression. In addition, consumption of alcohol during pregnancy by the mother can cause fetal alcohol spectrum disorder (FASD), which is characterized by lifelong behavioral and neurodevelopmental abnormalities.

Alcohol is also strongly linked with family problems, including domestic violence, child abuse, and neglect. The National Drug Strategy states that ‘heavy alcohol use amongst parents is … one of the major causes of unhealthy early childhood development for many children.’

Tobacco

According to the Department of Health, ‘tobacco remains a significant cause of death and disability in Australia. Around 2.6 million Australians smoke, and each year smoking is estimated to kill almost 19,000 people. Tobacco smoking also carries the highest burden of drug-related costs on the Australian community.’

Smoking rates have declined over the past two decades, due to measures taken to limit use, such as high taxes. Smoking is more common among Aboriginal and Torres Strait Islander populations and is a major contributing factor to the chronic disease burden and shorter life expectancy of First Nations people. Smoking is also more common among people with a mental illness.

Non-Medical Use of Pharmaceuticals

Health systems, individuals and communities are struggling with the harm caused by use of pharmaceutical substances for non-medical reasons. The pharmaceutical substances most commonly correlated with addiction and abuse are:

• Opioids (such as oxycodone, fentanyl, morphine, methadone, pethidine and codeine)
• Benzodiazepines (such as diazepam, temazepam and alprazolam)
• Analgesics (such as paracetamol and ibuprofen in preparations combined with codeine)
• Performance and image enhancing drugs (such as anabolic steroids, phentermine and human growth hormones)

Harm associated with non-medical use of pharmaceuticals includes overdose, memory impairment, aggression, and lack of coordination (possibly resulting in motor vehicle accidents). Pharmaceuticals are particularly dangerous because of their relative availability and ‘gateway’ status. ‘Gateway’ drugs are substances that are seen as relatively harmless or socially acceptable, but which may initiate drug dependence in individuals who then move on to ‘harder’ substances.

Cannabis

Cannabis is the most commonly used illicit drug in Australia. More than one third (34.8%) of Australians aged over 14 have used cannabis in their lifetime. Cannabis has been linked with the following health issues:

• Psychosis
• Respiratory illness
• Cognitive defects

Opioids

According to the Therapeutic Goods Administration, ‘opioid use and misuse is having a critical impact on patients, their families, and the health system. Every day in Australia, nearly 150 hospitalisations and 14 emergency department admissions involve opioid harm; and three people die from drug-induced deaths involving opioid use.’ It is interesting to observe that between 1998 and the present, use of illicit opiates such as heroin have declined in Australia. However, during the same period, prescription opiates have increased exponentially to a level of 14 million prescriptions annually. It is important to note that prescription opiates are chemically very similar to heroin, are similarly addictive, and have an equal or greater potential to cause harm due to the ease of access. The negative health consequences of opiate use include:

• Addiction
• Transmission of Blood Borne Viruses
• Death from overdose

New Psychoactive Substances

According to the Department of Health, ‘new psychoactive substances (NPS) are a range of drugs that have been manufactured to mimic other illicit drugs such as cannabis, cocaine, ecstasy, and lysergic acid diethylamide (LSD). They include, but are not limited to, synthetic cannabis, mephedrone and methylenedioxypyrovalerone (MDPV). While the effect of the drugs may be similar to other illicit drugs, their chemical structure is different and the effects are not always well known.’ NPS pose a range of challenges for support and health workers, namely:

• NPS are rapidly changing and evolving, meaning that their effects are unpredictable.
• Their production and chemical structure are unpredictable, meaning their effects on human health even in tiny quantities can be very damaging.
• Several of these substances have proven toxic, including 4-methylmethcathinone (mephedrone), methylenedioxypyrovalerone (MDPV) and 4-methylamphetamine (4-MA) which have caused death.

The following table provides an overview of commonly misused drug types, how they are taken, signs and effects of use, and harms:

Current Trends in Drug Use

According to the Australian Institute of Health and Welfare’s report ‘Alcohol and Other Drug Treatment Services in Australia 2019–20’:

• From 2019 to 2020, the main drugs of concern, which led to 139,300 people aged 10 and older seeking treatment for their own drug use from publicly funded AOD treatment services, were alcohol (34%), amphetamines (28%), cannabis (18%) and heroin (5%).
• The majority of treatment episodes for these principal drugs of concern were provided in non-residential facilities (64%), followed by residential treatment and outreach treatment (both 13%).
• Just over two-thirds (64%) of the 139,300 clients receiving treatment were male.
• More than half (53%) of all clients were aged 20 to 39.
• Clients who identified as Aboriginal or Torres Strait Islander made up 17% of clients.

There has been an increase in amphetamine use Australia-wide, especially in the last seven years and especially in South Australia and Western Australia.

Pattern of Drug Use

Different people are affected by drugs differently. Tolerance tends to depend on body weight and size, overall health, and frequency of use.

Polydrug use is when users take two or more drugs at the same time or close together. For example, it is common for people to drink alcohol and take illicit drugs at the same time, and alcohol, tobacco, and cannabis are frequently used at the same time. Polydrug use presents the following risks:

• People may take excessive amounts of a drug or drugs because their judgment is impaired, leaving them more vulnerable to the effects of excessive use, which could range from a severe hangover to overdose.
• People may take one drug to manage the come down from another drug. Over time, this could increase the risk of dependency on several drugs, increase the toxic load in the body, and impact on lung health (when drugs are smoked).

Sometimes drug users may also swap one drug for another to gain a false sense of recovery and control, but this usually only makes recovery more problematic. There is a greater risk of overdose when a person has more than one drug in their system. Combining prescription drugs and illicit drugs (e.g. taking benzodiazepines, alcohol, and cocaine together) can be especially harmful, particularly for the heart.

Symptoms of Withdrawal

The following table details the typical signs of withdrawal for commonly used drugs:

Drug Use in the Elderly

In people aged over 65, alcohol is the most misused drug. However, it is also common for older people to take more than one pharmaceutical medication at once (poly-pharmaceutical drug use), especially if these drugs are contraindicated (i.e. not meant to be taken together for health reasons) or if people take a medication ‘off label’ (i.e. for longer than its recommended safe duration, or for a condition it was not prescribed for).

Additionally, some pain relief and sleep medications can be addictive, such as benzodiazepines and some hypnotic drugs, which are drugs for sleep problems.

GPs, prescribers, and aged care workers need to be aware of what drugs a person is currently taking, to reduce the risks of over-prescribing and to prompt conversations around the risks of poly-pharmaceutical drug use. Support workers can best serve elderly clients when – with client consent – a shared-care approach is taken that involves different healthcare providers.