Treatnet Training Volume B: Module 1 - Updated 24 January 2007

Leaders Guide Drug Addiction and Basic Counselling Skills Treatnet Training Volume B, Module 1: Updated 13 February 2008 1 Volume B: Elements of Psychosocial Treatment Module 1: Drug Addiction and Basic

Counselling Skills Module 2: Motivating Clients for Treatment and Addressing Resistance Module 3: Cognitive Behavioural and Relapse Prevention Strategies Workshop 1

Workshop 1 Workshop 1 Workshop 2 Workshop 2 Workshop 2 Workshop 3 Workshop 3

Workshop 3 Workshop 4 Module 1: Training goals Increase knowledge of the biology of drug addiction, principles of treatment, and basic counselling strategies 2. Increase skills in basic counselling strategies for drug addiction treatment 3. Increase application of basic counselling skills for drug addiction

treatment activities 1. 3 Module 1: Workshops Workshop 1: Biology of Drug Addiction Workshop 2: Principles of Drug Addiction Treatment Workshop 3: Basic Counselling Skills for Drug Addiction Treatment Workshop 4: Special Considerations when Involving Families in Drug

Addiction Treatment 4 Icebreaker: If I were the President If you were the President (King, Prime Minister, etc.) of your country, what 3 things would you change related to drug policies, treatment, and / or prevention? 15 minutes 5 Workshop 1: Biology of Drug Addiction

6 Pre-assessment Please respond to the pre-assessment questions in your workbook. (Your responses are strictly confidential.) 10 minutes 7 Training objectives

At the end of this workshop you will be able to: 1. Understand the reasons people start drug use 2. Identify 3 main defining properties of drug addiction 3. Identify 3 important concepts in drug addiction 4. Understand characteristics and effects of major classes of psychoactive substances 5. Understand why many people dependent on drugs frequently require treatment 8 Introduction to Psychoactive Drugs

9 What are psychoactive drugs? (1) Any chemical substance which, when taken into the body, alters its function physically and/ or psychologically.... (World Health Organization, 1989) any substance people consider to be a drug, with the understanding that this will change from culture to culture and from time to time. (Krivanek, 1982)

10 What are psychoactive drugs? (2) Psychoactive drugs interact with the central nervous system (CNS) affecting: mental processes and behaviour perceptions of reality level of alertness, response time, and perception of the world

11 Why do people initiate drug use? (1) Much, if not most, drug use is motivated (at least initially) by the pursuit of pleasure. 12 Why do people initiate drug use? (2) Key Motivators & Conditioning Factors Forget (stress / pain amelioration) Functional (purposeful)

Fun (pleasure) Psychiatric disorders Social / educational disadvantages Also, initiation starts through: Experimental use Peer pressure 13 Why do people initiate drug use? (3) After repeated drug use, deciding to use drugs is no longer voluntary because

DRUGS CHANGE THE BRAIN! 14 What is Drug Addiction? 15 What is drug addiction? Drug addiction is a complex illness characterised by compulsive, and at times, uncontrollable drug craving, seeking, and use that persist even in the

face of extremely negative consequences. 16 Characteristics of drug addiction Compulsive behaviour Behaviour is reinforcing (rewarding or pleasurable) Loss of control in limiting intake 17

Important terminology 1. Psychological craving 2. Tolerance 3. Withdrawal symptoms

18 Psychological craving Psychological craving is a strong desire or urge to use drugs. Cravings are most apparent during drug withdrawal. 19 Tolerance Tolerance is a state in which a person no longer responds to a drug as they did

before, and a higher dose is required to achieve the same effect. 20 Withdrawal The following symptoms may occur when drug use is reduced or discontinued: Tremors, chills Cramps Emotional problems Cognitive and attention deficits Hallucinations

Convulsions Death 21 Drug Categories 22 Classifying psychoactive drugs Depressants Alcohol Stimulants

Amphetamines Hallucinogens LSD, DMT Benzodiazepines Methamphetamine Mescaline Opioids Cocaine PCP Solvents

Nicotine Ketamine Barbiturates Khat Cannabis (high doses) Cannabis (low

doses) Caffeine Magic mushrooms MDMA MDMA 23 Alcohol

24 Alcohol: Basic facts (1) Description: Alcohol or ethylalcohol (ethanol) is present in varying amounts in beer, wine, and liquors Route of administration: Oral Acute Effects: Sedation, euphoria, lower heart rate and respiration, slowed reaction time, impaired coordination, coma, death 25

Alcohol: Basic facts (2) Withdrawal Symptoms: Tremors, chills Cramps Hallucinations Convulsions Delirium tremens Death 26 Long-term effects of alcohol use Decrease in blood cells leading to anemia,

slow-healing wounds and other diseases Brain damage, loss of memory, blackouts, poor vision, slurred speech, and decreased motor control Increased risk of high blood pressure, hardening of arteries, and heart disease Liver cirrhosis, jaundice, and diabetes Immune system dysfunction Stomach ulcers, hemorrhaging, and gastritis Thiamine (and other) deficiencies Testicular and ovarian atrophy Harm to a fetus during pregnancy

27 Tobacco 28 Tobacco: Basic facts (1) Description: Tobacco products contain nicotine plus more than 4,000 chemicals and a dozen gases (mainly carbon monoxide) Route of administration: Smoking, chewing Acute Effects: Pleasure; relaxation; increased

concentration; release of glucose; increased blood pressure, respiration, and heart rate 29 Tobacco: Basic facts (2) Withdrawal Symptoms: Cognitive / attention deficits Sleep disturbance Increased appetite Hostility Irritability Low energy

Headaches 30 Long-term effects of tobacco use Aneurysm Cataracts Cancer (lung and other types) Chronic bronchitis Emphysema Asthma symptoms Obstructive pulmonary diseases

Heart disease (stroke, heart attack) Vascular disease Harm to a fetus during pregnancy, low weight at birth Death 31 Cannabinoids Marijuana Hashish 32

Cannabis: Basic facts (1) Description: The active ingredient in cannabis is delta-9-tetrahydrocannabinol (THC) Marijuana: tops and leaves of the plant Cannabis sativa Hashish: more concentrated resinous form of the plant

Route of administration: Smoked as a cigarette or in a pipe Oral, brewed as a tea or mixed with food 33 Activity 1 Think of all the names for marijuana in your

community and how this drug is consumed. Share your thoughts with the rest of the group. 34 Cannabis: Basic facts (2) Acute Effects: Relaxation

Increased appetite Dry mouth

Altered time sense Mood changes Bloodshot eyes Impaired memory

Reduced nausea Increased blood pressure Reduced cognitive capacity Paranoid ideation 35 Cannabis: Basic facts (3) Withdrawal Symptoms:

Insomnia Restlessness Loss of appetite Irritability Sweating Tremors Nausea Diarrhea 36 Long-term effects of cannabis use

Increase in activation of stressresponse system Amotivational syndrome Changes in neurotransmitter levels Psychosis in vulnerable individuals Increased risk for cancer, especially lung, head, and neck Respiratory illnesses (cough, phlegm) and lung infections Immune system dysfunction Harm to a fetus during pregnancy 37

Stimulants METHAMPHETAMINE CRACK COCAINE 38 Types of stimulants (1) Amphetamine Type Stimulants (ATS)

Methamphetamine Speed, crystal, ice, yaba, shabu Amphetamine Pharmaceutical products used for ADD and ADHD Methamphetamine half-life: 8-10 hours 39 Types of stimulants (2) Cocaine

Powder cocaine (Hydrochloride salt) Smokeable cocaine (crack, rock, freebase) Cocaine half-life: 1-2 hours 40

Activity 2 What stimulants are used in your community and how are they consumed? Share your thoughts with the rest of the group. 41 Stimulants: Basic facts (1) Description: Stimulants include: (1) a group of synthetic drugs (ATS) and (2) plant-derived compounds

(cocaine) that increase alertness and arousal by stimulating the central nervous system Route of administration: Smoked, injected, snorted, or administered by mouth or rectum 42 Stimulants: Basic facts (2) Acute effects: Euphoria, rush, or flash Wakefulness, insomnia Increased physical activity

Decreased appetite Increased respiration Hyperthermia Irritability Tremors, convulsions Anxiety Paranoia Aggressiveness 43 Stimulants: Basic facts (3)

Withdrawal symptoms: Dysphoric mood (sadness, anhedonia) Fatigue Insomnia or hypersomnia Psychomotor agitation or retardation Craving Increased appetite Vivid, unpleasant dreams

44 Long-term effects of stimulants Strokes, seizures, headaches Depression, anxiety, irritability, anger Memory loss, confusion, attention problems Insomnia, hypersomnia, fatigue Paranoia, hallucinations, panic reactions Suicidal ideation Nosebleeds, chronic runny nose, hoarseness, sinus infection Dry mouth, burned lips, worn teeth

Chest pain, cough, respiratory failure Disturbances in heart rhythm and heart attack Loss of libido Weight loss, anorexia, malnourishment, Skin problems 45 Methamphetamine use leads to severe tooth decay

Meth Mouth (New York Times, June 11, 2005) 49 Opioids 50 Opioids Opium Heroin Morphine

Codeine Hydrocodone Oxycodone Methadone Buprenorphine Thebaine 51 Opioids: Basic facts (1) Description: Opium-derived or synthetic compounds that relieve pain, produce morphine-like addiction,

or relieve symptoms during withdrawal from morphine addiction. Route of administration: Intravenous, smoked, intranasal, oral, and intrarectal 52 Opioids: Basic facts (2) Acute effects: Euphoria Pain relief Suppresses cough reflex Histamine release

Warm flushing of the skin Dry mouth Drowsiness and lethargy Sense of well-being Depression of the central nervous system (mental functioning clouded) 53 Opioids: Basic facts (3) Withdrawal symptoms: Intensity

of withdrawal varies with level and chronicity of use Cessation of opioids causes a rebound in functions depressed by chronic use First signs occur shortly before next scheduled dose For short-acting opioids (e.g., heroin), peak of withdrawal occurs 36 to 72 hours after last dose Acute symptoms subside over 3 to 7 days Ongoing symptoms may linger for weeks or months 54

Long-term effects of opioids Fatal overdose Collapsed veins Infectious diseases Higher risk of HIV/AIDS and hepatitis Infection of the heart lining and valves Pulmonary complications & pneumonia Respiratory problems Abscesses Liver disease Low birth weight and developmental delay Spontaneous abortion

Cellulitis 55 Other drugs Inhalants Petroleum products, glue, paint, paint removers

Aerosols, sprays, gases, amyl nitrite Club drugs (MDMA-ecstasy, GHB) Hallucinogens (LSD, mushrooms, PCP, ketamine)

Hypnotics (quaaludes, mandrax) Benzodiazepines (diazepam / valium) Barbiturates

Steroids Khat (Catha edulis) 56 Activity 3 Working individually or in small groups, think of the drugs that are consumed in your area and the way they are consumed both by youth and adults:

Share your thoughts with the rest of the group. 57 Introduction to Addiction and the Brain 58 Addiction = Brain Disease Addiction is a brain disease that is chronic and relapsing in nature. 59

60 How a neuron works 61 62 The reward system Natural rewards Food Water

Sex Nurturing 63 How the reward system works 64 65 Activating the system with drugs

66 The brain after drug use (1) Control Methamphetamine (Source: McCann et al. (1998). Journal of Neuroscience, 18, 8417-8422.) 67 Partial Recovery of Brain Dopamine Transporters in Methamphetamine (METH) Abuser After Protracted Abstinence 3

0 ml/gm Normal Control METH Abuser (1 month detox) METH Abuser (24 months detox) The brain after drug use (2)

DA = Days Abstinent 69 Drugs change the brain After repeated drug use, deciding to use drugs is no longer voluntary because DRUGS CHANGE THE BRAIN! 70 Questions?

Comments? 71 Thank you for your time! End of Workshop 1 72 Workshop 2: Principles of Drug Addiction Treatment 73

Training objectives At the end of this workshop you will be able to: 1. Identify 3 basic components of comprehensive treatment for substance abuse 2. Identify 2 individual factors that help people stay in treatment

3. Identify 3 factors within a programme that help people stay in treatment 4. Understand and identify 5 basic principles of effective treatment 74 Comprehensive Treatment

75 Addiction treatment goals The goals of addiction treatment are to help the individual: Stop or reduce the use of drugs Reduce the harm related to drug use

Achieve productive functioning in their family, at work, and in society 76 Why is comprehensive addiction treatment needed? Addicted individuals usually suffer from mental health, occupational, health, or

social problems that make their addictive disorder difficult to treat For most people, treatment is a longterm process that involves multiple interventions and attempts at abstinence 77 Components of comprehensive drug abuse treatment 78 Activity 1: Your organisation

Using the previous graphic, think about all the services that your organisation provides. What services do your clients most often need? What services could your organization add to meet your clients needs? 10 minutes 79 Treatment duration Individuals progress through drug

addiction treatment at various speeds, so there is no predetermined length of treatment. In general, longer treatment duration results in better outcomes. 80 Treatment compliance (1) Client factors that affect treatment compliance are Readiness Degree

to change drug-using behaviour of support from family and friends Pressure to stay in treatment from the criminal justice system, child protection services, an employer, or family members 81

Treatment compliance (2) Factors within the program that affect treatment compliance are A positive therapeutic relationship between the counsellor and client A clear treatment plan, which allows the client to know what to expect during treatment

Medical, psychiatric, and social services Medication Transition available when appropriate to continuing care or aftercare 82 Drug addiction treatment

Drug addiction treatment is offered in specialized facilities and mental health clinics by a variety of professionals such as: Medical doctors Psychiatrists Psychologists Social workers Nurses Case managers Certified drug abuse counsellors Other substance abuse professionals

83 Activity 2: Group activity Identify factors within your program (or others programs) that may do the following: 1. 2. Help clients to comply with their treatment plan Interfere with clients compliance with their treatment plan

15 minutes 84 Principles of Addiction Treatment 85 Principles of effective treatment (1) 1. NO single treatment is APPROPRIATE FOR ALL 2.

Treatment needs to be READILY AVAILABLE 3. Effective treatment attends to MULTIPLE NEEDS, not just to drug use problems 4. The treatment plan must be ASSESSED CONTINUALLY and MODIFIED AS NECESSARY to insure that it meets the clients changing needs

5. Remaining in treatment for an ADEQUATE PERIOD OF TIME is critical for treatment effectiveness. Continued 86 Principles of effective treatment (2) 6. Counselling (individual and/or group) and other behavioural therapies are CRITICAL

7. Medications are IMPORTANT elements of treatment for many clients, especially when combined with behavioural therapy 8. People with coexisting mental disorders should be treated in AN INTEGRATED way 9.

Detoxification is only the FIRST STAGE of addiction treatment and by itself does little to change longterm drug use. Continued 87 Principles of effective treatment (3) 10. Treatment does NOT need to be voluntary to be effective 11.

Possible drug use during treatment must be MONITORED continuously 12. Treatment programs should provide assessment for HIV/AIDS and other infectious diseases as well as counselling to help clients change behaviours that place themselves or others at risk of infection 13.

Recovering from drug addiction can be a LONGTERM PROCESS and frequently requires multiple episodes of treatment 88 Categories of Treatment 89 Categories of treatment Research treatment components include Detoxification

Pharmacological treatment Residential treatment Outpatient Treatment

90 Medical detoxification Detoxification is a process where individuals are treated for withdrawal symptoms upon discontinuation of addictive drugs Detoxification treatment is conducted

under the care of a physician in an inpatient or outpatient setting 91 Pharmacological treatment Medications to reduce the severity and risk of withdrawal symptoms Medication to reduce relapse to illicit drug use

Agonist maintenance treatment for opiates (methadone, buprenorphine) Antagonist treatment for opiates (naloxone, naltrexone) 92

Residential treatment Residential treatment programs provide care 24 hours / day in non-hospital settings. Models of care include: Therapeutic community (TC) Residential, or rehab, program

93 Residential treatment models Therapeutic Highly structured treatment (6-12 months) Focus on re-socialization Developing

community (TC): personal accountability Residential (rehab) program Typically 30 days long Aftercare

includes counselling and / or peer support 94 Outpatient treatment Recommended elements of outpatient treatment include the following: Weekly sessions for around 90-120 days Family involvement Positive reinforcement approaches

Cognitive-behavioural materials 12-step meetings or support group participation Urinalysis and breath alcohol testing Medication as appropriate 95 Ethical and Legal Issues 96 Ethical guidelines Ethical Values: Be good!

Do good! And above all: Do no harm! 97 Ethical and legal issues Ethical guidelines are A set of professional standards A set of principles to guide professional behaviour Often a matter of opinion

and cultural context Not always a legal concern Legal guidelines are Determined by laws Implemented if ethics are consistently violated Often enforced by civil or criminal penalties 98

Professional and ethical issues Treatment professionals should have a copy of the following: Relevant ethical guidelines or code of conduct for your region Laws or regulations affecting their clinical professions

99 Professional boundaries Maintain a professional relationship with a client at all times Avoid dual relationships with clients Avoid sexual relationships with clients

Avoid personal relationships with clients 100 Confidentiality (1) The clients rights and the limits of confidentiality should be explained at the beginning of treatment

The relationship with any client should be private and confidential Client information should not be communicated outside of the treatment team Information should only be released with the

clients or guardians permission 101 Confidentiality (2) Confidentiality must be maintained at all times, except when to do so could result in harm to the client or others. 102 Activity 3: Case study Discuss in small groups the following cases: A young man tells his clinician that he intends to kill

his former girlfriend just as soon as she returns from an out-of-town trip. B) A clients employer comes to you asking for information on your clients test results. How should the clinician act in cases A and B? A) 15 minutes 103 Additional principles of counselling An addiction treatment professional should

Respect the client Be a role model Control the therapeutic relationship

Emphasise the clients personal responsibility for recovery Provide direction and encourage self-direction Be conscious of his or her own issues 104

Questions? Comments? 105 Thank you for your time! End of Workshop 2 106 Workshop 3: Basic Counselling Skills for

Drug Addiction Treatment 107 Training objectives (1) At the end of this workshop you will be able to: 1. Identify a minimum of 4 counselling strategies useful in drug abuse treatment 2.

Conduct a minimum of 3 counselling strategies 3. Structure a regular counselling session 4. Understand the importance of clinical supervision 5. Conduct a minimum of 3 listening strategies and 3

responding and teaching strategies to be used in counselling for drug abuse treatment 108 Introduction to Counselling 109 What is counselling? (1) Counselling involves the following: Interactive relationship Collaboration

Set of clinical skills & teaching techniques Positive reinforcement Emotional support Formal record 110 What is counselling? (2) The purpose of counselling is to establish: Goals of treatment Treatment modality Treatment plan

Scheduling of sessions Frequency and length of treatment Potential involvement of others Termination of treatment 111 Basic Counselling Skills 112 Basic Counselling Skills ACTIVE LISTENING

PROCESSING RESPONDING TEACHING Active Listening 114 Active listening Active listening by the clinician encourages

the client to share information by providing verbal and nonverbal expressions of interest. 115 Active listening skills Active listening includes the following skills: Attending Paraphrasing Reflection of feelings

Summarising 116 Attending (1) Attending is expressing awareness and interest in what the client is communicating both verbally and nonverbally. 117 Attending (2)

Attending helps the clinician Better understand the client through careful observation Attending helps the client Relax and feel comfortable Express their ideas and feelings freely in their own way

Trust the counsellor Take a more active role in their own sessions 118 Attending (3) Proper attending involves the following: Appropriate eye contact, facial expressions

Maintaining a relaxed posture and leaning forward occasionally, using natural hand and arm movements Verbally following the client, using a variety of brief encouragements such as Um-hm or Yes, or by repeating key words Observing the clients body language

119 Example of attending Um-hm. Please continue... I see. I am so tired, but I cannot sleepso I

drink some wine. When I wake upit is too late already Too late for workmy boss fired me. 120 Activity 1: Case study

The client asked the clinician about the availability of medical help to deal with his withdrawal symptoms. The clinician noticed that the client is wringing his hands and looking very anxious. Discuss how the clinician should respond. 15 minutes 121 Paraphrasing (1) Paraphrasing is when the clinician restates the content of the clients previous statement.

Paraphrasing uses words that are similar to the clients, but fewer. The purpose of paraphrasing is to communicate to the client that you understand what he or she is saying. 122 Paraphrasing (2) Paraphrasing helps the clinician verify their perceptions of the clients statements

spotlight an issue Paraphrasing helps the client realise that the counsellor understands what they are saying clarify their remarks

focus on what is important and relevant 123 Example of paraphrasing My mom irritates me. She picks on me for no reason at all. We do not like each other. Soyou are having

problems getting along with your mother. You are concerned about your relationship with her. Yes! 124 Reflection of feelings (1) Reflection of feelings is when the clinician expresses the clients feelings, either stated or implied. The counsellor tries to

perceive the emotional state of the client and respond in a way that demonstrates an understanding of the clients emotional state. 125 Reflection of feelings (2) Reflection of feelings helps the clinician

Check whether or not they accurately understand what the client is feeling Bring out problem areas without the client being pushed or forced Reflection of feelings helps the client Realise that the counsellor understands what they feel

Increase awareness of their feelings Learn that feelings and behaviour are connected 126 Example of reflection of feelings When I get home in the evening, my house is a mess. The kids are dirty My husband does not care about dinner...I do not feel like going home at all. You are not satisfied with the way the house

chores are organized. That irritates you. Yes! 127 Summarising (1) Summarising is an important way for the clinician to gather together what has already been said, make sure that the client has been understood correctly, and prepare the client to move on. Summarising is putting together a group

of reflections. 128 Summarising (2) Summarising helps the clinician Provide focus for the session Confirm the clients perceptions

Focus on one issue while acknowledging the existence of others Terminate a session in a logical way Summarising helps the client Clarify what they mean Realise that the counsellor understands Have a sense of movement and progress 129

Example of summarising We discussed your relationship with your husband. You said there were conflicts right from the start related to the way money was handled, and that he often felt you gave more importance to your friends. Yet on the whole, things went well and you were quite happy until 3 years ago. Then the conflicts became more frequent and more intense, so much so that he left you twice and talked of divorce,

too. This was also the time when your drinking was at its peak. Have I understood the situation properly? Yes, that is it! 130 Processing 131

Processing (1) Processing is the act of the clinician thinking about his or her observations about the client and what the client has communicated. 132 Processing (2) Processing allows the counsellor to mentally catalogue the following data: Clients

beliefs, knowledge, attitudes, and expectations Information given by his or her family Counsellors observations 133

Responding 134 Responding Responding is the act of communicating information to the client that includes providing feedback and emotional support, addressing issues of concern, and teaching skills. 135

Expressing empathy Empathy is the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experiences of another. 136 Example of expressing empathy I see. I understand.

I am sorry about your job. I am so tired, but I cannot sleep So I drink some wine. When I wake upI am already too late for work. Yesterday my

boss fired me ...but I do not have a drinking problem! 137 Probing (1) Probing is the counsellors use of a question to direct the clients attention to explore his or her situation in greater depth.

138 Probing (2) A probing question should be open-ended Probing helps to focus the clients attention on a feeling, situation, or behaviour

Probing may encourage the client to elaborate, clarify, or illustrate what he or she has been saying Probing may enhance the clients awareness and understanding of his or her situation and feelings Probing directs the client to areas that need attention

139 Example of probing Work problems related to drug use? I was always known to be a good worker. I even received an award. Lately I had some issuesmy husband is just not helpingthat is why I am always late.

Tell me about the problems you have been having at the work place? Actually I have had lots of problems, not only being late. 140 Interpreting (1)

Interpreting is the clinicians explanation of the clients issues after observing the clients behaviour, listening to the client, and considering other sources of information. 141 Interpreting (2) Effective interpreting has three components: 1. Determining and restating basic messages

2. Adding ideas for a new frame of reference 3. Validating these ideas with the client 142 Example of interpreting You say you had difficulty in getting

along with your boss. Once you mentioned that sometimes you simply broke the rules for the sake of breaking them. You also said that you are always late, even when your husband had everything ready for the children. In the past, you said it was because of the negative behaviour of your boss. This time you blamed your husband. Is it possible that your problems at work, like being late, are related to your alcohol use?

I always thought I could control it. 143 Silence Silence can encourage the client to reflect and continue sharing. It also can allow the client to experience the power of his or her own words.

144 Activity 2: Now its your turn! Rotating Roles This role-play gives you and your colleagues an opportunity to practise as clinicians and clients. Role-play with one of your partners the new counselling skills you have learned. A third partner will be an observer. After 10 minutes switch roles (30 minutes total).

Each observer will provide feedback at the end of each role-play (5 minutes). 35 minutes 145 Teaching Clients New Skills 146 Teaching clients new skills Teaching is the clinicians transfer of skills

to the client through a series of techniques and counselling strategies. 147 Use repetition Repetition entails counsellors restating information and clients practising skills as needed for clients to master the necessary knowledge and skills to control their drug use. 148

Encourage practise Mastering a new skill requires time and practise. The learning process often requires making mistakes and being able to learn from them. It is critical that clients have the opportunity to try new approaches. 149 Give a clear rationale Clinicians should not expect a client to practise a skill or do a homework assignment without

understanding why it might be helpful. Clinicians should constantly stress how important it is for clients to practise new skills outside of the counselling session and explain the reasons for it. 150 Activity 3: Script 1 It will be important for us to talk about and work on new coping skills in our sessions, but it is even more important to put these skills into use in your daily life. It is very important that you give yourself a chance to try new skills

outside our sessions so we can identify and discuss any problems you might have putting them into practise. Weve found, too, that people who try to practise these skills tend to do better in treatment. The practise exercises Ill be giving you at the end of each session will help you try out these skills. 151 Activity 3: Case study Script 1 Discuss in groups the teaching strategies employed by the clinician.

10 minutes 152 Monitoring and encouraging Monitoring: to follow-up by obtaining information on the clients attempts to practise the assignments and checking on task completion. It also entails discussing the clients experience with the tasks so that problems can be addressed in session. Encouraging: to reinforce further progress by providing constructive feedback that motivates

the client to continue practising new skills outside of sessions. 153 Use the assignments Use the information provided by the clients in their assignments to provide constructive feedback and motivation. Focus on the clients: Coping style Resources Strengths and weaknesses

154 Explore resistance Failure to implement skills outside of sessions may be the result of a variety of factors (e.g., feeling hopeless). By exploring the specific nature of a clients difficulty, clinicians can help them work through it. 155 Praise approximations

Counsellors should try to shape the patients behaviour by praising even small attempts at working on assignments, highlighting anything they reveal as helpful or interesting. 156 Activity 4: Case study Script 2 Discuss the teaching strategies employed by the counsellor in the following example: I noticed that you did not fully complete your homework, but I am really

impressed with the section that you have completed. This is greatin this section you wrote that on Monday morning you had cravings but you did not use. That is terrific! Tell me a little more about how you coped with this situation. In this other section, you wrote that you used alcohol. Tell me more about itlets analyse together the risk factors involved in this situation. 10 minutes 157 Develop a plan (1) A plan for change enhances your client's

self-efficacy and provides an opportunity for them to consider potential obstacles and the likely outcomes of each change strategy. 158 Develop a plan (2) Offer a menu of change options Develop

a behaviour contract or a Change Plan Worksheet Reduce or eliminate barriers to action 159 Activity 5: Role-playing This role-play gives you and your colleague another opportunity to practise as counsellors and clients.

Observe the role-playing Complete the Change Plan Worksheet form and ask each other the following questions: When do you think is a good time to start this plan for

change? Who can help you to take action on this plan? 30 minutes 160 Questions? Comments? 161 Thank you for your time! End of Workshop 3

162 Workshop 4: Special Considerations when Involving Families in Drug Abuse Treatment 163 Training objectives At the end of this workshop you will be able to: 1. Understand the importance of involving a clients family in the

treatment process 2. Identify a minimum of 4 family feelings and reactions to their relatives drug dependence 3. Identify strategies to insure that the clients confidentiality is maintained when you are working with relatives 4.

Understand the basics of child protection 5. Identify a minimum of 3 strategies for engaging families in treatment 6. Conduct a minimum of 2 strategies for engaging families in treatment.

164 Introduction to Family Support 165 Family support The family is a powerful source of assistance and support. Families and significant others can effectively participate in the treatment process if the client consents.

166 The goals of involving the family Involving the family Helps family members understand and cope with the clients addiction Helps achieve the recovery goals of the drug-dependent person 167 Working with Families

168 First contact with your client At the point of first contact with a client, counsellors should ask questions such as: Who is important in your life at this moment? How do they support you? Do they know that you are getting treatment? Would

they support you in getting treatment? Would you like them to be involved in treatment and, if so, in what way? 169 Family reactions (1) Family members usually experience the following feelings and reactions in response to their relatives drug problems: Denial

Shame Self-blame Anger Confusion Continued 170 Family reactions (2)

Preoccupation Making changes in themselves Bargaining Controlling Disorganisation 171 Activity 1: Identify maladaptive reactions Discuss the maladaptive reactions of Annas husband in the following scenario:

Anna has been in treatment for alcoholism for 3 months. Annas husband is suspicious about her behaviour and is tracking all her movements through the day. His compulsive preoccupation drives him to waste his energy in unproductive ways, and as a result, he fails to do his own work. He tries to hide Annas problem from everybody and denies that there is a problem. It is too shameful for him, Anna, and the rest of the family. He justifies her alcohol abuse in public by saying that she is under a lot of pressure from her work. He denies that she drinks at home. He takes responsibility for Anna. For example, he calls her office every day to make sure she is at work and if she is not, he makes excuses for her absence.

10 minutes 172 How to engage the family (1) To effectively engage family members: Recognize their perceptions of the situation Provide a range of service options for families to choose from

Actively engage family members (follow-up with phone calls and letters) Dont give up easily Deliver flexible services

Continued 173 How to engage the family (2) To effectively engage family members: Make sure that the family's greatest need is the one addressed first Be responsive to a crisis

Insure that the service offered is what the family wants Present clear information Insure that promises and commitments are met

Promote strengths-oriented conversations 174 Building Positive Communication Between the Client and the Family 175 Communication problems Frequently, a clients addiction can create

many problems within a family. Family members often feel guilty, angry, hurt, and defensive These feelings can negatively affect the way they communicate with one another Negative

patterns of interacting often become automatic 176 Positive communication skills Positive communication skills include the following: Avoid assuming what the other is thinking Communicate

directly instead of hinting Avoid double messages Admit mistakes Use

I statements 177 Avoid assuming what the other is thinking Nancy asked her husband Pete, Will you be coming home right after work? Pete exploded, You dont have to check up on me every 5 minutes! Do you want a urine sample, too? Nancy responded angrily, Well, youve sure given me enough reasons to check up on you. 178

Communicate directly instead of hinting Ricardo, a 17-year-old in recovery, was playing a video game when his mother, Rosa, walked by and said, Ricardo, the kitchen trash can is getting full. Ricardo responded, Uh huh, and continued playing his game. Half an hour later, Rosa noticed that Ricardo hadnt emptied the trash. She angrily confronted Ricardo for not taking the trash out right away. Ricardo responded to her anger by loudly saying, Hey, Ill do it when Im ready to do it!

179 Avoid double messages Tanya asked her husband, Andre, Do you mind if I go fishing with Sharonne Saturday? Andre had been planning to spend time with Tanya on the weekend and didnt want her to go with Sharonne. However, he replied, Sure, go ahead. As he said this, his arms were stiffly crossed across his chest and he didnt look directly at Tanya. Tanya felt uneasy and said, Youre really OK with it? Andre responded angrily, I said I was, didnt I? The discussion escalated into an argument.

180 Admit mistakes Bob forgot that it was his and Catherines 5th wedding anniversary. A coworker invited him to bowl a few frames after work, and he accepted. When he arrived home, he discovered the table set for two and Catherine in tears. When she confronted Bob about being so late, he responded defensively. You know I have trouble remembering these things. You should have reminded me! How am I supposed to know you were planning a special dinner? Catherine responded, How could you forget our

anniversary? Bob was feeling guilty at this point, but not wanting to admit he was wrong, defensively replied, Listen, Catherine, weve been married for 5 years now. Whats the big deal? Catherine locked herself in the bedroom. 181 Use I statements Pam, a senior in high school, was out on a date. Her curfew was midnight, and she was already late. When Pam arrived home at 1 a.m., her mother, Emily, was extremely worried. Emily greeted Pam at the door saying, Youre late! You could have picked up a phone and called. Youre always so

inconsiderate! Pam responded angrily, I am not always inconsiderate! A fight ensued. . 182 Activity 2: How to engage the family Take time to think about strategies to involve the family and how you would implement them in your organisation. Share your ideas with the rest of the group. 15 minutes

183 Confidentiality 184 Confidentiality It is the right of the client to determine to whom they or others disclose details of their treatment. No information regarding a person's treatment should be disclosed without the client's explicit consent in writing.

185 Organisations confidentiality policy Organisations should have policies and procedures in place to assist practitioners in insuring confidentiality for the client and their records. These policies should include: Having an agreement with the client and informed consent before releasing any information regarding treatment Having a signed release of information form from the client

Clarifying to the client the purpose and types of case records and what happens to them 186 Precautions Written consent should be obtained before disclosing: 1. Details of a client's treatment to any family member 2.

Information about the clients attendance 187 If in doubt Ask your client if it is OK to talk about it Respect

the clients or the family members wishes if they decide they do not want to talk about a particular issue In some circumstances, employ different practitioners for the family and the client If a family member requests a service, but the client does not want to be involved, refer the

family member to another service 188 Support and Information for Clients who have Children 189 Support and information for clients who have children Clinicians should identify the needs of clients with children. These might include:

Referral to a specialist in parenting or family support programs Attention to child safety issues within the physical environment of the agency Provision of child-friendly areas within the clinic, including toys and resources for children, posters, and other aids to

establish a welcoming and age-appropriate environment Provision of information on a range of welfare, child care, and family recreation services available in the local area 190 Child protection Organisations should have policies and procedures in place to assist practitioners in responding to suspicions of child abuse and neglect such as:

Access to immediate supervision from an experienced practitioner Knowledge of what constitutes risk Knowledge of the child protection system

Training in how to discuss concerns about safety with clients 191 Questions? Comments? 192 Post-assessment Please respond to the post-assessment questions in your workbook.

(Your responses are strictly confidential.) 10 minutes 193 Thank you for your time! 194

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