Empowering coaching and crisis interventions by Jaime Lavid

Empowering Interventions

Guide for Empowering Coaching and Crisis Interventions Composed by Dean Amory

Empowering Interventions

Guide for Empowering Coaching and Crisis Interventions Composed by Dean Amory

Title: Empowering Interventions – Guide for Empowering Coaching and Crisis Interventions Composed by: Dean Amory Dean_Amory@hotmail.com Publisher: Edgard Adriaens, Belgium eddyadriaens@yahoo.com ISBN: © Copyright 2013, Edgard Adriaens, Belgium, - All Rights Reserved.

This book is a compilation of information freely available in the Public Domain and gathered and composed by Dean Amory. It has been composed based on the contents of trainings, information found in other books and using the internet. It contains a number of articles and coaching models indicated by TM or © or containing a reference to the original author. Whenever you cite such an article or use a coaching model in a commercial situation, please credit the source or check with the IP -owner. If you are aware of a copyright ownership that I have not identified or credited, please contact me at: eddyadriaens@yahoo.com

When I invite you into my confidence my secret places introduce you to my devils my ancestors my way of being Show me this much: that you will tread lightly over the graves yield to my wisdom know me as creator, lover, maker of my life amidst this ruckus.

Ellen Hawley McWhirter

Index: Introduction ................................................................................................................................................... 8 Chapter 1 ........................................................................................................................................................ 9 Goals of this Guide.................................................................................................................................... 9 The goals of empowering intervention services .......................................................................................... 9 Chapter 2 ...................................................................................................................................................... 10 Definition of “Personal Crisis”.................................................................................................................. 10 Types of personal crisis ............................................................................................................................ 10 Chapter 3 ..................................................................................................................................................... 11 Empowering Intervention Components .................................................................................................. 11 1. Importance of the first contact ........................................................................................................ 11 Sample of a telephone script for the correct handling of incoming calls ....................................... 12 2. The Personal Crisis Intervention Services SARE Model................................................................ 13 1. Screening .................................................................................................................................... 13 2. Assessment .................................................................................................................................. 15 3. Building Rapport ........................................................................................................................ 21 4. Empowering ............................................................................................................................... 37 3. Foundations of Empowering Interventions..................................................................................... 82 1. Brief Solution Focused Counseling.......................................................................................... 82 2. Cognitive Behavioural Counselling............................................................................................ 89 3. Empowering Language............................................................................................................. 110 4. Sample Formats for Sessions.................................................................................................... 112 Chapter 4 ................................................................................................................................................... 116 The Intervention Process....................................................................................................................... 116 What is involved in the crisis intervention process?........................................................................... 116 Active Listening ............................................................................................................................ 116 The five stages of grief are:............................................................................................................ 124 Identifying a major problem.......................................................................................................... 127 Exploring possible alternative solutions ........................................................................................ 130 Evaluating ..................................................................................................................................... 130 Chapter 5................................................................................................................................................... 132 Critical Incident Stress Management (CISM) ......................................................................................... 132 Moving Past a Moment of Crisis........................................................................................................ 138 Post-Traumatic Stress Disorder:......................................................................................................... 138 Apprehension Am I Stressed Out...?................................................................................................ 140 Critical Incident Stress: Tips on How to Recover from a Critical Incident ...................................... 146 Critical Incident Stress – Tips to Colleagues and Family................................................................. 148 Chapter 6................................................................................................................................................... 149 Harm Assessment (Suicide, Homicide, Injury to self or others) .............................................................. 149 What should a responder knew about suicide? .................................................................................. 149 What makes depression and alcohol/drug abuse important?............................................................ 154 Assessing dangerousness to others...................................................................................................... 157 Annex 1: Screening ................................................................................................................................... 164 Annex 2 : Assessment tools....................................................................................................................... 187 Annex3 : How to deal with an existential crisis ........................................................................................ 192 Annex4: How to help a friend with depression ......................................................................................... 196 Sources: ..................................................................................................................................................... 202

Introduction Therapists, Counsellors, Coaches, Lifeline Volunteers, Recovery Coaches, Crisis Intervention Operators, ... every day, many people provide support to other people that are passing through a diffult phase in their lifes or are affected by crisis, disaster or other critical events, such as loss or serious illnesses, depression, burn out, living in isolation or being stigmatised, ... Although everybody concerned with responding to human suffering, will find many useful techniques in this manual, the main purpose of the guide is to help lay counsellors, relatives and friends of people in need to discover empowering techniques to support the people around them that find themselves afflicted by crisis. The shoulder and ear of a friend or a lifeline volunteer, the psychosocial support they provide, should never replace professional counselling where this is needed and one of the responsibilities of anybody assisting people in need without having a professional mental health background or formal degree in counselling, is to refer the people who turn to them for support and advice to qualified officials, when this is deemed useful or required. Yet, not all people affected by crisis need or want professional help, and even though at times the intervention of a professional counselor or therapist will be absolutely necessary for the individual seeking help, at other times the input of a peer: a fellow journeyer or trusted friend or relative, will suffice to make the difference and help the person affected by crisis to get back on his feet. Also, to all the people that are going through a phase of personal crisis and are treated in an ambulant way, it will make a huge difference when they can fall back to friends and relatives who master empowering intervention skills, allowing them to provide better support during the time they spend together. Since all of us will find ourselves sooner or later in a situation in which relatives or friends need our help and support, we may as well prepare ourselves for the occasion. The skills required of a lay counsellor will differ depending on the situation and the setting in which they are working. For example, counselling on a phone line for people at risk of suicide will be different from helping in the immediate aftermath of a disaster, which will again differ from counselling grieving or depressed people or people living with serious illnesses. However, certain skills apply to all these situations. I am convinced that the techniques joined in this manual provide for a basis that will prove of utmost importance in any kind of coaching or crisis intervention. Dean Amory

Chapter 1 Goals Goals of this Guide A primary goal of this guide is to offer an empowering basic approach for coaches and providers of personal crisis services aimed at providing support to the distressed and suicidal and, more in general, all people going through a phase of personal crisis in their lives. Another goal of this guide is to increase awareness and understanding that a personal crisis often is a situation defined as such by the perception of the individual experiencing it. An outcome of applying the techniques set forth in this guide is increased awareness and utilization of the most appropriate and motivating instruments available to encourage empowerment and recovery of individuals served. The goals of empowering intervention services The goals of empowering intervention services include, but are not limited to: 1. Promote the safety and emotional stability of individuals experiencing a personal crisis. 2. Minimize further deterioration of these individuals. 3. Provide sufficient information to clients for them to learn how to make their own decisions, encouraging them to re-take control of their lives and decision making power 4. Assist individuals in rebuilding self-confidence and developing or enhancing better coping skills, better problem solving skills and a natural support system. 5. Help individuals find and obtain ongoing support, care and treatment; 6. Getting the client to see himself as the agent of change, capable of using the knowledge and skills of others in furthering their own interest and creating responsible social change. 7. Encourage the use of the best techniques available to meet the individual's needs.

Chapter 2 Definition of “Personal Crisis” A personal crisis is defined as an intensive behavioral, emotional, or psychiatric situation which, if left untreated, could result in an emergency situation, in the placement of the person in a more restrictive, less clinically appropriate setting, including, but not limited to, inpatient hospitalization or at the very least, significantly reduce levels of functioning in primary activities of daily living. "A personal crisis can be thought of as a system out of balance. Normally, all of us maintain our state of equilibrium on a day-to-day basis without too much trouble. Obstacles are overcome because we've learned good coping skills to re-establish equilibrium after some event has temporarily knocked us off balance. Personal crises occur when the balance cannot be regained, even though we are trying very hard to correct the problem.” Types of personal crisis Two Different types of personal crisis occur. One is a developmental crisis, like a job change, retirement, having a baby, your baby turns 14. The other is a situational crisis like rape, robbery, sudden death, or being diagnosed with a chronic or terminal disease. With regards to a situational crisis, the cause is often defined as a “Critical Incident”. A Critical Incident is any event that has an impact sufficient enough to overwhelm the usually effective coping skills of either an individual or even a group. Critical incidents are typically sudden, powerful events that are outside of the range of a person’s ordinary experiences. Because they are so sudden and unusual, they can have a strong emotional effect. If the critical incident is extreme in nature, it may serve as the starting point for the psychiatric disorder called “Post-traumatic Stress Disorder.” Critical Incident Stress services help mitigate this possibility. Critical Incident Stress (CIS) or traumatic stress is an unusually strong emotional reaction that has the potential to prevent the individual from maintaining their normal duties and responsibilities within their work, social and family environments. The reaction may be immediate or delayed. Most personal crises however occur because a person is just overloaded. A reprimand from a supervisor may be accepted without issue one day. However, if it happens when you already have several stressors using up your reserve of coping ability, it may be the event or precipitator that pushes you off balance. In other words, the person is pushed enough off balance that he or she needs assistance to rebalance his or her system. This definition focuses on the needs of a person who is being stressed rather than the cause that evokes this response.

Chapter 3 Empowering Intervention Components 1. Importance of the first contact In a crisis situation, each component of working is important, however the first few minutes of a contact could determine if the individual will continue to seek out assistance or not. Assuring a supportive, therapeutic interaction right from the very first moment of contact will therefore be very important in the outcome of the situation. If the first contact is made over the phone, normally, within seconds, the caller is forming an opinion of the people they may interact with and the possible services they may receive. The service provider answering the telephone must ensure the initial contact is a positive one, setting the stage for a successful experience and instilling confidence in the professionalism of the service quality. As each service component is reviewed throughout this manual, it is important to understand that although one person may present with a crisis situation, family members and/or significant others are also affected by the crisis situation. It will often be important to engage family members and/or significant others for information and clarity of the crisis situation to the extent appropriate. Although this concept is not directly stated through out this manual, it is implied and should always be practiced. What are crisis telephone answering skills? Often, the first contact with the individual experiencing a personal crisis, will occur through a telephone call to a crisis service provider or crisis line. The manner in which the crisis telephone is answered sets the tone for the contact. All telephone calls are required to be answered in a uniform, courteous, and professional manner to be followed by all telephone operators on answering incoming calls The following are a few tips to assure these requirements are met: 1. Answer the telephone as soon as possible, but preferably within at least three (3) rings. 2. All telephone calls are to be answered "liveâ&#x20AC;?. No answering machines or other electronic mechanisms are allowed to field crisis calls. 3. All telephone operators of hotlines should answer the telephone in a standardized and courteous way. For example, "Good morning, Lifeline Services, how may I help you?"

Sample of a telephone script for the correct handling of incoming calls 1. Welcome Goodmorning, Lifeline Services. This is <Myname> speaking. 2. Caller Identification In case we are accidentally disconnected could I please have - Your full name? - Your telephone number? - The address from which you are calling? - And your Email address?. 3. Screening / Establishing the purpose of the call How can I help you today? 4. Commence Assessment / Troubleshooting / Empowering Can you describe the nature of the difficulty you are experiencing? 5. Conclusion of the call -

Is there anything else I can help you with today? My name is <Myname>. If you have any further difficulties please do not hesitate to call again. Thank you for calling Lifeline Services. Have a good day, goodbye.

General call behaviour rules 1. Always ask for permission before you put caller on hold 2. Provide an estimate of how long they may expect to be on hold Example - “would you mind if I place you on hold for a few minutes while I check some of our systems?” 3. If a caller is placed on hold, check back with the caller every minute to give him/her feedback regarding the status of the call. 4. When you return from placing the customer on hold say: “thank you for holding” 5. If you need to talk to other staff, press the mute button. - Do not place the person on a speaker telephone. - This may make them feel there is no privacy in the conversation and may prevent them from telling you important information. - Using a speaker telephone may also compromise the confidentiality of the caller's right to protect their private health information.

2. The Personal Crisis Intervention Services SARE Model The SARCE mnemonic stands for: 1. 2. 3. 4.

Screen Assess Build Rapport Empower

1. Screening Prior to initiating any crisis assessment service, some sort of screening of the potential crisis situation must be conducted. The screening may be formal or informal, occur through a telephone call to a crisis line, an appointment with the personal crisis service provider or through information obtained from a third party (family member, friend or others). The screening determines the problem and needs of the individual as well as provides guidance for crisis prevention and/or early intervention. This screening information (which may be incomplete or from an untrained person) can help to determine if a formal crisis assessment service is warranted. The screening should not be more intrusive than necessary. It should be done before any details of the problem are elicited and the caller should be told the reason for the questions upon request. What is included in a crisis intervention screening? The screener must gather basic demographic information, determine whether a crisis situation may exist, identify parties involved, and determine an appropriate level of response. The screener must use active and supportive listening skills to determine if a crisis intervention is required, and which service intervention would best address the person's needs and circumstances. The initial screening must consider all available services to determine. For some individuals, information about services or a referral to a local service provider would be an appropriate and sufficient intervention. Others may need telephone or a face-to-face intervention. Based on the information gathered to this point, the screener must determine whether a crisis requires further assessment. It should be noted that disruptions in life that may not create a crisis situation for one person at any given time might create a crisis situation for another person. Alternately, disruptions that might not have posed a challenge during one time may cause significant turmoil at other times in the person's life. If the person believes that he or she is experiencing a personal crisis, it is best to honor that belief. Whenever we screen and identify specific needs, we have an ethical responsibility to either provide the necessary next steps (assessment or intervention) or refer to an appropriate source for follow up. Screening processes always should define a protocol or procedure for determining which clients need further assessment (i.e., screen positive) for a condition being screened and for ensuring that those clients receive a thorough assessment. That is, a professionally designed screening process establishes precisely

how to score responses to the screening tools or questions and what constitutes a positive score for a particular possible problem (often called a “cutoff” score). The screening protocol details the actions taken after a client scores in the positive range. In a professional context, it also provides the standard forms for documenting the results of the screening, the actions taken, the assessments performed, and that each staff member has carried out his or her responsibilities in the process. Screening alone is not sufficient to diagnose a situational, developmental, behavioral, or health concern. It is one piece of information that may indicate the need for further evaluation by a qualified professional. If the screening raises concerns, then the screened individual should be referred to a qualified professional who will perform further evaluation. If the person is eligible, the qualified professional will lead the development of an Individualized Service Plan and coordinate services Although a screening can reveal an outline of a client’s situation and needs, it does not result in a diagnosis or provide details of how previous experiences have affected the client’s life. Appropriate Screening Tools Screening procedures and tools should be: - Linguistically appropriate. When possible, the screening tool should be in the individual’s primary language - Age and developmentally appropriate. - Culturally appropriate. Some developmental skills may look different depending on the culture and background of the individual screened. When possible, use a screening tool or procedure that takes into account the person’s cultural context. When a culturally and linguistically appropriate screening tool is not available, information from families is even more critical to ensure validity. - Valid, reliable, and standardized when available to ensure that the tool gives information about the how a person is developing relative to a larger group of their peers. - Identified as screening tools. Screening tools might inform ongoing assessment, but a tool created for assessment would not be appropriate for screening.

2. Assessment The Difference Between Screening and Assessment The purpose of screening is to determine whether a person needs assessment. The purpose of assessment is to gather the detailed information needed for an action plan that meets the personal needs of the individual. Screening involves asking questions carefully designed to determine whether a more thorough evaluation for a particular problem or disorder is warranted. Many screening instruments require little or no special training to administer. Screening differs from assessment in the following ways: •

Screening is a process for evaluating the possible presence of a particular problem. The outcome is often a simple yes or no.

•

Assessment is a process for defining the nature of that problem, determining a diagnosis, and developing specific treatment recommendations for addressing the problem or diagnosis.

Assessment The assessment examines a client’s life in far more detail so that accurate diagnosis, appropriate treatment placement, problem lists, and treatment goals can be made. Usually, a clinical assessment delves into a client’s current experiences and her physical, psychological, and socio-cultural history to determine specific treatment needs. Using qualified and trained clinicians, a comprehensive assessment enables the treatment provider to determine with the client the most appropriate treatment placement and treatment plan (CSAT 2000c). Notably, assessments need to use multiple avenues to obtain the necessary clinical information, including self-assessment instruments, clinical records, structured clinical interviews, assessment measures, and collateral information. Rather than using one method for evaluation, assessments should include multiple sources of information to obtain a broad perspective of the client’s history, level of functioning and impairment, and degree of distress. Assessment is a process that is much more comprehensive than the screening-process. It includes the family, and assesses the individual in all life domains including evaluating strengths and family. An assessment should be conducted as soon as possible after the screening results have determined its necessity. - Whereas a screening is always necessary, an assessment will only be conducted in the individual needs a more thorough evaluation, empowering guidance or counselling and when conditions permit: o Almost always during face to face meeting at the client’s home or in the premises of the service provider o When the client is cooperative, that is: able and willing to answer the questions in a calm and rational manner o When the time and the will to achieve a more thorough evaluation is present with all parties.

In case of an intake, it usually takes place within 30 days of intake and screening and contains such components as: - It should be conducted by a qualified individual with the appropriate credentials required by the licensing authority. - The assessment should be culturally and linguistically appropriate for the individual and the family, taking into consideration the family’s level of acculturation and assimilation; their cultural world views of health/wellness, illness, and treatment; and their values, traditions, beliefs, rituals, and practices. In addition, it should be conducted in the preferred language and in a setting that is conducive to the most cooperation from, and ease for both the individual and the family. In general, assessment must be individualized to meet the needs and identify the strengths of the person assessed. As with all interventions, informed consent must be sought and properly documented. The Assessment Interview To provide an accurate picture of the client’s needs, a clinical assessment interview requires sensitivity on the part of the counselor and considerable time to complete thoroughly. While treatment program staff may have limited time or feel pressure to conduct initial psychosocial histories quickly, it is important to portray to clients that you have sufficient time to devote to the process. The assessment interview is the beginning of the therapeutic relationship and helps set the tone for treatment. Initially, the interviewer should explain the reason for and role of a psychosocial history. It is equally important that the counselor or intake worker incorporate screening results into the interview, and make the appropriate referrals within and/or outside the agency to comprehensively address presenting issues. For instance: the notion that a person’s substance use is not an isolated behavior but occurs in response to, and affects, other behaviors and areas of their lifes is an important concept to introduce during the intake phase. This information can easily disarm a client’s defensiveness regarding use and consequences of use. General Guidelines of Assessment •

Similar to the screening process, the individual assessed should know the purpose of the assessment.

•

To conduct a good quality assessment, counselors need to value and invest in the therapeutic alliance with the client. Challenging, disagreeing, being overly invested in the outcome, or vocalizing and assuming a specific diagnosis without an appropriate evaluation can quickly erode any potential for a good working relationship with the client.

•

The assessment process should include various methods of gathering information: clinical interview; assessment tools including rating scales; behavioral samples through examples of previous behavior or direct observation; collateral information from previous treatment providers, family members, or other agencies (with client permission); and retrospective data including previous evaluations, discharge summaries, etc.

•

Assessment is only as good as the ability to follow through with the recommendations.

•

Assessments need to incorporate socio-cultural factors that may influence behavior in the assessment process, interpretation of the results, and compliance with recommendations.

•

The assessment process should extend beyond the initial assessment. As the assessed person becomes more comfortable, additional information can be gathered and incorporated into the revised assessment. Subsequently, this new information will guide the reevaluation of presenting problems, treatment priorities, and treatment planning with input and guidance from the client.

•

Reassessments help monitor progress across the continuum of care and can be used as a barometer of effective treatment. Moreover, the presenting problems and symptoms may change as recovery proceeds.

Looking at strengths Focusing on strengths instead of deficits improves self-esteem and self-efficacy. Familiarity with the individual’s strengths enables the counselor to know what assets they can use to help them during recovery. The use of good self-assessment worksheets that focus on individual strengths are to be recommended. In addition to assessing strengths, coping styles and strategies should be evaluated (see Rogers 2002). What is included in a crisis assessment? A crisis assessment evaluates any immediate need for emergency services and, as time permits, the person's: -

current life situation; sources of stress and acuity level; mental health problems and symptoms; Strengths; cultural considerations; identifiable and realistic support network; drug and alcohol use; current medication use; vulnerabilities; and current functioning.

What is a personal crisis intervention service? "Personal crisis intervention service" refers to an isolated intervention or to a series of interventions which may be face-to-face or telephonic short term, intensive conversations initiated during a personal crisis or emergency to help the person cope with immediate stressors, identify and utilize available resources and strengths, and begin to return to the person's baseline level of functioning. Intervention settings may include the person's home, the home of a friend or family member, the service provider’s premises, a hospital or emergency room, jail or other community settings. Personal intervention services can take place at any time or day of the week. Possible determinants indicating the need for a face-to-face intervention include: • extreme dysphoria (deep sadness, anxiety and restlessness), • severe depression, • suicidal intent, • homicidal intent, • acute psychosis

Others include: • hopelessness, • helplessness, • extreme tearfulness, and • extreme detachment or withdrawal/isolation If the crisis assessment determines that crisis intervention services are needed, the intervention services must be provided as urgent or emergent. Who may conduct a crisis assessment intervention? Whereas mental health crisis interventions should be always conducted by trained, credentialed and/or approved mental health personnel and professionals who have a licensed psychiatrist or physician experienced in psychiatry available for consultation, everybody will live through moments in life when the circumstances require of them that they act to help and support people going though a personal crisis. What is the function of hotlines in this context? Hotlines are designed to help individuals to handle crisis situations. Hotlines cannot operate alone. They rely on a network of other organisations that offer professional health and counselling services Hotline telephone operators can: - Listen to people without judging; support them in their journey by showing empathy for them and their problems - Provide basic information - Connect people to available resources where they may find practical help - Provide limited emotional support Hotline telephone operators cannot do the following: - Tell People what to do - Provide extensive counselling or emotional support - Provide medical care or services directly For all hotline telephone operators and first line service providers in a professional environment, a structured approach providing the necessary administrative, educational and emotional support must be put into place: information and training should be made available to all operators, including up to date referral lists and resources for callers, training in communication techniques, assertiveness, setting personal boundaries and personal stress reduction strategies, as well as offering an outlet to talk about their feelings and a chance to discuss difficult calls. Supervisors should express appreciation for a job well done. Positive feedback is important for operators to feel they are doing a good job. "Debriefing", "case review" or "psychological first aid" are terms used by mental health professionals to describe interventions that should be available when a crisis service provider experiences a completed suicide or traumatic event that involves a service recipient. The goal of these interventions is to allow a crisis service provider to express their personal reactions to the event and to identify steps that might relieve stress symptoms related to their exposure to the event. In some cases, emergency mental health interventions may include staff members outside of the crisis service provider. Any of these interventions should be conducted by, or in consultation with, a trained mental health professional in the area of emergency mental health services.

Debriefing occurs preferably in a structured manner, occurs immediately after a shift, and is mainly supportive and not as formal as supervision. By taking place immediately following a shift, operators can discuss feelings about upsetting calls and deal with responding to other issues, prior to the next shift. Making a difference in someone's life, helping individuals improve their lives and find solutions to their problems, can be extremely challenging and satisfying for those who enjoy seeing the positive results of their direct action. Another benefit reported by those working in this field is the level of camaraderie that often exists within these organizations. It can be inspiring and invigorating to see what people can accomplish when they gather for the sole purpose of helping others live better lives. However, while this work can be highly satisfying, it can also be emotionally draining and full of frustrations. One of the reported difficulties of providing services within some bureaucratic systems is the amount of paperwork often required. For people who enter this field because of their desire to help people, this can be a significant challenge. In addition, this work can be frustrating because change often happens in a slow, sometimes almost undetectable way, and seeing the benefits of your work may take a long time. For people who are committed to helping others, accepting the fact that there is always more to do than could ever be done, can be difficult. One of the greatest challenges for people who see themselves as â&#x20AC;&#x153;helpersâ&#x20AC;? is to balance giving with knowing when you have done enough. Working as a hotline operator is a great responsibility and should never be taken lightly. As a hotline operator, you don't want to wing it with people whose lives are hanging by a thread. You should only use established procedures and training to get the person back from the brink. As a hotline operator, it is important not to place too much pressure on yourself. You are there to help people â&#x20AC;&#x201C; you can't diagnose or advise them, so rely on your training and people skills to help them find the right people who can help and to make their own choices. Preventing burn-out by setting personal boundaries is critical to longevity and success in the social service field. Things you may need to learn if you want to become a hotline are: - Emergency procedures - what to do if things aren't going well with a caller. - State laws concerning the operation of a crisis center - these concern the liabilities and restrictions that are important to know, even as a volunteer. - The range of help available out in the community to direct callers to, from financial and legal to rehabilitation or detox help. - Counseling techniques - getting people who are really hurt to talk to you openly or even at all can be difficult. You'll need to learn the ways of helping people to open up and how you can demonstrate trust. Also, most crisis hotlines will teach you that your role is to facilitate the caller's own decision-making process through prompts and guides. You don't make the decisions for the caller, nor do you counsel. How soon must o crisis intervention plan be developed? As part of the crisis intervention services, the crisis services provider must develop a crisis intervention plan during the initial face-to-face assessment. The plan must address the needs and problems noted in the crisis assessment and refer to identified services to reduce or eliminate the crisis. What if the personal crisis service provider determines that the person requires extra services? If the crisis service provider determines that the person requires mental health crisis stabilization services, such as crisis respite or crisis stabilization, the crisis services provider must arrange for the provision of

these services either directly or through other resources, depending on his professional qualifications and the circumstances at hand. - Crisis stabilization services are designed to assist the person in returning to his or her prior functional level or improved level of functioning, if possible. - Mental health stabilization services are individualized mental health services that are provided to a person following a crisis assessment

3. Building Rapport We all know that “A man convinced against his will, remains of the same opinion still ..” That is why every sales- or hypnosis course and every article about dating will tell you that you need to start with creating as much rapport as possible. Only after you have created sufficiently emotional connection and trust, will the other person feel comfortable enough to actually listen to you, and accept and emotionally respond to images that you are describing. How to create rapport? Creating rapport is about establishing a tangible and harmonious link by getting on the same wavelength with another person. You know there is rapport when everything clicks and feels right, when it is as if you know and understand each other and your ideas are synchronized. When there is rapport, you feel bonded, connected and enjoy time together. Link yourself with people and things the other person knows about and likes. Make them talk about subjects that are familiar and enjoyable to them. Search for common ground. If they like gardening and you do too, then tell and show hem how much you enjoy gardening. 1. You can develop rapport faster by paying attention to body language, mirroring and matching and empathic listening. Body language •

Reading body language correctly enables you to identify the individual’s emotions and discomfort.

•

Using body language appropriately, including eye-contact and touch, helps you to get the attention desired and can create a positive perception.

Be conscious of your body language. When meeting people for the first time, it’s obviously important that you appear relaxed and open in your stance and that you make good eye contact. As the conversation goes on, it can also help to mirror the body language of the person you’re speaking to, not in an obvious way, but in a way that gives the impression that you’re “in synch” with each other. Make sure as well that you’re focused on the person that you’re talking to, not looking around the room, which can give the impression that you’re looking for someone more interesting to talk to. Mirroring and matching A/ Mirror your listener’s body language That is: their posture, movements, breathing rhythm and physical state. Why? Copying their behavior causes them to feel similar to you, which in turn will lead to your listener starting to copy you in response •

•

The idea is to align your movements and body image with the other person’s demeanour. Mirroring or reflecting is not the same as imitating, but by presenting similar demeanours as the other person’s, they will subconsciously feel that you have much more in common with them than may actually be the case. You can mirror or match language, including rate of speech and vocabulary used, breathing, voice, moods, movements, energy level, …

B/ Confirm and match your listener’s inner world. That is: their values, perceptions, beliefs, emotions, ideas and assumptions. Why? when you copy your listener’s way of seeing the world (visual, audio …), their way of expressing themselves (words and expressions he uses), repeat their values, accept them as they are and confirm them in their beliefs and opinions, they will listen to you, accept what you are saying and start to like you because they will see you as very similar to themselves and will appreciate the respect you show them. After all, you are confirming them in what and how they are and what you are telling, is the truth, such as they too perceive it. Here is how to do it: 1. Match the persons sensory modality What I mean here is to match and mirror the way that they think and talk. Remember when we were talking about visual, auditory and kinesthetic modalities? Well, this is about putting it into practice. Listen for the indicator words that the person is using and use words/phrases from the same modality. Also, look out for eye movements to spot thinking patterns. 2. Mirror the persons Physiology By copying the persons posture, facial expressions, hand gestures, movements and even their eye blinking, will cause their body to say unconsciously to their mind that this person is like me! 3. Match their voice You should match the tone, tempo, timbre and the volume of the person's voice. You should also make use of matching the key words that they use a lot. Examples of this may be: "Alright", "Actually", "You know what I mean" 4. Match their breathing You should match the persons breathing to the same pace. Matching the in and out breath. 5. Match how they deal with information You should match persons CHUNK SIZE of how they deal with information. For example are they detailed or do they talk and think in big pictures. If you get this wrong you will find it very difficult indeed to build rapport as the detailed person will be yearning for more information and the big picture person will soon be yawning! 6. Match common experiences After all, what are you going to talk about! This is all about finding some commonality to talk about. Matching experiences, interests, backgrounds, values and beliefs. One point to bare in mind is that you need to be subtle when you are matching and mirroring. Don't go over the top! Typically however, the other person will be focussing so much on what they have to say that they will not even notice.

Breaking the mirror There are two sides to every coin. If you feel the need to create distance or to break the synchronization because you want the other person to get out of their comfort zone, or in order to show disagreement: stop mirroring and behave differently from the individual. Empathic listening Empathic listening or Active listening basically is acknowledging the indivual’s feelings and reflecting them. The subject is treated more in detail in the next chapter of this book. The basis of empathic listening is validating the other person and incorporating their words into your answers and conversations 2. Other techniques include Agree, Praise and Confirm •

“O.k., right, exactly my idea” – “you are great, smart, good, …”

Validate the persons' concerns, struggles, perceptions, and feelings •

No wonder you feel that way…

•

No wonder you’re so frustrated and stressed out (validating feelings). You’ve struggled with this problem for a long time, and it makes sense to me that you’re wondering whether it’s best to ... or ... (validating concerns and experience of the problem).

Compliment people on their courage, resilience, and other attributes •

After everything you’ve been through, I’m impressed that you’re still hanging in there and trying to make things better for yourself. Where do you find the courage and strength to stay at it instead of giving up? (complimenting courage and resilience)?

•

How did you manage to get through the whole day? improvement);

•

I'm really glad you brought that up.

•

I think what you are doing is really difficult. I'm really proud to be working with you on this.

•

So many people avoid seeking help. It says a lot about you that you are willing to take this step.

•

What have you noticed about yourself in the past few months since you started coming here? (This question is designed to prompt the client to self-affirm.)

(giving credit for resilience and

Note on compliments: Compliments can be direct: commenting directly on a person’s actions: “You did a great job on this assignment” Indirect: folding compliments into questions: “How did you get yourself to work on time yesterday?” or attribution-based: referring to positive characteristics of the person: “You’re a caring person”

Be curious (vs. all-knowing): Ask a lot of questions. People trust people who are interested in them. The reason for this is that people tend to feel isolated as life gets more complicated. And when someone pays attention to us we feel safer and less isolated. Think of the car buying situation with the car salesperson being you. The salesperson who focuses on finding out the customer’s needs before trying to close the sale will do much better than the salesperson who focuses on the product. When someone tries to sell us something, whether a car or an idea, if we feel they know us, we will feel safer and be more open to what they have to say. As a crisis service provider the more you use curious information gathering to build rapport the more likely it is that the individual you want to help will trust you and be coachable. “I wonder what would happen if…” Ask (vs. tell): •

“What might change when ...?”

•

"How are things going?"

•

"What is most important to you right now?"

•

"Hmm... Interesting... Tell me more..."

•

"How did you manage that in the past?"

•

"How would you like things to be different?"

•

"What will you lose/gain if you give up XXX?"

•

"What do you want to do next?"

•

"How can I help you with that?"

Offer options, not solutions Overall empathic interaction Act as if the other person is your whole world. Focusing intently on them will build rapport. It will make them feel important and make it easier for them to trust you and this trust will make them more sympathetic to your coaching. In order to focus intently on them, if possible, get into a quiet space. This should be away from distractions. Make it easy on yourself to focus. For example, avoid places where there is a lot of action going on. If necessary, face a wall with the individual in front of you to make it easy on yourself. If you are distracted during the intervention, it is like saying that the other person is of less importance than what is distracting. What does it say to answer a phone while listening to another person? Copy patterns of speech, words and images used To make someone you’re talking to feel comfortable it is helpful to mirror their demeanour. If they are slow and deliberate they will feel most comfortable if you are the same way. If you’re in a hurry they will feel uncomfortable and less safe. When trying to mirror someone look for their language pattern. Is it deliberate or fast? Try to measure their breathing pattern in the same way. Is it fast or slow? Reflect it. Watch out for their

body language. If they are relaxed, don’t lean in aggressively. Being flexible in how you act around your intervention. In order to obtain a deep contact and influencing power with the other, you must let them help you to find the correct ways to achieve your goal. Tuning in to them will help you build rapport by including their feelings of safety and their receptiveness to your suggestions. Tell about similar experiences One other way to build rapport is let the other person know that you understand where they are coming from. When you acknowledge them, that is you say and demonstrate that you understand, it doesn’t mean you agree it just means that you have heard them. This creates an absence of vulnerability because people want to know that they have been heard. That makes them feel important and makes it easier to trust. To demonstrate that you understand let them know that their words make sense to you and, when possible, that you have had similar experiences and thoughts. This might be done by telling them about a personal experience that is like theirs. If that is not possible say that you understand or ask them to explain further in a way that lets them know you are interested in their experience. Being heard is a building block of trusting. “I have that same feeling all the time.” – “I was just about to say exactly the same thing” – “I couldn’t agree more” Ask for advice •

“How would you … ? What would you do if … ?”

Insert pauses between phrases, talk slowly, whisper When you ask a question, deliberately pause to let the person you’re asking answer. This is a sign of respect, which builds feelings of safety and trust. Imagine if you had an audience with the Pope. Would you ask a question and then jump in while he was answering? No, not at all. You would respectfully wait for the answer. It is the same in building rapport. To build trust you must patiently provide an empty space for the answer to fill. Patient open space listening produces respect, an absence of vulnerability and rapport. Smile I know that this one’s obvious, but we’re much more approachable when we smile. Alternatively, a greeting without a smile lacks warmth and makes it difficult for us to connect with others. A solid handshake A good handshake isn’t very memorable, but a bad one is. Make sure that your handshake is firm (without breaking fingers) and doesn’t go on for too long. Hanging your hand out like a dead fish comes across as insipid and lacking in confidence, a bad start to any relationship and to be avoided. Whilst you may have used the same handshake for your whole life so far, it’s never too late to change, so if you’re conscious that you sometimes don’t come across well in this area, start practicing.

Get, and use, their name To assist you to build rapport with others, getting their name early in the interaction is crucial. It’s just as important to use it a few times, making the conversation more personal and increasing the likelihood that you’ll remember it the next time you meet them. Find common interests, but keep it about them People like people who share interests with them, so asking questions about their family, work, background, even favourite sporting teams can assist you to find common ground with the other person. However, when you’ve found one or two points of affiliation, don’t take that as permission to talk too much yourself. Ask questions to get the other person talking, enabling them to feel more comfortable and confident with you. Building Rapport: Paving the road to Collaboration Building A supportive relationship always demands giving your full attention to the other person. By doing so, you make it easier for them to tell their story and enable them to look at ways that will allow them to handle their problems better or even solve them. Giving attention includes listening actively, being genuine and showing respect. In other words: totally being there for the individual. You tune into the other. You tune into his use of language, words, intonation, attitude, movements and emotions. Do this unobtrusively. If you tune into them, it will become easier for you to imagine what it would be like being him and having his problems. On the other hand, the person you want to help will also feel more at ease with you. This can be called Mirroring. One of the active ingredients that makes supportive relationships work is Rapport. More rapport between two people will typically make the exchange and acceptance of ideas go more quickly. Less rapport will make it less effective. What this means is that more time spent by actively listening to the other and mirroring his actions, thoughts and feelings up front will lead to less effort later to produce results. Less effort up front to create rapport will mean more effort is needed later to stimulate the other to right action. You should therefore always take the time to establish rapport if your aim is to influence somebody else. Establishing Rapport will make your intervention more efficient and more successful. In extreme circumstances the rapport building might need to be 99% of the relationship. So what is rapport. The dictionary definition speaks of mutual trust. My favourite definition of trust is ‘an absence of vulnerability.’ So rapport could be considered a ‘mutual absence of vulnerability.’ Building rapport is taking steps to create trust by creating an absence of vulnerability. This is done by helping the other to feel safe. Steps to take include being curious, creating an open space for answers to questions, mirroring the demeanour of the other, giving the individual your total attention and acknowledging that they are being heard. It’s all about being an excellent listener. Rapport is the ultimate tool for producing results with other people and thus it is so vital for effective communications. When you bear in mind that 93% of all communication is down to the tonality of your voice and your body language, building rapport is far more than just talking about common experiences. It's an important point to remember but people like people when they are like themselves and when they are not it so much more difficult to have any sort of relationship with that person never mind an effective one!

How to develop collaboration building 1 : Prepare to compromise. When working with a team, it is impossible for everyone to get their way, so compromise is imperative. Don't consider it a blow to your ego, simply a necessity when you develop collaboration skills and put them to use. 2 : Avoid taking it personally. When collaborating with a group, there is always a chance of getting your feelings hurt by insensitive team members or group decisions. Remember that decision-making should not be personal, it is just a natural part of the process. 3 : Focus on the well-being of the project. In order to fully develop collaboration skills, it is important to keep your eye on the task at hand. Focusing your efforts on the success of a project removes the urge to get your own way and helps a group stay on task. 4 : Communicate effectively. Without communication all sorts of problems are likely to pop up. By communicating in thoughtful ways and remaining mindful of others' feelings and motivations, you will be more likely to collaborate successfully. 5 : Identify challenges. If you have trouble developing collaboration skills, take some time to reflect on your difficulties. By pinpointing the hurdles in your way and the causes of your discomfort, you can map out ways to overcome them. 6 : Participate in team building activities. There are a number of team building workshops and activities that are easily accessible online or in person. Take the time to participate in team building activities as a way to quickly and efficiently develop collaboration skills. A-to-Z strategies for building collaboration in organizations Most people agree that effective collaboration is more important than ever in today’s turbulent environment. In a “do-more-with-less” reality, it takes ongoing teamwork to produce innovative, costeffective, efficient and targeted solutions. In fact, the ultimate success of your intervention may depend on how well you and the other person can combine your potential and the quality of the information they possess with your ability (and willingness) to share that knowledge . So, what’s to be done? Here, from A to Z, are the most successful strategies to tear down fences, reduce conflicts and increase collaboration. A. Find ways to ACKNOWLEDGE collaborative contributors. Recognize and promote people who learn, teach and share. And, penalize those who do not. In all best-practices companies, those hoarding knowledge and failing to build on ideas of others face visible and serious career consequences. In those top companies, employees who share knowledge, teach, mentor, and work across departmental boundaries are recognized and rewarded. B. Watch your BODY LANGUAGE. All leaders express enthusiasm, warmth and confidence – as well as arrogance, indifference and displeasure through their facial expressions, gestures, touch and use of space. If leaders want to be perceived as credible and collaborative, they need to make sure that their verbal messages are supported (not sabotaged) by their nonverbal signals. C. Focus on the CLIENT. Nothing is more important in an organization – whether it’s a for-profit company or a non-profit group – than staying close to the end-user of the service or product you offer. When you build collaborative relationships with your customers, you give them power and co-ownership of your organization’s success.

D. DIVERSITY is crucial to harnessing the full power of collaboration. Experiments at the University of Michigan found that, when challenged with a difficult problem, groups composed of highly adept members performed worse than groups whose members had varying levels of skill and knowledge. The reason for this seemingly odd outcome has to do with the power of diverse thinking. Group members who think alike or are trained in similar disciplines with similar knowledge bases run the risk of becoming insular in their ideas. Instead of exploring alternatives, a confirmation bias takes over and members tend to reinforce one another’s predisposition. Diversity causes people to consider perspectives and possibilities that would otherwise be ignored. E. ELIMINATE the barriers to a free flow of ideas. Everyone has knowledge that is important to someone else, and you never know whose input is going to become an essential part of the solution. When insights and opinions are ridiculed, criticized or ignored, people feel threatened and “punished” for contributing. They typically react by withdrawing from the conversation. Conversely, when people are free to ask “dumb” questions, challenge the status quo and offer novel – even bizarre – suggestions, then sharing knowledge becomes a collaborative process of blending diverse opinion, expertise and perspectives. F. To enhance collaboration, analyze and learn from FAILURE. The goal is not to eliminate all errors, but to analyze mistakes in order to create systems that more quickly detect and correct mistakes before they become fatal. G. Collaboration takes GUIDANCE by managers who know how to harness the energies and talents of others while keeping their own egos in check. Successful organizations require leaders at all levels who manage by influence and inclusion rather than by position. H. Eliminate HOARDING by challenging the “knowledge is power” attitude. Knowledge is no longer a commodity like gold, which holds (or increases) its worth over time. It’s more like milk – fluid, evolving and stamped with an expiration date. And, by the way, there is nothing less powerful than hanging on to knowledge whose time has expired. I. Focus on INNOVATION. Creativity is triggered by a cross-pollination of ideas. It is in the combination and collision of ideas that creative breakthroughs most often occur. When an organization focuses on innovation, it does so by bringing together people with different backgrounds, perspectives and expertise – breaking down barriers and silos in the process. J. JOIN the social media revolution. Utilize Web technologies – tools and processes that allow people to share opinions, insights, experiences and perspectives in order to collaborate and to self organize. K. Realize that there are two kinds of KNOWLEDGE in your organization: Explicit knowledge can be transferred in a document or entered in a database. Tacit knowledge needs a conversation, a story, a relationship. Make sure you are developing strategies to capture both. L. LEADERS at all levels of an organization can nurture collaboration within their own work group or staff. The most successful of these leaders do so by taking the time and effort necessary to make people feel safe and valued. They emphasize people’s strengths while encouraging the sharing of mistakes and lessons learned. They set clear expectations for outcomes and clarify individual roles. They help all members recognize what each of them brings to the team. They model openness, vulnerability and honesty. They tell stories of group successes and personal challenges. And most of all, they encourage and respect everyone’s contribution.

M. MIX it up by rotating personnel in various jobs and departments around the organization, create cross-functional teams, and invite managers from other areas of the organization to attend (or lead) your team meetings. N. Employees with multiple NETWORKS throughout the organization facilitate collaboration. You can accelerate the flow of knowledge and information across boundaries by encouraging workplace relationships and communities. Use a tool like Social Network Analysis (SNA) to create a visual model of current networks so you can reinforce the connections and help fill the gaps. O. Insist on OPEN and transparent communication. In an organization, the way information is handled determines whether it becomes an obstacle to or an enabler of collaboration. Employees today need access to information at any time from any place. P. Collaboration is a PARTNERSHIP. As one savvy leader put it, “To make collaboration work, you’ve got to treat people the way you want to be treated. It’s pretty simple, really. Treat all employees as your partners. Because they are.” Q. Ask the right QUESTIONS. At the beginning of a project, ask: What information/knowledge do we need? Who are the experts? Who in the organization has done this before? Do we have this on a database? Who else will need to know what we learn? How do we plan to share/hand off what we learn? R. The success of any organization or team – its creativity, productivity and effectiveness – hinges on the strength of the RELATIONSHIPS of its members. Collaboration is enhanced when employees get to know one another as individuals. So, when you hold offsite retreats, organization-wide celebrations or workplace events with “social” time built in, be sure to provide opportunities for personal relationships to develop. Taking time to build this “social capital” at the beginning of a project increases the effectiveness of a team later on. S. Collaboration is communicated best through STORIES – of successes, failures, opportunities, challenges, and knowledge accumulated through experience. Find those stories throughout your organization. Record them. Share them. T. TRUST is the foundation for collaboration. It is the conduit through which knowledge flows. Without trust, an organization loses its emotional “glue.” In a culture of suspicion people withhold information, hide behind psychological walls, withdraw from participation. If you want to create a networked organization, the first and most crucial step is to build a culture of trust. U. Combating silo mentality requires UNIFYING goals. Business unit leaders must understand the overarching goals of the total organization and the importance of working in concert with other areas to achieve those crucial strategic objectives. V. The incentive to collaborate is the VALUE of the exchange to both the organization and the individual. When the assets and benefits of productive collaboration are made visible, silos melt away. W. Your WORKPLACE layout encourages or impedes the way the organization communicates. To facilitate knowledge sharing, you need to create environments that stimulate both arranged and chance encounters. Attractive break-out areas, coffee bars, comfortable cafeteria chairs, even wide landings on staircases – all of these increase the likelihood that employees will meet and linger to talk. X. Take a tip from XEROX. It discovered that real learning doesn’t take place in the classroom – or in any formal setting. In fact, people were found to learn more from comparing experiences in the hallways than from reading the company’s official manuals, going online to a knowledge repository or attending training sessions.

Y. Collaboration is crucial for YOUR success. We’ve witnessing the death of “The Lone Ranger” leadership model, where one person comes in with all the answers to save the day. We now know that no leader, regardless of how brilliant and talented, is smarter than the collective genius of the workforce. Z. Forget about reaching the ZENITH. Collaborative cultures are learning cultures – and knowledge sharing is an ongoing process, not an end point. Practical collaboration building 'It's amazing how much can be done when it doesn't matter who gets the credit'. (attributed to George C. Marshal) This page contains principles that when put into practice will produce results. Start with a unifying purpose: The purpose may need to be broad enough to bring in enough people with energy, imagination, commitment, resources, and creativity, to generate success. (For example, a community council interested in family and children issues or a business opening a new market.) Sometimes the purpose may also be very specific and narrow when the energy, imagination, commitment, and creativity, are sufficient. Start with two or three or a small group of people who have passion for the purpose. (For example, drug prevention.) This apparent conflict between broad and specific or narrow collaborations can sometimes be resolved by creating an umbrella committee with a more broad purpose and mission and subcommittees with more narrow and specific missions and purposes. (For example, a community council supporting family and children issues and a subcommittee dealing specifically with drug prevention or a committee working on absentee issues and a subcommittee dealing specific with drug prevention and/or treatment or even a business trying to recreate itself with a number of subcommittees.) Start with the End in Mind: Create, maintain, and update, simple and practical Mission and Vision statements. Create short and concise Mission and Vision Statements, and possibly a strategic plan. Be willing to update and change as the need arises. Keep the Mission and Vision statements in full view of all of the participants at every meeting. Some organizations place their mission and vision statement at the top of each agenda. Stick with it........however, If it doesn't fit any more, change it. Do it by consensus (unless a specific and different level of authority has been clearly communicated. Sometimes it can be helpful to create by-laws. Be careful that you do not get caught in the minutia and loose track of the prize (goal). Consider creating and displaying a value statement. Set goals and objectives. Goals are where you want to go. Objectives are how you are going to get there. Goals should be measurable and observable. They should have specific achievable steps (objectives) with built in accountability for accomplishment.

Goals should be built upon a consensus and can develop and adapt as the process matures. Some goals should be met quickly and easily, others should stretch you and the organization. Celebrate and advertise success. Emphasize both process and product. Document baselines to which you can compare. Evaluate how your results compare with the results of others working on similar goals. Be willing to learn from the success of others. Always strive for improvement, evaluate, solicit feedback, and adjust your course as needed. Believe in what you are doing and the people who are doing it. "If you think you can do a thing or think you can't do a thing, you're right." (Henry Ford) Radiate and speak Optimism. Expect Success Expect the best from people that you are working with. Leadership "What you are thunders so loudly in my ears that I cannot hear what you say." (Emerson ) Someone needs to be responsible for facilitating, moderating, and managing the meeting and discussion. Value-based dedicated leadership is essential for anything lasting, significant, and positive, to be accomplished. Be supportive, consistent, and dependable. Set high standards of excellence. True collaboration requires shared leadership. Cultivate leadership in others. Leadership must value an inclusive, collaborative, process. Coordinate - Organize Seating can be very important. Sitting behind tables can have the advantage of giving people a place to write and providing emotional protection. It also creates an atmosphere conducive to getting down to business and working. Preferably, tables should allow everyone to see each other (circle, semicircle, rectangle, or square). Very small groups can often do well sitting on something comfortable such as two or three couches and/or other comfortable chairs that face each other. Very large groups can sit in a circle or semicircle. These formats will increase communication. Avoid rows of people. This cuts down on interaction and communication. Hold regular, consistent (same place and same time), mutually beneficial, constructive, profitable, informative, and brief meetings. Take notes from the meeting and provide them to everyone in the collaboration. When there is a discussion, write down what is said. Writing on a board or flip chart where everyone can see is often preferred. (In some settings, writing on a board or flip chart can seem pretentious.) Accurately write what people say. Always have an agenda. In most cases it is better to send it to everyone ahead of time. Stick to the schedule. Respect everyone's time. When someone brings something up that is not on the agenda, write it down where they can see it. Be sure and address it at a later time, such as at the end of the meeting, after the meeting, or during another meeting. Let everyone know ahead of time what the process will be for addressing

items brought up during the meeting, but not on the agenda. Occasionally in some urgent situations, items will need to be addressed immediately, this should be rare. Stick to your mission statement. For community collaboration regularly nominate and vote for officers or set a system for rotation. Even when this is a committee, within a single organization, this can have value. Small subcommittees or groups can often accomplish specific technical work or complete projects more quickly than a larger group, committee, or collaboration. These smaller groups can receive direction or report to the larger group. Remember to keep Levels of Authority clear.Show Respect for People and Time. Ask for help. Say please and thank you. Demonstrate common courtesy. Apologize when warranted (know when it's warranted, be humble enough to appologize, at times, even when it's not.) 8 a.m. is often a good time for meeting with participants from Agencies and Schools. Lunch time can also be a good time. Evenings and weekends are usually best for Church, Family, Neighborhood, and General Community Meetings. I am aware of one community coalition which meets at 4:30 P.M., to make it easier for teachers to attend. If your goal is to involve youth, be sure to meet at a time and place convenient to youth. When there is a meeting for a work group with different organizations/agencies who have a mandate for the collaboration, the time is usually more flexible. Always start and end on time. Be consistent. Consider logistical needs of others Consider parking, transportation, acoustics, and child care, when required. Access and comfort should also be considered. disabilities.

Accommodate needs of individuals with

Be sure there are adequate restrooms, water, et. etc. Be Open-minded * Share Ownership. * Empower others * Share Leadership. Be willing to accommodate others, when possible and appropriate. Concentrate on the areas that you have in common with others who are involved. A lifetime of good may be accomplished in the areas that you agree. Sometimes working together towards positive goals can be more important than your specific agenda. As you work together and develop relationships you will likely come to a greater unity of purpose. Encourage and help your organization to grow and change as the need arises. When others feel ownership and empowerment in the organization, they become more committed, creative, and loyal. For many people the process is as important, and sometimes even more important, than the results. Everyone needs to be heard. Manage/Lead the process, don't control it. (The process does not belong to any one individual, and usually does not belong to any one organization, or agency).

Allow for conflict and disagreement. Create a healthy atmosphere for disagreement and discussion. As much as possible, resolve conflict and support the solution. Members/Participants need to clearly understand and respect each other's values, knowledge, and skills. Knowledge needs to be shared in order to increase the capacity of all the members, which in turn extends the capacity of the organization/collaboration. Knowledge shared is more powerful than knowledge kept. Enthusiastically support other people's successive or intermittent approximations of the goal. (As much as possible, let it be someone else's idea.) If their bandwagon is headed in the general direction of where you want to go, jump in and cheer it on. Use genuine compliments and recognition. At times it is wise to put it in writing and make it public. At times it is wise to make it private. Be specific about the behavior that you are complimenting. When appropriate encourage volunteers. Provide everyone who wants it, something meaningful to do. Remember that what is meaningful to you may not be meaningful to another. When ever possible, encourage and support others in their interests. Share and rotate leadership responsibilities. Support and encourage leadership in others whenever possible. Learn and practice critical thinking skills...without being critical. Build relationships Allow time before and after meetings for visiting. This can often be as important as the meeting itself. Take time to build friendships with members of the organization outside of the meeting times. Serving light refreshments or snacks can help to build relationships and ease conversation. Occasionally you may want to send a simple greeting card or thank you note to participants. This can help to build relationships. Sometimes a hand written note is greatly appreciated. Get to know and as much as possible understand the needs, issues, and passions of all the members of the coalition and stake holders in and out of the coalition. You are more likely to have positive influences over a friend, than an enemy. Emphasize both process and product. Communicate For many people the process is as important, and sometimes even more important, than the results. Everyone needs to be heard. Serving refreshments or light snacks can open help to relax people and open communication. Use common language. One of the most important building blocks of collaboration and consensus is communication. Sometimes our differences are magnified in the words we choose when we come together. At times this is because we get used to using certain words, phrases, or acronyms (words formed from the first letter of each word in a phrase such as USA), with our

peers, because these words save time and helps us feel like we fit into a group. When we come together with other people from different backgrounds, we sometimes forget that others may not understand some of the language that we use. Sometimes, some people may use words, phrases, or acronyms, that others may not understand on purpose. This can be a way to appear superior to others or to hide behind language as a way of self-protection. It is important to understand that we all have fears and concerns and that part of the purpose of this process is to overcome and move beyond fears and concerns together. When meeting together, use words, and phrases that all will understand. Avoid acronyms. (Common language can include words, phrases, examples, and stories, which are familiar.) Sometimes people don't feel comfortable sharing ideas in a group. Take time to solicit opinions and ideas one on one. Use surveys. Break into smaller groups to increase participation. Go around the group asking each person for an idea or their opinion. As people become more comfortable and feel safer with each other, participation will likely increase. Let everyone know that their opinion and contribution is valuable. Promote and encourage open dialogue. Remember that language is more than just the spoken or written word. It is also the way words are spoken, timing, body language, and the way silence is used. Use the media and other communication tools to communicate with stake holders outside of the collaboration. Some times members of the media are great additions to the collaboration/coalition. Send letters, e-mails, agendas, notes, flyers, et. Etc. to other members of the coalition on a regular basis. Make phone calls and when possible personal visits to other members of the coalition to build relationships, keep people involved, and communicate. Maintain strong and consistent communication with stake holders outside of the coalition/collaboration. "Real listening shows respect. It creates trust. As we listen, we not only gain understanding, we also create the environment to be understood. And when both people understand both perspectives, instead of being on opposite sides of the table looking across at each other, we find ourselves on the same side looking at solutions together". (Stephen R. Covey) Motivate Find the commonalities and common passions. Find out what motivates the members of the coalition/collaboration and the stake holders. Remember that what motivates you, may not motivate them. Appreciate and respect the differences. Understanding each other's Love Languages may be helpful. Take responsibility and give credit. Give credit for success to everyone else involved with that success. Take responsibility for mistakes, and when they occur, failures that you have any part in. Find and take opportunities to compliment and celebrate the success of others. As collaboration matures, both responsibility and success will be shared more evenly.

Stick with it...Persevere.. Work. "The only place you'll find success before work is in the dictionary". Mary B. Smith "That which we persist in doing becomes easy to do. Not that the nature of the thing has changed, but the power to do had increased". Heber J. Grant Building Collaboration requires substantial and sustained effort, often without recognition or equal distribution of responsibility. Keep your passion alive. Help others to find and harness their own passions. Complete and encourage the completion of assignments, provide accountability. Let Go, Forgive. Be willing to "let go," forgive, and look past the shortcomings in others. When you do this, they will be more likely to do it for you. Sometimes you have to hear before you will be heard. (This does not mean that you allow yourself or anyone else to be abused.) Everyone must be treated with dignity and respect. Allow for mistakes and even failure. Look for feedback from failure. Don't worry too much about perfection. perfection.

Participation is sometimes more important then

Let go of preconceptions. Continuity â&#x20AC;&#x201C; Consistency - Dependability Even though the organization or collaboration may evolve over time, it is important to demonstrate consistency and dependability in values and character. There should be a continuity in programs and message. Changes in direction should be openly discussed, understood, and consensual. Be honest and trustworthy. Your influence will be greatly dependent upon how dependable and trustworthy you and the organization are over time. Evaluate - Feedback Develop ongoing evaluations, feedback, and course correction, for continuous quality improvement. Collect and present data which is accurate, relevant, and easily understood. Find the feedback in failure when it occurs. Eliminate (or at least decrease) Financial Dependency Stable resources are essential for anything enduring. Consider creating an endowment fund. Sometimes extraordinary results can be accomplished through volunteer efforts and limited funds. Keep good, clear, financial records. Create sustainability.

Celebrate Success Look for success. Learn to recognize success. Celebrate small successes. Celebrate big successes. Celebrate publicly and privately. Acknowledge and reward success. Don't go overboard, find out what people really appreciate, make it genuine. Be flexible Remember that there are often exceptions. Show gratitude Show gratitude for gifts of every kind. Remember Robert's Rules of Order. There are times when a more formal process can be helpful and times when it can be an encumbrance and times in-between when some formality might help. When some or a lot of formality might be helpful you may want to consider incorporating all or some of Robert's Rules of Order. Underlying these rules, always remember three fundamental principals. 1. Everyone needs to be treated with dignity and respect. 2. Everyone needs to be heard. 3. All of the information needs to be clear for everyone.

4. Empowering "Empowerment means increased assertiveness and self-management skills. It is associated with positive human growth and change processes (McWhirter, 1991). As helping professionals, counsellors are committed to the growth, healing, and development of the clients they serve. Unfortunately, the intention to help does not always guarantee that counsellors are helpful. Some have argued that counselling and psychotherapy can actually serve to oppress rather than empower clients. For example, Steinbock (1988) argues that helping relationships is oppressive to the extent that helpees embrace a view of themselves as needy and dependent on the helper for solutions to their problems. Further, he contends that problem resolution focuses on the individual rather than the systems that create the problems, resulting in a very low likelihood of constructive, preventative change (Steinbock, 1988). Prilleltensky (1989) argues that interventions based on traditional approaches to psychotherapy serve to perpetuate the kinds of systemic problems and inequalities that lead clients to seek psychological services, preserving rather than transforming an unjust status quo. Caplan (1992) argues persuasively that feminist therapy, explicitly created to address women's oppression, is also vulnerable to reflecting and preserving the gender inequities of society. These critiques warrant serious consideration. In societies marred by inequality and injustice, racism and sexism, economic stratification and violence, all counselling relationships are vulnerable to subtly and even overtly reflecting these and other forms of oppression (Amold, 1997). By virtue of our training and education, counsellors are in a position of relative privilege that, unexamined, can contribute to maintaining the presence of oppressive social influences within the counselling relationship. For example, counsellors who fail to acknowledge the roles that racism and classism play in creating the environment of a low income client of color may blame the victim"; counsellors ascribing to the values of the dominant culture without examining the influence of their values in counselling may define client problems and engage in interventions that are inappropriate for their clients (e.g., Arnold, 1997; Katz, 1985; Sue & Sue, 1990). Empowerment Coaching Empowering = mobilizing strengths for change. The concept of empowerment was described as the process of helping clients discover personal strengths and capacities so that they are able to take control of their lives. The foundation for empowerment in counselling is the belief that clients are capable and have a right to manage their own lives. Thus, an empowerment attitude focuses on the capacities and strengths of clients. Empowerment values and methods challenge counsellors to forgo any need to control clients by taking on an “expert” role that puts clients in positions of dependency. Giving priority to empowerment constrains counsellors from hiding behind professional jargon. Moreover, counsellors who empower demystify the counselling process through open and non-jargonistic discussion with clients of their methods and assumptions. Self-determination, an important component of client empowerment, is promoted by helping clients recognize choices and by encouraging them to make independent decisions. Counsellors should not do for clients what clients can and should do for themselves. When empowerment is the priority, clients become the experts, and there is “collaboration and shared decision making within the professional relationship (Sheafor & Horejsi, 2008, p. 79). McWhirter (1991) asserts that the potentially empowering aspects of counselling include “an underlying belief in basic human potential and in clients’ ability to cope with their

life problems, a collaborative definition of the problem and therapeutic goals, skill enhancement and development, recognition and analysis of systemic power dynamics and an emphasis on group and community identity” (p. 226). Often clients come from disadvantaged and marginalized groups where they “have been ‘beaten down’ by oppression, poverty, abuse, and other harmful life experiences. They want better lives for themselves and their families, but they feel powerless to make the necessary changes. Some clients have a pervasive sense of failure and feel different from and rejected by other people” (Sheafor & Horejsi, 2008, p. 422). Sometimes powerlessness arises from negative self-evaluation and low self-esteem or from lack of confidence in one’s ability to alter one’s life, but sometimes the systems that are set up to assist clients are themselves oppressive and contribute to powerlessness. Describing the welfare system, Carniol (1995) observes, “As for the clients, evidence shows that they often find themselves blamed for the problems they face. They find they don’t get the help they need or they don’t get nearly enough to make a difference—or they get ‘cut off’ ” (p. 3). Racism and other prejudices may also deny clients access to jobs and resources such as adequate housing, a reality which reminds counsellors that they have some responsibility to advocate for progressive system and social policy changes. Ben Carniol, a Canadian social work educator, offers this challenge: “Social and economic and environmental justice demands a transformation of power, including a basic democratization of wealth-creating activities—so that the practice of democracy comes within the reach of everyone, rather than being manipulated by those who now dominate the heights of our political and social structures” (1995, p. 158). Client self-determination is enhanced when clients have more choices. This perspective draws counsellors into broader activities, including working to identify and remove gaps and barriers to service and encouraging more humane and accessible policies and services. In addition, as McWhirter (1991) argues, empowerment requires that clients “gain some degree of critical awareness of systemic power dynamics” (p. 225). One way counsellors can achieve this end is to provide clients with information on groups and organizations whose efforts are directed toward changing problematic elements of the system. The counselling process itself offers empowerment to clients. The beginning phase offers many clients a unique opportunity to explore their situation and their feelings. Active listening skills help clients bring long-forgotten or misunderstood feelings to the surface. Ventilation of feelings can energize clients, and it can lead to spontaneous insight into new ways of handling problems that seemed insurmountable. For some clients the work of counselling is finished at this phase. Empowerment and Change : The Purpose of Counselling Motivation and the stages of change Clients may have made conscious decisions to change and their motivation may be high, but they may also have mixed feelings about replacing established behaviour with new ways of behaving. Sometimes change involves a “selling” job, but the results are better when clients, not counsellors, do the selling. Clients need to convince themselves that the benefits of change outweigh the risks, and they need to develop positive attitudes and beliefs about their capacity for change. Counsellors with a strengths

perspective believe in the capacity of their clients to change, and this belief in them can be a powerful motivating factor. Motivation initiates and drives the change process. Johnson, McClelland, and Austin (2000) identify three factors important for motivation: “the push of discomfort, the pull of hope that something can be done to relieve the problem or accomplish a task, and internal pressures and drives toward reaching a goal” (p. 133). Thus, not only must clients want to change, but they must also believe in their capacity for change. Change is stressful; it requires risk and energy to give up established patterns of behaviour and thinking. Clients differ in the extent to which they have the skill or energy to take the associated risks. The following are the essential elements of high motivation: 1. willingness to engage in the work of counselling 2. commitment to devote energy and resources to the change process 3. capacity to sustain effort over time and in the face of obstacles 4. sufficient self-esteem to sustain the courage to change (Shebib, 1997, p. 252) Counsellors can assess clients based on these four elements, and then design appropriate strategies to meet each client’s particular need. These four elements suggest two major motivational tasks for counsellors: engaging clients to commit to change and supporting and energizing clients as they deal with the stresses of obstacles to change. The concept of secondary gain is a useful way of understanding why some people resist change despite the obvious pain or losses involved in maintaining their current situation. Secondary gain refers to the benefits that people derive from their problems. These benefits may include “increased personal attention, disability compensation, and decreased responsibility, as well as more subtle gratifications, such as satisfying the need for self-punishment or the vengeful punishment of others who are forced to take responsibility” (Nicoli, 1988, p. 13). Some clients can be exceptionally difficult and frustrating to work with. Sometimes it’s hard to do, but we should discipline ourselves to be nonjudgmental regarding motivation. Although it might be tempting to label some clients as unwilling, passive or lazy, we should remember that they may have given up for good reason. Perhaps society has not provided the resources or support they need for change. Clients may have given up to protect themselves from the further damage to their self-esteem that would come from repeated failure. In this way their behaviour may be seen as adaptive. It’s normal for counsellors to lose patience with them and give up, but it’s important to remember that that’s precisely what they did to themselves—give up. That’s one of the reasons they need counselling. Stages of Change The stages of change model (Prochaska & Norcross, 2001) is based on the notion that people go through different motivational stages, each of which requires different counsellor strategies for success. The stages of change model, also known as the transtheoretical model (Prochaska & Norcross, 2001), has received a great deal of attention in the literature since its inception in the 1980s. In this model five stages of change are recognized: precontemplation, contemplation, preparation, action, and maintenance. As well, change is viewed as progressive and developmental in this model, with success at any phase dependent on the success of previous phases. There is no orderly progression from one phase to another.

In reality clients may progress through stages and then drop back to an earlier stage (relapse) before starting again. An essential assumption is that counselling interventions need to be selected to meet the needs and motivation of the particular stage they are in. However, a client may be at different stages of change for different problems. For example, a client may be precontemplative (not interested in changing) regarding his drinking, but ready to take action with respect to his failing marriage. Discussing strategies for cutting down his drinking with this client is likely to meet with failure, but he is likely to respond positively to exploring strategies to improve his marriage. Precontemplative Stage: “I Don’t Have a Problem.” Clients at this stage have no intention of changing. These clients do not perceive themselves as having a problem, despite the fact that their behaviour is problematic for themselves or others in their lives. These clients are not thinking about change, and they may rationalize their problems, minimize the consequences of their actions, or blame others. For these clients empathic and sensitive listening that encourages them to examine their situation and its consequences can be very helpful. Counsellors can provide information, offer feedback, or encourage reflection with questions such as “Is what you’re doing now working to meet your needs?” Counsellors should proceed slowly when confronting denial, and they should remember that denial may be a defence mechanism that enables people to cope, perhaps by shielding them from feelings of hopelessness (George, in McNeece & DiNitto, 1998). DiClemente and Velasquez (2002) observe that “Sometimes the reluctant client will progress rapidly once he or she verbalizes the reluctance, feels listened to, and begins to feel the tension between the reluctance to change and the possibility of a different future” (p. 205). DiClemente and Valasquez offer a counterargument — that the natural tendency is to do more when the risk is higher: Clinicians often believe that more education, more intense treatment, or more confrontation will necessarily produce more change. Nowhere is this less true than with precontemplators. More intensity will often produce fewer results with this group. Contemplative Stage: “Maybe I Should Do Something About It.” At the contemplative stage clients know they have a problem and are thinking about change, but they have not developed a plan or made a commitment to take action. Contemplative clients may be ambivalent and may vacillate between wanting to alter their lives and resisting any shifts in their behaviour or lifestyle. At this stage clients may be open to new information as they self-assess their problems and the advantages and disadvantages of change. Example: Agnes has been in an abusive relationship for years. She wishes that she could leave and start over. In fact, she has left her husband twice in the past, but each time she has returned within a few weeks. Contemplative-stage clients like Agnes are “burnt out” from previous unsuccessful attempts at change. They are often in a state of crisis with considerable associated stress. Although they desire change, they doubt it will happen and they believe that if change is to occur, it will be beyond their control. They also lack self-esteem and believe that they do not have the skill, capacity, or energy to change. Example: Peter (55) has been unemployed for almost two years, but he has not looked for a job in months. He says, “There’s no work out there. Besides, who is going to hire a man of my age?” Seligman’s (1975) concept of learned helplessness is a useful perspective for understanding these clients. People with learned helplessness come to believe that their actions do not matter; as a result, they are unlikely to extend any effort to change since they believe that they have no control over their lives and that what happens to them is a result of chance. They believe in a “luck ethic” rather than a “work ethic.” Their beliefs are reflected in statements such as the following:

■ “You have to be at the right place at the right time to succeed.” ■ “If I’m successful, it’s because the task was easy.” ■ “It doesn’t matter if I work hard.” ■ “There’s nothing I can do about it.” The key to working with people with learned helplessness — indeed, most clients at the contemplation stage—is to assist them “in thinking through the risks of the behaviour and potential benefits of change and to instill hope that change is possible” (DiClemente & Velasquez, 2002, p. 209). Many people with low self-esteem and learned helplessness are in fact quite capable; it is the way they think and feel about themselves that is problematic. Consequently, it is important that counsellors look for ways to counter the client’s self-depreciating remarks (e.g., encourage clients to see their past failures as deficits “in the plan,” not deficits in them). As well, counsellors can encourage clients to see elements of success in previous efforts (e.g., partial goal achievement, lessening of problem severity, short-term achievement). Cognitive behavioural techniques, discussed later in this chapter, have also proven to be effective. Confrontation should be used cautiously. It may be useful as a way to help clients understand incongruities between what they believe and the way they act; selfdefeating ways of thinking and behaving; behaviour that is harmful to self or others; blind spots; blaming behaviours; and communication problems. As well, confrontation can also target unrecognized or discounted strengths. As a rule, confrontation is most effective when it is invited in the context of a collaborative relationship. Preparation Stage: “I’m Going to Do It Next Week.” When clients reach this third phase, they have made a decision to change and motivating them is no longer the principal task. However, counsellors need to sustain the energy for change through support, encouragement, and empathic caring. The principal task for the counsellor is to assist the client to develop concrete goals and action plan strategies. Without concrete, systematic plans, change efforts can be quickly frustrated and abandoned like soon-forgotten New Year’s resolutions. The essence of good planning consists of setting concrete goals, identifying and evaluating alternative ways of reaching goals, selecting an action plan, and anticipating potential obstacles. For clients with learned helplessness, setting small, achievable goals is crucial for establishing and maintaining a climate of success and hope. Example: Iris, a young single parent, is excited about the possibility of returning to school. She sees a school counsellor for assistance with enrollment in the high school’s special program for teen moms, but she has not yet considered issues like daycare. Using a strengths approach, counsellors can assist preparation-stage clients to draw from their past experiences (proven success strategies and lessons learned). As well, clients can learn about strategies that have worked for others. Finally, it is very important to coach these clients to anticipate potential obstacles and to plan strategies for addressing them, including the emotional stress of the change process. Action Stage: “I’m Changing.” At this stage clients are actively involved in the change process. They are working on the goals and implementing the plans developed in the preparation stage. DiClemente and Velasquez (2002) offer this perspective on counsellor strategies for this stage: Clients in action may still have some conflicting feelings about the change. They may miss their old lifestyle in some ways and be struggling to fit into this new behaviour. Careful listening and affirming clients that they are doing the right thing are important in this stage. It is also important to check with the client to see if he or she has discovered parts of the change plan that need revision.

When clients encounter anticipated obstacles, counsellors can remind them of previously developed contingency plans. If there are unanticipated obstacles, counsellors can assist with interventions to support clients as they deal with these potential setbacks. Maintenance Stage: “I’ve Done It. I Need to Keep Doing It” In the final stage the challenge for the client is to maintain the changes that have been made and to deal with relapses, which may occur for a number of reasons (e.g., unexpected temptation, personal stress, letting down one’s guard). Moreover, sometimes people are “actively sabotaged by others in their lives who were threatened by the changes” (Kottler, 1993, p. 81). Achievement of goals does not guarantee that there will be no relapse. “This is particularly true if the environment is filled with cues that can trigger the problem behaviour. We all know [of situations] where an individual who has stopped drinking relapses just when everyone thinks the problem is finally resolved” (DiClemente & Velasquez, 2002, p. 213). Counsellors can help clients accept that relapses, while undesired, are part of the change process and do not signify complete regression or failure. In fact, counsellors can help clients to reframe the relapse as an opportunity for better success next time. “Frequently, people who do relapse have a better chance of success during the next cycle. They have often learned new ways to deal with old behaviours, and they now have a history of partial successes to build on” (DiClemente & Velasquez, 2002, p. 213).

Motivational Interviewing (MI) Motivational interviewing (Miller & Rollnick, 2002) is a tool for helping clients to deal with the ambivalence that keeps many of them from making desired and successful changes. Cognitive behavioural counselling is a collaborative (counsellor and client) approach to helping clients make changes in the three major psychological domains: thinking, behaviour, and emotions. Motivational Interviewing (Miller & Rollnick, 2002) is an empirically validated strategy for helping people overcome ambivalence to change. Motivational interviewing requires a collaborative, nonconfrontational relationship. It assumes that motivation and capacity for change are within the client. Consequently, it honours the client’s right to self-determination regarding whether change is to take place as well as the ultimate goals of any change process. “MI allows clients, both mandated and voluntary, to discover their own reasons for making change. MI allows the impetus to change to emerge from within a client, thus honoring the client’s unique circumstances and worldview” (Capuzzi & Stauffer, 2008,). Stage/Goal Strategy Choices Precontemplative Stage (Client without desire to change) • Listen empathically. • Provide information and feedback (if contracted) or intention to change • Encourage clients to seek information and feedback from others. Counselling Goal Increase awareness • Help clients become aware of attractive alternatives. • Use thought-provoking questions of need for change. • Avoid directive and confrontational techniques. • Use films, brochures, books, and self-assessment questionnaires as tools to increase client insight. • With involuntary clients, explore feelings concerns openly, self-disclose your own feelings about being forced, give clients choices, involve them in decision making, and encourage client-initiated goals. Contemplative Stage (Clients who are arguing in favour of change, which tends to thinking about change) • Discuss risks and benefits of change, but avoid to make clients argue against change. Counselling Goal Resolve ambivalence depreciating remarks (e.g., reframe past failures to engage in the as learning experience). • Help clients understand and manage self-change process. • Identify elements of success in previous change efforts. • Explore deficits in previous change plans (emphasize failure of plans, not failure of clients). • Use support groups. • Convey hope.

Preparation Stage • (Clients who are committed to change) • Set goals. • Plan systematic action. • Assemble/mobilize resources to support change. Counselling Goals Develop concrete strategies for action. • Make contingency plans (anticipate obstacles). Action Stage • Reward (praise, support, acknowledge) change efforts. Counselling Goals Implement change and sustain momentum. • Assist clients to manage anticipated and unanticipated obstacles. Maintenance Stage • Assist client to deal with periodic obstacles and/or relapses Counselling Goals. Sustain change. Four broad principles define the application of motivational interviewing: ■ Express empathy. ■ Develop discrepancy. ■ Roll with resistance. ■ Support self-efficacy. (Miller and Rollnick, 2002, p. 36) Express Empathy Empathy and other active listening skills create an interview climate where clients are free to explore their values, perceptions, goals, and the implications of their current situation without judgment. Motivational interviewing accepts ambivalence and reluctance to change as predictable and normal. Active listening increases intrinsic motivation for natural change. Conversely, “confrontational counselling has been associated with a high dropout rate and relatively poor outcomes” (Miller & Rollnick, 2002, p. 7). Develop Discrepancy The overall goal of motivational interviewing is to help people get unstuck. The method is to initiate “change talk” by taking advantage of naturally occurring opportunities in the interview to embellish client statements that suggest differences between the way their life is and the way they would like their lives to be. Simply focusing on a client’s goals and aspirations can often help people appreciate how their current lifestyle is inhibiting their ideals. Motivational interviewing uses a number of strategies to evoke change talk, including the following:

■ asking evocative questions about disadvantages of the status quo, advantages of change, optimism about change, and intention to change ■ using scaling questions—for example, “On a scale of 1 to 10, where are you in terms of satisfaction with your life?” ■ exploring the positive and negative consequences of the status quo ■ using elaboration skills (e.g., asking for clarification, examples, description, and further information) to elicit further change talk ■ querying extremes, such as, “Suppose you don’t make any changes. What do you think might be the consequences of this in the worst-case scenario?” ■ looking back to help clients remember how things were before and compare with the current situation ■ looking forward by asking clients to describe their hopes and goals for the future ■ exploring goals and values to target discrepancies between important goals and current behaviour (Miller & Rollnick, 2002, pp. 78–83) ■ helping clients understand their ambivalence to change using the metaphor of a seesaw—when the costs of continuing present behaviour and the benefits of change outweigh the costs of change and benefits of continuing present behaviour, change will occur. Roll with Resistance Rolling with resistance requires that counsellors not engage in power struggles with clients, with counsellors arguing for change and clients resisting it. Client resistance is seen as a message that the counsellor needs to do something different. Power struggles are likely when counsellors: ■ offer unsolicited advice from the expert role ■ tell clients how they should feel ■ ask excessive questions ■ order, direct, warn, or threaten ■ preach, moralize, or shame ■ argue for change ■ blame, judge, or criticize Success Tip “As long as your clients are going to resist you, you might as well encourage it” (Milton Erickson). Radical acceptance is a strategy that involves encouraging expression of statements that you tend to disagree with or philosophically oppose, for example: Client: I don’t see the point. The only reason I came today is the fact that if I didn’t show up, I’d be cut off welfare. Counsellor: I’m very glad you brought this up. Many people share views such as yours but won’t speak up, so I appreciate your willingness to be honest. Amplified reflection is a technique that exaggerates what a client has said with the hope that the client will present the other side of ambivalence. However, as Miller and Rollnick (2002) stress, “This must be done empathically, because any sarcastic tone or too extreme an overstatement may itself elicit a hostile or otherwise resistant reaction” (p. 101).

Client: I don’t see what the problem is. What’s the harm in having a few drinks after a hard day’s work? Counsellor: So, you’re saying that drinking hasn’t caused any problems or given you any reason for concern. Client: Well, I wouldn’t go that far. Support Self-Efficacy To begin and sustain change, clients must believe in their capacity for change. For their part counsellors can have an enormous impact on outcome if they believe in their client’s ability to change and when they take steps to enhance client confidence. One choice is to help clients identify past success. Another is encouraging clients to make an inventory of their strengths and resources. Working on small achievable goals often starts a change process that gathers momentum. Counsellors can also look for opportunities to affirm their clients’ efforts, strengths, and successes. The goals of empowerment coaching include providing sufficient information to clients for them to make their own informed decisions, encouraging them to re-take control of their lives and decision-making power, providing assistance in obtaining the knowledge and learning the skills that rebuild selfconfidence, and creating responsible social change.

ASKING PERMISSION Rationale: Communicates respect for clients. Also, clients are more likely to discuss changing when asked, than when being lectured or being told to change. Examples of Asking Permission •

“Do you mind if we talk about [insert behavior]?”

•

“Can we talk a bit about your [insert behavior]?”

•

“I noticed on your medical history that you have hypertension, do mind if we talk about how different lifestyles affect hypertension?” (Specific lifestyle concerns such as diet, exercise, and alcohol use can be substituted for the word “lifestyles” in this sentence.)

ELICITING/EVOKING CHANGE TALK Rationale: Change talk tends to be associated with successful outcomes. This strategy elicits reasons for changing from clients by having them give voice to the need or reasons for changing. Rather than the therapist lecturing or telling clients the importance of and reasons why they should change, change talk consists of responses evoked from clients. Clients’ responses usually contain reasons for change that are personally important for them. Change talk, like several Motivational Interviewing (MI) strategies, can be used to address discrepancies between clients’ words and actions (e.g., saying that they want to become abstinent, but continuing to use) in a manner that is nonconfrontational. One way of doing this is shown later in this table under the Columbo approach. Importantly, change talk tends to be associated with successful outcomes. Questions to Elicit/Evoke Change Talk •

“What would you like to see different about your current situation?”

•

“What makes you think you need to change?”

•

“What will happen if you don’t change?”

•

“What will be different if you complete your probation/referral to this program?”

•

“What would be the good things about changing your [insert risky/problem behavior]?”

•

“What would your life be like 3 years from now if you changed your [insert risky/problem behavior]?”

•

“Why do you think others are concerned about your [insert risky/problem behavior]?”

Elicit/Evoke Change Talk For Clients Having Difficulty Changing: Focus is on being supportive as the client wants to change but is struggling. •

“How can I help you get past some of the difficulties you are experiencing?”

•

“If you were to decide to change, what would you have to do to make this happen?”

Elicit/Evoke Change Talk by Provoking Extremes: For use when there is little expressed desire for change. Have the client describe a possible extreme consequence. •

“Suppose you don’t change, what is the WORST thing that might happen?”

•

“What is the BEST thing you could imagine that could result from changing?”

Elicit/Evoke Change Talk by Looking Forward: These questions are also examples of how to deploy discrepancies, but by comparing the current situation with what it would be like to not have the problem in the future. •

“If you make changes, how would your life be different from what it is today?”

•

“How would you like things to turn out for you in 2 years?”

EXPLORING IMPORTANCE AND CONFIDENCE Rationale: As motivational tools, goal importance and confidence ratings have dual utility: (a) they provide therapists with information about how clients view the importance of changing and the extent to which they feel change is possible, and (b) as with other rating scales (e.g., Readiness to Change Ruler), they can be used to get clients to give voice to what they would need to do to change. Examples of How to Explore Importance and Confidence Ratings •

“Why did you select a score of [insert #] on the importance/confidence scale rather than[lower #]?”

•

“What would need to happen for your importance/confidence score to move up from a [insert #] to a [insert a higher #]?”

•

“What would it take to move from a [insert #] to a [higher #]?”

•

“How would your life be different if you moved from a [insert #] to a [higher #]?”

•

“What do you think you might do to increase the importance/confidence about changing your [insert risky/problem behavior]?”

OPENED-ENDED QUESTIONS Rationale: When therapists use open-ended questions it allows for a richer, deeper conversation that flows and builds empathy with clients. In contrast, too many back-to-back closed- or dead ended questions can feel like an interrogation (e. g., “How often do you use cocaine?” “Howmany years have you had an alcohol problem?” “How many times have you been arrested?”). Open-ended questions encourage clients to do most of the talking, while the therapist listens and responds with a reflection or summary statement. The goal is to promote further dialogue that can be reflected back to the client by the therapist. Open-ended questions allow clients to tell their stories.

Examples of Open-Ended Questions •

“Tell me what you like about your [insert risky/problem behavior].”

•

“What’s happened since we last met?”

•

“What makes you think it might be time for a change?”

•

“What brought you here today?”

•

“What happens when you behave that way?”

•

“How were you able to not use [insert substance] for [insert time frame]?”

•

“Tell me more about when this first began.”

•

“What’s different for you this time?”

•

“What was that like for you?”

•

“What’s different about quitting this time?”

REFLECTIVE LISTENING Rationale: Reflective listening is the primary way of responding to clients and of building empathy. Reflective listening involves listening carefully to clients and then making a reasonable guess about what they are saying; in other words, it is like forming a hypothesis. The therapist then paraphrases the clients’ comments back to them (e.g., “It sounds like you are not ready to quit smoking cigarettes.”). Another goal in using reflective listening is to get clients to state the arguments for change (i.e., have them give voice to the change process), rather than the therapist trying to persuade or lecture them that they need to change (e.g., “So, you are saying that you want to leave your husband, and on the other hand, you worry about hurting his feelings by ending the relationship. That must be difficult for you. How do you imagine the two of you would feel in 5 years if things remain the same?”). Reflections also validate what clients are feeling and doing so communicates that the therapist understands what the client has said (i.e., “It sounds like you are feeling upset at not getting the job.”). When therapists’ reflections are correct, clients usually respond affirmatively. If the guess is wrong (e.g., “It sounds like you don’t want to quit smoking at this time.”), clients usually quickly disconfirm the hypothesis (e. g. “No, I do want to quit, but I am very dependent and am concerned about major withdrawals and weight gain.”). Examples of Reflective Listening (generic) •

“It sounds like….”

•

“What I hear you saying…”

•

“So on the one hand it sounds like …. And, yet on the other hand….”

•

“It seems as if….”

•

“I get the sense that….”

•

“It feels as though….”

Examples of Reflective Listening (specific) •

“It sounds like you recently became concerned about your [insert risky/problem behavior].”

•

“It sounds like your [insert risky/problem behavior] has been one way for you to [insert whatever advantage they receive].”

•

“I get the sense that you are wanting to change, and you have concerns about [insert topic or behavior].”

•

“What I hear you saying is that your [insert risky/problem behavior] is really not much of a problem right now. What you do think it might take for you to change in the future?”

•

“I get the feeling there is a lot of pressure on you to change, and you are not sure you can do it because of difficulties you had when you tried in the past.”

NORMALIZING Rationale: Normalizing is intended to communicate to clients that having difficulties while changing is not uncommon, that they are not alone in their experience, or in their ambivalence about changing. Normalizing is not intended to make clients feel comfortable with not changing; rather it is to help them understand that many people experience difficulty changing. Examples of Normalizing •

“A lot of people are concerned about changing their [insert risky/problem behavior].”

•

“Most people report both good and less good things about their [insert risky/problem behavior].”

•

“Many people report feeling like you do. They want to change their [insert risky/problem behavior], but find it difficult.”

•

“That is not unusual, many people report having made several previous quit attempts.”

•

“A lot of people are concerned about gaining weight when quitting.”

DECISIONAL BALANCING Rationale: Decisional balancing strategies can be used anytime throughout treatment. A good strategy is to give clients a written Decisional Balance (DB) exercise at the assessment session and ask them to bring the completed exercise to their first session. A sample of a completed exercise is shown in Appendix 4.10b. The DB exercise asks clients to evaluate their current behaviors by simultaneously looking at the good and less good things about their actions. The goal for clients is two fold: To realize that (a) they get some benefits from their risky/problem behavior, and (b) there will be some costs if they decide to change their behavior. Talking with clients about the good and less good things they have written down on their DB can be used to help them understand their ambivalence about changing and to move them further toward wanting to change. Lastly, therapists can do a DB exercise with clients by simply asking them in an open ended fashion about the good and less good things regarding their risky/problem behavior and what it would take to change their behavior.

Examples of How to Use a Decisional Balance Exercise •

“What are some of the good things about your [insert risky/problem behavior]? [Client answers] Okay, on the flipside, what are some of the less good things about your [insert risky/problem behavior].”

After the clients discuss the good and less good things about their behavior, the therapist can use a reflective, summary statement with the intent of having clients address their ambivalence about changing. COLUMBO APPROACH Rationale: The Columbo approach can also be characterized as deploying discrepancies. The goal is to have a client help the therapist make sense of the client’s discrepant information The approach takes its name from the behavior demonstrated by Peter Falk who starred in the 1970s television series Columbo. The Columboesque approach is intended as a curious inquiry about discrepant behaviors without being judgmental or blaming and allows for the juxtaposing in a non-confrontational manner of information that is contradictory. In other words, it allows the therapist to address discrepancies between what clients say and their behavior without evoking defensiveness or resistance. When deploying discrepancies, when possible, as shown in the example below try to end the reflection on the side of change as clients are more likely to elaborate on the last part of the statement. •

“It sounds like when you started using cocaine there were many positives. Now, however, it sounds like the costs, and your increased use coupled with your girlfriend’s complaints,have you thinking about quitting. What will your life be like if you do stop?”

Examples of How to Use the Columbo Approach: While the following responses might sound a bit unsympathetic, the idea is to get clients who present with discrepancies to recognize them rather than being told by their therapists that what they are saying does not make sense. •

“On the one hand you’re coughing and are out breath, and on the other hand you are saying cigarettes are not causing you any problems. What do you think is causing your breathing difficulties?”

•

“So, help me to understand, on the one hand you say you want to live to see your 12-year old daughter grow up and go to college, and yet you won’t take the medication your doctor prescribed for your diabetes. How will that help you live to see your daughter grow up?”

•

“Help me understand, on the one hand I hear you saying you are worried about keeping the custody of your children. Yet, on the other hand you are telling me that you are using crack occasionally with your boyfriend. Since you also told me you are being drug screened on a random basis, I am wondering how using cocaine might affect your keeping custody of your children.”

STATEMENTS SUPPORTING SELF-EFFICACY Rationale: Eliciting statements that support self-efficacy (self-confidence) is done by having clients give voice to changes they have made. Because many clients have little self-confidence in their ability to change their risky/problem behaviors, the objective is to increase their selfconfidence that they can change. Self-

confidence statements can be sought from clients using scaling techniques (e. g, Readiness to Change Ruler, Importance and Confidence related to goal choice). For example, when using a Readiness Ruler, if clients’ readiness to change goes from a lower number (past) to a higher number (now), therapists may follow-up by asking how they were able to do that and how they feel about their change. Examples of Eliciting Statements Supporting Self-Efficacy •

“It seems you’ve been working hard to quit smoking. That is different than before. How have you been able to do that?”

•

“Last week you were not sure you could go one day without using cocaine, how were you able to avoid using the entire past week?”

•

“So even though you have not been abstinent every day this past week, you have managed to cutyour drinking down significantly. How were you able to do that?”

•

“Based on your self-monitoring logs, you have not been using cannabis daily. In fact, you onlyused one day last week. How were you able to do that?” Follow-up by asking, “How do you feelabout the change?”

After asking about changes clients have made, it is important to follow-up with a question about how clients feel about the changes they made. •

“How do you feel the changes you made?”

•

“How were you able to go from a [# 6 months ago] to a [# now]?” [Client answers] “How do you feel about those changes?”

READINESS TO CHANGE RULER Rationale: Assessing readiness to change is a critical aspect of MI. Motivation, which is considered a state not a trait, is not static and thus can change rapidly from day to day. Clients enter treatment at different levels of motivation or readiness to change (e.g., not all are ready to change; many are ambivalent about changing). In this regard, if therapists know where clients are in terms of their readiness to change, they will be better prepared to recognize and deal with a client’s motivation to change. The concept of readiness to change is an outgrowth of the Stages of Change Model that conceptualizes individuals as being at different stages of change when entering treatment. While readiness to change can be evaluated using the Stages of Change Model, a simpler and quicker way is to use a Readiness to Change Ruler (Appendix 4.7). This scaling strategy conceptualizes readiness or motivation to change along a continuum and asks clients to give voice to how ready they are to change using a ruler with a 10point scale where 1 = definitely not ready to change and 10 = definitely ready to change. A Readiness Ruler allows therapists to immediately know their client’s level of motivation for change. Depending on where the client is, the subsequent conversation may take different directions. The Readiness to Change Ruler can also be used to have clients give voice to how they changed, what they need to do to change further, and how they feel about changing. Examples of How to Use a Readiness to Change Ruler • Therapist (T): “On the following scale from 1 to 10, where 1 is definitely not ready tochange and 10 is definitely ready to change, what number best reflects how ready you are at the present time to change your [insert risky/problem behavior]?” Client (C): “Seven.” T: “And where were you 6 months ago?”

C: “Two.” T: “So it sounds like you went from not being ready to change your [insert risky/problem behavior] to thinking about changing. How did you go from a ‘2’ 6 months ago to a ‘7’ now?” •

“How do you feel about making those changes?”

•

“What would it take to move a bit higher on the scale?”

Clients with lower readiness to change (e.g., answers decreased from a “5” 6 months ago to a “2” now) •

“So, it sounds like you went from being ambivalent about changing your [insert risky/problem behavior] to no longer thinking you need to change your [insert risky/problem behavior]. How did you go from a ‘5’ to a ‘2’?”

•

“What one thing do you think would have to happen to get you to back to where you were 6 months ago?”

AFFIRMATIONS Rationale: Affirmations are statements made by therapists in response to what clients have said, and are used to recognize clients’ strengths, successes, and efforts to change. Affirmative responses or supportive statements by therapists verify and acknowledge clients’ behavior changes and attempts to change. When providing an affirmation, therapists should avoid statements that sound overly ingratiating (e.g., “Wow, that’s incredible!” or “That’s great, I knew you could do it!”). While affirmations help to increase clients’ confidence in their ability to change, they also need to sound genuine. Example of Affirmative Statements •

“Your commitment really shows by [insert a reflection about what the client is doing].”

•

“You showed a lot of [insert what best describes the client’s behavior—strength, courage, determination] by doing that.”

•

“It’s clear that you’re really trying to change your [insert risky/problem behavior].”

•

“By the way you handled that situation, you showed a lot of [insert what best describes the client’s’ behavior—strength, courage, determination].”

•

“With all the obstacles you have right now, it’s [insert what best describes the client’s behavior— impressive, amazing] that you’ve been able to refrain from engaging in [insert risky/problem behavior].”

•

“In spite of what happened last week, your coming back today reflects that you’re concerned about changing your [insert risky/problem behavior].”

ADVICE/FEEDBACK Rationale: A frequently used MI strategy is providing advice or feedback to clients. This is a valuable technique because clients often have either little information or have misinformation about their behaviors. Traditionally, therapists and other health care practitioners have encouraged clients to quit or change behaviors using simple advice [e.g., “If you continue using you are going to have (insert health consequence).”]. Research has shown that by and large the effectiveness of simple advice is very limited (e.g., 5% to 10% of smokers are likely to quit when simply told to quit because smoking is bad for their

health). The reason simple advice does not work well is because most people do not like being “told what to do.” Rather, most individuals prefer being given choices in making decisions, particularly changing behaviors. What we have learned from MI is that how information is presented can affect how it is received. When relevant, new information should be presented in a neutral, nonjudgmental, and sensitive manner that empowers clients to make more informed decisions about quitting or changing a risky/problem behavior. One way to do this is to provide feedback that allows clients to compare their behavior to that of others so they know how their behavior relates to national norms (e.g., percentage of men and women drinking at different levels; percentage of population using cannabis in the last year; see Appendices 4.2c and 4.2d for examples of such feedback). Presenting personalized feedback in a motivational manner allows clients to evaluate the feedback for personal relevance (“I guess I drink as much as my friends, but maybe we are all drinking more than we should.”). When therapists ask clients what they know about how their risky/problem behavior affects other aspects of their life (e.g., health—hypertension) clients typically say, “Well not much” or they might give one or two brief facts. This can be followed-up by asking if they are interesting in learning more about the topic and then being prepared to provide them with relevant advice feedback material that the therapist has prepared or has available. Lastly, whenever possible, focus on the positives of changing. A good example of providing positive information about changing is evident with smoking. Within 20 minutes of stopping smoking an ex-smoker’s body begins a series of changes ranging from an immediate decrease in blood pressure to 15 years after quitting the risk of coronary heart disease and death returns to nearly that of those who have never smoked [http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=33568]. What is interesting with this example is that many smokers are not aware of the multiple benefits that occur soon after quitting. In this regard, therapists can ask, “What do you know about the benefits of quitting smoking?” and followup with asking permission to talk about the client’s smoking (“Do you mind if we spend a few minutes talking about your smoking?”). Remember that some clients will not want information. In these cases, if the therapist uses scare tactics, lectures, moralizes, or warns of disastrous consequences, most clients are not likely to listen or will pretend to agree in order to not be further attacked. Examples of How to Provide Advice/Feedback (often this can start by asking permission to talk about the client’s behavior) •

“Do you mind if we spending a few minutes talking about….? [Followed by] “What do you know about….?” [Followed still by] “Are you interested in learning more about…..?”

[After this clients can be provided with relevant materials relating to changing their risky/problem behavior or what affects it has on other aspects of their life.] •

“What do you know about how your drinking affects your [insert health problem]?”

•

“What do you know about the laws and what will happen if you get a second drunk driving arrest?”

•

“Okay, you said that the legal limit for drunk driving is 0.08%. What do you know about how many drinks it takes to get to this level?”

•

“So you said you are concerned about gaining weight if you stop smoking. How much do you think the average person gains in the first year after quitting?”

•

“I’ve taken the information about your drinking that you provided at the assessment ,calculated what you report drinking per week on average, and it is presented on this form along with graphs showing levels of drinking in the general population. Where do you fit in?”

•

“On one of the questionnaires you filled out, the Drug Abuse Screening Test, you scored a 7. This form shows how scores on that measure are related to drug problem severity. Where do you fit in?”

SUMMARIES Rationale: Summaries are used judiciously to relate or link what clients have already expressed, especially in terms of reflecting ambivalence, and to move them on to another topic or have them expand the current discussion further. Summaries require that therapists listen very carefully to what clients have said throughout the session. Summaries are also a good way to either end a session (i.e., offer a summary of the entire session), or to transition a talkative client to the next topic. Examples of Summaries: •

“It sounds like you are concerned about your cocaine use because it is costing you a lot of money and there is a chance you could end up in jail. You also said quitting will probably mean not associating with your friends any more. That doesn’t sound like an easy choice.”

•

“Over the past three months you have been talking about stopping using crack, and it seems that just recently you have started to recognize that the less good things are outweighing the good things. That, coupled with your girlfriend leaving you because you continued to use crack makes it easy to understand why you are now committed to not using crack anymore.”

THERAPEUTIC PARADOX Rationale: Paradoxical statements are used with clients in an effort to get them to argue for the importance of changing. Such statements are useful for clients who have been coming to treatment for some time but have made little progress. Paradoxical statements are intended to be perceived by clients as unexpected contradictions. It is hoped that after clients hear such statements clients would seek to correct by arguing for change (e.g., “Bill, I know you have been coming to treatment for two months, but you are still drinking heavily, maybe now is not the right time to change?”). It is hoped that the client would counter with an argument indicating that he/she wants to change (e.g., “No, I know I need to change, it’s just tough putting it into practice.”). Once it is established that the client does want to change, subsequent conversations can involve identifying the reasons why progress has been slow up to now. When a therapist makes a paradoxical statement, if the client does not respond immediately by arguing for change, the therapist can then ask the client to think about what was said between now and the next session. Sometimes just getting clients to think about their behavior in this challenging manner acts as an eye-opener, getting clients to recognize they have not made changes. Therapeutic paradoxes involve some risk (i.e., client could agree with the paradoxical statement rather than arguing for the importance of change), so they are reserved for times later in treatment when clients are not making changes and may or may not be aware of that fact. Such clients often attend sessions regularly but make no significant progress toward changing the risky/problem behavior for which they sought treatment. Another reason for caution is such statements can have a negative effect on clients. Lastly, the therapist must be sure to sound genuine and not sarcastic.

When using the therapeutic paradox, the therapist should be prepared that clients may decide that they do not want to change at this time. In such cases the reasons can be discussed, and the therapist can suggest that perhaps it might be a good idea to take a “vacation” from treatment. In such instances, therapists can tell clients that they will call them in a month or so to see where they are in terms of readiness to change. Another way to think about what a therapeutic paradox is doing is reflecting the person’s behavior in an amplified manner. Examples of How to Use a Therapeutic Paradox •

“Maybe now is not the right time for you to make changes.”

•

“You have been continuing to engage in [insert risky/problem behavior] and yet you say that you want to [insert the behavior you want change—e.g., get your children back; get your driver’s license returned; not have your spouse leave]. Maybe this is not a good time to try and make those changes.”

•

“So it sounds like you have a lot going on with trying to balance a career and family, and these priorities are completing with your treatment at this time.”

There are five questions that are central to empowerment coaching:

1. What would a good situation look like? 2. What would need to change? 3. What are the steps necessary to make the change? 4. What help would you need to take these steps? 5. Who could provide you with support as you take these steps? These five questions can be used as the centerpiece of a successful reference interview as well as a successful coaching intervention. The first question, asking for the definition of a good or right situation, may address what the patron expects to get out of the reference session. The obvious assumption is that the good or right situation would be having complete and accurate information to accomplish the intended task. The client survivor, however, might be looking for something in addition to this, such as a sense of empowerment that comes from just having information about the issue and knowing that she is not alone. The second question, concerning desired changes, is also applicable to both the coaching situation and the reference interview. When a patron seeks reference service, it can be assumed that he or she is looking to change something. Changes may include making a research paper better, getting a better job, etc. The client, however, may be looking for an entirely different kind of change, such as getting away from an abusive situation, finding coaching to regain her mental health or finding support from peers. For this reason, the reference interview must be kept as confidential as possible. She might be extremely sensitive to even being seen in a library asking about options. A librarian should make every effort to get the client into a private area for the reference interview. The third question concerns the steps that are needed to reach the intended “good” situation. This is where the librarian’s research skills are essential. Someone who has been a victim of violence may have no idea what to do and may simply want to know, “What do I do now?” It is recommended that every library investigate services for survivors in the local area and keep a list of services and contact information near the desk, including national or state hotline numbers. The survivor may see the librarian as a kind, helpful professional and try to use them as a coach. At this point, it is important to gently remind the patron that the librarian is not a coach and cannot give advice on how to proceed but will be glad to help her look for information on all of the options. The fourth question involves the kind of help that is needed in order to make the change. A librarian should be able to locate resources that discuss all of the options available. It is very important not to give the patron advice such as “you should go to the police,” but to make sure she has information about all of the options so that she can leave with the necessary tools to make an informed choice. It is a good idea to have some free materials such as pamphlets (a local crisis center may be able to provide these) that the patron can take with her. Free materials that do not need to be returned are an excellent resource for survivors who may have taken a great personal risk to come to the library. The fifth question involves help and support. A survivor of a sexual assault may be asking for help without actually voicing a question. It is a good idea for a librarian to give any patron who asks about sexual assault contact information for a helping resource, such as the number of a rape crisis hotline. Not only can these organizations assist survivors, they can also provide excellent information to researchers.

In empowerment coaching, the coach is advised not to use questions that ask or imply “why.” Dewdney and Michell advised against excessive use of “why” questions in the reference interview. They explained that the librarian and patron may view a “why” question differently. The librarian may be looking for a motivation for the patron’s query in order to give a more complete or relevant answer, but the patron may view the question as suspicious, intrusive or confusing. Dewdney and Michell further suggested that these feelings on the part of the patron may lead to hostility and a breakdown of the reference transaction. There is, however, an additional reason to avoid the use of “why” questions with (sexual) assault survivors. When asking “why,” one is looking for a reason or motivation. If a reference librarian were to say “why are you looking for information on sexual assault coaching?” a survivor would be faced with two choices: reveal sensitive information or lie. No one should be forced into that dilemma by someone who purportedly is serving her. Additionally, a self-revelation might lead to questions about the abusive event or situation. When one asks a question like “why did he rape you?” the question implies that he must have had a reason, and this reason may be the responsibility of the victim. It is imperative that anyone in a service role, whether librarian, coach or even friend, avoid “why” questions that may sound like victim blaming. Empowerment in the context of counselling has been defined as follows: Empowerment is the process by which people, organizations, or groups who are powerless or marginalized: (a) become aware of the power dynamics at work in their life context, (b) develop the skills and capacity for gaining some reasonable control over their lives, (c) which they exercise, without infringing upon the rights of others, and (d) which coincides with supporting the empowerment of others in their community. (McWhirter) (a) In fact, powerful systemic and structural influences including racism, sexism, hetero-sexism, inaccessible environments, and ageism may be reflected within the counselling relationship as well, thus, the counsellors critical awareness of power dynamics within the counselling relationship and in the client's larger social context is prerequisite to facilitation of client awareness. (b) Develop the skills and capacity for gaining some reasonable control over their lives refers to skill acquisition as well as the motivation and self-efficacy expectations required to exercise those skills. Counsellors often play an important role in facilitating the acquisition of new skills. It is important to keep in mind, however, that counsellors are often trained in skill building exercises rooted in European American values, worldviews, and norms. Thus the nature of each skill, as well as the manner and context in which the skill is practiced, must be shaped in accord with the clients concerns as well as other salient client characteristics such as personal and sociopolitical history, culture, interpersonal style, level of acculturation, and preferences. Further, counsellors must not overlook the vital resources with which the client enters the counselling relationship: specific coping mechanisms, attitudes, knowledge, and experiences that sustained the client through life thus far. (c) Which they exercise without infringing upon the rights of others addresses the fundamental nature of empowerment as integrative power or "power with others" (Hagberg, 1984) rather than power over others, or power "to do to" others. The exercise of skills that violate the human rights of others is fundamentally incompatible with empowerment. (d) Coinciding with supporting the empowerment of others in their community can range from interpersonal behaviours such as providing encouragement and support to community consciousness-

raising efforts such as participating in marches or helping to organize cultural and educational events. The role of the counsellor is to facilitate and support the clients connections with community, and to enhance the clients ability to support the empowerment of others as appropriate for the clients current situation. These elaborations should make clear that empowerment is not a linear process, nor one that concludes with the achievement of a particular "empowered" state. Many clients will not be ready for or interested in the empowerment of others- in the form of interpersonal relationships or community participation - when they terminate the counselling relationship. This must not be considered a failure on the part of the client or the counsellor to "achieve" the goal of empowerment. The counsellors role is to meet clients where they are in the empowerment process and work to support increasing, enhancing, or otherwise promoting empowerment in additional ways that are consistent with the client's goals. Critical components of an empowerment model can be represented in terms of "Five Cs": Collaboration, Competence, Context, Critical Consciousness, and Community. Collaboration. "Collaboration" refers to the dynamic relationship between counsellor and client. The relationship should be characterized by collaborative definition of problematic issues, goals, and development of interventions and strategies for change or growth. These interventions and change strategies are consistent with the client's values, goals, skills, experiences, and abilities. The client is viewed a la Paulo Freire (1971) as an active member of a team rather than a passive recipient of services. Competence: All clients have existing skills, resources, and a wealth of experience to contribute to the counselling process. To overlook these resources is likely to reinforce neediness, to foster dependency, to discourage esteem-building, and is generally contrary to the goals of empowerment and to good counselling. Counsellor recognition and authentic appreciation of client resources is essential. Honest counsellor feedback regarding skill deficits or personal weaknesses is also part of supporting client competence. The vast majority of clients understand that they have weaknesses (which they often perceive to be more serious than does the counsellor) and counsellor avoidance of constructive feedback is likely to make it hard for clients to believe positive feedback. So too with counsellors themselves: they must learn to identify their own strengths and weaknesses, grow in their understanding of how to utilize their strengths more effectively, and how to enhance areas of weakness. Counsellors are unlikely to truly appreciate the strengths of others if they are unable to appreciate their own competencies, just as they are unlikely to accept others weaknesses without accepting their own. Context. The dynamics of power and privilege shape the clients context as well as the context in which we provide counselling services. This context includes larger social forces (e.g., ageism, racism, sexism, classism, homophobia, able-bodied assumptions) and the effects of these assumptions on care providers, families, and individuals, as well as on faculty members, departments, educational institutions, and individual students. Context also includes systems such as families, social networks, neighborhoods, ethnic groups, professional and work groups, and faith communities. Integration of the context component into counselling means that we acknowledge the role of context in the clients current situation or problem, including how the context serves to maintain or exacerbate problems, while at the same time acknowledging the clients options and responsibilities related to change.

The context component of empowerment is directly dependent upon the critical consciousness component That is, without critical consciousness, efforts to address context are likely to be ineffective, because understanding context requires the development of critical consciousness. Critical Consciousness. Supporting the empowerment process requires that counsellors engage in an ongoing attempt to facilitate client awareness of context through the process of consciousness raising in a manner consistent with the clients situation, needs and abilities. Counsellors cannot engage in consciousness-raising without developing their own understanding of the power dynamics affecting both clients and themselves. Critical consciousness can be increased through two overlapping processes: power analysis and critical selfreflection. Power analysis refers to examining how power is distributed in a given situation in terms of race/ ethnicity, gender, disability status, sexual orientation, age, experience, family position, etc. (McWhirter, 1994) . Example: To illustrate power analysis, a faculty member might engage students in exploring the personal and professional repercussions of the program / department / university's adherence to medical, economic, or sociopolitical models of disability (Hahn, 1988). According to Hahn (1988), the medical model defines disability in terms of individual limitations, while the economic model focuses on the individuals functional limitations. By contrast, the sociopolitical model defines disability as a multifaceted product of the interaction between the individual and the environment, and emphasizes disabling features of the environment. The economic and medical models of disability arise out of modem day cultural assumptions regarding disability, such as: "disability" equals "needing help"; disability is a fact of biology alone; and people with disabilities, as victims of biological injustice rather than social injustice, must change their personal behaviour rather than their social context (Fine & Asch, 1988) . Exploration of the extent to which these models are represented in the department, and the implications of each model for counselling students with disabilities, would engage students in thinking critically and concretely about one important aspect of power dynamics. In addition to raising awareness, such a discussion could lead to actions that improve the departmental environment for students with disabilities. Critical self-reflection overlaps with power analysis in the sense that counsellors must understand how they contribute to specific power dynamics in their behaviours, assumptions, and interactions with others. In addition, critical self-reflection involves developing awareness of privilege, and of how counsellors have benefitted from privilege at the expense of those who are not privileged. The vast majority of counsellors enjoy privilege at multiple levels, such as age, racial/ethnic group membership, sexual orientation, socioeconomic status, disability status, education level, and gender. This is not to say that most counsellors are young, white, straight, middle or upper class, able-bodied males, but to say that most counsellors are members of more than one of these categories of privilege. One way to explore privilege is to examine the common assumptions or things that people take for granted by virtue of membership in a privileged group. (Of course, these will not be true for all members of that privileged group.) European Canadians, for example, usually assume that everyone does (or should) speak their language (English), are far less likely to be hated or "tolerated" by persons with greater power because of their ethnicity, and generally experience higher teacher expectations than persons of color. Heterosexuals can engage in public displays of affection without their actions

representing a political act; they also experience freedom from fear of losing their jobs on the basis of sexual orientation, and freedom from the threat of being outed or targeted by anti gay hate crimes. Males are less likely to be interrupted, more likely to be judged on the basis of characteristics beyond purely physical characteristics, and are far less likely to be raped by strangers, acquaintances, or family members, than are females. An exploration of works enumerating these aspects of privilege may serve as a point of departure with students, for example, the work of Henning-Stout (1994) , Freire (1971) , and others. Community. Community may be defined in terms of ethnicity, family, friends, place of residence, faith, sexual orientation, common organizational affiliation, or other bonds. A community is a source of strength and hope, identity and history, support and challenge, interaction and contribution. Community is fundamental to empowerment in two ways. First, the community can provide resources, support, and affirmation for clients. Second, the clients mutual contribution back to that community is essential in furthering the empowerment process. Counsellors work with clients to develop an understanding of the clients sense of community, the resources available, and the extent and quality of client interactions with the identified community. Often clients will not experience a sense of community with any others in their environment, or may belong to communities that undermine their resources and abilities. Thus, counsellors must also be aware of potential new sources of community, and assist clients in accessing or fostering community. This may include helping clients develop skills for drawing upon the communityâ&#x20AC;&#x2122;s support. Finally, counsellors can assist clients in identifying ways to support the empowerment of others in their community. Source: Excerpt of article published in the Canadian Journal of Connselling / Revue canadienne de counseling / 1998, Vol. 32:1 - An Empowerment Model of Counsellor Education By Ellen Hawley McWhirter University of Oregon

Techniques for creating collaborative relationships and useful goals: 1. Clarify where people are now vs. where they want to be in the future a/ Where are they now? (what is the problem?) • • •

Of all these concerns on …, which one should we work on first? What does the problem look like? Where and when does it usually happen? What would I see if I watched this problem happening on a video? (having the client describe the problem in “video-talk”); What does the problem look like? What happens first? Next? Then what?; Where/when does it occur? How does this problem affect you and your life; ….

•

What have you already tried? – How did things work?

•

What’s most important to you?

b/ Where do they want to be in the future? (What is the Goal?) Explore how the goal will impact clients’ lives • •

What do you want your life to stand for? How will life be different when things start improving?

• • •

What would you rather be doing instead of the problem? What will you be doing instead? (start based) What can you do differently? (self-manageable)

• • •

What would it exactly look like ? If we watched a videotape of you being “less depressed,” what would you be doing? What will be the first small sign of improvement?

and explore clients’ willingness and confidence •

On a scale or 0 to 10, how willing are you to change something in order to reach your goal?;

•

How confident are you in moving closer to your goal?. What are you willing to do this week to move a little closer to that?

•

What are you willing to do to make this mark move up one or two centimeters on the line.

2. Invest in what is right a/ search for exceptions : build on moments when the problem was not – or less - present Techniques for building on exceptions: Identify one or more “exceptions” to the problem (When is the problem absent or less noticeable?), explore details of the exception (What was different about that time?), and encourage “more of” the exception (What would it take to do more of this? Are you willing to try that ?) Identifying, Exploring, and Encouraging “More of” the Exception: Identify an exception • • •

When is the problem absent or less noticeable? Tell me about the moments when you were least aware of / suffer least from the problem? Tell me about a time this week when you and X got along a little better than usual.

Exploring details of the exception • •

What was different about that time? How are you different then compared to other moments?

Encouraging “more of” the exception • •

What will it take to do this again? What will it take to do more of that next week?

•

I wonder what would happen if you tried this approach during other moments throughout the day?

•

Are you willing to try it?

Example: Congratulations on changing your behavior last week. I’d like to learn more about what you did to make things better. Your ideas and advice will help me in my work with other peoples who are struggling with similar challenges. I look forward to learning more from you." b/ Search for other Natural Resources: Listen, look for, ask about resources you can build on. Listen, examine records, reports, and other information with an eye toward discovering resilience, cultural factors, special interests, and other potentially useful resources; Listen, look for, and ask about “natural resources” in the indivual’s life (cultural heritage, life experiences, resilience, heroes and influential people, special interests); Incorporate their natural resources into interventions (inviting a respected grandparent to a meeting, building on their solution ideas or advice to others, incorporating their special interests and talents into counseling conversations and interventions. Examples: The only thing I care about are my friends and my music. I wouldn’t come to school at all if it wasn’t for art class and Ms. Baxter.”); • •

How have you kept things from getting worse? Of everyone who knows you, who would be most surprised that you’re having this problem? - Why would they be surprised?

•

Who do you look up to most in your life?

• • •

Who are your biggest heroes? - What would they do if they were in your shoes? Who do you respect the most? - What would he or she advise you to do about this? Who else is on your “support team” and how might they help you with this problem?

• •

How have you managed to hang in there instead of giving up? How have you kept things from getting worse?

•

If you were a counselor, what advice would you have for others who are dealing with this type of problem?

Incorporate the natural resources into interventions. Ask how the individual has handled other tough challenges (resilience), and explore how one or more of the resources that helped them through a previous challenge might help them with the current problem. Request the involvement / advice of influential people in the person’s life by calling them, asking them to speak with the individual, or inviting them to a counseling session or meeting; Explore connections between the individual’s hobbies and special interests (skateboarding, music) and solutions to the problem

•

I wonder how the courage you developed when you learned how to ride a skateboard / play the guitar … might help you with this current problem. What do you think?

3. Empower desired changes by giving clients credit, preparing for setbacks, exploring their plans to continue positive changes, and using therapeutic letters and documents. Examples of Giving Credit, Preparing for Setbacks, and Exploring Plans to Continue Positive Changes: •

How did you manage to remain focused through the whole day? (giving credit for improvement); What will it take to continue this? (exploring plans to continue positive changes); A lot of times things don’t change in a straight line, but more like two steps up, one back, two up, three back, and so on. So let’s talk about what you can do to get back on track when you hit rough spots along the way (inviting to prepare for setbacks).

4. Invite something different by changing the viewing and doing. 1. Changing the view: Invite people to consider a different yet plausible view of the problem (Could it be that…?); Offer a different motive or meaning for the behavior; Externalize the problem from the person. For a person who views her aggressive behavior as a sign of strength and independence, invite her to consider the possibility that the problem behavior reflects her desire for more attention from and connection with her peers. For a person who views another individual’s disruptive behavior as a personal attack or sign of disrespect, offer the possibility that the individual’s behavior may reflect an attempt to avoid public embarrassment about his personal difficulties. NOTE: In order to be most effective, the different view that is offered needs to: • • •

fit the facts at least as well as existing views; be different enough from existing views to make a difference; and make sense and be acceptable to the client.

Examples: •

Could it be that your boss / teacher gets on you a lot because she cares enough to want you to succeed?

•

Can you think of any other reasons why this person might be acting this way?

2. Changing the doing: Invite people to alter their performance of or response to the problem (Pattern interruption strategies including altering the sequence, tone, time of day, and other aspects of problem performance; “Do Something Different” experiments. •

Are you willing to try something really different?

• •

I wonder what you could do to be less predictable. It might be interesting to do something really different next time this happens just to shake things up and see what happens.

•

Maybe you could think of something really different this week and try it out as an experiment.

Encourage clients to alter the problem pattern by doing something...anything…different For a person who argues a lot with her boss, invite her to be “unpredictable” by saying something nice to the boss upon entering the workplace for three consecutive days and observing any differences in the relationship; For a supervisor concerned about the behavior of a disruptive team member, encourage the supervisor to alter the problem pattern in the following way: The next time the problem starts, tell the individual that you are going to start at the end and work backwards by saying, “I’m sorry I had to do this without you, because it’s important to me that you remain part of the team, but I can’t talk with you all the time and organize things at the same time.” Examples of “Do Something Different” Experiments For parents who complain about “daily arguments” with their daughter shortly after she arrives home from school, invite them to try a “Do Something Different” experiment in which they (a) do something very different when their daughter arrives home from school, and (b) make careful observations, perhaps even notes, on her response to the experiment. Practice Exercise: Invite Something Different by Changing the Doing Instructions: (a) The supervisor/teacher/parent describes a problem they are having with another person; (b) The service provider invite the supervisor/teacher/parent to consider being unpredictable by doing something different in order to change the problem. 1. The service provider describes the problem in specific terms (Who does what, when, to whom?). 2. The service provider and the supervisor/teacher/parent work through the following steps: • • • •

What do you usually do in response to this person’s problem behavior? What is the usual result? What could you do that would be totally different and unexpected the next time the person performs the problem behavior? (Brainstorm some possibilities before ruling anything out) Of all the options we just discussed, which one would you be most likely to try? On a scale of 0 to 10 where 0 = “not at all likely” and 10 = “very likely,” how likely is it that you will actually do this when you return to work? (circle one) - 0 1 2 3 4 5 6 7 8 9 10

3. Externalizing the problem from the person. Discuss the problem as a separate and distinct entity that is external to the client by giving it a name, exploring its power in the relationship, and exploring times in which the client has stood up to it instead of yielding to its influence Examples: •

If you were to name this problem, what would you call it?

• • •

How long has Ms. Nasty been part of your life? How does she get you to dance to her tune? Tell me about a time that you stood up for yourself and did things your way instead of giving in.

• •

How will your life be different as things change between you and Ms. Meany? What would happen if you switched seats with Mr Nasty (the problem) so that you became the driver and he (the problem) became the passenger?

5. Questions for Young People Viewed as Reluctant or Resistant (“Mandated” Clients) •

How can you get out of coming here?

•

What would convince your teachers/parents that you no longer need counseling?

• •

What would your teacher (OR parent/judge/probation officer) say needs to happen? What will I need to say or write to the court to convince them that you no longer need counseling?

• •

What are you willing to do to make that happen? Who suggested that you talk to me?

• •

Why do you think they suggested it? What makes them think you need counseling? - Do you agree with them?

•

Would you be interested in finding ways to get your teachers and parents off your case?

•

What have you found helpful to keep your others from hassling you as much about this? [Insert the client’s own words into questions when possible—hassling, yelling, being picked on, etc.]

• • •

How can I help? - What can I do to help you? What are you willing to do differently to help your cause? What would be the first small step you could take in that direction?

•

What would be the first small sign that would tell your teacher/parent that you are making progress and improving things?

•

Of all the people in your life, who do you look up to and respect the most? What would s/he advise you to do about this?

•

What else would you rather work on here? [Discuss something important to the client to engage their involvement and energy]

•

I can’t force you do anything you don’t want to do, and I respect your choice to participate or not participate in counseling. If you choose not to, I want you to know that you can come back anytime to make sure you have a say in things.

"The process by which the client reconstructs his experience is not one the worker creates; he simply enters, and leaves... he is an incident in the life of his client. Thus the worker should ask himself: What kind of incident will I represent... How do I enter the process, do what I have to do, and then leave?" (Schwartz W. (1974): The Social Worker in the Group, in: Klenk, R.W./ Ryan, R. (Eds.): The Practice of Social Work, Belmont Cal., 208-228.)

The Best Way To Empower Someone Is To Show Them Their Strengths and praise them for who they are I come in contact with many people who are really down on their luck or who just feel completely defeated by life. You hear it in their words and you see it in their body language. Listening to them and letting them vent is helpful, up to a point. Being non-judgmental and supportive is also helpful, up to a certain point. If it’s someone close to you, being there for them is helpful. Yes, you guessed it, up to a point. The best way to empower people who feel down or at a low point, starts with listening really carefully. When you listen carefully, even if the story is negative, sad or tough, you can, from the words being spoken, identify the person’s strengths and qualities. When you then show the person what amazing strengths they have, strengths that you can back up by examples of things they said, and praise them for what they are doing and who they really are, it empowers them in a way far beyond any other method I know about.

Take the case of a 24 year old guy who works in the hospital come into the ER. He was having back pain and he had a painfully stiff neck. It turns out that this guy was working in a job he hated. Okay, nothing new there, many of us do that at one point or another. He told me about how he had no other option. (Of course, I felt compelled to point out that there is always more then one choice or option in any given situation. In the end, what we do is our choice based on the pluses and minuses to be gained or lost. But that is a completely different post.) When I started digging deeper, he told me about the mortgage he has to pay as an example of one of his many burdens in life. That intrigued me. A 24 year old with a mortgage. The conversation went on for a while. To make a long story short he was supporting his mother, divorced sister and her child who all lived with him. I was blown away. What a heck of a burden for a 24 year old guy to shoulder. I couldn’t leave him like that so I started telling him about his qualities and strengths. Qualities and strengths that I heard during our conversation. I told him about his highly developed sense of responsibility. I pointed out to him how committed he was to his family. I pointed out his selflessness. Many people his age put themselves and their needs before anything else. I also pointed out to him how rare it was for someone his age to be able to plan ahead the way he is. (He had bought an apartment because the rent is just as high as his mortgage.) The more I pointed out his positive strengths, especially ones that connected him with his sense of values, the more he perked up. The point of this story is twofold. First, even a few minutes can make a big difference in someone’s day and sometimes even their life. Secondly, if you really want to encourage and empower someone, listen to them carefully. Even within their tales of despair you can find a person’s strength. When a person recognizes, remembers and connects to their strengths, they are ready to soar. Has someone ever empowered you through emphasizing or pointing out your strengths? “Praise is like sunlight to the human spirit. We cannot flower and grow without it.” ~Jess lair I chose to share this story with you mostly because I found it so amazing to see how things that you learn - in this case things that I learned in my coaching training program - actually come to life in your day to day interactions. I realize what a tremendous difference learning theory, as well as certain techniques, whether it be listening, re-framing or encouragement just to name a few, make on the way you view and react to things. Yet, another example of why constant learning and self advancement is so important. On our journey through life, each of our inner circles is growing and encompassing more people: children, significant others, friends, colleagues, and random people we meet and don’t know as intimately. As the circle grows, so too does our influence. Every nod, every smile, every interaction can completely change the course of someone else’s day. We can either wield that influence in a positive or negative way. The following I would like to dedicate to those special people who identify with their fellowmen, and use their influence to empower them. •

Empowering others is one of the most important acts of kindness one can do for his fellow man.

• •

Empowering others means not criticizing them. Empowering others means not judging them.

• •

Empowering others means not being cynical toward them. Empowering others means praising the struggling student in the class on his or her progress — any progress, no matter how small.

• •

Empowering others means curbing your ego. Empowering others means connecting to the best elements that lie within you.

• •

Empowering others is contagious. Empowering others means giving them the feeling that they are loved.

•

Empowering others is to understand that the cashier at the supermarket, the waiter at the café, the guy who pumps your gas, the doorman, the street cleaner, and the janitor are not transparent. They are people just like us.

•

Empowering others means smiling at these people, inquiring about their wellbeing, thanking them for the services they provide, and wishing them a good day.

•

Empowering others means being happy for them, and praising them on their accomplishments. Praising them in any way possible. Always.

•

Empowering others means identifying with them.

• •

Empowering others is easy. It does not require any effort. Empowering others means smiling when someone else approaches.

•

Empowering others also empowers us.

• •

Empowering others makes the world a better place. Empowering others means to be moved by the American poet and author Maya Angelou, one of the most important figures in the American Civil Rights Movement, who said, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”

"Empowerment suggests a sense of control over one's life in personality, cognition, and motivation. It expresses itself at the level of feelings, at the level of ideas about self worth, at the level of being able to make a difference in the world around us... We all have it as a potential." (Rappaport, J.: The power of empowerment language, Social Policy, 15, 1985. p. 15-21). Gutierrez adapted this definition and tried to clarify it by adding four necessary changes which have to be seen in a person before he/she can be described as "successfully empowered" - an increased selfsufficiency, a developed group consciousness, a reduction of self-blame in the face of problems and the ability to assume personal responsibility for change. That is, not relying on other people to help out, but trying to take matters in one's own hands and pursuing a change to the better. Another definition has been given by Solomon who has developed a very good definition of empowerment related to social work, adaptable to our focus on migrants and refugees. This is the definition that is used in this text for empowerment. Empowerment is defined as "a process whereby the social worker engages in a set of activities with the client (...) that aim to reduce the powerlessness that has been created by negative valuations based on member-ship in a stigmatised group. It involves identification of the power blocks that contribute to the problem as well as the development and implementation of specific strategies aimed at either the reduction of the effects from indirect power blocks or the reduction of the operations of direct power blocks." (Solomon, B.: Black Empowerment: Social Work in Oppressed Communities, New York 1976.) In this context, empowerment can be best described as a process which can be initiated and accompanied by advice, counsel and orientation programmes. Through this process, individuals, organisations or groups, who seem powerless or deprived of the means to reconstitute themselves in an alien society, can become 'empowered'. They can become aware of the power dynamics at work, develop skills and the capacity to gain some control over their lives, exercise this control without infringing upon the rights of

others and support the empowerment of others in their community. In summary, therefore, empowerment can be described as having four goals: • •

that the client sees himself as the agent of change; that the client is able to use the knowledge and skills of others in furthering their own interest;

• •

that the client is able to work in partnership with professionals; that the client is open to developing the problem-solving skills to address their situation.

It is important to identify some basic principles of practice with regard to the relationship between the practitioner and client: • •

interact with the person and not the "migrant", “patient”, …; respect the person's right to self-determination; accept the client's definition of the problem;

•

focus on strengths; respect the diversity of skills and knowledge that clients bring ;

•

share power and control; respect the client's right to contribute and trust his or her motivation to learn and direct his or her life; be aware of cultural differences with regards to hierarchy and superiority.

•

look for groups: mutual help, consciousness raising, participation.

General Methods The empowerment process can be described as being made up of four elements. • •

•

Attitudes, beliefs and values. This refers to the psychological aspects of empowerment. It covers self-sufficiency and belief in self-worth. It is concentrated either on individuals or groups. Validation through collective experience. Sharing common experiences can avoid misinterpreting individual experiences and help put these into perspective, alleviating loneliness and isolation. The collective experience can motivate a group to pursue changes, that go beyond the individual. Knowledge and skills for critical thinking. The ability to access and acquire information is an important element of empowerment. This can enable individuals to analyse their situation independently and critically, reducing self-blame and feelings of helplessness. Action. Through empowerment individuals can develop plans for action to solve a problem. They can develop strategies and behavioural patterns that might help them in future challenges. An increased ability to co-operate with others is another possible outcome.

In addition, the empowerment process can be said to involve four stages: •

Establishing a relationship between the adviser and the client to meet immediate needs such as access to social services and benefits or to other sources of information;

• •

Educating the client to improve his or her skills and thereby increasing the ability for self-help; Securing resources. This implies the development of skills to deal with other organisations and agencies, joining self-help-programmes and groups, or establishing and using social networks. Enabling social and political action. Helping the client to be able to articulate social and political needs at the appropriate time, enabling them to understand the basic principles of lobbying, negotiation, campaigning and so forth.

The last stage is the most politicised stage in the empowerment process and might not be relevant to all advisers and organisations. But to ensure real change, the social and political context of the individual has to be considered. How far practitioners want to take the four stages of empowerment depends on their objectives.

Empowering individuals The blocks to empowering an individual are often psychological. Firstly, there is the phenomenon of alienation from the self. This is a phenomenon that has been identified as a psychological and emotional response to oppression. It is manifested through the inability to identify and articulate one's needs and take active steps to meet them. It can lead to low self-esteem and feelings of powerlessness, with the perception that one cannot influence and resolve issues in one's own life. Secondly is the use of stereotypes or stigmatisation. The migrants, who have repeatedly experienced rejection, for whatever reason, will feel stigmatised or of being subsumed under a stereotype. This will be exacerbated by their experiences of racism. The migrants might find themselves caught in a vicious circle of stigmatisation, rejection and, subsequent self-blame. This circle can be quite destructive for the individual. Three steps are important for the empowerment of individuals: The first step is to define the problem. To define the problem, different factors have to be considered, such as the specific legal framework of each country, particularly around their residency status and employment rights. Also the attitude of each country towards migrants and refugees is significant. In a society with an assimilationist approach, there is an expectation of complete adjustment to all relevant features of the host society. In countries where integration is the key-word, differences are accepted and even encouraged. The second step addresses the issue of self-determination. It is important to define the criteria of success for every individual. From this perspective it is possible to set targets against which the goals can be said to be achieved. Establishing self-sufficiency and belief in one's own abilities starts from the moment contact with the client begins. As soon as he or she is regarded as a valuable source of competence in dealing with the problem, an important step in the direction of empowerment has been taken. This leads us to the third step which relates to consciousness raising. It is necessary to confirm to the clients that they are the experts of their particular situation and the best arbiters of their own treatment. The acceptance of the independence of the client is crucial, otherwise there can be no talk of empowerment. An important precondition to any empowerment-process is access to information. A lot of problems arise because of a lack of information on both sides: Those seeking for employment and those able to give jobs. The availability of information on the labour-market and its regulations ensures that the clients are not reliant on the advisor to assess their options.

The EMPLOYMENT working group on empowerment has assembled a number of "indicators" for individual empowerment. These are: • •

•

Skills: Literacy and numeracy, marketable skills, having confidence and understanding of one's own strengths. Actual or real potential: having secure and decent housing, being aware of the impact of good health and how to keep it, access to decision making processes, having choices for career development, being able to make decent plan financially, being able to get a credit, interest in positive change in the host society. Employment: Having a job, better a job with a secure contract of employment, establishment of own business, becoming an employer in own business.

The EMPLOYMENT working group has formulated a number of indicators of success for group empowerment. These are: •

Support and motivation: Existence of peer support structures (self-help, voca-tional guidance), emergence of role models within the target group, availability of mentors from within the target group, skilled trainers from within the target group, opportunities to collaborate with other to create common and effective projects.

•

Relationships with other organisations: Participation in decision making process, provision of training to official agencies.

•

Campaigning: Development of an account of the group's previous exclusion, of value attached to direct experience of that exclusion, training and skill development for group members in the specific skills needed to engage with decision making processes.

•

Services: Provision of practical services for target group members, development of credit unions.

The EMPLOYMENT working group in empowerment has identified some "indicators" for empowerment within the context of the wider community. These are: •

policies respond to representatives of target group;

•

change in public attitudes - the rights of the target group are acknowledged, there is indignation when there are not supported, target group members are described as having rights, rather than needs;

•

removal of obstacles to participation, e. g. greater availability of child-care, change in time of public meetings etc.;

•

increase in numbers of target group being employed in jobs concerned with maintenance of the state, e. g. police, armed forces, civil service;

•

children of target group members born in the host society do not experience exclusion.

Proposed reading Gutiérrez, Lorraine et al. (eds.): Empowerment in Social Work Practice. A Sourcebook, Pacific Grove et al. 1998. Lee, Judith A. B.: The Empowerment Approach to Social Work Practice, New York 1994. Lewis, J.A et al. (eds.): Community counselling. Empowerment strategies for a diverse society, Pacific Grove et. al. 1998.

In life, like in business, you never get everything you want; you get what you can negotiate. Here are five steps to empower people. 1. Know their skills and qualifications. Look over their curriculum vitae, and find out what their strengths and abilities are. This will help you decide where to maximize their potentials. 2. Ask them what they are best capable of and find most enjoyment in doing, within the scope of their work description. Encourage them to contribute in their areas of speciality and interests. 3. Give frequent praises for good work everyday. Most people (with possible exception of those with schizoid personality disorder) thrive in positive feedback. It helps them to know what they are doing is appreciated, and will encourage them to continue their good work. 4. Avoid criticisms if at all possible. Criticisms has the opposite effect of praises, and can discourage people greatly. Always assume good faith, be understanding, think in terms of good aspects, compare their mistakes to mistakes you have made yourself, or could have made. If you must give criticism, be constructive, and always praise first, and provide clear suggestions on how to improve. 5. Provide opportunities for further training and education. Allow them to expand their knowledge and skills so they can contribute in greater ways. “The beauty of empowering others is that your own power is not diminished in the process,” said Barbara Coloroso. In fact, empowering other people puts out the positive vibes into the atmosphere that will be returned to you, not in any sort of karmic sense necessarily, but in terms of improving your own sense of self-awareness and confidence. This can be achieved in a number of little ways that can range from simply boosting someone else’s mood to helping them realize new aspects of their personalities. We are all in this life together, and helping others achieve their goals can get our own on track. The following are 50 little things you can do to empower other people and get started down this path. 1. Give out compliments that you mean. Most people can see straight through a phony compliment, but if you think your friend looks especially nice today with that new hairstyle, tell her so. Just be open and direct in your interactions. 2. Speak and act with honesty. If you always speak with integrity and believe in your own words and actions, others will also pick up on this and mimic it, fostering an atmosphere of trust. 3. Listen to others. Always listen to what other people say. I used to zone out when others were speaking but now make a point of looking into their eyes and listening to their words, which has made a world of difference in personal interactions. 4. Help illustrate your points with visual aids. When leading a meeting or presentation, realize that many other people are visual learners. My girlfriend can’t understand a concept without a diagram to back it up. 5. Teach a class. If you have a skill or knowledge to share, why not teach your own class that helps spread it to others?

6. Get involved in community art projects. Artistic projects in the community are a great way to help get everyone involved in making the city a more beautiful place to live, instilling a sense of pride in all residents. 7. Mentor a child or student. Getting involved in one child’s life, especially if they are at-risk, helps you both make connections throughout your lifetime. 8. Volunteer with local organizations. These can be community discussion groups or of a more volunteeroriented nature. 9. Lead a group on a travel expedition. My friend works for the local art museum leading groups of the elderly on art-oriented field trips around town and abroad, which helps everyone connect and learn something new. 10. Donate money to charity. If you have extra money, helping organize a fund for a pet cause helps bring the community together. 11. Help the spread of community health clinics. This can be done by volunteering yourself, or donating money. Either way, it can be vital in helping those who have problems affording health care to realize that they are still valued individuals and that their health matters. 12. Take the time to talk to strangers. That conversation that is simply small talk to you can mean a lot to someone else who is shy or feels that their opinion isn’t taken into consideration often enough. 13. Start a non-profit. This is a project that can be difficult but ultimately rewarding not only for you but for the others who become involved as well, helping you all to work together towards an ultimate goal. 14. Travel abroad and make new friends. Getting out there as an ambassador of sorts in the world helps you connect with others who may want to learn more about your culture but otherwise wouldn’t have the opportunity. This ends up being a learning experience for both parties involved. 15. Reach out to friends and relatives at a distance. If you have lost touch with loved ones, give them a call and let them know that someone is thinking of them. 16. Be aware of body language. Your body language sends a strong message to others, so be aware if you have your arms folded across your chest while you talk that you are shutting others out, for example. 17. Be sincere. Your sincerity will help to make people feel appreciated. 18. Nurture talent in others. If you notice someone has a talent that they aren’t putting to use, let them know. Gently offer suggestions of where they may go to learn more. If the child you are mentoring is constantly doodling, for example, get them signed up for an art class. 19. Go out and support local musicians. In every city there are unimaginable numbers of young struggling musicians who could be the next Beatles if given the chance. I’ve seen some amazing live acts recently by picking a name out of the listings and simply turning up in support. 20. Give thoughtful gifts. When giving gifts during birthdays or the holidays, take the time to think about what the person might really need or appreciate. 21. Join a community farm or grocery coop. Working together to provide fresh, sustainable food for the community is one of the hot trends in some community organizations. 22. Volunteer in schools. Though it might sound cliché, young people are our future indeed, and helping out in schools that are struggling financially can make a big difference in a young person’s life. Be a positive role model.

23. Stay in touch with local politics. Helping others get empowered means also being kept up to date with the latest in what is going on in your own town. 24. Throw dinner parties with a mixed range of guests. Get together a group of people who don’t necessarily know each other yet but you feel that their personalities might mesh well together. This is how we learn from one another. 25. Smile more often. There is an anonymous quote that states, “A smile confuses an approaching frown.” 26. Use public transportation. Not only is this better for the environment, but it gives you a chance to interact more with the community. 27. Organize recycling projects. This helps give back to the community and teaches people about the need to respect our natural environment, which is empowering for all. 28. Run a benefit event. Leading a team of volunteers; set up a means for raising money for a cause that you all are interested in. This can be a chain reaction, with the volunteer team then feeling more empowered to go a step further with its own charity efforts. 29. Project positivity and eliminate negative thoughts. This positivity will then be returned by others. 30. Join a book group or club. The exchange of ideas tends to be helpful for all people involved, and can spark new business or interpersonal ideas in between all of you. 31. Start or join a language exchange program. This helps foster feelings of competency in a foreign country for someone who may be feeling like an outsider, and also helps you build your own language skills. 32. Lead team-building exercises at work. This can go beyond old-fashioned trust falls to more imaginative retreats. My friend recently led his team out in a wild-mushroom foraging expedition, which was a unique way for them to learn something new as well as get to know each other, in a beautiful outdoor setting. 33. Encourage social activities. Get new social activities planned within your group of friends, your family, or in a larger community sense. 34. Initiate physical contact. In this society in particular, there is a hesitance to touch one another. By simply placing a hand on someone’s shoulder, you are helping to reconnect with that person. 35. Tell your loved ones how you feel about them. Don’t wait till it’s too late to let someone you love know how you feel about him or her. Life is wonderful but short. 36. Make sure the atmosphere at work is a democratic one. Let everyone’s opinion be heard, and be sure to give feedback to their ideas. 37. Nod your head when someone is making a point. A simple piece of non-verbal communication like this can help inspire someone to move forward in the discussion more. 38. Help foster creativity. If someone is talented, tell them so. Andy Warhol was notoriously shy as a child and perhaps would never have branched out to become the powerful artist he is now known as if someone had not said a few words of encouragement to him in his early art classes. 39. Run meetings with an open, discussion oriented atmosphere. Whether at work or in a larger community sense, let everyone know their opinion is valued.

40. Have suggestions ready for those who need advice. This means taking the time to think about your own behavior, past mistakes, and how you’ve moved forward. With this information in hand, you will be well equipped to advise others. 41. Take walks to new areas of town. I’ve met some of my good friends by simply walking around in their neighborhood and having to ask for directions. 42. Spend time planting trees in the community. This helps improve the overall beauty and positive feelings in the city, instilling a sense of pride in other residents. 43. Set up a food or blanket drive. This helps others in the community and empowers the other volunteers by letting them see they can make a difference. 44. Learn inspiring quotes that can be doled out. As Bill Gates once said, “The vision is really all about empowering workers.” 45. Learn new listening techniques. This can be a combination of proper responses and cocking your head at the right time to show someone else their opinion matters. 46. Study psychology. A friend of mine went back to school to be a psychologist in order to reach out to people on a scientific level, but even a few basics of human behavior are both interesting and can help you be more effective in interpersonal communications. 47. Give a helping hand. Whether it’s helping someone who fell to get back up, or picking up something that spilled in the supermarket, it shows you care, which is empowering. 48. Give encouragement instead of criticism. Dale Carnegie said, “Abilities wither under criticism; they blossom under encouragement.” Every one of us has the magic power of empowering other people simply by generously giving praise and showing encouragement instead of criticism to help them realize their potential. 49. Take time for yourself to help others. By taking the time to sit and reflect upon my own actions each day, I find I’m better able to mentally be available for others when out in public or at home with my family. You can do the same. 50. Learn intervention techniques. In the event that someone you know is struggling with addiction, this is a way to help them get over it and empower themselves to get back on track.

Empowering Crisis Interventions TAASA outlines nine steps for effective crisis intervention:

1. Establish Rapport 2. Active Listening 3. Define the Problem 4. Assess the Situation 5. Explore Options 6. Discuss Acceptable Alternatives 7. Referral 8. Closing 9. Follow-up The first step, establishing rapport, is intuitive. No successful transaction occurs when there is a lack of comfort and trust. Both librarians and crisis counselors should work hard to make that good first impression. The most striking similarity is that regarding the concept of active listening. According to Bopp, “Active listening involves reflecting back to the user the librarian’s understanding of the question to verify that it is being properly understood.” TAASA advises a crisis coach to “check out what you understand them to be saying to see if you are on the same wavelength.” Active listening can serve much the same purpose in both situations: clarifying the problem or question, making sure that it is being understood completely, rephrasing it to cast it in a different light and using this broadened understanding to form an action plan. The third step recommended by TAASA is defining the problem. This is necessary in all reference interviews. Hoskisson stated that the first question asked seldom addresses the true need. Eidson recommended that librarians should be able to adjust to a question that changes as the conversation continues. In crisis coaching, defining the problem might involve isolating the survivor’s true emotions and needs. In a reference interview, the patron’s emotions might play a lesser role, but the patron’s needs are still paramount. The fourth step, assessing the situation, is crucial to conducting a successful interview. The librarian should take stock of the patron’s appearance and behavior. Is she nervous or agitated? Are her questions clearly articulated or frantic? Such an assessment might help the librarian learn the immediacy of the patron’s needs. Exploring options is an effective way to help a survivor in her decision-making process. TAASA recommended avoiding advice and presenting all of the available options to the survivor. A survivor who has options from which to choose is taking back power over her own life from the assailant who took it away. Librarians should be interested in giving complete information, including options for finding help, but a survivor might not be interested in all of the options. A librarian should understand that this does not mean that the interview has been unsuccessful. If a referral is necessary, it is a good idea to give more than one. If a patron is given several different sources of assistance, this increases the options and gives back a small part of that power over her life that an abuser took away. Nolan advised that an unsuccessful interview should be ended with a referral. In the case of a possible survivor, even a successful interview should be ended with a referral. It may not be

possible to recognize a survivor, so a referral to a rape crisis center “for more information” might be very useful for a survivor or even for a researcher. Many larger hould be aware of all campus resources. The closing of a crisis coaching encounter is ideally initiated by the survivor. Nolan pointed out that a reference interview may be closed by either the reference librarian or the patron, or both simultaneously. He recommended that a librarian encourage the patron to come back for more help if necessary. It may appear that in this situation the librarian is closing the interview, but in actuality he or she is leaving it open to continue at a time of the patron’s choosing. TAASA also recommends that the crisis coach let the survivor know that calling the hotline was the right thing to do and that it is the first step in the healing process. Eidson recommended a similar approach, but at the beginning of the reference interview. He suggested affirming that the patron has come to the right place and the librarian is open, available and ready to help. This approach is well-placed at either end of the interview with a survivor. At the beginning of the interview, it may encourage the survivor to relax and be more willing to ask questions openly, knowing that she will be heard and respected. At the end of the interview, such an approach may make the survivor feel comfortable returning to the library and working with its staff. It may also make her feel that if the librarian is kind, encouraging and affirming, there may be others who are the same way. This might encourage her to seek the assistance of counseling professionals. Follow-up is defined as summarizing the encounter, encouraging the survivor to call the crisis center anytime and saying goodbye. This leaves the decision of whether to have any more contact with the crisis couach in the survivor’s hands. Nolan takes much the same position. In a crisis intervention situation, it might be helpful to offer to call the survivor a few days later in order to offer additional help. A follow-up call, of course, should only be made with the survivor’s permission. This is an excellent practice for librarians, too. A reference librarian may need to contact a patron to offer additional information found after the patron has left or for related purposes. If the patron is currently in an abusive relationship or does not want the people in her household to know that she has been assaulted, a call from a librarian may raise suspicions. If a patron does not give permission, it is best to wait for the patron to come back or call. Qualities for empowering family advocacy (Amended from Marie Sherrett) Which Type of Advocate Are You? Defender Protector Promoter Enabler Investigator Mediator Supporter Monitor Teacher

Fights for the rights of individuals, children and families Works to keep individuals, children and families from physical or psychological harm Works to cause something to happen Provides individuals, children & families with the resources needed to achieve their goals Searches for facts and information Listens to and understands all points of view and remains objective Listens to and gives acknowledgement to feelings, and needs without passing judgment Checks in periodically to see if things are going according to the plan Assists in trying to decide the best possible approach to the situation.

Caregivers are not empowering if they: • Beat around the bush • Fail to describe problems • Feel guilty or are afraid to be vocal • Agree with professionals to keep peace • Ignore the right to services • Leave everything to others • Accept excuses for inappropriate or inadequate services • Beg for what the law says a child should have • Abdicate to others the right to advocate for a child • Depend on others to advocate • Give up because of red tape • Are too hasty to act • Fail to act • Accept the status quo • Give in to defeat • Are comfortable with accomplishments • Discourage your child from having hope for success. Caregivers are empowering if they: • Express themselves clearly , directly and without guilt • Are not intimidated • Prepare for meetings • Stay together • Are informed • Keep Records • Collaborate • Communicate effectively • Demonstrate self-confidence • Advocate effectively • Are self-reliant and independent • Persist • Analyze problems • Organize to effect change • Are positive and strong • Have pride • Encourage others and hold people accountable Resources What is it that you need to know if you want to be an empowering advocate for your child ? First know that you are the expert when it comes to your child. You know your child better that anyone else. You know: • How your child responds to different situations • Your child’s strengths and needs • What your child likes and dislikes • What has worked to help your child • What has not worked

You are the person who decides what services and supports your family and child need. Include your child in decision making whenever possible. You child needs to be an active participant in the services you receive. Every child is different, yet there are children similar to yours. You are not alone. Other families have faced similar problems and shared the same experiences. Getting connected to other families who are willing to help you can make all the difference. You need to begin asking the following questions: • • • •

What do I need to know and to do to help my child? What agencies in the community have programs or services that can help my child and other members of my family? How do I get services from them? How will my child’s health, growth and development, social interaction, and ability to learn be affected by the problem we face? What has helped other children like mine?

In the context of your interactions with children, always: 1. Look through the child’s eyes: Consider the world from the child’s point of view. What joys and challenges exist for this child each day? What is their level of ability and support to meet their challenges? Who are their friends? Is the child’s life basically happy or full of considerable stress and loss? Too often as adults we view the child from the adult lens thinking about how the child’s behavior affects our work or our day. Instead, remember what it was like to be very young and consider what daily life is like for this young child. When you truly understand the needs of the child then you have a much stronger ability to assist this child with your professional skills. 2. Look for the positive: Develop an extensive list of the skills, interests, motivators, and personality attributes of this child. This becomes essential information when you develop positive action plans to help the child address challenges in their life. Regardless of age, we all are much more effective in responding to difficulties when personal strengths are identified and utilized to address needs. 3. Meet at the child’s level: Develop professional plans that start at the child’s level of comfortable functioning. If required skills are above the child’s functional developmental level then the child will not be successful. Since children are unique, it is normal for there to be variation in developmental levels across the developmental domains (cognitive, social, emotional, behavioral, and physical). Assessment should include evaluation of each of these domains independently and is critical for a thorough understanding of the child’s strengths as well as challenges. 4. Plan Success: Interventions and strategies should be designed with success in mind. Don’t create a plan if there is a question about the child being able to accomplish the goal. Behavior plans should include positive incentives which will encourage increased self-esteem and motivation for change and growth. 5. Child as expert: At an early age we all find ways to communicate our likes and dislikes in life. Gifted caregivers learn to recognize these communications and respond to them. Be sensitive to the child’s communication and find ways to include the child in intervention planning. Even small children can choose their own rewards and acknowledge simple rules. As the child grows, increase their participation in all decision processes about them.

Empowerment Checklist for Professionals Use the following checklist to help guide your professional approach with children and their families to be one that is empowering. •

The child’s needs are the guiding force for all decisions Evaluate/assess the child within your own skill base & training

•

Utilize best practice approaches for the child’s developmental age and issue(s) that are the focus of care

•

Seek knowledge and expertise of adult family members about the child

•

Acknowledge complexity of issues

• • •

Provide an honest appraisal of available resources Refer to other professionals for additional supports & assessments that are indicated Obtain authorization for releases of information for additional service providers so care can be coordinated & comprehensive

•

Include adult family members as full partners in action planning

•

Include the child at developmentally appropriate levels in action planning

•

Explanation is given to the child and family about all initiatives and interventions

• • •

Provide regular feedback, including positive growth, to the child & family Reinforce positive social skills for the child Educate child & family about educational & legal rights

• • •

Encourage family member advocacy on behalf of the child Support qualities that lead to hope and resilience in the child/family Facilitate a positive solution focused approach to issues.

Empowerment Checklist for Families Use the following checklist to help guide the approach of your family with professionals to be one that is empowering for the child. • •

Know the Laws and your Child’s Rights Come to meetings prepared with written questions and thoughts

•

Never leave a meeting until you are in full understanding of what took place and what is going to be the next step

•

Make sure any verbal agreements are put in writing

• • •

Take along a peer or other support person when needed Advocate for the best interest of your child Be willing to negotiate

•

Take notes and keep a list of people present at any meetings pertaining to your child

• •

Know your child and family strengths Document phone calls and make copies of letter correspondence

• •

Stay connected to the plan, asking for updates and feedback Provide information to professionals about how things are going at home and any changes whether positive or negative are occurring

• •

Be persistent and assertive Tell your child’s story

•

Keep the focus on what will support your child in reaching his/her goals

For a deeper understanding read: Empowering conversations: A Resource Guide for Team Building Between Families and Professionals to Support Action Planning for Young Children By Laura Beard, Lead Family Contact; Michelle Dipboye Sames, Early Childhood Empowerment Specialist, Kentuckyâ&#x20AC;&#x2122;s System to Enhance Early Development, Kentucky Partnership for Families and Children, Inc.

http://gucchdtacenter.georgetown.edu/resources/ECMHC/ECSOC%20Toolkit/KY%20Resources %20-%20Conversations%20with%20Families.pdf

3. Foundations of Empowering Interventions 1. Brief Solution Focused Counseling Research Support for the Tasks and Techniques of BSFC: The “Change Pie” The tasks and techniques of Brief Solution-Focused Counseling are supported by a large body of research on “common factors of change” in helping relationships. These factors, and their percentage contributions to successful outcomes, are based on over 1000 studies involving a wide range of clients, problems, settings, and practitioners. Client Factors (Accounting for 40% of change; the Filling). The client is clearly the most potent factor in counseling (some research indicates an even stronger influence than 40%). Client factors include the client’s life experiences, values, opinions, interests, successes, resilience, and role models. Counseling outcomes depend largely on the extent to which the client’s strengths, feedback, and other resources are integrated into therapeutic conversations and interventions (Gassman & Grawe, 2006). Brief Solution-Focused Counseling empowers client factors by helping people discover and apply their strengths and resources toward solutions. Relationship Factors (Accounting for 30% of change; the Crust). Relationship factors, the second most powerful ingredient of effective counseling, include people’s perceptions of respect, validation, and encouragement from the practitioner. Client involvement is the centerpiece of a strong therapeutic relationship. The client’s early ratings of the helper and helping relationship (during first couple sessions) are highly predictive of outcomes (Norcross, 2010). Brief Solution-Focused Counseling empowers relationship factors by involving people in every aspect of their care, by obtaining their feedback, and by adjusting services based on their feedback. Hope Factors (Accounting for 15% of change; the Anticipation). Hope factors refer to people’s belief that change is possible, and confidence in their ability to change in positive ways. Hope plays a key role in effective outcomes, though its influence is relatively smaller than client and relationship factors. Brief Solution-Focused Counseling empowers hope factors by treating people as resourceful and capable of changing, and by focusing on future solutions rather than past problems. Model/Technique Factors (Accounting for 15% of change; the Topping). Model/technique factors refer to the practitioner’s theory and related techniques. Given that no single counseling model or set of techniques has proven superior to others in overall effectiveness (Wampold, 2010), the most successful practitioners are flexible in their selection and application of therapeutic techniques. Brief Solution-Focused Counseling encourages practitioners to fit themselves and their techniques to clients instead of the other way around, and to try something different when one idea or technique is not working—in other words, don’t marry the model or techniques! Note: The factors above are applicable to any change-focused activity including group work, behavioral intervention, teacher/parent consultation, assessment, and systems-level change.

Brief Counselling Be kind whenever possible. It is always possible. — Dalai Lama Brief counselling is an approach to counselling characterized by a focus on resources and solutions rather than problems. The purpose of brief counselling is “to provide people with a pleasant experience that turns problems into challenges, fosters optimism, enhances collaboration, inspires creativity, and, above all, helps them to retain their dignity” (Furman & Ahola, 1994, p. 65). How Brief Counselling Helps Often counselling relationships are brief, sometimes limited to a few sessions, a single session, or even a brief encounter. Michael Hoyt (1994) reviewed the literature and found that single-session therapy is often the norm and that a significant number of clients and counsellors found it desirable and useful. In three systematic studies of the effectiveness of single-session therapy (SST), more than 50 percent of clients showed improvement (Hoyt, 1994, p. 41). Moreover, many people solve psychological problems without professional consultation. For others the “light touch” of a single visit may be enough, providing experience, skills, and encouragement to help them continue in their life journey (p. 153). Furthermore, a change in some part of a client’s life can affect other aspects of his or her life, including relationships with significant others. Thus, brief counselling that helps a client achieve some success (e.g., insight, reduction of painful feelings, new skills), however small, can have a dramatic long-term impact if it switches the client from a point of despair to a position of optimism and a ripple effect occurs. “When clients alter their behaviors ever so slightly, it causes a chain reaction in response to the initial change. Those affected by the change find themselves adjusting their responses, which in turn elicits further changes in clients” (Sklare, 1997, p. 11). De Shazer (1985) argues that it is not necessary to spend time searching for the root causes of a problem, nor is it necessary to have elaborate knowledge about the problem. In brief counselling the goal is to help clients do something different to improve their situation rather than repeat the same ineffectual solutions. Brief counselling may help in many ways. Because of its emphasis on action and change, brief counselling helps clients to become “unstuck” from ineffectual ways of thinking, feeling, and acting. Clients can be encouraged to reframe by focusing their attention on what’s working, thus interrupting their preoccupation with problems and failure. This focus may generate or renew the clients’ optimism that change is possible. In addition, brief counselling, even a single session, can be therapeutic for clients if they are able to unload pent-up feelings. A caring and empathic counsellor can encourage such ventilation and reassure clients that their reactions and feelings are normal. This can significantly reduce feelings of isolation by disputing the belief that many clients hold: “I’m the only one who feels this way.” Brief counselling can also provide important information to clients. For example, they can be referred to appropriate alternative services. Or they can be given information that might help them deal with their situation. Finally, brief counselling can be used to demystify the counselling process and to help clients understand what they might reasonably accomplish in counselling. In this way brief counselling may be useful for motivating reluctant clients to engage with or to continue with counselling. Brief or single-session therapy is not appropriate for all clients. It is less likely to be effective with these client groups: clients who need inpatient psychiatric care, including those who are suicidal; clients with

schizophrenia, bipolar disorder, or drug addiction; clients who need help in dealing with the effects of childhood abuse; and clients with chronic eating disorders (Hoyt, 1994). Selected Brief Counselling Techniques Precounselling Change Momentum for change is often established at the moment that clients seek counselling. Carpetto (2008) notes that studies have shown that changes frequently occur in the interval between the time clients make an appointment to see a counsellor and the first meeting. Thus, counsellors can make use of the fact that some clients realize progress while waiting for their first scheduled appointment. The Miracle Question A typical miracle question might be formulated as follows: “Suppose that tonight while you’re sleeping a miracle happens and your problem is solved. When you wake up, what will be different about your life?” Variations of this question may need to be developed to accommodate different clients. For example, some clients may object to the religious overtones in the question and a more neutral term, such as something remarkable, could be used. The example below illustrates the process: Counsellor: Suppose when you woke up tomorrow something remarkable has happened and your problem is gone. How would you know that your problem is solved? Client: Well, for one thing, I’d be worrying less. Counsellor: What might your family see as different? Client: I’d be more willing to get involved in family activities. Counsellor: Activities? Client: Things like sports, family outings—movies and so forth. Counsellor: What else would they find different? (Note: It is important for the counsellor to use probes such as this to elicit detail. If a change can be imagined, the more possible it will seem and the more the behavioural changes to make it possible will become apparent.) Client: I think that we’d be happier. Not just because we’re doing fun things together, but we’d be arguing less about money and our other problems. Counsellor: How much of this is already happening? The above excerpt shows how quickly the counsellor can move the interview to focus on solution possibilities. When clients engage with the miracle question they begin to identify potential changes that might occur, and they often become more hopeful about their situation. As Carpetto (2008) concludes, “they are already on their way to finding solutions to their problems” (p. 181). Since the client has imagined and described some of what needs to happen to solve the problem, the counsellor’s next task is to get clients moving in the direction of the “miracle” with questions such as “What would you need to do now to begin to move toward the miracle?” or “What would it take to make the first step?” Success Tip Capitalize on the possibility of precounselling change by asking questions such as, “Since making your appointment, have you noticed that things have improved in any way, however small?” If the response is positive, sustain this change movement by helping the client identify the feelings, thoughts, and behaviour associated with it.

Helping Clients Get on Track Counsellors need to shift their own thinking away from believing that they have to stay with clients until the clients’ problems are solved and their lives are in order. For example, counsellors might assist clients to organize their thinking about grieving, but the process of grieving is normal and might last a long time, and counsellors do not have to be present for the entire grieving process (Walter & Peller, 1994). Counselling ends with the client still grieving but with a much greater sense of control and of being on track. If clients have a plan in mind for dealing with their problems, they have the capacity to put that plan into action. Moreover, if they are already implementing that process, counsellors should consider getting out of their way. Looking for Exceptions Huber and Backlund (1991) propose working with the exceptions to the times when clients are having difficulty. They contend that regardless of the severity of their clients’ problems, there are moments when clients are managing their troubles. Moments when anxious persons feel calm, acting-out children listen to their parents, and angry people are peaceful can all be studied to discover potentially successful answers to chronic problems. Huber and Backlund believe that clients become fixated on their problems and on what doesn’t work. By doing so, they often fail to notice those times when their problems have abated. In fact, they often continue to repeat or exaggerate “solutions” that have already proved unworkable. Using this exceptions approach, counsellors ask clients to focus on those moments, however rare, when they are coping successfully. So when clients are asked, “What is different about those occasions when your child obeys you or at least responds more receptively to your requests?” or “What is different about those times that you’re not angry or only minimally upset?” the counsellor is requesting that clients report on experiences to which they have paid almost no attention. Consequently, they have given little or no credence to the more successful manner in which they were resolving what at other times they experienced as a persistent difficulty (Huber and Backlund, 1991, p. 66). Working with exceptions provides a dramatic and quick way to motivate and energize clients to think about solutions rather than problems. In the following brief excerpt, the counsellor uses the technique to assist a client who is having trouble dealing with her teenage son. Counsellor: From what you’ve been saying, it’s a rare moment when you and your son can sit together and talk calmly. Client: Maybe once or twice in the last year. Counsellor: Let’s look at those two times. I’m really curious about what was different about them that enabled you to talk without fighting. Pick one time that worked best. Client: That’s easy. My son was excited because he was going to a rock concert, and he was in a really good mood. I felt more relaxed too. He just seemed more approachable that day. Counsellor: Have you considered that part of your success might have to do with your mood? Perhaps your son was more approachable because you were more relaxed. Client: Interesting point. Counsellor: Let’s explore that a bit further. Because you were more relaxed, what else was different about the way you handled this encounter? Client: I didn’t feel stressed, so I think I was more open to listening to him. Counsellor: What were you doing differently?

Client: I let him talk without jumping in to argue. The counsellor’s goal in the above interview is to find what works and then to encourage the client to apply successful solutions more frequently. The process is as follows: 1. Identify exceptions to those times when the client is having difficulty. 2. Explore what was different about those times, including what (specifically) the client was doing differently. 3. Identify elements (e.g., behaviour, setting, and timing) that contributed to a successful solution. 4. Help the client increase the frequency of the success-related elements when dealing with the problem situation. Clients are often more experienced in using ineffectual strategies to deal with their problems. Despite the fact that these strategies do not work, clients may compulsively repeat them to the point where they give up and conclude that their problems are hopeless. Consequently, counsellors need to encourage clients to apply the elements of success. For example, a behavioural rehearsal (role play) that focuses on systematic exploration of the elements of success can be used. Counsellors also need to encourage clients to pay attention to what they are doing when they are managing their problem, as in the following case: Rodney came to counselling asking for help to quit what he described as “compulsive marijuana use.” He was concerned that he might slip into heavy drug use. The counsellor asked him to observe what he was doing when he was not using marijuana and what he did to overcome his urge to use. This technique empowered Rodney by helping him become aware of successful strategies he was already using. Subsequently, he was encouraged to increase the frequency of these successful behaviours. Success Tip When using the miracle question, it is important that the client, not the counsellor, generates the vision of the situation where the problem has been removed (response to the miracle question). Similarly, it is the client who must describe what changes or solutions need to happen for the miracle to occur. The role of the counsellor is to manage the exploration and solution-finding process. Finding Strengths in Adversity Hardships and difficulties often have positive spin-offs in that people develop skills to deal with their misfortunes or discover capacities that they did not know they had. Below are some sample probes: ■ How have you managed to keep going in conditions that would have defeated a lot of people? ■ You have dealt with this problem for a long time. Many people would not have survived. How did you manage to keep going? What strengths were you able to draw on? ■ What have you learned from life’s trials and tests? ■ Have hardships helped to shape your values and character in positive ways? ■ People often develop talents or discover strengths from facing challenges. How has this been true for you?

Using Solution Talk Furman and Ahola (1994) introduced the idea of “solution talk” as a way to evoke a solution-oriented focus to the counselling interview. The goal is to create a climate of discovery and action. For example, to get clients to notice their skills and capacities, counsellors can use statements and questions such as, “When you’ve successfully coped, how did you do it?” In addition, counsellors need to be alert for opportunities to reinforce clients’ strengths. Personal qualities, actions that underscore their determination, attitudes, positive decisions, accomplishments, effort toward change, and courage in the face of adversity can all be used to bolster clients’ sense of capacity and selfesteem. Clients may already have a rich understanding of their problems and the ways in which they might be solved. So counsellors need to tap their clients’ expertise about possible answers to their problems. The central assumption here is that clients have the capacity to resolve their distress. ■ What solutions have you already tried? ■ What would your best friend advise you to do? ■ Suppose one day you received an invitation to give a lecture to professionals about the kind of problem you have had to live with. What would you tell them? (Furman & Ahola, 1994, p. 51) ■ To solve your problem, what will you have to do? Creative solution finding can be stimulated with statements and questions such as these: ■ Let’s try to identify something different for you to do to solve your problem. ■ Let’s brainstorm ideas. Don’t censor anything. The wilder the idea, the better. Reframing is another a way to help clients modify their thinking. Reframing suggests another way of looking at problems, which in turn generates new ways of looking at solutions. Reframing is elaborated more in depth at another part of this guide. The miracle question (Sklare, 1997; Hoyt, 1994) can also be used to direct clients to think about solutions: ■ If a miracle occurred and your problem was solved, what would be different in your life? ■ How could you make that miracle happen? What would you have to do differently? A variation is to use the miracle question to probe for examples of success and exceptions to clients’ problems: ■ Tell me about the times when part of this miracle has already happened, even just a little bit (Sklare, 1997, p. 68). Success Tip Use a question such as, “What do you want to change about yourself today?” as a quick way to set a goaldirected sessional contract.

The Change Continuum Often clients are overwhelmed with the number and depth of their problems. Their despair can easily infect counsellors. The continuum is a tool to assist clients to become motivated in the direction of positive change. When clients can gain some control over their situation through small successes, this promotes further optimism and change. Counsellors do not have to be involved for the whole change process. Sometimes helping clients head in the right direction is the extent of their involvement. Kim, a young woman of 19 who is heavily involved in drugs, seeks counselling for help “to get her life in order.” Counsellor: (Uses a flip chart to draw the continuum depicted below.) Kim, think about an area of your life where you would like to make a change. The continuum represents things as bad as they could be if things got worse at one end, and your ultimate goal at the other end. Kim: I need to change my whole life. Counsellor: Where are you on the continuum? Kim: (Draws a circle.) I’m about here, pretty near the bottom. Counsellor: What direction are you heading? Kim: (Draws an arrow.) “My life is a mess, and it’s getting worse.” Counsellor: Maybe you’d agree that the direction you’re heading in is ultimately more important that where you are on the continuum. Kim: Absolutely, I can see that. Counsellor: So what’s one thing that would need to happen for you to change directions? Kim: That’s easy. I need a place of my own, and I need to get out of this area. Counsellor: Let’s start there and make that the focus of our work. Comments: The continuum has a number of useful features. It is visual, which makes it easier for some clients to understand. It is a quick way to prioritize complex problems and goals. This helps clients generate a sense of control and direction. Once completed, it provides shorthand communication for counsellors and clients. The two basic questions of the continuum can be used at the beginning of subsequent interviews to assess progress and to identify emergent issues: “Where are you on the continuum?” and “What direction are you headed?”

2. Cognitive Behavioural Counselling

Watch your thoughts; they become words. Watch your words; they become actions. Watch your actions; they become habits. Watch your habits; they become character. Watch your character; it becomes your destiny. —Frank Outlaw

Cognitive behavioural counselling (therapy), or CBT, has been empirically tested in hundreds of studies. The results have demonstrated its usefulness for a wide range of social, emotional, and mental health problems such as mood disorders (depression, bipolar disorder), anxiety disorders (obsessive-compulsive disorder, post-traumatic stress disorder), substance use problems, eating disorders, gambling problems, anger, personality disorders, stress, and unresolved grief (Butler, Chapman, Forman & Beck, 2006; Chamless & Ollendick, 2001). American psychiatrist Aaron Temkin Beck (1921–) is considered the founder of CBT. The central assumptions behind Beck’s approach are these: ■ Problems/distress is caused by faulty thinking (cognitive distortions) and negative interpretation; thus, our thoughts and beliefs affect our behaviour and emotions. ■ People may pay too much attention to anxiety-provoking stimuli rather than to neutral or positive stimuli. ■ Behaviour is learned; it can be unlearned. The key to changing problematic behaviour or emotions is to explore and modify distorted thinking, and then to learn and practise new responses. CBT focuses on understanding current thinking (the present) and problem solving to develop new behaviours. Marie and Aiesha are passengers on the same airline flight. Marie is consumed by her fear that the plane will crash, thinking, “This is a dangerous situation. What if the engines fail? And air turbulence will surely tear the plane apart.” Aiesha boards the plane and quickly immerses herself in a book with no intrusive thoughts of dying. Ellis (2004) developed the famous ABC model (Figure 7.2) as a tool for understanding why Marie and Aiesha experience the flight so differently. In the model: ■ A represents an activating event (in this case the airplane flight). ■ B refers to the beliefs that are triggered by the activating event, A. ■ C is the consequent emotion or behavioural reaction. Clearly, Marie’s beliefs about flying are markedly different from Aiesha’s. Cognitive behavioural counselling would concentrate on how Marie can modify her thinking about flying, which is based on erroneous and distorted beliefs about its dangers.

A Activating Event B Beliefs C Consequent Behaviour or Emotion Cognitive behavioural counselling uses a combination of methods to help clients learn more effective coping strategies, including: ■ helping clients recognize and modify thinking patterns ■ a wide range of techniques to help clients understand and modify behavioural patterns. This includes such tactics as “autopsies” (a detailed review of actions to see what went wrong), contingency planning, goal setting, relationship problem solving, anxiety management, and the use of homework. As well, exposure can be used in real or imagined situations to assist clients to systematically overcome anxiety. Drama Cycle/Drama Buster The Drama Cycle is • a repetitive, automatic pattern of behavior that is “thought-driven” followed by feeling, followed by action • pattern happens in a 4-part cycle that‟s complete within 30 seconds or less • words, issues, dishonored values, situations, &/or personalities trigger our “drama cycles.” • when our drama cycles are triggered, our communication becomes distorted & ineffective – it prevents effective listening • we tune out, prejudge, criticize, & condemn speaker, situation & self. The Drama Buster is a 4-step process to assist you to recognize and bust your drama cycle: Set 1: Thought_______________ Feeling________________ Action_________________ Set 2: Thought_______________ Feeling________________ Action_________________ Set 3: Thought_______________ Feeling________________ Action_________________ Set 4: Thought_______________ Feeling________________ Action_________________

Recognizing and Modifying Thinking and Core Beliefs Frequently, clients have difficulty breaking out of established patterns because of the way they think about issues or problems (De Bono, 1985). In addition, dysfunctional thinking patterns that affect reactions are frequently outside a client’s awareness. Success Tip If one’s thinking changes, behaviour and emotions also change. If one’s behaviour changes, thinking and emotions also change. If one’s emotions changes, thinking and behaviour also change. Understanding how one thinks is crucial to the change process because thoughts precede and influence feelings and behaviours. Momentary thoughts are heavily influenced by core beliefs or schema, so it is important to recognize that how one thinks is not necessarily driven by fact. Schema or core beliefs are defined as the “basic beliefs individuals use to organize their view of the self, the world, and the future” (Sperry, 2006, p. 22). Maladaptive beliefs can lead to distress, inaction, low self-esteem, depression, and reluctance to engage in healthy risk-taking such as initiating social relationships. Cognitive behavioural counselling helps clients to recognize automatic thoughts, identify “errors in thinking,” and explore how thoughts hinder them from reaching goals. Once clients become aware that an automatic thought is about to happen, they can practise replacing that thought with an alternative. This interrupts the repetitive cycle of problematic behaviour. On a broader level, clients learn to understand and modify schemas that drive dysfunctional behaviour and painful emotions. Example: A new social setting triggers Troy’s automatic thoughts: “I don’t belong. I won’t fit in.” These thoughts originate from his core belief, “I am unlovable.” His automatic thoughts and his core beliefs create anxiety and fear. His strategy is to use drugs to curb his anxiety, which in turn lead to the new belief that he won’t be able to cope unless he uses drugs. Maladaptive (unhealthy) and Adaptive (healthy) beliefs • I am unlovable.

• I am a person worthy of love and respect.

• To seek help is a sign of weakness.

• I can ask for and offer assistance.

• Without a relationship partner, I am nothing

• I am responsible for my own happiness

• I will fail. I am helpless.

• I will do my best, savour my success, and learn from my mistakes.

• I have to be loved by everyone.

• I accept that not everyone will love me.

• I must be perfect in everything that I do

• I accept my limitations; they do not diminish me.

• I must be seen by others as the best. • I am special; I can take advantage of others

• My rights as well as the rights of other people need to be respected.

Common Thinking Errors Since major errors in thinking may be outside one’s awareness and can easily lead to faulty interpretations and maladaptive behaviour, it is important to understand the major types of thinking errors, such as distortion, selective attention, magnification/minimization, perfectionism, and self-defeating thought.

Distortion Distortion results from misinterpretations, faulty assumptions, or cultural biases. Here are some common examples: ■ Misreading another person’s silence as lack of interest (mind reading). ■ Assuming that others should know what we want, need, or feel without being told. ■ Interpreting lack of eye contact as a sign of disrespect or lying when, in fact, the other person is from a culture where direct eye contact is discouraged. Selective Attention Selective attention errors arise from a failure to look at all aspects of a problem or situation. For example: Only listening to information and facts that support your point of view. De Bono (1985) made this important observation: “Unfortunately, Western thinking, with its argument habits, prefers to give a conclusion first and then to bring in the facts to support that conclusion” (p. 35). Rigid thinkers act as if to say, “We’ll keep talking until you agree with me.” ■ Selective memory: This behaviour involves recalling only selected aspects of the past. We might overlook events or facts that threaten our self-image. Conversely, people with low self-esteem may overlook evidence to the contrary, remembering only their failures and mistakes. ■ Losing focus on what a person is saying: This happens because of factors such as lack of interest, preoccupation with other thoughts, or distracting noise. ■ Focusing only on the present: For example, prison inmates may overestimate their ability to cope with life outside jail. They may become clouded by unrealistic optimism that they will be able to avoid getting caught again or beat any charges if they are caught. In addition, they may neglect to consider the longterm consequences of their criminal behaviour, a pattern of thinking that is characteristic of lifestyle or habitual criminals. Walters (1991) reached this conclusion: “Until high rate offenders realize the selfdestructive nature of their super-optimism, they will continue to resist change because they are operating on the mistaken belief that they can get away with just about any crime” (p. 36). Walters sees lazy thinking as the root of the offenders’ problems. Even those with the best of intentions may find themselves in trouble because they fail to think about long-term outcomes. ■ Egocentric thinking: Errors of this kind come from a failure or inability to consider other people’s ideas or to look at how one’s behaviour affects others. People may adopt an arrogant position of selfrighteousness, confident that their ideas and conclusions are sound. Egocentric thinkers are likely to be seen by others as aggressive and insensitive, interested in meeting only their own needs. Egocentric thinkers are not only poor thinkers but also poor listeners. Typically, they believe that the purpose of thinking, listening, and responding is to prove themselves right. De Bono (1985) contends that selfprotection is a major impediment to their thinking: “The main restriction on thinking is ego defence, which is responsible for most of the practical faults of thinking” (p. 29). Magnification/Minimization These types of thinking errors distort facts by extreme and exaggerated thinking. Some examples: ■ Splitting—the tendency to interpret people, things, and experiences as either totally good or totally bad, with no shades of grey.

■ Overgeneralization—drawing conclusions from a single fact or event. For example, after being turned down for a job, a man concludes that he is worthless and no one will ever hire him. ■ Discounting—rejecting compliments by refusing to believe that the other person is telling the truth. ■ “Catastrophizing”—magnifying small mistakes into disasters or total failures. Perfectionism Healthy individuals set realistic, challenging, and achievable goals. They are motivated to do their best and they maintain high standards for themselves. Conversely, people who are perfectionist set unrealistic standards of achievement with an expectation of constant success. Perfectionist individuals are under constant stress caused by the anxiety to perform, or the realization that they have failed to reach or sustain their unrealistic expectations of self. Irrational beliefs that arise from perfectionism include: ■ I can’t make a mistake. ■ I am a failure if I am less than perfect. ■ I have no value unless I achieve the very best. ■ If I can’t be perfect, then I might as well give up. ■ I have to be the best. To win is the only option. ■ I’m probably going to fail anyway, so why try? The personal cost of perfectionism can include chronic pessimism, low self-esteem, lack of confidence, depression, anxiety, and obsessive concern with order and routine. Perfectionists frequently use the words must, only, always, never, and should (the MOANS acronym). Self-Defeating Thoughts Self-defeating thoughts are irrational ideas about one’s own weaknesses. Albert Ellis has written a great deal about what he defined as irrational thinking and its impact on emotions and behaviour (2004, 1993a; 1993b; 1984; 1962). Ellis argues that people’s belief systems influence how they respond to and understand problems and events. When their beliefs are irrational and characterized by an unrealistic should, they are likely to experience emotional anxiety or disturbance. This thinking is often accompanied by self-depreciating internal dialogue: “I’m no good,” “Everyone must think I’m an idiot,” and “No one likes me.” Ellis concludes that irrational beliefs fall into three general categories with associated rigid demands or shoulds: 1. “I (ego) absolutely must perform well and win significant others’ approval, or else I am an inadequate, worthless person.” 2. “You (other people) must under all conditions and at all times be nice and fair to me, or else you are a rotten, horrible person!” 3. “Conditions under which I live absolutely must be comfortable, safe, and advantageous, or else the world is a rotten place, I can’t stand it, and life is hardly worth living” Wicks and Parsons (1984) offer a similar perspective when they suggest that many clients are discouraged because they set unattainable goals: “These goals are often based on irrational, simplistic views: (1) if a person acts properly, everyone will like him; and (2) either a person is totally competent or he is completely inadequate” (p. 170).

Helping Clients Change Thinking Patterns When people learn to pay attention to their thoughts, they are more apt to test the reality of the truth of their beliefs. When people learn to recognize those thoughts that are dysfunctional, perhaps because they impede action and goal attainment or they cause distress, they can take steps to change their thinking. Among the strategies that counsellors can use to assist clients to change maladaptive thinking are the following: ■ reframing ■ encouraging clients to seek out information and data ■ suggesting to clients that they talk with others about their assumptions ■ Socratic questioning targeting overlooked areas ■ direct challenge of the validity of beliefs ■ teaching empathic skills as a way to help clients learn about other perspectives ■ brainstorming to generate new ideas and explanations ■ thought-stopping techniques to overcome self-defeating inner dialogue Here are some examples of questions that can be used to help clients shift perspective: ■ How are your thoughts consistent with the evidence? ■ How do you know this to be true? Do you have facts or are you assuming? ■ What are some other ways of thinking about your situation? ■ If a friend thought this way about his situation, what would you say to him? Reframing Reframing is a counselling skill that helps clients shift or modify their thinking by suggesting alternative interpretations or new meanings. It empowers clients by focusing on solutions and redefining negatives as opportunities or challenges. Client stubbornness might be reframed as independence, or greediness as ambitiousness. Example: Carl, age 11, is playing baseball by himself. He throws the ball into the air and exclaims, “I’m the greatest batter in the world.” He swings and misses. Once again, he tosses the ball into the air and says, “I’m the greatest batter in the world.” He swings and misses. A third time he throws the ball into the air proclaiming emphatically, “I’m the greatest pitcher in the world.” Success Tip Help clients practise thought stopping to break the pattern of repetitive self-defeating thought patterns. Techniques include thought replacement (immediately substituting rational ideas or pleasant thoughts for unwanted ones), yelling “stop” in one’s mind until the undesired thought disappears, snapping an elastic band on the wrist to shift thinking, and activity diversion. Before presenting reframed ideas, counsellors should use active listening skills to fully understand the client’s current perspective. As well, empathy is crucial; otherwise, clients may conclude that their feelings are being discounted or trivialized. Moreover, reframing should not be confused with platitudes, such as “It’s always darkest just before dawn,” which are typically not very supportive or helpful. An example of a well-meaning but misguided reframe that people give in times of grief over the loss of a child is “You’re young—you can have more children.” “Because strong emotions of sadness and loss are present, most people cannot accept a

reframing that does not take into account the most salient feature of their experience—the grief itself ” (Young, 1998, p. 282). Reframing should not trivialize complex problems with pat answers; rather, it should offer a reasonable and usable alternative frame of reference. Client’s Perspective or Statement

Counsellor’s Initiative to Reframe

This counselling is a waste of time.

Sounds as if you’ve done some thinking about how our work could be more relevant to you.

I don’t fit in. I come from a different culture and my ideas and values must seem strange.

Of course. Some people have not had much experience with your culture, and they may be frightened. Perhaps you could look at this in a different way. Your experiences might also be fascinating for people who have not lived outside the country. They might welcome your fresh ideas.

I’m very shy. When I first join a group, I usually don’t say anything.

You like to be patient until you have a sense of what’s happening.

People who are impulsive are working to develop this skill.

You also seem to want to develop alternatives, such as being more expressive in the beginning.

For the first time in 20 years, I’m without a job

Obviously, this is devastating. At the same time I wonder if this might also be an opportunity for you to try something different.

Whenever I’m late for curfew, mother waits up for me and immediately starts screaming at me.

I’m curious about why she might do this. Perhaps she has trouble telling you how scared she is that something may have happened to you. It might seem strange, but her anger could be her way of saying how much she loves you.

My life is a mess. I’ve lived on the streets for the last six months.

Sounds like you’ve had to survive under conditions that might have defeated most people. How did you do that?

Success Tip The fact that a client firmly defends a lifestyle that he knows is unworkable is proof that he is in need of great assistance and support. (Wicks & Parsons, 1984, p. 171) Clark (1998) offers guidelines for using reframing: 1. Use reframing to help clients break out of thinking that is self-defeating, constricted, or at an impasse. 2. Make sure that clients are not so emotionally distracted that they are unable to hear or process the reframed idea. 3. Offer a reframed idea in a tentative way that invites consideration. 4. Ensure that reframed ideas are plausible. 5. Allow clients sufficient time to consider a reframed idea. Clients with firmly entrenched perspectives may not immediately accept logical and sound reframes, but with gentle persuasion and patience they may

begin to accept new ideas. Even though it may be obvious that a client’s thinking is distorted, it may be wise to hold back on reframing until the client’s problem is fully explored. Moreover, as suggested above, it is important that the client’s feelings be acknowledged through empathy. Exploration and empathy ensure that the counsellor understands the client’s feelings and situation, and they provide a basis for the client to consider reframed ideas as reasonable or worthy of consideration. If counsellors push clients too quickly, clients may feel devalued and misunderstood, and in response they may resist new ideas. Empathy helps counsellors to establish and maintain credibility with their clients. In addition, counsellors can use directives to invite clients to use different language to describe the distorted idea (Young, 1998). For example, when clients avoid responsibility for their actions with statements such as “I can’t get organized,” counsellors can challenge them by proposing that they rephrase with statements such as “I won’t let myself get organized.” A client might say, “She makes me feel hopeless.” In response, the counsellor can propose that the client rephrase the statement by stating, “I have decided to feel hopeless.” The latter response underscores the client’s control over personal feelings. As part of this work, counsellors can empower their clients by explaining that clients have ownership over their feelings and that no one can make them feel a certain way. After offering a reframe, counsellors should check for the client’s questions and reactions to it. Then, if the reframed idea is accepted, they can encourage further exploration and problem solving based on the new perspective. Reframing can energize clients. When clients are locked into one way of thinking about their problems, their solutions are limited. But when they consider new perspectives, problems that seemed insurmountable can yield new solutions. Moreover, reframing can serve to redirect client anxiety away from self-blame and onto other rational explanations that are less self-punishing. In these ways effective reframing empowers clients to action, problem resolution, and management of debilitating feelings. When counsellors “consider the question, ‘What’s good about it?’ they give clients new perspectives on positive things that are already happening” (Miley, O’Melia, & DuBois, 2004, p. 327). Cognitive Behavioural Techniques The following interview excerpt illustrates some of the essential strategies of cognitive behavioural counselling. The client, a 40-year-old first-year university psychology student, has sought help to deal with the fact that she has been “overwhelmed and depressed” since returning to school. Dialogue Counsellor: As we discussed, one of the things we will do during our sessions is to explore how your thinking affects your feelings and your behaviour. Analysis Cognitive behavioural counselling requires a collaborative relationship. An important component of this is educating the client on how the process works. This will also help the client to make her own interventions when she recognizes problematic thinking. Client: I’m at the point where, if I don’t do something fast, I’m going to lose the whole term. I might as well drop out. Counsellor: You’re feeling desperate. Analysis

In all phases of counselling, empathy is an important response. More than any other skill, it tells clients that they have been heard and that their feelings have been understood. Counsellor: Can you remember a time in the last few days when these feelings were particularly strong? What was going through your mind at the time just before class? Analysis Eliciting and exploring examples such as this provides a database for helping this client understand how her thoughts contribute to her feelings. Significantly, probes to discover thinking patterns may reveal “inner dialogue” (self-defeating thought patterns) or images. Client: Yesterday, I was scheduled to make my first class presentation. I was thinking that I was going to make a fool of myself in front of the whole class. Everyone else seems so confident when they talk, but I haven’t been in school for 20 years. Counsellor: And that made you feel . . . Client: Stupid and terrified. I finally phoned in sick. Counsellor: So, here we have an example of how what you were thinking—“I’m going to make a fool of myself”—influenced how you were feeling and what you did. Does this make sense to you? Let’s use the ABC model to illustrate it. (The counsellor uses a flip chart: A [activating situation]—thinking of making the presentation; B [belief]—“I’m going to look like a fool”; C [consequent emotion]—fear, feeling overwhelmed. Counsellor: If you agree, I’d like to ask you to make notes during the next week when you find yourself feeling worse. When this happens, I want you to pay attention to what’s going through your mind. Analysis Earlier the counsellor and the client discussed the essential elements of cognitive behavioural counselling. Now the client’s example can be used to reinforce the principles. Using a flip chart or drawing is very helpful for many clients, particularly for those who are less comfortable in the verbal modality. Homework is essential to effective cognitive behavioural counselling. Here, the homework creates an opportunity for the client to become more familiar with how her feelings and behaviour are intimately connected to her thinking. In the next session (excerpted below) the counsellor uses reframing and thought stopping as tools to help the client change her thinking. Counsellor: Your journal is great. You’ve identified lots of great examples. Let’s try something different for a minute. What if it were possible to look at your fears differently? (Client nods approval.) Analysis The counsellor introduces the possibility of reframing. Counsellor: I think it’s natural when we have a problem to dwell on all its unpleasant aspects. I know that I tend to do that unless I discipline myself not to. For example, when you think of how nervous you are, you think of all the negatives, such as you might make a fool of yourself, or your mind might go blank while you’re talking.

Client: (Laughs.) Or that I might throw up in front of everyone. Counsellor: Okay, those are real fears. But by considering only your fears, you become fixated on the negatives and you may be overlooking some important positives. If you can look at it differently, you might discover a whole new way of dealing with your class presentation. Counsellor: Want to try it? (The client nods.) Okay, try to identify some positive aspects of your fear. Client: Well, I guess I’m not the only one who is scared of public speaking. Counsellor: So you know that there will be other people in the class who understand and will be cheering for you to succeed. Client: I never thought of that before. Here’s another idea: Because I’m so nervous, I’m going to make sure that I’m really prepared. Counsellor: Great! Do you think it might be possible to look at your fears differently? Consider that it’s normal to be nervous. Or go a step further and look at it positively. Maybe there’s a part of it that’s exciting — kind of like going to a scary movie. Analysis The counsellor’s short self-disclosure communicates understanding and a nonjudgmental attitude. One tenet of cognitive behavioural counselling is that people tend to pay too much attention to the negative aspects of their situations while ignoring positives or other explanations. As a rule, it’s more empowering for clients to generate their own suggestions before counsellors introduce their ideas and suggestions. In this way clients become self-confronting and are more likely to come up with ideas that they will accept as credible. In this example the client is able to generate a reframe, which the counsellor embellishes. In other situations, counsellors might introduce reframes of their own. The counsellor offers the client a reframed way of looking at nervousness. Client: I did come back to school because I hated my boring job. One thing is for sure, I’m not bored. Counsellor: So the more you scare yourself, the more you get your money’s worth. (The counsellor and the client laugh.) Counsellor: Here’s an idea that works. If you agree, I’d like you to try it over the next week. Every time you notice yourself starting to get overwhelmed or feeling distressed, imagine a stop sign in your mind and immediately substitute a healthier thought. Analysis The client’s response suggests that this notion is plausible. Spontaneous humour helps the client see her problems in a lighter way (yet another reframe). Another example of counselling homework. The counsellor introduces thought stopping— a technique to help clients control self-defeating thinking (Gilliland & James, 1998; Cormier &

Cormier, 1985). The basic assumption is that if self-defeating thoughts are interrupted, they will eventually be replaced by more empowering, positive perspectives. At this point the counsellor could also help the client develop different choice strategies for dealing with dysfunctional thinking, such as an activity diversion to shift attention, use of a prepared cue card with a positive thought recorded, imagining success, or substituting a different image. Making behavioural changes Goal Setting Obstacles are those frightful things you see when you take your eyes off your goals. (Anonymous) Goal setting is a counselling process that helps clients define in precise, measurable terms what they hope to achieve from the work of counselling. Two types of goals are outcome goals and process or task goals (Shebib, 1997; Jacobs, Masson & Harvill, 1998). Outcome goals relate to what the client hopes to achieve from counselling. These goals have to do with changes in the clientâ&#x20AC;&#x2122;s life, such as getting a job, improving communication with a spouse, dealing with painful feelings, or managing self-defeating thoughts. Process goals concern the procedures of counselling, including such variables as the frequency of meetings and the nature of the counselling relationship. Process goals are strategies for reaching outcome goals. In practice there may be some overlap between process and outcome goals. For example, a process goal might be to develop trust in the counselling relationship. Success in achieving this process goal might assist the client in achieving an outcome goal targeted at improving communication with family and friends. There is wide support in the counselling literature for the importance of setting goals (Egan, 1998; Young, 1998). Goal setting serves many important purposes, including giving direction, defining roles, motivating, and measuring progress. Giving Direction Goals help to give direction, purpose, and structure to the work of counselling. Moreover, goals help counsellors and clients decide which topics and activities are relevant. In addition, when clients are clear about their goals, they can begin to structure their thinking and action toward their attainment. Finally, setting goals helps clients make reasoned choices about what they want to do with their lives. Goal setting helps clients prioritize these choices. Defining Roles Goals provide a basis for defining roles. When goals are clear, counsellors know which skills and techniques are appropriate, and clients know what is expected of them. Moreover, when counsellors know the goal of the work they can make intelligent decisions regarding whether they have the skills, capacity, and time to work with the client. If not, they may make a referral. Motivating Goals motivate clients. Setting and reaching goals is also therapeutic. It energizes clients and helps them develop optimism and self-confidence about change. Goal achievement confirms personal capacity and further promotes action. Writing down goals may add an extra measure of motivation.

Measuring Progress Goals help provide benchmarks of progress, including defining when the counselling relationship should end—that is, when the goals have been reached or their pursuit is no longer viable. Developing Effective Goal Statements Sometimes clients are able to clearly articulate what they hope to achieve as a result of counselling. At other times they have difficulty identifying their goals; however, through systematic interviewing counsellors can help these clients define and target their goals. In addition, counsellors can use their knowledge base to develop simple checklists of potential goals, customized to the common needs and problems of particular client groups. However, these goals should always be concrete, measurable, challenging but realistic, and “owned” by the client. Effective Goals Are Concrete One defining feature of a counselling relationship is its goal-directed nature. But some clients begin counselling with vague and undefined goals: ■ “I want to feel better.” ■ “My husband and I need to get along better.” ■ “I need to make something of my life.” These goals are starting points, but they are useless until they are described as clear and concrete targets. Beginning phase work that explores problems and feelings should lead to the development of goals that define and structure subsequent work. Then in the action phase clients can develop these goals as specific and measurable targets. This step is a prerequisite for action planning—the development of strategies and programs to achieve goals. Vague goals result in vague and ill-defined action plans, whereas explicit goals lead to precise action plans. Concreteness is the remedy for vagueness. Concreteness can add precision to unclear and ambiguous goals. For example, when clients are describing their goals, counsellors can use simple encouragers, such as “Tell me more” and “Yes, go on” to get a general overview of what clients hope to achieve. This is the first step in shaping workable goals. The next step is to use questions to identify goals, define terms, probe for detail, and develop examples. This step helps to cast the emerging goals in precise language and move from good intentions and broad aims to specific goals (Egan, 1998). Listed below are some examples of probes and directives that might be used to start the process: •

What is your goal?

•

When you say you’d like to feel better, what exactly do you mean?

•

Describe how your life would be different if you were able to reach your goal. Try to be as detailed as possible.

•

If your problem were to be solved, what would need to be different in your life?

•

What do you think would be the best resolution to your problem?

•

What are some examples of what you would like to achieve?

•

As a result of counselling, what feelings do you want to increase or decrease?

•

What do you want to be able to do that you can’t do now?

•

If I could watch you being successful, what would I see?

Some clients are reluctant or unable to identify goals, and they may respond with a dead-end statement such as “I don’t know” when they are asked for their goals. To break this impasse, counsellors can use

100

some of these responses: “Guess.” “What might your best friend (mother, father, teacher, etc.) suggest as your goal?” “What would you like to achieve but don’t think is possible?” A good general technique is to encourage clients to visualize themselves reaching their goals. Success Tip When clients say, “I don’t know,” don’t rush in too quickly with another question or comment. Often, after a short silence, clients will generate new ideas, feelings, or thoughts. Note also that when clients say, “I don’t know,” their responses may indicate friction in the counselling relationship and this answer is a way of sabotaging the work. In such cases goal setting might be premature, and the focus of the interview may need to shift to relationship problem solving (immediacy). Moreover, when clients say, “I don’t know” they might also be saying, “I can’t do it” or “I’m afraid.” In such situations suggesting a very small goal may be a starting point (e.g., “If you could make just one tiny change in your life, what would it be?”). The miracle question (de Shazer, 1985; Carpetto, 2008) is widely used in brief and single-session counselling as a way to help clients shift their thinking away from problems to goals and possibilities for change (more on the miracle question below). Effective Goals Can Be Measured When goals are measurable, clients are able to evaluate progress and they know precisely when they have reached their goals. Moreover, clear goals sustain client enthusiasm and motivation. Vague and unmeasurable goals, on the other hand, can result in apathy and vague action plans. Thus, goals need to be defined in terms of changes (increases or decreases) in behaviours, thoughts, or feelings. •

Example (skill): “My goal is to express my opinion or ask a question once per class.”

•

Example (thoughts): “My goal is to manage self-depreciating thought patterns by substituting positive affirmations.”

•

Example (feelings): “My goal is to reduce anxiety.”

Help clients frame goals in quantifiable language with questions such as “How often?”, “How many times?” and “How much?” Goals should also have a realistic schedule (a target date to start working on them and a target date to reach them). For example, “Target weight reduction of 9 kilograms in ten weeks” or “Make five calls per day to potential employers.” Effective Goals Are Challenging but Realistic A goal has to be something that clients can reasonably expect to achieve, even though it may require effort and commitment. So counsellors need to consider variables such as interest in achieving the goals, skills and abilities, and resources (including the counsellor) available to help in reaching the goals. In addition, the goals need to be significant enough to contribute to managing or changing the core problem situation. But some clients may be reluctant to set challenging goals or even to set goals at all.

101

This situation can occur for a number of reasons: ■ poor self-esteem ■ fear of failure ■ lack of awareness of capacity for change ■ fear of change and reluctance to give up established patterns ■ lack of resources to support pursuit of the goal (Shebib, 1997, p. 210) So addressing these reluctance issues is a prerequisite for goal setting. When problems are complex and the client’s capacity or self-esteem is low, setting short-term goals or subgoals is particularly useful. Short-term goals represent small, attainable steps toward long-term goals. Achieving them helps build optimism and helps clients overcome a sense of inadequacy (Pincus & Minahan, 1973). Effective Goals Are “Owned” by Clients Clients need to see goals as relevant to their needs and consistent with their values. Thus, when clients are involved in the process of deciding what their goals are, they are more likely to be motivated to work toward achieving them. Counsellors can suggest goals, as in the following example: Evelyn was referred to the counsellor for help in coping with Trevor, her 18-year-old stepson, who was involved in petty crime. Evelyn’s immediate goal was to encourage Trevor to move out of the house, and she hoped that the counsellor might help her do this. During the interview it became apparent to the counsellor that Evelyn needed help developing parenting skills for dealing with Trevor and her two other teenage stepsons. Without dismissing Evelyn’s objective, the counsellor suggested that this be part of their agenda. When clients are forced to come to counselling by a third party, they may not feel committed to any of the goals of counselling. Thus, the chances of success are diminished greatly unless some mutually acceptable working agreement can be reached. Understanding a client’s values is an important part of goal setting. Some clients are motivated by spiritual values, some by material gain, and others by family values. Other clients focus on immediate gratification, while still others have objectives that are long-term. Ming left his family in China to come to North America. He has seen his wife only once in the last five years, when he returned to China for a short visit. He maintains regular contact with her and their six-yearold son. He sends much of his monthly pay home to support his wife and extended family. Although he hopes that one day his family will be able to join him, he has accepted that his purpose is to position future generations of his family for a better life. Sometimes clients set goals that require others to change, such as “I want my husband to stop treating me so badly.” Counsellors need to encourage clients to form goals based on what is under their control, namely their own feelings, behaviour, and thoughts. Client complaints and problem statements can usually be reframed as positively worded goal statements.

102

Here are some examples: Example 1

Client: Everyone always takes advantage of me. Counsellor: Sounds as though you’d like to learn to stand up for yourself.

Example 2

Client: I’m tired of not working. Counsellor: Put simply, your goal is to get a job.

Example 3

Client: My life is a mess. Counsellor: You would like to find a way to get your life in order.

The above responses change the focus of the interview from problems to goals. Of course, the counsellor and client will have to work together to shape these vague goals into more explicit terms. The overall goal of any counselling relationship is change. But, depending on the needs of individual clients, the targets for change might focus on behaviour, feelings, thoughts, skills, relationship enhancement, or other areas of the client’s life. Target Area

Vague Goal

Specific Goal Statements

Behaviour

To do better in my courses

To improve my grade-point average from C to B by the end of the semester

Feelings

To feel better

To overcome depression so I am able to enjoy Life. That would include mixing socially with people and having a sense that life is worth living. I’ll be more able to accept my problems without withdrawing or drowning in self-pity.

Thoughts

To stop putting myself down

To regard mistakes as normal and as learning opportunities. When I’m successful, I’ll take credit. Overall, I’ll be able to say to myself that I’m capable.

Skills

To get organized

To develop skill at organizing my time and setting priorities. I need to set up a schedule so I can plan at least a month in advance.

Relationship

To be able to communicate better

To reduce the number of fights that we have by not being so explosive. Instead of yelling, I need to remain calm. Instead of husband not listening, I need to check with him to make sure I understand what he wants, too.

Health and fitness

To get in shape

To lose 5 kg over the next two months; to increase my weekly running from 5 to 10 km

Spiritual

To be closer to God and nature

To make meditation a daily part of my life. To read something spiritual at least once a week. To walk in the forest three times a week

103

Action Planning Counselling is a developmental process. In the beginning phase, the focus is on the development of a strong working relationship based on a contract that describes the work to be done and the respective roles of both the counsellor and the client. The beginning phase is also concerned with problem identification and exploration. This work provides the foundation for clients and counsellors to define goals. So attention to detail in the beginning phase helps prevent problems from premature action. Problem exploration leads to goal setting, which in turn forms the foundation for action planning. Problem Exploration -> Goals -> Action Planning Some clients will need additional coaching and support to develop and implement systematic action plans to avoid the New Year’s resolution syndrome. Action planning and implementation consists of a series of steps leading to the client’s goal (or subgoal). Put simply, action planning involves developing strategies to help clients get where they want to go. This involves four steps: (1) identify alternatives for action, (2) choose an action strategy, (3) develop and implement plans, and (4) evaluate outcomes. Step 1: Identify Alternatives The first task in selecting a plan is to list alternative ideas for achieving the goals. This step serves two purposes. First, it holds clients back from impulsive action based on the first alternative available, which may simply be a repeat of previous unsuccessful attempts at change. Second, it helps ensure that clients have choices based on a full range of possibilities. When there is choice, clients can make more rational decisions. Brainstorming is one way to quickly generate a list of possibilities. To encourage clients to generate ideas, counsellors can use leads such as these: “Let your imagination run wild and see how many different ideas you can come up with that will help you achieve your goals.” “Don’t worry for now about whether it’s a good idea or a bad one.” Sometimes counsellors can prompt clients to be creative by generating a few “wild” ideas of their own. The following interview excerpt illustrates goal-setting techniques. Prior to this dialogue, exploration and active listening enabled the counsellor to develop a solid base of understanding. With this work apparently finished, it seems timely to move on to goal setting. Dialogue Counsellor: You’ve talked about how you’re determined to change—as you put it, “now or never.” That suggests to me that you’re ready to set a change goal. Client: Yeah, I can’t go on living like this. Something has to happen, and soon. Counsellor: I think it might be helpful at this point to figure out what you want to achieve, what you’d like to change. This would give you something to work toward. What do you think? Client: Sounds good. I think it’s time to do something. For one thing I really haven’t invested too much in my marriage. I have to change my priorities. Counsellor: What do you mean by “change your priorities”?

104

Client: If possible, I’ve got to stop spending so much time at work. By the time I get home I’m so tired that I have no energy or motivation to be involved with my family. Counsellor: Okay, I think I get a sense that what you’d like is to be more committed to your family. To do that, you’d have to cut back on work. Client: Exactly. Counsellor: Just so we can be clear, can you try to be more specific? Suppose you’re successful. What will be different from the way things are now? Client: I don’t understand. What do you mean? Counsellor: Well, maybe you can’t plan it out exactly, but what do you see happening in terms of the amount of time you’d like to spend with your family? Try to be specific, so you’ll have something to aim for. Client: (Laughs.) Oh, I see. You want to nail me down and close the deal. You should be a salesperson. Well, I think it’s important that I free up the weekends and at least two nights a week. Sunday should be strictly family time, a time to do something with the kids. Counsellor: From your excited tone I get the sense that you’d feel really good if you could do that. Client: In my heart it’s what I’ve always wanted. Counsellor: A while back you used the words “if possible” when you talked about cutting back on work. What problems do you anticipate? Client: I’d like to try for a management position at the company, but everyone’s so competitive. I’ve got to put in the hours if I’m going to keep my sales above the others. And high sales is the first thing they look for when it’s time for promotion. Counsellor: You’re torn. To compete, you’ve got to put in the hours. But if you do that, it takes away from your time and energy with the family. That’s a lot of stress. Client: Now that you point it out, it seems obvious. I’ve been under stress for so long I don’t even think about it anymore. It’s clear to me now that the price of success is just too much. (continued) Analysis The counsellor recognizes the client’s positive motivation for change and uses it to make a transition to goal setting. Problem statements can often be reframed to make goal statements. The client makes a general statement confirming motivation for change. This undeveloped goal is a useful starting point, but it is not yet an operational goal. The counsellor seeks to contract with the client to work on goal setting. The counsellor uses the criteria for effective goals as a reference point. As the interview progresses, other questions will be asked that help frame the goal. There is no secret agenda to this, and the counsellor might decide to review the process with the client. The final open question reaches for client input and agreement. The client begins to identify an area for change. The counsellor requests more definition (goal specificity). This ensures that no assumptions are made. Often, as here, client goals are stated in the negative — that is, in terms of what the client would like to stop doing. The counsellor attempts to help the client put an emerging goal statement in behavioural terms by reframing the idea. This request for more specificity encourages the client to reframe the goals in positive terms by stating what will be done differently. The client is confused, but the relationship is strong enough that the client is able to ask for help.

105

The counsellor clarifies the question. This helps to educate the client regarding some of the criteria for goal setting. A clear goal statement has emerged, but the work is not yet finished. Empathy lets the client know that the counsellor has recognized the client’s feelings and their importance. The client confirms acceptance of the counsellor’s empathy. An important part of goal setting is to assist the client to look at potential problems, including the relative advantages and disadvantages of goal attainment. Having identified this potential barrier, the client can address it — for example, by considering ways to overcome it — or make a decision about whether the costs involved are too high. The counsellor recognizes the client’s ambivalence. Solutions to problems, however obvious, are often not acted upon because of such ambivalence. (continued) Dialogue (continued) Counsellor: Meaning that if you have to sacrifice time with your family to get ahead, you’re not interested. (Client nods.) Sounds as if you’ve made a decision, but let me play devil’s advocate. Suppose you cut back on your job and lost a promotion. How would you feel about that? Client: It would be hard on me, but I think not nearly so hard as what’s happening now. At heart I’m really a family man. I’m certain of it. Family has to be number one. My career is important to me, but it’s my second priority. Counsellor: Let’s go back to your goal. What other problems do you anticipate? (20 seconds of silence.) Client: Here’s one. My family is so used to getting along without me, they’ve developed lives of their own. I guess I can’t expect them to drop everything for me. Counsellor: So how can you deal with that reality? Client: That’s easy. I guess I’ll just have to negotiate with the family on how much time we’ll spend together. Counsellor: One thought occurs to me. How will your boss react if you suddenly start spending less time on the job? Do you think that’s something to consider? Analysis (continued) The counsellor’s empathy provides a basis for insight. Such responses ensure that the client will not gloss over or minimize difficulties. The counsellor also prevents the client from acting impulsively. By anticipating risks, the client is challenged to decide whether the costs are acceptable. The client confirms a decision. If the counsellor is satisfied that the client has taken a serious look at all reasonable risks, it’s time to move on. The counsellor challenges the client to look ahead to see if there are other risks. Similar responses are called for until all difficulties are explored. The counsellor must be patient and give the client enough time to complete the thought process.

106

This type of response ensures that the client sets goals and embarks on action plans with a clear sense of direction and planning. Problems may be prevented or anticipated, and the client is far less likely to face a crisis that leads to abandonment of otherwise healthy objectives. It is appropriate for the counsellor to tentatively introduce some of her own ideas, leaving a lot of room for the client to respond. However, as a rule, counsellors should let the client have the first opportunity. Adapted from Shebib, 1997. Step 2: Choose an Action Strategy Once a creative list of alternative action strategies is identified, the next task is to assist clients in evaluating alternatives and making choices. This involves helping clients intelligently consider each alternative against a number of criteria. An obvious first criterion is that the alternative is potentially effective for meeting the client’s goal. It must be sufficient to make a difference and relevant to the problem being addressed. A second criterion is that the alternative is within the capacity of the client. Otherwise, failure is inevitable. A third criterion is that the alternative is consistent with the values and beliefs of the client. A fourth is that the alternative is reviewed in terms of potential cost. Cost might be measured by time, money, and energy expended in finding resources to execute the alternative. As well, alternatives might result in other losses for the client. For example, suppose a client wishes to end a pattern of alcohol abuse, but the person’s friends are drinking buddies. If quitting drinking involves developing new activities, the potential loss of friends and social structure must be considered as a negative consequence that will have an impact on the client. Understanding and exploring this loss is important, for unless clients are aware of and prepared for these contingencies, they may be unable to sustain any efforts at changing. Success Tip Help clients conduct autopsies (also known as post-mortems) on past experiences as a tool to help them identify errors in thinking, triggers, problematic responses, and successes. Help them answer the questions “What went wrong?” “What could I have done differently?” and “What worked well?” Step 3: Develop and Implement Plans Developing and implementing plans involves four substeps: (1) sequencing plans, (2) developing contingency plans, (3) putting plans into action, and (4) evaluating plans. Effective plans are maps that detail the sequence of events leading to the final goal. Counsellors should avoid tailor-made plans in favour of customized strategies that are designed in collaboration with individual clients. Some of the important questions that need to be answered include the following: ■ What specific strategies will be used? ■ In what order will the strategies be used? ■ What resources or support will be needed at each step? ■ What are the risks and potential obstacles? Contingency Planning Effective plans anticipate the potential obstacles that clients might encounter along the route. Once clients know and accept the possible barriers that could interfere with their plans, they can develop contingency plans to deal with these barriers. This preventive work helps keep clients from giving up when things

107

don’t go smoothly. A variety of different strategy choices can be used to support contingency planning, including the following: ■ anticipatory questions such as “What will you do if . . . (detail possible obstacles)?” ■ role playing (including counsellor modelling) to explore and practise strategies ■ use of contracting—Before problems occur, counsellors can ask clients for advice on how they can respond when the time comes. For example (to a client who has just begun a job search): “What would you want me to do if a few weeks from now I notice that you’re becoming frustrated with your job search?” With flight simulators airline pilots learn to fly aircraft in emergencies. Should a real-life emergency happen, they are able to respond with confidence knowing that their training has prepared them. Similarly, contingency planning helps clients prepare for personal challenges that might arise as they implement their action plans. Success Tip HALT (hungry, angry, lonely, tired) is an acronym for common feelings that can trigger relapses. Help clients explore what they tend to do, and what they might do differently, when they are hungry, angry, lonely, or tired. Counsellors need to support and encourage clients as they deal with the stress of change. One way they can help is to remind clients that anxiety, awkwardness, and periodic slumps are normal when change is occurring. Meanwhile, counsellors can look for ways to reframe failure or setbacks as learning opportunities. Wilson’s (1994) comments might be offered to clients: “Although you may fail to reach the goal, there are benefits of having worked toward it. One benefit is the practical education of making the effort. Another is the opportunity to practice specific skills. A third is the recognition that meeting some goals and failing to meet others is part of the ebb and flow of life. Recognize that you probably will not achieve significant goals without some failures. Failing provides unique learning opportunities that ultimately contribute to your personal growth.” Moreover, empathy is particularly important at this time to support clients dealing with feelings that accompany change. During implementation, counsellors should also encourage clients to use family, friends, and support groups to assist them. Step 4: Evaluate Outcomes Effective plans include continual evaluation during the implementation phase. Evaluation recognizes and confirms success and is a powerful motivator. However, evaluation may also uncover problems that need to be addressed. For example, it may become apparent that the goals are too unrealistic. If they are too challenging and unreachable, counsellors can help clients define smaller goals. Similarly, if goals prove to be too easy, they can be modified to provide more challenge. Thus, regular review of progress ensures that goals and action strategies remain relevant and realistic. When evaluation reveals that the plan is unlikely to be successful, efforts can be redirected toward redesigning the plan or selecting a different strategy for action. In some cases the client may need help that is beyond the capacity of the counsellor; in this case, referral to another counsellor or service is appropriate.

108

Dialogue “I’ve Tried Everything” STUDENT: I get stuck when a client says, “I’ve tried everything and nothing seems to work.” TEACHER: You feel stuck, which is precisely how the client feels. Clients often bring out in counsellors the same feelings that they are experiencing. This reality can be a useful tool for empathy. When clients say they’ve tried everything, it’s important not to get into a “yes, but” game, whereby counsellors generate ideas and clients dismiss them with a “yes, but” response. STUDENT: So what are my choices? TEACHER: I’d be interested in exploring what the client did. Did he or she try long enough? At the right time? In the right way? Sometimes problems get worse before they get better, and clients may give up too soon. A mother might try ignoring her child when he has a tantrum and then tell you ignoring doesn’t work, but she may have abandoned this tactic after a few minutes when it appeared that the intensity of her child’s tantrum was increasing. In this situation you could help her anticipate this obstacle so that she would not be demoralized if it recurred. Or maybe she has been giving her child lots of nonverbal attention, not realizing how this has been reinforcing the tantrum. STUDENT: I can think of another example. One of the members of my work group was having trouble with her supervisor. She told us that there was no point in talking to him because he didn’t listen anyway. But from the way she described how she talked to him, I wouldn’t listen either. She was vicious and cruel. TEACHER: So, if she were your client, she would need some help developing awareness about how she affects others.

109

3. Empowering Language Replacing disempowering language with empowering language can transform our perspective. We can shift how we hold things, even if circumstances remain the same. That shift can move us to a place of empowerment. It's part of recognizing that we are always at choice. How often can you replace…

…with empowering language?

I should; I ought to

I will; I choose to

I need to

It's important to me to

I have to

I choose to; I want to

I can't

I am not willing to

I'll try to

I will; I intend to; I aim to; I commit to

I should have [done]

Next time I can; Next time I will

but

and

I am just; I am only

I am

You know; like

[nothing needed]

kind of; sort of

[nothing needed]

I would like to say/acknowledge/do

[just make the statement; these prefaces diminish it]

Value In Replacing Disempowering With Empowering Language Language, as our expression of thoughts and feelings, has the power to transform. It's inextricably linked to our view of reality. By changing our language, we can affect our view of reality, which is, in effect, our reality. I've observed significant energy shifts as clients replace disempowering language with empowering language. This means that, just by changing our language, we can move from playing the victim to having choices, from feeling powerless to being in control of our life, from fear to love. And we can move into action: "I really want to…" → "I will…" "I have to…" → "I choose to…" But… → Personally, I have replaced most uses of "but" with "and". I picked this because, when I read the empowering language table above, it was the entry most charged for me! My initial reaction was, "'But' is a perfectly good and useful word. Why should I replace it!?!" Holding Space For Both The word "but" separates two clauses representing things that are in some way in opposition. The implication is often that one or the other must be chosen, or one or the other is true. The word "and" just conjoins two things in a list, with a sense of inclusivity. Technically, the word "but" expresses more information about the relationship of the things being described, AND using an inclusive conjunction ("and") serves better to hold space for both, expanding the possibilities as I'm considering the issue.

110

"I" Statements Another important piece of using empowering language is using "I" statements. These are claims a person makes about themselves using the pronoun "I" rather than "you". For example, imagine I said, "You know how you sometimes don't want to get up in the morning? Having the aroma of freshly brewed coffee reach your nose can really help!" Clean CommunicationI am, in fact, telling you something about myself: "Sometimes I just don't want to get up in the morning. Having the aroma of freshly brewed coffee reach my nose can really help!" Expressed using "you" and "your", I'm implying that you should agree. However, you may never have trouble getting up in the morning, or you may not even like the aroma of coffee. Rather than assuming these things and telling you what will help you, it's much cleaner if I just claim what is true for me. Then, if you notice that resonates with you, you can offer your agreement. The value in using "I" statements is ownership. When I use "I" statements I am owning what I say as my view or reality. I am not projecting it onto "you". This facilitates my separating my issues from your issues so that I can deal with mine and don't have to take responsibility for dealing with or responding to yours. That's a win for me. How about for you?

111

4. Sample Formats for Sessions Sample Format for First Session 1. Orient Client: Small talk; State your desire to be helpful and the importance of client feedback. 2. Identify the Problem; Determine the client’s main concern and clarify details (Who/what/when/where?; What’s already been tried and how well has it worked?; How can I help you with this?). 3. Create Useful Goals: Use rating scales or other methods to create useful goals (What will you do different when this mark moves a little higher? What will a 3.5 look like?). 4. Identify Exceptions and Other Resources: Exceptions (When is the problem absent or less noticeable?; What is different about those times?); Other Resources (Explore the client’s special talents and interests, resilience, heroes, influential people, solution ideas, and other resources). 5. Can Interventions Be Built from Exceptions or Other Resources? If yes, collaborate to develop interventions based on exceptions or other resources. If no, move to the next step. 6. Change the Viewing or Doing of the Problem: Viewing (Invite client to consider a different view/explanation/interpretation); Doing (Invite client to “do something different”) 7. Compliment, Review, Session Rating Scale, Wrap-Up: Compliment the client on positive attributes, coping, persistence, and other assets; Review/refine intervention plans and responsibilities; Address closing questions or comments from the client; Administer/discuss rating scales; 8. Thank client for cooperation and input; 9. Schedule next meeting.

112

Sample Format for Second (and Later) Sessions 1. Assess Progress: Use rating scales or other client feedback/scaling technique to assess progress from the client’s perspective. 2. When improvements are reported: a. b. c. d.

Ask for the client’s theory (How do you explain this?), compliment and credit the client (How did you make it happen?); Explore exceptions (What was different this week?); Empower progress (How is life different for you now?).

3. When no change or slips are reported: a. Ask for the client’s theory (What do you make of that? Should we try something different or hang in there and see what happens next week?); b. Normalize and validate (Sometimes it takes a while to get some traction; Sometimes things get worse before they get better); c. Ask coping questions (Where do you find the strength to keep trying?); d. Explore exceptions and other resources (As bad as it was, was there any small thing that went well this week? How did you keep things from getting worse?). 4. Can Interventions Be Built from Exceptions or Other Resources? If yes, collaborate to develop interventions based on exceptions or other resources. If no, move to the next step. 5. Change the Viewing or Doing of the Problem: Viewing (Invite client to consider a different view/explanation/interpretation); Doing (Invite client to “do something different”) 6. Compliment, Review, Session Rating Scale, Wrap-Up: Compliment the client on positive attributes, coping, persistence, and other assets; Review/refine intervention plans and responsibilities; Address closing questions or comments from the client; Administer/discuss rating scales; 7. Thank client for cooperation and input; 8. Schedule next meeting or terminate services based on client progress and input (How will we know when to quit?).

113

Summary The foundation for empowerment in counselling is the belief that clients are capable and have a right to manage their own lives. To empower clients, counsellors need to forgo controlling them, demystify the counselling process, promote client self-determination, advocate for progressive changes in the system, and assist clients to change established patterns of thinking and acting that are interfering with their lives. Counsellors can help clients change established patterns with strategies such as motivational interviewing, cognitive behavioural counselling, and brief counselling. Motivating involves engaging clients in a change process as well as supporting and energizing them as they deal with the rigours of change. Counsellors may face a range of motivational challenges, and they can employ different strategies to address each of them. The stages of change model (precontemplative, contemplative, preparation, action, and maintenance) provides a useful framework for understanding where clients are at in the process of change. Motivational interviewing is a practice approach that uses the stages of change model to help clients overcome ambivalence to changes. Its central features include active listening, especially empathy, developing discrepancies, and rolling with resistance. Cognitive behavioural counselling helps clients understand how to break out of established patterns of thinking and behaviour. One central feature includes helping clients understand and modify dysfunctional thinking through strategies like reframing, a tool for helping clients examine problems from another perspective. A variety of strategies help clients modify behaviour, including the use of “autopsies,” contingency planning, anxiety management, relationship problem solving, and goal setting. Goal setting serves many important purposes, including giving direction, defining, roles, motivating, and measuring progress. Effective goals need to be concrete, measureable, challenging but realistic, and owned by clients. Effective goals can be developed from problem statements. Action planning consists of a series of steps leading to the client’s goal or subgoal. Selecting a plan involves systematic identification and evaluation of the possibilities for action, then choosing one or more alternative action plans. Action planning involves four substeps: identifying alternatives, choosing an action strategy, developing and implementing plans, and evaluating outcomes. Often counselling relationships are limited to a few sessions or even a single session. Nevertheless, these brief encounters have the potential to be helpful for clients. Brief counselling works on the assumption that a change in some part of a client’s life will affect other aspects of his or her life, including relationships with significant others. Brief counselling techniques include the use of the miracle question, looking for exceptions, finding strengths in adversity, using solution talk, and the change continuum.

114

Exercises 1. Consider areas in your life where change is possible, is necessary, or has already occurred. Classify your stage of change with each issue, based on the stages of change model: precontemplative, contemplative, preparation, action, maintenance. What could potentially “move” you from one stage to another? 2. Suggest questions you might ask clients to assess their stage of change. 3. Identify which stage of change best describes each of the following clients: a. “I hardly know anyone who smokes anymore. I’ll get there too one day.” b. “What’s the point of looking for work? Since the big stock market crash there aren’t any jobs out there anyway.” c. “It’s been almost six months since my last drink. I don’t even crave it like I used to.” 4. Working with a colleague, take turns exploring a time in your life when you were unmotivated. What feelings were associated with this period? What helped you get unstuck? 5. Start a log that chronicles your automatic thinking, for example, when you meet someone new, before asking a question in class, when you want to ask for help, etc. 6. Identify errors in thinking for each of the following client statements. a. “I’ll never get a job.” b. “She didn’t even say hello when she saw me at the store. I guess she doesn’t like me.” c. “I have to be number one.” 7. Suggest reframed responses for each of the following client statements. a. I can’t do it. b. (A student counsellor.) I feel so unnatural and phony expressing empathy all the time. c. I really want my kids to avoid making the same mistakes I did. I don’t know why they don’t listen to me. d. If he really loved me, he’d send me flowers. e. My life is a mess. f. I’m tired of being depressed all the time. 8. Name at least ten different ways to motivate clients. 9. Evaluate how effectively the following statements meet the criteria for effective goals: a. to be a better person b. to get my boss to stop hassling me c. to drink less d. to be able to disagree with someone without dismissing them or their ideas e. to improve my fitness by next year to the point where I can run 1 kilometre in 15 minutes 10. Practise brainstorming techniques. Identify different action strategies for a client who wishes to quit drinking. 11. Use the concepts from this chapter to practise goal setting and action planning for yourself. Pick one or more target areas (behaviour, feelings, thoughts, skills, or relationship).

115

Chapter 4 The Intervention Process What is involved in the crisis intervention process? Alan A. Roberts, in his book Crisis Intervention and Time Limited Cognitive Treatment, identifies seven stages of working through a crisis situation with someone. These stages include the following: 1. Assessing lethality (potential for harm to self or others) and safety needs; 2. Establishing rapport and communication; 3. Identifying the major problems; 4. Dealing with feelings and providing support; 5. Exploring possible alternatives; 6. Formulating an action plan; and 7. Follow up measures A brief assessment of lethality and safety needs should be done in any telephone screening or face to face assessment and should hold an important place in any intervention. (Is the person safe? Is the person alone? Does the person intend harm to self or others? Does the person have means to carry out his or her intentions?) These screenings must be done with sensitivity. Some callers are offended if asked questions about suicidal or homicidal intent before they are allowed to identify the issues that they are calling about. Assessment of danger to self or others should continue throughout any crisis assessment, crisis intervention, and crisis stabilization process. Lethality and safety needs are however not the only elements of a telephone screening or face to face assessment. What is the first step in interviewing in a personal crisis? "In the midst of a crisis, or most other times for that matter, people want to be heard, understood, validated and valued as a human being. Instead, we are likely to get advice, "I told you so," or "you think you have it bad." A person in crisis needs to be empowered, given choices, options, resources, encouragement, and hope. A responder needs to establish rapport and communication with the person. One of the best tools in building rapport and communicating clearly is active listening. Active Listening “Active Listening provides empowerment. As a listener, you don't have to „do anything, „fix anything, or „change anything. When people are „heard, they will „do, „fix, and/or „change things for themselves.” Listening is an art. A lot of people stop talking and in their mind they're already trying to think of what they're going to say next. That is not really listening. If you are (pre)occupied with your own thoughts, then there is no room for the other anymore. Not really. And even if you are listening and not busy with your own thoughts on the matter, listening is so much more than just hearing the words and being able to repeat them. To get the essence of what's being said -the words behind the words, is just as important, if not more so. While the other person is telling his story, try to also listen for things like a slip of the tongue, jokes, omissions, recurring themes, metaphors and contradictions. They can speak volumes.

116

Apart from the intonations you can pick out the different emotions in the individual's voice. Body language and other signals can strengthen or weaken the story. Contradictions are called incongruence and you can either keep these in mind or ask about them. Make sure you do this carefully, so the other won't feel caught out. In active listening, the personal crisis intervention provider has an open and alert attitude, he's completely there for the other and is peeling his ears, so to speak. To listen empathically means that the service provider shows a lot of understanding for what the other is experiencing and in a way he manages to convey this warm understanding to them, who can appreciate it. Before asking questions, we must learn to listen attentively and effectively. Active listening is a major part of communicating well. It is extremely important and necessary. By actively listening to a person's story, the responder will hopefully accomplish the following with the individual: • Find out what their real needs are • • •

Understand their reality and emotions Know what is motivating them and what is keeping them back Help them make sense of what happened;

• Validate their concerns, emotions, and reactions; • Offer perspective from your objective viewpoint; • Provide hope and a sense of direction; • Point out resources they may have forgotten; • Give them power to make choices, and take action. • Set correct and smart goals • • •

Concentrate on one goal at the time Plan good action steps Proceed towards their goal with enhanced commitment and accountability

•

Deal with setbacks and celebrate successes

To the individual, the personal crisis intervention services provider listening actively to them proves that they are taken seriously as a person and that the other is making efforts to understand their situation. Active listening sounds easy, but it requires skill and practice. Active listening skills are essential for a crisis services provider. Good communication is a solid foundation for any relationship. Communicating well sounds easy, but it is really quite complex in practice. Typical expressions related to active listening are: - If I understand correctly, you think that … - So, what you are saying is … - If you think …, then I can see why this situation makes you upset - I understand why you are so …. - Wow, I want to acknowledge the courage / maturity / persistence / … you have shown in speaking up to … / in taking this initiative … / in working so long …

117

- In reply to a statement - In reply to “I must”: - In reply to “I cannot”: - In reply to “nothing, all, always, never …”: - If you don’t know what to answer, ask:

ask : how do you know? what would happen if you don’t? what is stopping you? ask to think of exceptions Why do you say that?

Active Listening Skills Contrary to what some think, active listening does not stop at listening and creating rapport by nodding and humming, but involves a wide range of different skills. Each skill is used concurrently with the others while attempting to remain objective, empathic, and human. •

Paying attention to body language

•

Minimal encouragements;

• •

Asking questions Repeating and summarizing the message;

• •

Acknowledging the feelings expressed and the reasons for these feelings Acknowledging the qualities shown, that is: who they have to be to accomplish …

•

Probing for background information

•

Checking the quality of the communication

• •

Paraphrasing; Reflecting;

• • •

Summarizing Emotional labeling; Validating;

•

Reassurance

• •

Encouraging; and Waiting.

Paying attengion to Body language Body language is important. Excessive eye-contact may be felt as threatening. Not maintaining enough eyecontact on the other hand might be interpreted as a lack of interest (e.g. when listener is repeatedly looking at their watch or documents on their desk!), or as an indication that the listener is hiding information or is not sufficiently open or honest. Body language includes (affirmative) head nodding and the use of silence, which are powerful tools in any conversation. Gerard Egan describes the correct position for listening as follows : SOLER S :

Sit squarely, face interlocutor O: keep an Open posture L: Lean forward when appropriate E: maintain regular Eye contact (don’t stare) R: Relaxed body language

Show individuals that you are interested in the situations, experiences and feelings that they are communicating and that you care not only about what they are saying, but also about how this affects them.

118

Using Minimal Encouragements Non verbal encouragement such as making eye contact, nodding, orienting your body toward the person and leaning slightly forward, humming, and short expressions like “Yes”, ”I see", “go on”, “what happened next?” … are used to confirm the other person that you are listening to him keenly. These expressions also help them to understand which part of their message is being appreciated and to elaborate on that particular topic. Asking questions Asking questions is another way of showing your interest and making people feel understood, valued, respected and listened to. Well chosen, powerful questions facilitate a person in finding his own answers. (Life-coaching for dummies – Jeni Mumford) Clarifying and reflective questions often are a very good idea: Clarifying brings unclear or vague subjects into sharper focus. It is useful to confirm what was said, to get supplementary information, to present fresh points of view or add details, or to shed light on new elements. 1. Restate what you heard the trainee say 2. Listen for confirmation that what you are saying is correct 3. Encourage trainees to tell you if you are right or wrong Examples of clarifying questions: -

Tell me more about … Go on … I am interested to hear more about … What did you do then? You say …, why is this so ? Is this always the case? Let me see if I’ve got it all … Let me try to state what I think you said …

Examples of reflective questions: -

How was this different from …? What would it look like if …? What would happen if …? What do you wish …? What did you want him to do instead? How would this impact / change … ?

Repeating words, content, meaning and feelings Often enough, it is also very useful to repeat in some way what they have said. This forces people to concentrate on what you are saying, thus helping them to take some distance from their own story and obtain an improved general view of the whole situation. By repeating their messages, you also stimulate their thought process, without introducing new subjects.

119

Different options to repeat a message are available: 1.

Parroting : literally echo their exact words. Often, only the last words are repeated (mirror-questions) in an invitation to amplify on them. The use of parroting should however be limited, since hearing your own words echoed repeatedly soon becomes very annoying.

Repeating Content: This technique goes beyond parroting: The individual’s exact words are repeated, inviting them to elaborate on their story or to continue it.

Repeating Conflict: Repeat both sides of a conflict situation, opposing pros and cons stimulate them to make a considered choice.

Paraphrasing or Reflecting Meaning: Repeating the individual’s message in your own words, that is: reflecting the facts or ideas, but not the emotions and without getting emotionally involved, may open new perspectives. Often an element of acknowledgement or positive feedback will be part of the paraphrasing, thus motivating the other to continue sharing.

Paraphrasing Paraphrasing expresses interest and focuses on the individual and his/her problem. By actively seeking clarity, you achieve a shared meaning, avoid misunderstanding, and gain the trust of the person with whom you are speaking. Paraphrasing includes several elements. Repeating the intent or content of what the person has stated is very helpful in making sure that the responder understands the meaning of the words the person is using. Most people do this when communicating on a regular basis. Take this brief example: - A woman walks into her house after being at work all day. "Boy, what a rough one!" she says. - Her daughter asks, "You had a bad day?" - The woman responds by saying "No, not the whole day, just the drive home. The traffic was horrible." In this example, the daughter stated what she thought her mother meant, and the mother clarified. The daughter, however, does not use the same words to "paraphrase" her mothers' statement. Crisis service providers must be very careful about parroting phrases that the person uses. Unless done thoughtfully, this can come across as not hearing or mimicking the person. Clarifying can be done in a number of ways. The crisis service provider can simply say, "I am not clear about what you mean when you say ..." or "Tell me more about that." Simple paraphrasing also opens the door for the person to restate his or her intent in a different way. In order to ensure a shared understanding of the situation, the crisis service provider may want to summarize the information to be sure that he or she has understood correctly and has the whole picture. Simultaneously, paraphrasing is - either a request for verification of your perceptions (feedback) - or a confirmation that you have correctly understood the message. Good openings for paraphrasing are: - So you think, …. - You don’t believe that … - You don’t understand why …

120

- So, what you are saying is … - Sounds to me like you …. - The way you see things … - To you, this means … - So, you are saying that … - I guess it is your opinion that … - If I understand correctly … - You’ve always thought …, but now you found out that … Some manuals use the term “reflecting” to indicate reflection of meaning (thoughts) only and use “paraphrasing” for referring to reflecting thoughts AND emotions Reflecting Feelings Reflecting Feelings - or Repeating Feelings - is very similar to paraphrasing, but instead of reflecting the meaning, the service provider now reflects the emotions that are the basis of other person’s words. Reflecting feelings resorts a much stronger effect, because the individual will experience that the service provider is not only understanding him, but is also empathizing with his feelings. Reflecting feelings is the basis of emphatic listening and creates rapport. Naming the feeling that you recognize in their story, helps people to define and explore their own feelings and become more aware of their seriousness. Reflecting is very useful also when you feel people are rattling information without feeling involved. Reflecting gives the person an idea of what is being interpreted from their information. It can help him/her identify what he or she is feeling and projecting. Tone of voice and pointing out what is being heard or sensing helps make sense of the confusion and adds to rapport. Reflecting means telling the person how they are being seen such as "You look really worried (scared, etc.)" or heard such as "You sound very anxious, (angry, etc.)". Reflecting is giving feedback on the situation such as "You seem so tense right now, what would help you relax while we talk?" An objective party is an ideal person to provide this sort of feedback. Feedback is a way to communicate thoughts and reactions to another person. Example of a specific method to present feedback: • Identify what you are thinking, feeling, etc. • Identify the behavior that you think provoked your response. • Indicate how this might impact the individual. (For example), "It concerns me when you talk about committing suicide, even though you've said that you are not serious; it may scare others enough that they don't want to talk to you about it or about your situation." The person has a lot to gain by hearing honest, direct feedback in a sensitive way. People who are too closely related to the problem may hesitate for fear of hurting someone, fear of a reprisal or they may just feel inadequate in handling a sensitive situation. Unfortunately, if the person is not aware of how his or her behaviour affects others, he or she can't change. This type of feedback should always be given in a very thoughtful way or else the person may shut down and not discuss their thoughts or feelings with anyone.

121

Good introductions for reflecting are: - You feel doubly hurt, because … - The situation is worrying you, … - You are disappointed, … - You feel it’s a shame, … - You are feeling sad, … - You were angry, because … - You don’t dare to, … - You are afraid, … - You must be very fond of him. - You feel you have failed … - You are worried that you … - You had the strong feeling that … - Yet, I notice some doubt in your voice - You don’t sound very convinced though - And yet, you sound sad. Maybe you can tell me what happened? - I sense you are still angry, troubled, mixed up, confused … maybe that’s why … Summative Reflection Summative Reflection involves summarizing the message in order to provide a structured, complete and comprehensive feedback. Aside from organizing and integrating the major aspects of the dialogue, summarizing also establishes a basis for further discussion and offers a sense of progress in the conversation. It is required to also plan regular summaries and evaluations during which you repeat the essence of what has been said or done provide a clear image of the situation locate where the other is with respect to the total journey Logical moments for summarizing and evaluating are: At the start and end of each session At transiting to a new phase At any moment that you feel a summary might be helpful to keep track of the situation or to stimulate the individual. Alternatively, it is a good idea to ask individuals every now and then to summarize and evaluate things themselves. This will help you to take notice of Their point of view Which elements have stuck What is most important to them now What they are “forgetting”

122

The most important elements in a summary are: -

Accurate summary of core material Clarity and structure Reflection of content Reflection of feelings Deeper empathy

Possible opening lines for summarizing: A. X, let’s see how far you got until now: You came to me X weeks ago, because … and because …. We determined that …, because …. Is there something you would like to add at this point? B. So, to summarize, you say that …, is that correct? C. At that moment, you set yourself the target of …. Because …. To this end, we composed an action plan Now, the question is when to start with the execution of this plan. D. Summarizing your story, you reported that … , but …, and … - Can you agree with this presentation? E. This seems a good moment to summarize what we have done during this session. - Is there something you want to add? - How did you experience the conversation? - By the next session, I would like you to consider / go through today’s points again / to start the actions we agreed upon - Which would allow us to proceed next time with …. F. Is there anything you want to add? Examples: I don't understand why my wife is getting worked up, I for instance never get mad!! Still I hear a bit of anger in your voice. Your wife might perceive this as you being angry. If you think it helps, I'm quite willing to do it, you know? You don't sound convinced, what might be holding you back? I actually wanted to stop coming here as I think I'm doing much better now. I'm glad you're feeling a lot better and of course you're free to stop whenever you want. However I've noticed there are still some things that seem to trouble you... I haven't touched a drink in weeks, it's clear I'm not an alcoholic... (hiccup) Being an alcoholic might be too strong a word, but something tells me you still do have a drink regularly. I don't know what's wrong with me or where to start. We can take our time. You sound very sad, maybe you could tell me what has happened?

123

Emotional Labeling During a crisis situation, feelings are often confusing and hard to define. Helping the person label the emotions that he or she is feeling helps him or her to make sense and gain some control of these emotions. Labeling the emotions also gives the person a chance to clarify and correct the perceptions of the crisis service provider. Crises happen as a result of some loss, real or perceived, in a person's life. The pain felt in a crisis is grief over that loss. The loss may be something you can put your hands on like an automobile, money, or a home. It may also be less tangible, like loss of self-'esteem, power, freedom, or prestige. The resulting grief is the same. There may be a number of losses present in a single event. For instance, it is not unusual for a widow to lose financial well-being because of her husband's death; thereby she loses security, power, prestige, and quite possibly friends and social contact. Two key elements in any crisis are grief/loss and anxiety. No one can predict exactly what a grieving person will feel like. However, there are stages identified by Elizabeth Kubler-Ross, which are seen in most people experiencing grief. The five stages of grief are: 1) Denial; 2) Anger; 3) Sadness/depression; 4) Bargaining; and 5) Acceptance These stages provide a road map of sorts that point out where someone may be in the process of his or her grief. Grief doesn't progress through the stages and end there. Rather, it seems like a series of loops, traversing the same ground over and over. We may be at different stages with each aspect of our grief at any given time. The following responses may or may not occur as a grief reaction. This is not meant to be a complete list; other reactions may occur that are quite normal. Emotional reactions and their somatic, or physical, counterparts often occur in "waves", lasting a varied period of time. Emotional responses

Behavioral responses

Sadness/Abandonment/Despair Anger/Rage/Resentment - Irritability/Vengefulness Relief Fear/Panic/Anxiety/Worry Guilt Feeling Lost/Numbness Hopelessness/Helplessness/

Crying at unexpected times Hostile reactions to those offering help or solace Restlessness Lack of initiative or desire to engage in activities Difficulty sleeping Constantly talking about the loved one and his death Isolation or withdrawal Increased smoking/alcohol use

Somatic (physical) responses Cognitive responses Tightness in the throat Shortness of breath Empty feeling in the stomach Nausea / Headaches / Dry mouth Weakness, overall lack of physical strength

Delusions/Hallucinations Nightmares Poor attention span/Indecision/Slowed thinking Disorientation/Memory problems/Blanking out

124

Anxiety is an emotional response that can be expected to manifest in any crisis situation, because there are no answers, and seemingly no resolution. People may become afraid of the unknown or what they fear might happen. This projecting into an unsure future is a normal, natural response to crisis situation. Anxiety also acts as a motivator to find options, solace, and resolution to problems. Sometimes anxiety can be experienced as free-floating fear or panic. Bereaved by Suicide Losing someone close to you brings about intense grief and mourning. The loss of someone through suicide often results in different responses and emotions. Bereavement by suicide is prolonged. Shock, social isolation and guilt are often greater and the element of choice raises painful questions. You may experience some or all of the following: Intense Shock The sense of shock and disbelief following a death of this kind may be very intense. A common aspect of grief is recurring images of the death, even if this was not witnessed. Finding the body may be another traumatic and indelible event. It is a natural need to go over and over the very frightening and painful images of the death and the feelings these create. Questioning - Why? Bereavement through suicide often involves a prolonged search for an explanation of the tragedy. Many people eventually come to accept that will never really know why. During the search for explanations, different members of the same family may have very different ideas as to why a death happened. This can be a strain on family relationships, particularly where an element of blame is involved. Questioning - Could it have been prevented? It is common to go over and over how the death might have been prevented and how the loved one could have been saved. Everything can seem painfully obvious in retrospect. The 'what-ifs' may seem endless. Rewinding events is a natural and necessary way of coping with what has happened. Research suggests that some people bereaved by suicide feel more guilt, self-blame and self-questioning than those bereaved in some other way. Abandonment / rejection You may experience a sense of rejection. It is common to feel abandoned by someone who 'chooses' to die. "I was upset that he hadn't come to talk to us. I think we all went through anger at some point. You think: 'How could you do this to us?' ". (A sister whose brother took his life.) Suicidal fears and feelings Despair is a natural part of the grieving process, but after the suicide of a loved one hopelessness may be combined with fear for one's own safety. Identification with someone who has taken their life can be deeply threatening to one's own sense of security. You may suffer more anxiety than those bereaved in other ways and be more vulnerable to suicidal feelings.

125

Media Attention When someone dies by suicide or other unexpected causes, it may attract public interest. The inquest that may be demanded by law draws attention to the person who has died and to close relatives and friends. Attention from the media can be very stressful for bereaved relatives and friends, particularly where a death is reported in an insensitive or inaccurate manner. Stigma and Isolation Social attitudes to suicide are changing, but they may still limit the support that is available. The silence of others may reinforce feelings of stigma, shame and 'being different'. If others are embarrassed, uneasy or evasive about suicide, you may be left feeling intensely isolated. Opportunities to talk, remember and celebrate all aspects of a loved one's life and personality may be denied. A strong need to protect a loved one, and oneself, from the judgement of others may also be felt. A mother writing about her son's death pointed out that we have never been told what to say to someone who has had a suicide in the family. She needed to hear the same thing that might be said to anyone else who had experienced the death of someone close: "I'm truly sorry for your pain and is there anything I can do? If you need to talk about it, I am a good listener. I've got a shoulder to cry on." Needs: A group of Canadians bereaved by suicide were consulted and felt that they needed help and support to: • • • • • • • •

get the suicide in perspective deal with family problems caused by the suicide feel better about themselves talk about the suicide obtain factual information about suicide and its effects have a safe place to express their feelings understand and deal with other peoples' reactions to suicide get advice on practical/social concerns

How to give support to a grieving person? • • • • • • • • •

Be available. Remember that the individual is in a very different place emotionally. If you're not sure what to say or do, just ask. Say, "Do you feel like talking about this right now?" If they do, be there for them. Don't tell them you know how they feel, unless you've really been there. You don't have to know exactly what they are going through to offer support. If they don't want to discuss their heartache, don't press the issue. Let them know that you are there for them regardless. Don't treat the individual like an invalid. Encourage him or her to get out and get busy doing day-today activities. Be supportive but not smothering. Recognize that you may need your own support system. Sometimes you can give support, and other times you'll need to receive it. Don't expect yourself to always be the leader. Watch out for a shift into depression. If you see the individual withdrawing into an emotion fetal position, it's time to intervene.

126

Validation Perhaps the most important support to give to a person in crisis is validation. Validation is conveying that it is okay to feel whatever it is the client is feeling and that he or she is not alone, in that given the same circumstances, others might feel the same way. Affirm their worth and their efforts to cope with the situation. Crises spawn feelings of inadequacy. Reassure them that they can get through this crisis, and that they deserve help when things seem intolerable. The most important thing is to somehow convey the idea that the feelings the person is having are normal. Some examples of validation are listed below: - "You don't sound crazy to me." - "I'd be angry too if that happened to me." - "With so many things going on, of course you feel overwhelmed; I think anyone would in your situation." Affirmations Affirmations are simple, direct statements that go a long way toward instilling confidence, hope, and reassurance. For example: -

"I'm glad you decided to talk to me." "You sound like a very (strong, caring, sensitive) person." "I'm glad you've decided to get help, you deserve it." "You have a good sense of humor, that's a great way to cope sometimes."

It is very important not to make a statement that is not true. If you say that the person sounds like a sensitive person but do not believe that, the person may sense that you are being less than truthful. False statements ruin rapport and trust. Identifying a major problem A number of questions need to be answered to identify the nature of the crisis situation: 1) What happened to prompt the call? 2) What led up to the precipitating event? 3) Who is involved in the situation? 4) What does the person feel? 5) What do they fear? Many of these questions will be answered as the person tells his/her story and rapport is built. The basic information needed is the answer to "Where does it hurt?" and "How can I help?" Responding to specific symptoms of behavior How can a person who is experiencing specific symptoms or behaviors be assisted? Review the symptom behavior below with suggested actions.

127

Symptom Behavior- Anxiety or Agitation Decrease stimuli that might increase agitation Identify the agitating stimulus and remove it if possible Remain calm Ask the person to slow down Reassure the person that there is plenty of time to sort the situation out Give the person enough personal space. (You may wish to ask about what is "enough" as personal space varies. People who experience paranoia generally need more personal space.) - Don't demand answers - Help the person find a safe, quiet space as needed

Symptom Behavior- Low self-esteem - Assist person in pointing out his or her own strengths, but if he or she is unable, then the crisis services provider can point out strengths - Do not discuss past failure or weaknesses unless brought up by the person - Discuss any weaknesses or past failure the person brings up in a tactful manner - Help the person problem-solve ways to deal with these perceived weaknesses Symptom Behavior- Oppression, frustration, loneliness, feelings of guilt -

Allow the person to vent his/her feelings Listen and accept his/her feelings as stated Allow the person to cry Beware of trying to cheer someone up because the person may perceive this as minimizing the pain Help in problem solving and making changes in behavior that will have an impact on the feelings

Symptom Behavior- Hallucinations and/ or delusions or disorganized or illogical thinking -

Do NOT dispute the person's reality of experiencing delusions or hallucinations Accept that this is what the person truly believes or perceives Do not encourage the person to express accelerated or illogical thoughts Encourage the use of a quiet place Stay calm Word sentences in simple terms Ask one question at a time Be clear, practical, and concrete Allow time for the person to decode your communication and form an answer/response Act as a buffer between the person and outside stimuli or other people if needed

Symptom Behavior- Slow response time - Be patient - Allow the person time to formulate a response Symptom Behavior Loss of contact with reality-based personal boundaries - Support reality-'based statements - Do not encourage out of touch with reality statements - Be careful with the use of touch

128

Symptom Behavior Difficulty with establishing self-initiated goal directed activity - Make expectations clear and realistic - Help the person identify meaningful tasks and break these down into "doable" pieces Symptom Behavior Difficulty making decisions - Decrease stimuli - Limit number of decisions to be made if possible - Take a directive stance about issues that relate to the person's safety Symptom Behavior Bizarre behaviour - Set firm limits - Identify bizarre or inappropriate behavior specifically. (It is better to say "Wrapping your fingers with aluminum foil to block thought transmissions might seem strange to many people," rather than "You have some habits that other people would find strange.") Symptom Behavior- Withdrawn behaviour -

People with schizophrenia need a quiet place to withdraw and may wish to be alone more often than others Allow the person some quiet time as a way to cope with chaos Do not take withdrawal as rejection Be available at the person's request

Symptom Behavior- Exaggerated response to stimuli - Reduce exciting stimuli - Assist the person to find a quiet space - Use clear, concise questions or statements Symptom Behavior- Aggressive behaviour - Set limits on behaviour - Be aware of threatening statements and take them seriously Symptom Behavior Lethargy, loss of interest - Help the person set realistic, doable goals Symptom Behavior- Sleep disturbances -

Encourage adequate physical activities during the day Encourage reduction of caffeine and other stimulants Encourage a regular bedtime and wake-up time Help the person identify a calming pre-sleep routine

129

Exploring possible alternative solutions How does a crisis services provider help the person go about exploring possible alternative solutions? Several questions are pertinent to exploring alternatives: 1. 2. 3. 4. 5. 6.

What does the person believe is the most important issue that he/she is dealing with? What is the person hoping for? What does the person think he/she needs? What has he/she already tried? What has worked in the past? What personal and community resources does this person have to draw on?

Many people in crisis tend to see their world in black and white. They feel that they have limited options. Offer alternatives that the person may not have thought of. Evaluating In a supportive conversation, you will not want to stop at listening. Towards the end of the conversation, you will want the other to take a next step, start changing things, commit to action. Examples: So, where does this leave us? What will you do next? How will this help you to proceed towards your goal? What will be your first step now? Formulating an action or crisis plan If someone has an active mental health provider, it is possible they may have an existing crisis plan they have developed with their mental health provider. If this is the case, it is necessary to try to access the person's current crisis plan. If a plan has not been developed then the person may find it useful to develop a plan. The plan that is developed should be short-term, clear, doable and developed as much as possible by the person experiencing the crisis situation. Specific activities that will give the person the feeling of control over his/her life should be included. Alternatives to harmful or unproductive behavior should be included. For instance, instead of going for a drive when feeling upset, the person might decide to call a friend or play with the dog. Including resources identified by the individual is also useful. The person may be able to think of these resources when he/she is working with the crisis services provider but may not be able to identify them when alone or in the midst of an escalating situation. Writing the plan down and making a copy for both the person and the crisis services provider is important. The crisis services provider may also find it appropriate to make referrals to other services in the community. They may serve an "introductory role" to ensure that a person who has experienced a crisis makes connections with services that he/she needs to prevent further crises. Agreeing on Follow-up measures The follow up service is a very important part of the crisis intervention services. These services can range from a telephone call or a face-to-face contact the next day, depending on the need of the person. Follow-up measures should be written into the crisis plan and agreed to by both the person and the crisis service provider.

130

Contractual time frames and/or standards for follow-up must be followed. DOâ&#x20AC;&#x2122;s and DONâ&#x20AC;&#x2122;Ts in De-Escalating Crisis Situations DO approach clients in a calm non-threatening manner. DO be assertive, not aggressive. DO allow clients to resolve a situation themselves, if possible. DO remove any bystanders from the area. DO remove any dangerous articles from the area. DO encourage clients to use more appropriate behavior to get what they want. DO work with other staff or significant others available as appropriate in defusing a crisis. DO give an agitated client time and space to calm down. DO make use of PRN medication when appropriate based on a consultation with a physician, nurse practitioner, or physician assistant. DO negotiate temporary solutions to buy time. DO be respectful toward the client. DO leave a physical escape route for both yourself and the client. DONT get into an argument or power struggle with the client. DONT be authoritarian or demanding. DONT tell clients you are frightened even if you are. DONT argue with clients over the reality of hallucinations or delusions. DONT "humor" clients regarding hallucinations or delusions. DONT overreact to the situation. DONT insist that a client discuss a situation if he or she doesn't want to. DONT confront a client under the influence of substances.

131

Chapter 5 Critical Incident Stress Management (CISM) The Critical Incident Stress Management process includes education and awareness. CISM is a comprehensive range of integrated services, procedures, and intervention strategies designed to mitigate the effects of exposure to a critical incident. The core components of CISM are: 1. Pre-Crisis Preparation 2. Mobilization/Demobilization and Crisis Management Briefing (CMB) 3. Defusing 4. Critical Incident Stress Debriefing (CISD) 5. Individual (One-On-One) Crisis Intervention 6. Family Crisis Intervention 7. Follow-up Services. Mobilization/Demobilization Mobilization and Demobilization are group processes that are generally reserved for crisis interventions by trained crisis intervention staff operating in the wake of deeply distressing events that have the potential for widespread effect on a particular group of people. This includes events that are prolonged or have high media visibility. Support is provided by way of factual information about the incident, stress education information and rest/refreshment as necessary. This is often delivered in conjunction with start of shift or end of shift staff meetings provided by management. Specially trained employee peers usually conduct Mobilization / Demobilization on a rotating basis for the first few days post-incident. Crisis Management Briefing (CMB) CMB is a large group crisis intervention ideally suited to business and industrial applications for up to 300 persons. It is used after large-scale events (disasters, major crisis, etc.). A CMB may be thought of as a form of “town meeting” for the expressed purpose of crisis intervention and is led by CISM Team members – it should NOT be considered an “operational debriefing”. A CMB may include a panel of CISM peer support personnel, mental health professionals, management and union representatives, and operational experts from within the organization or suitable outside agencies, as required. A CMB consists of four distinct phases (Assembly; Information; Reactions; and Coping Strategies/Resources) and may be used to triage individuals for more intense and appropriate intervention at a later time. It is primarily used to assist tertiary groups who may be less directly affected by a crisis. This is sometimes used when emergency operations impact a community. A CMB assists community members cope/cooperate with an increased operational presence.

132

Defusing Defusing is the front-line response to a critical incident or potential critical incident. It is provided within a few hours of a crisis event to minimize the effect of acute critical incident stress. Its goal is to reduce intense reactions to the event; to normalize the experience; to provide practical/useful information (stress education); to develop expectancies about recovery, and to assess the need for follow up with a Critical Incident Stress Debriefing (CISD). This process is used primarily to assist small groups of individuals who were directly exposed to and most seriously affected by a critical event. A Defusing is led by a trained peer team member without the aid of a mental health professional. It is less structured and less time consuming (approximately 30 to 60 minutes) than a Debriefing. A Defusing may eliminate the need for, but should NOT substitute for a formal Debriefing if one is obviously required. After a Defusing, follow up is essential. Defusings are highly flexible in how they are delivered and are of low visibility. This combines to make them one of the most effective CISM tools. Critical Incident Stress Debriefing (CISD) CISD is a structured seven-phase group process utilized in the normalization of critical incident stress or traumatic stress and integrates crisis intervention strategies with educational techniques. It is best conducted in the short-term aftermath of a critical incident, approximately 24 hours post-incident, but usually within the first 72 hours (later if circumstances require). A CISD is called for after obvious, deeply disturbing events that may overwhelm the coping skills of those involved. Typically a 2-3 hour confidential group intervention led by a specially trained mental health professional and assisted by trained employee peers, after delivery, follow up is essential. Two main goals of a Critical Incident Stress Debriefing 1. Mitigate the impact of the Critical Incident on those who were victims of the event. Victims are defined as: a) Primary victims i.e. those directly traumatized by the event. b) Secondary victims i.e. those individuals who are in some way observers of the immediate traumatic effects that have been experienced by the primary victims. Co-workers peripheral to the scene would be an example. c) Tertiary victims i.e. those affected indirectly by the trauma via later exposure to the scene of the disaster/trauma or by a later exposure to primary or secondary victims. Typically tertiary victims are those not exposed to the immediate “first-hand” aspects of the traumatization, thus not impacted by the “shocking immediacy”. Staff from other departments, family members & co-worker friends of victims or rescuers might be examples of tertiary victims. 2. Accelerate recovery process in people who are experiencing stress reactions to abnormal traumatic events. Individual Intervention (One-On-One) This is an individual intervention provided by a Peer Team Member after a critical incident or potential critical incident. Individual Intervention is used to support, stabilize and provide stress education and to help assess the need for a formal Debriefing, in a group setting, if other individuals were involved. It is best provided within 24 to 72 hours of an incident (later if circumstances require) and may be conducted by specially trained peers, in person or by telephone. An Individual Intervention should NOT substitute for a formal Debriefing if one is obviously required for a group of individuals. After delivery, follow up is essential and a referral(s) may be required.

133

Family Crisis Intervention Support is not complete unless it also includes special support services for spouses and significant others who may be indirectly and negatively impacted by the same traumatic events. Support for the families may include providing educational information, Debriefings, One-on-One interventions and Crisis Management Briefings (CMB). Follow-up Services Every time a CISM intervention is provided (Defusing, Debriefing, Mobilization/ Demobilization, Crisis Management Briefing, One-on-One) it is necessary to ensure that follow up services are provided. Follow Up Services are generally provided by Peer team volunteers, and may include telephone calls; chaplain contacts; small group meetings; peer visits; one-on-one services; family contacts; referrals for professional contact or any other helpful outreach programs. CISM Assessment Criteria – Emergency Triage • Nature of incident and complications • Location, date, time of incident • Present location of person(s) affected • Any injuries or fatalities? • Number of people involved • Personal information of people involvement in incident Full Name Gender Age Address Gsm or cell phone number Landline telephone number Fysical situation: general health / injuries Mental condition Contact Data of spouse / relatives • Are individuals asking for CISM intervention? • Any stress reactions/ symptoms noticed in any of the individuals? • Source of incident report(s) Assessing the Need for a Critical Incident Stress Debriefing (CISD) Debriefings are to be conducted only when it is necessary. The following questions and comments should be helpful in determining if a Debriefing is necessary:

134

Additional Information: •

How long ago did the incident occur? Is the event ongoing? Is it getting worse / more complicated?

•

Does the event fit within the definition of a Critical Incident? Is the event of sufficient magnitude to cause significant emotional distress among those involved? (“Defusing” within initial few hours may allow for assessment of involved personnel.)

•

How many individuals are involved in the incident? (If more than three, think CISD! If less, perhaps individual intervention would be more appropriate.)

•

Are there several distinct groups of people involved or is there only one? Are there witnesses? Does everyone belong to the same community? Organisation? Team or work group? Are they staff or management? Are they related (married, partners, etc.)? Do they have the same incident perspective? Etc… Depending on criteria, more than one CISD may be required.

•

What is the status of the involved individuals? Where are they and how are they reacting?

•

What signs and symptoms of distress are being displayed?

•

Are any of the following key indicators present: Behavioural change Regression Continued symptoms Intensifying symptoms New symptoms arising Group symptoms

•

How long have the reactions or signs and symptoms of distress been going on? Significant symptoms that continue past a few days indicate a Debriefing may be necessary. If symptoms of distress continue longer than one week after the incident, a Debriefing is definitely necessary.

•

Are the symptoms growing worse as time passes? Worsening symptoms may indicate a need for Debriefing.

•

Are individuals simply requesting information on stress, stress management, operational details, etc? (A formal Debriefing may be unnecessary if these requests are not accompanied by significant stress reactions.)

•

Are they willing to come to a Debriefing?

•

What other stressors or influences are complicating? Are there any other issues that might inhibit or otherwise derail a successful Debriefing?

Automatic CISM Debriefings The incidents listed below will mandate that a Critical Incident Stress Debriefing be automatically offered to affected individuals. In the interim, whenever possible a Defusing should be conducted within 12 hours of the incident and prior to the individuals return to home. If a Defusing is not possible and/or a formal Debriefing is not practical then a Peer Team member can provide individual interventions (in-person or by telephone) to those involved.

135

Incidents that will result in automatic CISM Debriefing: • line of duty death • suicide or homicide • armed / violent assault • hostage-taking • disaster • client / traveler fatality Potential CISM Debriefings The incidents listed below have a potential to result in a Critical Incident Stress Debriefing and will depend on Defusing held within a number of hours of the incident prior to the affected people’s return to home. This provides an opportunity to assess the impact of the incident on them. If a Defusing is not possible then a Peer Team member can provide individual intervention (in-person or by telephone) to those involved. Incidents that have the potential to result in a CISM Debriefing: • serious injury or death of a relative, friend or co-worker, especially when under unusual circumstances • perceived threat to personal safety • medical emergency

136

Critical Incident Stress Signs and Symptoms: Critical Incident Stress is a normal reaction by normal people to an abnormal situation. It may affect individuals at varying degrees and for different lengths of time. It is significantly more intense than everyday stress and is tied to a specific event. CIS reactions may include emotional, physical, and cognitive reactions that are beyond a person's control (listed below). After a Critical Incident, individuals are likely to experience one or more of the following... Physical reactions

Cognitive reactions

1. Exhaustion 2. Nausea/vomiting 3. Weakness 4. Difficulty breathing* 5. Chest pains* 6. Rapid heart rate 7. Headaches 8. Dry mouth/always thirsty 9. Elevated blood pressure 10. Fainting/dizziness 11. Exacerbation of allergy problems 12. Symptoms of shock*

1. Blaming attitude 2. Confusion 3. Reduced attention span 4. Flashbacks 5. Poor concentration/loss of confidence 6. Negative self-talk/loss of confidence 7. Decreased awareness 8. Troubled thoughts 9. Nightmares 10. Easily distracted 11. Short-term memory disturbance 12. Time/place/person distortion*

Emotional reactions

Behavioural reactions

1. Frustration 2. Strong need for recognition of what they experienced 3. Anxiety 4. Guilt/feeling strongly for victims 5. Sense of loss 6. Anger 7. Denial 8. Fear of loss of control 9. Irritability/agitation 10. Depression 11. Feeling overwhelmed 12. Feeling isolated 13. Loss of emotional control

1. Emotional outbursts 2. Change in activity level 3. Disturbed sleep 4. Increase in smoking 5. Easily startled/ hyper-vigilance 6. Antisocial behaviour 7. Withdrawal 8. Change in eating habits (increase or decrease in food consumption) 9. Difficulty relaxing 10. Fidgety/restless 11. Increased use of alcohol and other drugs 12. Change in sex drive

* definite indication of the need for medical evaluation Individuals experiencing cumulative stress or delayed stress reactions should seek out help from an EAP practitioner.

137

Moving Past a Moment of Crisis If you have recently had a traumatic experience, you may be having feelings that are new to you. Dr. Phil explains that some of these emotions and fears are normal under the circumstances, and offers suggestions on how to move past the moment of crisis: If you fear that something traumatic might happen again, you are experiencing rational regression. Understand that this is a natural reaction to a traumatic event. Be patient with yourself and realize there is rational fear and irrational fear. With rational fear, we react to a real threat and protect ourselves. When we have irrational fear, we are scared even though there is no threat to us. If you were injured during your traumatic event, it's normal to have fears (that may seem irrational) until your body heals. Understand that it will not be like this for the rest of your life. You will heal. Stop asking "What if something happens again?" Remember that something traumatic happened and you got through it. If something else happens, you will get through that too. When you do survive a moment of crisis, know that there is a reason. Don't have survivor's guilt. Decide that there's a purpose, find it, and live it. Don't be afraid to reach out and ask for help from friends, family or a mental health professional. The American Counseling Association recommends Five Ways to help with coping AFTER a crisis situation. 1. Recognize your own feelings about the situation and talk to others about your fears. Know that these feelings are a normal response to an abnormal situation. 2. Be willing to listen to family and friends who have been affected and encourage them to seek counseling if necessary. 3. Be patient with people; fuses are short when dealing with crises and others may be feeling as much stress as you. 4. Recognize normal crises reactions, such as sleep disturbances and nightmares, withdrawal, reverting to childhood behaviors and trouble focusing on work or school. 5. Take time with your children, spouse, life partner, friends and co-workers to do something you enjoy. Post-Traumatic Stress Disorder: The Symptoms Post-Traumatic Stress Disorder (PTSD) is a complex anxiety disorder that may develop after exposure to an extremely stressful or life-threatening event — involving death, the threat of death or serious injury — with resulting intense fear, helplessness or horror. If you experience these symptoms for a duration of more than a month, you could be suffering from PTSD. "This is not meant to be used to diagnose yourself, but rather raise your awareness of when you might need to reach out," Dr. Phil says. Persistently Re-Experiencing the Event Having recurring dreams about the event or having persistent and distressing recollections of the event. Feeling and acting as if the trauma was reoccurring — hallucinations or flashbacks — and experiencing distress when exposed to cues. For example, Dr. Phil's guest, Shelita, was attacked at gunpoint in her house, so when she is at home, she often replays the event in her mind.

138

Avoiding Stimuli Associated with the Trauma Making efforts to avoid thoughts, conversations, people, places and activities associated with the trauma, and avoiding activities, places or people that arouse recollections of the trauma. Shelita makes every effort to avoid being inside her house. She often spends long periods of time at the mall and sits in her car outside her home so she doesn't have to go inside. Numbing of General Responsiveness Pulling back and having a diminished interest in activities that are significant, and suffering low energy. Feeling detached or estranged from others. Displaying a restricted range of affect — unable to have loving feelings, or don't want to become excited and happy or let scared emotions out. Increased Arousal Symptoms Not Present before the Trauma Being easily startled, having difficulty sleeping or concentrating. Developing a heightened irritability and/or having angry outbursts. Becoming hypervigilant — behaviors you did not experience before the event. Disturbance Impairs other Areas of Functioning Experiencing significant impairment in social or occupational activities or any other important areas of functioning. Shelita has a difficult time working, because loud noises easily startle her. Other Possible Symptoms • •

Inability to recall important aspects of the trauma Sleep difficulty

• •

Irritability or anger Feeling hopeless

• •

Sense of foreshortened future Excessive drug and/or alcohol use

If you find yourself experiencing these symptoms, don't let it drain your life energy. Seek help from a medical professional. Post Traumatic Stress Disorder may come on silently. It is a very progressive illness that becomes more severe year after year if left untreated. It will eventually consume those victims who have experienced trauma beyond what their minds are able to comprehend or deal with at one time.

139

Common Signs and symptoms of Post Traumatic Stress Disorder Physical

Behavioral

Emotional

Fatigue Vomiting or Nausea Chest Pain Twitches Thirst Weakness Insomnia or Nightmares Breathing Difficulty Muscle Tremors Grinding of Teeth Profuse Sweating Pounding Heart Diarrhea or Intestinal Upsets Headaches

Withdrawal Pacing and restlessness Anti social acts Suspicion and Paranoia Inability to rest Loss of interest in hobbies Increased Alcohol Consumption Other substance abuse

Anxiety or Panic Fear Denial Irritability Depression Intense Anger Agitation

Apprehension Am I Stressed Out...? If you experience the symptoms below, Post Traumatic Stress Disorder may be starting to show its early signs. Please see a doctor, as well as a qualified Police Stress Therapist, to discourage the disorder from getting worse. Headaches â&#x20AC;&#x201C; Fatigue - Pounding Heart - Digestive Upsets - Teeth Grinding - Light Headedness - Lowered Sex Drive - Irritability - Short-temper - Backaches - Muscle Aches - Loss or Gain in Weight - Insomnia Restlessness - Muscle Tics - Drinking too Much How to Cope With Emotional Pain 1. Don't try to cure what is normal. Temporary emotional pain is caused by any number of events: death of a loved one, a breakup, thoughtlessness or cruelty on the part of others. When you're hurting because of any of the above, accept that it's normal to feel hurt or angry for a short time. Let's face it: if a loved one dies, only a very cold person would be unaffected by it. If you love someone and that person dumps you, it's natural to feel hurt. These things are normal. Trying to cure what is normal is pointless. Expect to feel pain for a while - it's normal. 2. There's a statement that goes something like, 'If you get (enter mad, hurt, insulted, offended, etc., here) it's your fault.' That's just not true. That suggests that people don't love, or bond, or trust, or invest emotions. If you have emotional pain, there's a reason for it. 3. Don't pretend you don't feel it. The pain is real. You have to address it, or you will never get beyond it. Don't try to rush through this season of pain. Even though all you can really think about is ending the pain, the truth is that just allowing yourself the feelings is important. Masking your pain when you're trying to work or just get through each day may be necessary to a point, but make sure to allow yourself some "me-time" - some time to allow yourself to really feel all of the feelings you are having, rather than just suppressing and denying them.

140

4. Identify all of your feelings. Are you just heartbroken? Or are you angry, too? Maybe just the tiniest bit relieved - which is also making you feel guilty? Do you feel betrayed? Insecure? Afraid? Giving some thought to exactly how you are feeling can be very helpful in processing all of your emotions in the wake of a traumatic or life-changing event. 5. Endure it. Things that cannot be cured must be endured. It sounds obvious, but sometimes, thinking of emotional pain as if it were physical pain can be very helpful. Think of your broken heart just as if it were your arm that is broken instead. A broken arm takes time to heal, and it hurts like crazy just after it's broken, even after it's been set and casted. A few days later, it doesn't hurt so much. But weeks or even months later, if you bump or jar it, that pain can come roaring back to life with a vengeance. You baby it a little, take care not to aggravate it, and eventually, it's stronger where it was broken than it was before. You have no choice - you can't cut off the arm. That won't make it hurt any less. You just have to endure it while it heals. 6. Talk to someone. There are times when it seems that the hurt you feel inside is just too deep to talk about. You feel like no one could understand. Or maybe you worry because your loved ones didn't share your feelings about whatever it is that's hurting you. Maybe they didn't care for your boyfriend, whom you just broke up with, or they didn't know your friend, who passed away. You may be right - they may not totally understand. But right now, it isn't being understood that you need. It's compassion. Your family and friends love you. They see you hurting and want to help. Sometimes, if you will just try to talk out your feelings, say something about what hurts, it can help start your healing. Letting someone put his or her arm around you and hearing them say, "It's going to be okay" may not seem that helpful, but it really is, because it helps you feel you're not totally alone. Realizing that someone wants to be there for you will help. 7. Don't let anyone tell you that your feelings aren't real. They are real, significant, and important. And, they're your feelings. Feeling alone doesn't mean there is no one around. Feeling sad doesn't mean you'll never be happy. Feel your feelings, think your thoughts, but realize they're just feelings and thoughts. 8. Get your mind off yourself and how bad you feel. You have the right to feel sorry for yourself - for 10 minutes. Then move on. No exceptions. Go out with friends. Tell yourself that you will not talk about your pain for more than a few minutes - you will not bring down the activity by wallowing in it. Don't let your friends walk on egg shells around you just because you've been traumatized. You still need to live. Distract yourself by just forgetting it for a little while. If you're grieving a death, or heartbroken over a breakup, especially, giving yourself a little time to just be without obsessing on the event that hurts will help you to heal and move past it. That's not to say that you just forget about it and move on - no. It's only to say that even grief needs to take a breather. Give your weary heart a little respite, and let it mend with the love and lightness of heart that comes from being with friends, or doing something that brings you pleasure. There will be time to cry again, but not just now. 9. Allow time to heal. This is part of just enduring. You will need to muster up the patience to allow healing to commence. There isn't any substitute for just ... waiting. Time requires one thing: that you allow it to pass. Getting past emotional pain requires a grieving process, which takes time. 10. Don't let your pain define you. Remember you are greater than this hard time, you have a past and a future. You have awareness and creativity. This was a single episode which will soon pass.

141

11. Write a letter. Writing down your feelings can help you to sort them out. It can help more if you use positive "I messages" instead of negative ones. If you don't write, talk about your feelings with someone close or a therapist. Don't justify them, just talk about them, get them out, and listen to what you say. 12. Stay away from statements that blame you or others. Take responsibility for your actions, and your part of whatever went wrong, but do not indulge in blaming. The question of "And whose fault is/was that?" does not apply. 13. Develop a learning orientation. Life hands you difficulties so you can learn from them. People who have really easy lives fall apart when bad things happen because they have never learned how to cope or let things roll off their backs. Everything, even very painful times, can be used to learn better coping skills and to develop wisdom and perspective about life that will help you deal with many difficulties in the future. Whatever doesn't destroy you can serve to make you stronger. 14. Make a 'Thankfulness List'. Write down what you are thankful for, even basic things like having clothes and a warm place to sleep, then moving to people who care for you, and good things in your life. Being thankful is naturally healing and will balance out any trauma over time. 15. If the pain is lasting more than a week or so, or you've lost hope or you're thinking of suicide, you're either suppressing your pain or you have deeper unresolved issues that you need to complete. The strategies above are healthy ways to deal with emotional pain. Often as kids, we didn't use these strategies and instead incorporate the pain into our character, our subconscious. Said another way, when we're young, it's easy to let emotional pain define you. Often this needs to be undone, teased apart and handled in a healthy manner for us to be free. If a current incident upsets you too much or for too long, or your whole life is colored by a negative outlook, consider getting some help to unearth, re-examine and complete a prior incident.

142

CISM Follow Up Protocol CISM Debriefing Follow Up All participants in formal CISM Debriefing sessions will receive at least TWO follow up telephone calls or visits no later than: • 48 hours after conclusion of Debriefing session, and • Three weeks after conclusion of Debriefing session A second Debriefing session may be held for the same participants if: • There is an expressed need from the participants, and/or • Two or more groups wish to be debriefed together, and/or • Multiple events necessitate Anniversary follow up should be planned for one year later. Note: The same Peer Team Members who participated in Debriefing should provide follow up services whenever practicable. CISM Defusing Follow Up All participants in CISM Defusing will receive a follow up telephone call no later than 48 hours after conclusion of defusing session, or within 24 hours if circumstances warrant priority attention. CISM Individual Intervention (One-On-One) Follow Up All participants in One-On-One Intervention will receive a follow-up telephone call no later than 48 hours after conclusion of Intervention, or within 24 hours if circumstances warrant priority attention. Note: The same Peer Team Members who provided One-On-One should provide follow up services whenever practicable. CISM Mobilization/Demobilization Follow Up Follow up telephone calls should be made within 24 hours to any staff member who may be assessed to require additional and/or priority attention. CISM Crisis Management Briefing (CMB) Follow Up Follow up may be provided immediately after conclusion of CMB. Peers Team Members in attendance may provide this service as informal “walk and talk” conversations with audience members who request it or who may exhibit stress reactions. Refreshments The provision of refreshments is strongly advised to help facilitate certain CISM intervention techniques, specifically Debriefing and Mobilization/Demobilization. Care must be taken to ensure that the refreshments are appropriate for the intervention. DO NOT over-cater – the refreshments are intended as an incentive toward the goal of stress-reduction through healthy eating, and as an encouragement to participate in a particular CISM activity.

143

Use the following as a guide: •

Refreshments situated opposite entrance to room (across room if possible).

•

Healthy snacks, sandwiches (simple fillings), fruit, juice, bottled water, decaffeinated coffee (do not indicate), milk/sugar.

• •

No red food, no grilled food, no bone-in food (rare beef, Italian, barbeque, fried chicken, etc.). Avoid strongly-spiced, messy or “ethnic” foods whenever possible.

Critical Incident Stress Management (CISM) : “How do I know when I’m in over my head?” Prepared by: Gregory Janelle, Janelle & Associates Consulting Ltd., 1997. Revised 2001 Peer support training does not fully equip the average layperson for the occasionally overwhelming circumstances that may be encountered after a critical incident. This is especially true during Defusing and One-On-One intervention, when the Peer is often the first to respond and assessment of a survivor’s emotional state is difficult at best. No matter how experienced and confident one may feel going into a situation, there may inevitably come a point when it would be harmful, even dangerous, to try to handle a survivor without professional mental health intervention. A responsible Peer will always enter a dialogue cautiously and follow established guidelines with due care. It is very important that the Peer remain constantly vigilant to “danger signals” that may alert them to the moment when they feel they are beyond their limits as a caregiver and no longer capable of providing proper support to the traumatized individual. To err on the side of caution is always the best route to take. As a helpful guide, consider the following BEFORE speaking to a person in crisis: (Excerpt with permission, from “Coping With Survival” by Margaret A. Kilpatrick, 1981) Alertness and Awareness You can probably handle, if the survivor: • •

is aware of who he/she is, and what happened is only slightly confused or dazed, or shows slight difficulty in thinking clearly or concentrating on a subject

Consider referral, if the survivor: • •

is unable to give own name or names of people he/she is living with cannot give date; state where he/she is; tell what he/she does

•

cannot recall events of past 24 hours

•

complains of memory gaps

Actions You can probably handle, if the survivor: • •

wrings his/her hands; appears still and rigid; clenches his/her fists is restless, mildly agitated and excited

•

has sleep difficulty

•

has rapid or halting speech

144

Consider referral, if the survivor: •

is depressed, and shows agitation, restlessness and pacing

• •

is apathetic, immobile, unable to rouse self to movement is incontinent

• •

mutilates self excessively uses alcohol or drugs

•

is unable to care for self, eg. doesn’t eat, drink, bathe or change clothes

•

repeats ritualistic acts

Speech / Mental Functioning You can probably handle, if the survivor: •

has appropriate feelings of depression, despair, discouragement

• •

has doubts of his/her ability to recover is overly concerned with small things, neglecting more pressing problems

• •

denies problems; states he/she can take care of everything him/herself blames problems on others; is vague in planning; bitter in feelings of anger that he/she is a victim

Consider referral, if the survivor: • •

hallucinates – hears voices, sees visions, or has unverified bodily sensations states his/her body feels unreal and fears losing his/her mind

• • •

is excessively preoccupied with one idea or thought has delusion that someone or something is out to get him/her and family members is afraid of killing self or another

• •

is unable to make simple decisions or carry out everyday functions shows extreme pressure of speech; talk overflows

Emotions You can probably handle, if the survivor: •

is crying, weeping, with continuous retelling of the disaster

•

has blunted emotions, little reaction to what is going on around him/her

• •

shows excessive laughter, high spirits is easily irritated and angered over trifles

Consider referral, if the survivor: • •

is excessively flat, unable to be aroused, completely withdrawn is excessively emotional, shows inappropriate emotional reactions

145

Critical Incident Stress: Tips on How to Recover from a Critical Incident Critical Incident Stress (traumatic stress) tests your coping mechanisms to the limit. Because of the impact on your psychological system, a variety of coping mechanisms appear – some healthy, some not so healthy. Research has shown that the way in which a person takes care of him or herself during the first few days following a traumatic event will help to minimize the development of future psychological reactions to the event. Here are some tips on how to cope in the aftermath of an incident: 1.) Do not use alcohol or other drugs to cope. Drugs, in particular alcohol, are powerful symptom suppressors. Ethanol, the active ingredient in alcohol, saturates the brain, creating an artificial feeling of euphoria. As more ethanol is absorbed into the system, more and more areas of the brain are numbed or shut down, creating a distance from emotional issues. No psychic healing takes place because of the alcohol in the system. Consequently, once the alcohol leaves the body, not only is the original problem still there, but your body is now struggling with the depression and nausea from the alcohol. Similarly, drugs also prevent any psychological resolution at the subconscious level. 2.) Do not isolate yourself from family, friends and co-workers. People react to psychological trauma by keeping it inside. Often the trauma may seem so great that life seems meaningless. By withdrawing, you isolate yourself running the risk of allowing the incident to become larger than life. By remaining involved with others: • You prevent yourself from becoming obsessed with the incident; • You are more likely to appreciate that, though this incident was traumatic, life goes on; • You may end up talking out the incident, contributing to your working it through. 3.) Eat well and maintain a physical outlet. Diet is an important factor in reducing the negative effects of stress. Even though you may not feel hungry, eat something and make sure it’s healthy food. Exercise is critical to cleansing the body of the negative consequences of stress. It is recommended to get good exercise within 24 hours of the incident. But don’t stop with that. Keep up regular activity whether it’s a tennis game, a run or a swift walk. 4.) Assess your situation carefully. If you are very traumatized by an incident, it may be necessary to take time off work. Working while being emotionally vulnerable puts us more at a risk for an acute stress reaction. On the other hand, you may be someone who finds that being back on the job is just what you need. Assess your situation carefully. If you feel vulnerable, request time off or arrange to have a reduced workload. 5.) Watch your fixation on the incident. Some individuals become obsessed with finding reasons for the event. Shocked by what has happened, they feel a need to regain meaning or a sense of fair play in life. Whether they are looking for simple or complex answers, the solution doesn’t come immediately. Allow time to pass. Only over time will the real meaning of what has happened become apparent.

146

6.) Give yourself time to heal. Traumatic stress can seriously affect you. Accept that it takes time to heal. Beware of having unrealistic expectations for hasty recovery. 7.) Expect the incident to bother you. Take comfort in knowing that the incident won’t bother you forever. Though you may never completely forget the incident, recalling it doesn’t have to cause emotional distress. Your goal shouldn’t be to totally forget the incident, rather, it should be to heal. You know you are healed when you think you are able to think of or talk about the incident without profound emotion. 8.) Learn or review your facts about critical incident stress (C.I.S.) You need facts about what you are going through. By reading up on C.I.S. and it’s associated reactions, you will see that, however unusual they may seem, your reactions are normal. 9.) Take time for fun. You must take care of yourself – that includes doing what you enjoy. Take time for leisure activities. 10.) Get help if necessary. If you find the incident is staying with you longer than it should, seek individual counselling. Through talking with a trained professional, any unresolved issues can be faced and resolved. If you don’t get help, you run the risk of remaining distressed or of seeing this incident affect you more intensely in the future, when facing other events.

147

Critical Incident Stress – Tips to Colleagues and Family If a friend or mate has experienced a traumatic event, your behaviour may help the recovery process. Here are some suggestions: Learn about Critical Incident Stress (C.I.S.) so you can begin to understand what the person is experiencing. Encourage the individuals to talk about the incident, but don’t be overly demanding. They may feel that others don’t want to hear about their feelings or that you expect them to be able to “handle” the situation. You need to challenge these beliefs by indicating your willingness to listen. Ask “How are you doing?” or “How are you feeling?” If people want to talk they will; if not, they won’t. By your questions, you have at least sent the message that a listening ear is available. Don’t be afraid of deep emotion. Many of us have not experienced profound grief or anguish. Seeing someone cry uncontrollably can be somewhat distressing. Traumatized individuals need to vent their emotions and if they are in your presence; they need your support. Simply be there to listen and let them talk. Afterwards, suggest a walk to help them further reduce their level of stress. Share your feelings about the situation. Don’t say “I know how you feel,” because you don’t. You may have gone through a similar experience, but no two experiences are the same or perceived as being the same. You can, however, say things like “I can imagine this must hurt a lot” or “I feel sorry for what has happened.” Don’t make false promises such as “everything will be okay. No one knows the future. Your role is that of a support person, not a miracle worker. If you don’t know what to say, say nothing. In most cases, all people need is someone to “hear them out,” not necessarily to solve their problems. Say “it’s okay for you to feel the way you do.” Affirm that there has been a terrible tragedy and that it is normal to feel pain, confusion, etc. Such a statement is particularly reassuring if you are a peer. It is helpful to have co-workers legitimize your feelings. Do not explain away anything. At this stage, your explanation is not needed; emotional release is. Your explanation may be interpreted as minimizing rather than supporting the individual’s feelings. Encourage a subsequent debriefing or counselling session if the pain persists. Guidelines are difficult to provide. However, the situation should improve one week to next. Indications of progress include hearing comments such as “Yeah, I’m feeling better today,” seeing less stress and strain on the individual or seeing the individual become more like his/her former self. Take care of yourself; you are a co-survivor. Though not involved in the incident, you are a victim of the by-product of the incident. Make sure there is someone with whom you can talk things out.

148

Chapter 6 Harm Assessment (Suicide, Homicide, Injury to self or others) What should a responder knew about suicide? People become suicidal because of a crisis or series of crises in their lives. Sometimes people see suicide as a resolution to the pain they are experiencing in the midst of a crisis. What they may not see is that there are always other options. Suicide is rare, but devastating when it does occur. The information below shows a few relevant statistics: In 2001, suicide took the lives of 30,622 people in the US. In 2001, there were twice as many deaths due to suicide than due to HIV/AIDS (14,175) In 2004, suicide took the lives of 32,439 people in the United States. •

25,566 were males, 6,873 were females :

: 80% male vs 20% female!

•

29,251 were white , 3,188 were non-'white

: Non-whites = more than 25% of the population, account for only 10% of the suicides

•

4,316 were 15-24 years, 5,198 were 65+ years

: From 1999 to 2010, the suicide rate for men in their fifties rose 49,4%

• •

Average suicide rate is 12/100,000 – but for white men over 85 it is 65.3/100.000 Males are four times more likely to die of suicide than are females. However, females are more likely to attempt suicide than are males

In 2004, suicide was the 11th leading cause of death in the US. In 2010, 38.364 Americans killed themselves No official data was compiled on the number of attempts, but it is estimated to be 25 attempts for every death by suicide. Suicide attempts are expressions of extreme distress that need to be addressed, and not just a harmless bid for attention. A suicidal person should not be left alone and needs immediate mental health treatment. Suicide is a complex behavior usually caused by a combination of factors. Research shows that almost all people who kill themselves have a diagnosable mental or substance abuse disorder or both, and that the majority has a depressive illness. Studies indicate that the most promising way to prevent suicide and suicidal behavior is through the early recognition and treatment of depression and other psychiatric illnesses. How should a crisis service provider deal with someone who may be considering suicide? The statistics are nice as guidelines, but offer little help when dealing with an individual. Each individual has his/her own history and reasons for thinking of suicide. If someone is suspected to be thinking of suicide, the best thing to do is ask directly, "Are you thinking of killing yourself?" By asking directly you are actually giving the person permission to talk about it. Talking it through is the best way to prevent a suicide. You will not be putting the idea into someone's head. Ask open-'ended questions. Let the person talk about what happened, who else is involved, how long has he/she been thinking of suicide, what would happen if he/she went on living, how others would react, etc.

149

What do people who feel suicidal want? Someone to listen. Someone who will take time to really listen to them. Someone who won't judge, or give advice or opinions, but will give their undivided attention. Someone to trust. Someone who will respect them and won't try to take charge. Someone who will treat everything in complete confidence. Someone to care. Someone who will make themselves available, put the person at ease and speak calmly. Someone who will reassure, accept and believe. Someone who will say, "I care." What do people who feel suicidal not want? To be alone. Rejection can make the problem seem ten times worse. Having someone to turn to makes all the difference. Just listen. To be advised. Lectures don't help. Nor does a suggestion to "cheer up", or an easy assurance that "everything will be okay." Don't analyze, compare, categorize or criticize. Just listen. To be interrogated. Don't change the subject, don't pity or patronize. Talking about feelings is difficult. People who feel suicidal don't want to be rushed or put on the defensive. Just listen in a caring and non-judgmental way and you will be an invaluable resource to people who feel they have nowhere else to turn. Who knows? - Talking to you may help someone save their life. Being listened to If someone is feeling depressed or suicidal, our first response is to try to help. We offer advice, share our own experiences, try to find solutions. We'd do better to be quiet and listen. People who feel suicidal don't want answers or solutions. They want a safe place to express their fears and anxieties, to be themselves. Listening - really listening - is not easy. We must control the urge to say something - to make a comment, add to a story or offer advice. We need to listen not just to the facts that the person is telling us but to the feelings that lie behind them. We need to understand things from their perspective, not ours. It is important for people to have the opportunity to explore difficult feelings. Being listened to in confidence, and accepted without prejudice, can alleviate general distress, despair and suicidal feelings. Often being listened to is enough to help someone through a time of distress. Even just showing that you are there for them, and that you know they are going through a distressing time, can in itself be a comfort. Important elements of active listening when listening to a person who is feeling depressed or suicidal: •

Always try to give people your undivided attention

• •

Let them sit in silence and collect their thoughts if they need to Question them gently, tactfully and without intruding

• •

Encourage them to tell their story in their own words and in their own time Refrain from offering advice based on your own experience

•

Always try and see their point of view even though you may not agree with it

150

People who feel suicidal should not try to cope alone. They should seek help NOW. For people who are lonely, despairing and considering suicide, the most important step is to talk to someone they can talk to in complete confidence about their deepest fears and darkest secrets. • •

Talk to family or friends. Just talking to a family member or a friend or a colleague can bring huge relief. Call a hotline, search a support group on the internet, call a befriender. Some people cannot talk to family or friends. Some find it easier to talk to a stranger. There are befriending centers all over the world, with volunteers who have been trained to listen. If calling is too difficult, the person can send an email.

•

Talk to a doctor. If someone is going through a longer period of feeling low or suicidal, he or she may be suffering from clinical depression. This is a medical condition caused by a chemical imbalance, and can usually be treated by a doctor through the prescription of drugs and/or a referral to therapy.

Time is an important factor in ‘moving on', but what happens in that time also matters. When someone is feeling suicidal, they should talk about their feelings immediately. What other things might a crisis service provider need to keep in mind? Suicide is rarely a spur of the moment decision. In the days and hours before people kill themselves, there are usually clues and warning signs. The strongest and most disturbing signs are verbal - "I can't go on," "Nothing matters any more" or even "I'm thinking of ending it all." Such remarks should always be taken seriously. Other common warning signs include: Behaviors •

Crying

• • •

Fighting Breaking the law Impulsiveness

• • •

Self-mutilation Writing about death and suicide Previous suicidal behavior

• •

Extremes of behavior Changes in behaviour

•

Becoming depressed or withdrawn

• • •

Behaving recklessly Getting affairs in order and giving away valued possessions Showing a marked change in behavior, attitudes or appearance

•

Abusing drugs or alcohol

A person's history may actually make him or her more susceptible to completing a suicide. Predisposing Factors • •

Chaotic or disjointed life style Mental illness, especially depression

•

Adoption

• •

Isolation Physical health/weight concerns

151

• •

Family history of suicide or violence Sexual or physical abuse

• •

Suffering a major loss or life change Death of a close friend or family member

•

Divorce or separation, ending a relationship

•

Failing academic performance, impending exams, exam results

• •

Job loss, problems at work Impending legal action

•

Recent imprisonment or upcoming release

There are also certain perpetuating factors to take into account. If a person is in the midst of a crisis, these things may prevent him or her from getting assistance. Perpetuating Factors •

Negative coping patterns, i.e. hostile, no sense of humor, thinking everything is meant negatively toward them

• • •

Overly controlled, rigid personality Overachiever Poor communication skills

• • •

overly sensitive Low self-esteem Anti-social behaviour

• • •

Drug/alcohol abuse or addiction or gambling addiction Depression: Low mood that persists Change in eating or sleeping habits

• •

An inability to enjoy anything Irritability

• •

A hopeless, helpless outlook Feeling guilty for no apparent reason

•

Crying or weeping with little or no provocation

Physical Changes • •

Lack of energy Disturbed sleep patterns - sleeping too much or too little

• • •

Loss of appetite Sudden weight gain or loss Increase in minor illnesses

•

Change of sexual interest

• •

Sudden change in appearance Lack of interest in appearance

152

Thoughts and Emotions •

Thoughts of suicide

•

Loneliness - lack of support from family and friends

• •

Rejection, feeling marginalized Deep sadness or guilt

• •

Unable to see beyond a narrow focus Daydreaming

• •

Anxiety and stress Helplessness

•

Loss of self-worth

Additionally, the Surgeon General's Call to Action on Suicide identifies the following risk factors: • •

Previous suicide attempt Mental disorders - particularly mood disorders such as depression and bipolar disorder

• • •

Co-occurring mental and alcohol and substance abuse disorders Family history of suicide Personal history of abuse-physical, sexual, emotional, victimization

•

Hopelessness

• •

Impulsive and/or aggressive tendencies Barriers to accessing mental health treatment

• •

Relational, social, work, or financial loss Physical illness

•

Easy access to lethal methods, especially guns

•

Unwillingness to seek help because of stigma attached to mental and substance abuse disorders and/or suicidal thoughts

•

Influence of significant people - family members, celebrities, peers who have died by suicide - both through direct personal contact or media representations

•

Cultural and religious beliefs - for instance, the belief that suicide is a noble resolution of a personal dilemma

• •

Local epidemics of suicide that have a contagious influence Isolation, a felling of being cut off from other people

Of course, in most cases these situations do not lead to suicide. But, generally, the more signs a person displays, the higher the risk of suicide. Risk Factors for Jail Setting Individuals who are psychotic in a jail setting are also at increased risk for self injurious behaviors and suicide attempts. The psychotic individual is also at increased risk of being harmed by other inmates due to the perception of the individual with mental illness as vulnerable or bizarre.

153

Just as there are factors that create a higher risk for suicide, there are factors that lessen the probability of suicide. Protective Factors • •

Effective and appropriate clinical care for mental, physical, and substance abuse disorders Easy access to a variety of clinical interventions and support for help seeking

• •

Restricted access to highly lethal methods of suicide Family and community support

•

Support from ongoing medical and mental health care relationships

•

Learned skills in problem solving, conflict resolution, and nonviolent handling of disputes

• •

Affective coping techniques Cultural and religious beliefs that discourage suicide and support self-preservation instincts

All of the perpetuating, risk, and protective factors listed are important considerations in assessing a person's ability to cope and gain assistance during periods of crisis. There are two, however, that deserve special consideration: Depression and alcohol/ drug use. What makes depression and alcohol/drug abuse important? Studies have shown that roughly 90% of those who complete suicide have a diagnosable behavioral health disorder, commonly a depressive disorder or a substance abuse disorder.18 Most of us can relate to depression because we have felt a bit of the low mood, listlessness, restlessness, helplessness, and hopelessness that accompanies depression. However, true depression is far more intense than a blue mood. The Diagnostic and Statistical Manual of Mental Disorder, 4th Edition, Text Rev/sad (DSM-IV-TR) identifies criteria for a Major Depressive Episode. A condensed version of these criteria follows. Five or more of the following symptoms have been present nearly every day during the same 2-week period and represent a change from previous functioning: • • •

Depressed mood most of the day Markedly diminished interest in all or almost all activities most of the day Significant weight loss or significant weight gain without attempting to either lose or gain weight, or a decrease or increase in appetite

•

Insomnia (inability to sleep or stay asleep) or hypersomnia (need for more sleep than usual)

•

Psychomotor agitation or retardation (as noted by observation by others)

• •

Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt

• •

Diminished ability to think or concentrate or indecisiveness Recurrent thoughts of death, suicidal ideation or a suicide attempt

These symptoms must cause significant distress or impairment in functioning. (One depression sufferer described the effects of depression as having so little energy that lifting a pencil became an overwhelming task.) For many people, alcohol and other drug abuse is both a risk factor and a symptom. Alcoholism is a primary diagnosis in 25% of people who complete suicide. Self-medication to relieve symptoms of depression or other mental illnesses is not uncommon. It is estimated that approximately 50% of people who have a serious and persistent mental illness (SPMI) also abuse substances.

154

When providing crisis services, it important to remember that the use of alcohol and drugs may increase impulsiveness and reduce judgment. Additionally, drug intoxication or withdrawal from drugs (both licit and illicit drugs) may cause symptoms that are similar to symptoms of a mental illness. Responders should ask about psychotropic medications as well as illicit drug use. Antidepressants may allow the reason to regain physical energy before mood improves. Persons may be at higher risk of suicide at this point. At the time someone completes suicide, there is often some identifiable event that precedes the act, a conflict or loss that pushes a person to believe that the pain is no longer tolerable and even death is preferable to living through this misery. The event is what most people think of as the why of suicide. Suicide is almost always much more complicated than simply being the result of one event in a person's life. History, concurrent stressors, and coping ability are all part of the equation. There are many facts of the circumstances that add up to the whole story. When in the depths of despair, people are most likely to focus only on the negative, leaving out any positive aspects of their situation. The positives usually become obvious to anyone listening, and it is important to point them out. Pointing out positive aspects, "there are people who care, you do have value," will create ambivalence. The goal of course is to create enough ambivalence to tip the scale in favor of living rather than dying. Always start with the precipitator; what happened today or in the recent past that made the difference. Precipitating Factors Usually an accumulation of life stressors, conflict, or loss • • •

A conflict with family member or love relationship Failure to get a job, get a promotion, achieve something Loss of money, income, material goods

• • •

Legal problems, DUI, etc. Injury or illness Pregnancy

• •

The number and seriousness of previous attempts The level of stress and number of concurrent stressors

•

The intensity and duration of depression

•

The normal ability to cope with life's ups and downs

• •

The person's physical health Active symptoms of psychosis, especially command hallucinations

• • •

The level of external support available to the individual Impulsivity/absence of protective factors Alcohol and/or drugs and

•

Any prescribed or over the counter medication

Command hallucinations: Hallucinations that tell the hearer to act or behave in a particular way. In a true command hallucination, the hearer feels that he/she MUST behave in the way indicated by the hallucinatory voice.

155

Intuition or "gut sense" of the seriousness of this particular person's presentation is a very valuable tool in assessing suicide risk. From the beginning of the interaction with the person, begin to ask for contracts or little agreements. For example: "I know you feel lousy right now, but would you agree to sit and talk with me just for half an hour?" Take every threat of suicide seriously. Consult others as necessary and never promise anything that you cannot do. Do not say that you care if you do not really care. “It is very hard to make decisions when you are feeling this bad. Can you let us help you with decisions until you are feeling better?" Develop a strategy Help the person make a decision on a specific, short-term plan. You won't resolve all the problems; stick to one issue that is doable. There are three wishes identifiable prior to a person attempting suicide: 1. The wish to die or be dead 2. The wish to be killed 3. The wish to commit murder Any one of these wishes may create ambivalence. The work of the crisis services provider is to identify the ambivalence, point it out, and create more time. The more time between the impulse to commit suicide and the act, the more likely it is the person will choose life. Certain steps should be followed when intervening with someone who feels suicidal. Suggested guidelines for assessment and prevention CAUTION! NO ONE CAN PREDICT A SUICIDE! Assess lethality The following factors are important in determining if the person is likely to actually attempt suicide and how lethal the attempt may be: •

What resources does he/she have?

•

What resources can you offer?

•

What has this person already tried?

• •

The level of detail to which the person has planned the act The dangerousness and availability of the method

•

The level of isolation

OFFER OPTIONS -- NOT SOLUTIONS Choices empower a person to make decisions and create a plan that is specific, doable, and short-term.

156

What is the difference between para-suicide and suicide? Parasuicide is a word used to describe behavior in which a person hurts himself or herself by cutting, burning, etc. but does not intend to carry out the suicide. These behaviors are also referred to as SIS (self-injuries), SIBs (self-injurious behavior) or self-'mutilation. People who engage in parasuicidal behavior often indicate that their self-injury is a mechanism to cope with overwhelming emotion that they do not know how to regulate or express effectively. These individuals are sometimes diagnosed as having borderline personality disorder. What if a suicide occurs despite your best efforts? In the event that a suicide occurs, even after you have tried to help, get some support for yourself. Suicide is a very personal decision and no one else can ever take responsibility for another's suicide. In a like manner, each staff person will respond differently due to his or her individual history and relationship with the person who completes suicide. Take some time to support yourself and your colleagues. "Debriefing", "case review" or "psychological first aid" are terms used by mental health professionals to describe interventions that should be available when a crisis service provider experiences a completed suicide or traumatic event that involves a service recipient. The goal of these interventions is to allow a crisis service provider to express their personal reactions to the event and to identify steps that might relieve stress symptoms related to their exposure to the event. In some cases, emergency mental health interventions may include staff members outside of the crisis service provider. Any of these interventions should be conducted by, or in consultation with, a trained mental health professional in the area of emergency mental health services. Assessing dangerousness to others How does a crisis service provider work with a person who may become violent? Assessing for dangerousness to others is similar in many ways to assessing for suicidal intent. Many of the items considered and the process of developing a plan is similar. Risk assessment for dangerousness is a very in-exact science. Studies have shown that even trained professionals can accurately predict only one out of three episodes of violent behaviour. The following are some basic guidelines for interacting with a person who is potentially violent: •

Get as much information from records on file or other sources before going into any crisis situation.

•

Triage staff should ask about presence of weapons before dispatching crisis service provider, when applicable.

•

If you believe that a person may have a potential for violence do not intervene alone.

•

Partner with another crisis responder or involve law enforcement personnel.

•

Do not conduct an interview in a room with weapons present. o

•

If the person is armed, you may wish to ask the person why he or she feels a need to carry a weapon. The person's response to this question may help the responder to formulate a way to request the weapon be put aside with which the person may be willing to cooperate. If a potentially dangerous person refuses to give up the weapon, the crisis services provider should excuse him or herself and seek assistance from law enforcement officials.

Do not interview potentially violent people in cramped rooms, especially if they are agitated and need to pace. Kitchen, bedrooms, and bathrooms are usually poor intervention sites due to the potential presence of items that may be used as weapons.

157

•

Be aware of exit routes for yourself and for the person in crisis. A paranoid or agitated person must not feel that they are trapped, and a crisis service provider must have an avenue of escape if the person does become violent.

•

Pay attention to the person's speech and behavior.

Clues to impending violence include: • •

speech that is loud, threatening or profane; increased muscle tension, such as sitting on the edge of the chair or gripping the arms; o hyperactivity (pacing, etc.);

•

slamming doors, knocking over furniture or other property destruction.

•

Do not stay in a dangerous situation! What factors should be considered when assessing a person for potential of harm to others? The following factors are important in determining if the person is likely to actually attempt to harm someone else: •

Previous episodes of violent or assaultive behavior (This is perhaps the best indicator of potential for violent behavior.) Under what circumstances was the person violent in the past? What is the frequency of violence? How does the person behave in between episodes? What is the most violent thing that the person has ever done? What was the intent?

•

Clarity of the plan for violence. Has the person identified a victim? Do they have means or access to a means to harm the potential victim? Does the person have or could he or she gain access to the potential victim?

•

The level of isolation, agitation, paranoia, or belief that another is planning to or is hurting or harming them in some way.

•

Command hallucinations ordering violence.

•

Intoxication from alcohol or other drug use, especially cocaine, amphetamines or other stimulants or withdrawal from alcohol, drugs or medications.

• •

Psychotic symptoms/lack of contact with reality The level of stress and number of concurrent stressors.

•

The intensity and duration of homicidal or assaultive ideation.

• •

The normal ability to cope with life's ups and downs - coping skills and mechanisms. The person's physical health

•

Any history of mental illness, especially command hallucinations.

158

•

The level of internal ability to control impulses. Does the person wish to control him or herself? And if so can she or he? Is the person overly controlled? Does the person have a brain injury or other cognitive impairment that makes control difficult?

•

The level of external support or external constraints available to the individual.

•

If a person's mental state is so agitated that a full evaluation or assessment cannot be completed, the crisis responder should consider the person as potentially violent.

•

Collateral information from family, friends, and medical records is very important in intervening appropriately with potentially violent individuals.

Your own intuition or "gut sense" of the seriousness of this particular person's presentation is a very valuable tool in assessing risk. Establishing Rapport and Communication: How can a crisis services provider best intervene with a potentially violent person? 1.

Show concern for the person. Be respectful and offer some choices, even if they are small. (Where to sit, whether to have a snack or beverage). 2. Attempt to speak with the person at eye level. 3. Sit in a manner with feet solidly on the floor with heels and toes touching the floor; hands unfolded in your lap and your body leaning slightly forward toward the person. This position gives the person the feeling that you are attentive to what he or she is saying and it permits you to respond immediately if threatened 4. Stand in a manner with feet placed shoulder width apart; one foot slightly behind the other; weight on the rear leg, knees slightly bent; hands folded, but not interlocked, on the upper abdomen or lower chest; arms unfolded. This stance allows instant response to physical threat. Do not place hands in pockets. This slows response and may add to paranoia of the person. Folded arms also slow response and can be interpreted as threatening. Maintaining weight on rear leg with knees slightly bent also allows quick movement and response to any threat. Practice this stance to become comfortable in it before using it in a crisis situation. If the stance is unfamiliar to you, your discomfort will only add to the stress of the situation.

TAKE EVERY THREAT SERIOUSLY, CONSULT OTHERS AS NEEDED. DO NOT STAY IN A DANGEROUS SITUATION. 5. 6.

Develop some rapport with the person before asking questions about history or intent of violence. Assure the person that you will do what you can to help them stay in control of violent impulses. Set firm limits but do not threaten or display anger. 7. a person is experiencing paranoia, it is best to conduct the intervention as if the person and the intervener are facing the problem together. A crisis situation is not the time to tell the person that he or she is experiencing delusional thinking. 8. Give the person adequate physical space. 9. Develop a strategy. Help the person make a decision on a specific, short-term plan. You won't resolve all the problems; stick to one issue that is doable.

159

What are some of the legal implications of working with suicidal people? If a person completes suicide after a crisis services provider intervenes, it is possible that the family or friends of the individual may hold the crisis services provider responsible for the suicide. Three sorts of suicides are most prone to this sort of blaming and/or legal suits: 1) Outpatient suicides (should the clinician have hospitalized the individual?), 2) Inpatient suicides (Did the institution provide a safe environment?), and 3) Suicide following discharge or escape. In determining malpractice/liability, four elements must be present: 1.A therapist-patient relationship must exist which creates a duty of care to be present. 2.A deviation from the standard of care must have occurred. 3.Damage to the patient must have occurred. 4.The damage must have occurred directly as a result of deviation from that standard of Care. Risk management guidelines: • •

Documentation - always document, what is not documented, did not happen per most entities' opinion. Information on previous treatment

• • •

Involvement of family and significant others Consultation on present clinical circumstances Sensitivity to medical issues

• •

Knowledge of community resources Consideration of the effect on self and others

•

Preventive preparation.

DO'S and DON’TS in suicide prevention Remove opportunities Receive and accept suicidal communication Do intrude Prevent isolation and involve significant others Transfer rather than refer Follow-up Always obtain consultation when unsure Do know your own value system about suicide Get precipitant (Identify those issues, concerns, and/or events that led up to the current crisis.) Use self as instrument of prevention Do not worry about saying the wrong thing Do not consider suicidal persons as special Do not assume ability to solve problem(s) Do not try to talk the person out of committing suicide Do not engage in abstract discussion about suicide, death, Do not be too accepting of suicide Do not delegitimatize Do not give cheap general reassurance Do not lose confidence (may need more limited goals)

160

The following are examples of forms that can be utilize for crisis evaluations: Maureen Malloy, R.N. Behavioral Emergency Outreach Program. LETHALITY ASSESSMENT WORK SHEET

LOW LETHALITY PLAN METHOD AVAILABILITY TIME

HIGH LETHALITY.

Vague, indeterminate plan Method undecided

Clear thoughts, philosophical

Some specifics

Method: pills, cutting

Method: CO, oven gas, car

Method unavailable

Can acquire easily

Some effort required to

No time specified

Specified vaguely, within weeks 1 or 2 gestures

Day and time chosen, within aHx week of many threats, attempts Chronic

lethal attempt Major

depression

Several concurrent stressors

Major loss or conflict

Severe illness or injury, Recent Dx Alone, at home, no help nearby

Terminal illness, Recent Dx

Long term existence of several factors

Suicidal careers

PREVIOUS ATTEMPT

No Previous attempts

DEPRESSION

Feeling low or blue

Mild depression

RECENT LOSSES

No specific stress

1 minor conflict or loss

HEALTH

Physically healthy

Transitory illness

Disability or chronic health problems

ISOLATION

Others present and supportive

Roommates/SO there

Others close by

COMORBIDITY

No presence jf 0 predictors listed below

1 predictor present

More than 1 factor present,

Note & or will thought out, written Method: Hanging, Jumping Plan Complete today Plan to complete today Hx of highly

Note written, time, place method chosen Method: Gun Plan in progress Plan in progress Over 2 serious attempts Major depression, hopeless Several significant losses/changes

Alone, rented room or car , isolated

Common single predictors of suicide listed in order 1 2 3 4 5 6 7

Depressive illness, mental disorder Alcoholism, drug abuse Suicide ideation, talk, religion Prior suicide attempts Lethal means Isolation, living alone, loss of support Hopelessness, cognitive rigidity

8 9 10 11 12 13 14

Older white males Modeling, suicide in family, genetics Work problems, occupation, economics Marital problems, family pathology Stress, life events Anger, aggression, irritability, Physical illness

161

Critical Item Suicide Potential Assessment This tool should be used in assessing the risk of suicide for clients. I. PRIMARY RISK FACTORS: If any one of the following is present, the client should be considered a high risk for potential suicide, which should be given serious consideration in placement decisions. A. Attempt: 1. Suicide attempt with lethal method (firearm, hanging/strangulation, jumping from heights, etc.). 2. Suicide attempt resulting in moderate to severe lesions/toxicity. 3. Suicide attempt with low rescuability (no communication prior to attempt, discovery unlikely because of chosen location or time, no one nearby, active prevention of discovery, etc.). 4. Suicide attempt with subsequent expressed regret that it was not successful and continued expression of intent or unwilling to accept treatment. B. Intent: (as expressed directly by client or by another based on their observations) 1. Intent to commit suicide immediately. 2. Intent with lethal method selected and readily available. 3. Intent with post-mortem preparations (disposal of personal property, writing a will, writing a suicide note, making business and insurance arrangements, etc.). 4. Intent with planned time, place and opportunity. 5. Intent without ambivalence or inability to see alternatives. 6. Command hallucinations to kill self regardless of expressed suicidal intent. 7. Intent with active psychotic symptoms, especially affective disorder or schizophrenia. 8. Intent or behavior indicates intent, but client unwilling to cooperate in adequate assessment. II. SECONDARY RISK FACTORS: An individual's risk increases with the presence of the following factors. If over half of the following factors are present, consider the person a high risk for potential suicide in making placement decisions. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Expressed hopelessness. Recent death of significant other. Recent loss of job or severe financial setback. Significant loss/stress/change event (victimization, threat of prosecution, pregnancy, illness, etc.). Social isolation. Current or past major mental illness. Current or past chemical dependence/abuse. History of suicide attempt(s). History of family suicide (including recent suicide by close friend). Current or past difficulties with impulse control or antisocial behavior. Significant depression (clinical or not) especially with feelings of guilt, worthlessness or helplessness. 12. Recent separation or divorce. 13. Rigidity in adapting to change

(Adapted from the CISPA form used at the Hennepin County Crisis Intervention Center, Minneapolis, MN.)

162

What professional crisis services are currently available in â&#x20AC;Ś.? Every crisis service provider should at all times have an updated database of available crisis services centers at hand. Crisis services include 24 hour, seven days a week (24/7) toll free telephone lines answered in real time by a trained crisis specialist with face-to-face crisis service capabilities including, but not limited to: triage, intervention, evaluation, referral, tele-health capabilities, walk-in services, crisis respite services and/or crisis stabilization units for additional services/treatment and follow-up services. Many individuals and families access crisis services directly, but several of the high volume crisis calls are from emergency departments, law enforcement agencies, community providers, advocates, etc.

163

Annex 1: Screening Screening Tools The most important domains to screen include: 1.

Substance abuse

Immediate risks for self-harm, suicide, and violence

Pregnancy considerations

Immediate risks related to serious intoxication or withdrawal

Past and present mental disorders, including posttraumatic stress disorder (PTSD) and other anxiety disorders, mood disorders, and eating disorders

Past and present history of violence and trauma, including sexual victimization and interpersonal violence

Health screenings, including HIV/AIDS, hepatitis, tuberculosis, and STDs

1. Substance Abuse Screening The goal of substance abuse screening is to identify individuals who have or are developing alcohol- or drug-related problems. Routinely, women are less likely than men to be identified as having substance abuse problems (Buchsbaum et al. 1993); yet, they are more likely to exhibit significant health problems after consuming fewer substances in a shorter period of time. Substance abuse screening and assessment tools, in general, are not as sensitive in identifying women as having substance abuse problems. Screening for substance use disorders is conducted by an interview or by giving a short written questionnaire. While selection of the instrument may be based on various factors, including cost and administration time (Thornberry et al. 2002), the decision to use an interview versus a self-administered screening tool should also be based upon the comfort level of the counselor or healthcare professional (Arborelius and Thakker 1995; Duszynski et al. 1995; Gale et al. 1998; Thornberry et al. 2002). If the healthcare staff communicates discomfort, individuals may become wary of disclosing their full use of substances (Aquilino 1994; see also Center for Substance Abuse Prevention [CSAP] 1993).

How Much Is Too Much Men may be at risk for alcohol-related problems if their alcohol consumption exceeds 14 standard drinks* per week or 4 drinks per day, and women may be at risk if they have more than 7 standard drinks per week or 3 drinks per day. SOURCE: National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinicianâ&#x20AC;&#x2122;s Guide. NIH Pub No. 05â&#x20AC;&#x201C;3769. Bethesda, MD: the Institute, 2005. *A standard drink is defined as one 12-ounce bottle of beer, one 5-ounce glass of wine, or 1.5 ounces of distilled spirits.

164

General Alcohol and Drug Screening AUDIT The Alcohol Use Disorder Identification Test (AUDIT; Babor and Grant 1989) is a widely used screening tool that is reproduced with guidelines and scoring instructions in TIP 26 Substance Abuse Among Older Adults (CSAT 1998d). The AUDIT is effective in identifying heavy drinking among nonpregnant women (Bradley et al. 1998c). It consists of 10 questions that were highly correlated with hazardous or harmful alcohol consumption. This instrument can be given as a self-administered test, or the questions can be read aloud. The AUDIT takes about 2 minutes to administer. The Alcohol Use Disorders Identification Test: Interview Version Read questions as written. Record answers carefully. Begin the AUDIT by saying “Now I am going to ask you some questions about your use of alcoholic beverages during this past year.” Explain what is meant by “alcoholic beverages” by using local examples of beer, wine, vodka, etc. Code answers in terms of “standard drinks”. Place the correct answer number in the box at the right. 1. How often do you have a drink containing alcohol? (0) Never [Skip to Qs 9-10] (1) Monthly or less (2) 2 to 4 times a month (3) 2 to 3 times a week (4) 4 or more times a week 2. How many drinks containing alcohol do you have on a typical day when you are drinking? (0) 1 or 2 (1) 3 or 4 (2) 5 or 6 (3) 7, 8, or 9 (4) 10 or more 3. How often do you have four (women) / six (men) or more drinks on one occasion? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily Skip to Questions 9 and 10 if Total Score for Questions 2 and 3 = 0 4. How often during the last year have you found that you were not able to stop drinking once you had started? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily 5. How often during the last year have you failed to do what was normally expected from you because of drinking? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily 7. How often during the last year have you had a feeling of guilt or remorse after drinking? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily 8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? (0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily 9. Have you or someone else been injured as a result of your drinking? (0) No (2) Yes, but not in the last year (4) Yes, during the last year 10. Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down? (0) No (2) Yes, but not in the last year (4) Yes, during the last year

Record total of specific items here - If total is greater than recommended cut-off, consult User’s Manual

165

The Alcohol Use Disorders Identification Test: Self-Report Version PATIENT: Because alcohol use can affect your health and can interfere with certain medications and treatments, it is important that we ask some questions about your use of alcohol. Your answers will remain confidential so please be honest. Place an X in one box that best describes your answer to each question. Questions

1. How often do you have a drink containing alcohol?

Never (*)

Monthly or less

2-4 times a month

2-3 times a week

4 or + t. a week

2. How many drinks containing alcohol do you have on a typical day when you are drinking?

1 or 2

3 or 4

5 or 6

7 to 9

10 or more

3. How often do you have six or more drinks on one occasion? (for women: four or more)

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

4. How often during the last year have you found that you were not able to stop drinking once you had started?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

5. How often during the last year have you failed to do monthly what was normally expected of you because of drinking?

Never

Less than

Monthly

Weekly

Daily or almost daily

6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

7. How often during the last year have you had a feeling of guilt or remorse after drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

8. How often during the last year have you been unable to remember what happened the night before because of your drinking?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

9. Have you or someone else been injured because of your drinking?

Yes, but not in the last year

Yes, during the last year

10.Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

Yes, but not in the last year

Yes, during the last year

(*)

Total (*) Skip to questions 9 and 10 if total for question 1, or total for questions 2+3 = 0

166

Risk Level Intervention AUDIT score (*) Zone I Alcohol Education Zone II Simple Advice Zone III Simple Advice plus Brief Counseling and Continued Monitoring Zone IV Referral to Specialist for Diagnostic

0-7 8-15 16-19 20-40

Evaluation and Treatment The AUDIT cut-off score may vary slightly depending on the country’s drinking patterns, the alcohol content of standard drinks, and the nature of the screening program. Clinical judgment should be exercised in cases where the patient’s score is not consistent with other evidence, or if the patient has a prior history of alcohol dependence. It may also be instructive to review the patient’s responses to individual questions dealing with dependence symptoms (Questions 4, 5 and 6) and alcohol-related problems (Questions 9 and 10). Provide the next highest level of intervention to patients who score 2 or more on Questions 4, 5 and 6, or 4 on Questions 9 or 10. Total scores of 8 or more are recommended as indicators of hazardous and harmful alcohol use, as well as possible alcohol dependence. (A cut-off score of 10 will provide greater specificity but at the expense of sensitivity.) Since the effects of alcohol vary with average body weight and differences in metabolism, establishing the cut off point for all women and men over age 65 one point lower at a score of 7 will increase sensitivity for these population groups. Selection of the cut-off point should be influenced by national and cultural standards and by clinician judgment, which also determine recommended maximum consumption allowances. Technically speaking, higher scores simply indicate greater likelihood of hazardous and harmful drinking. However, such scores may also reflect greater severity of alcohol problems and dependence, as well as a greater need for more intensive treatment.

The AUDIT questionnaire: choosing a cut-off score. Conigrave KM, Hall WD, Saunders JB. Source Centre for Drug and Alcohol Studies, Royal Prince Alfred Hospital, New South Wales, Australia.

Abstract Three hundred and thirty ambulatory care patients were interviewed using a detailed assessment schedule which included the AUDIT questions. After 2-3 years, subjects were reviewed and their experience of alcohol-related medical and social harm assessed by interview and perusal of medical records. AUDIT was a good predictor of both alcohol-related social and medical problems. Cut-off points of 7-8 maximized discrimination in the prediction of trauma and hypertension. Higher cut-offs (12 and 22) provided better discrimination in the prediction of alcohol-related social problems and of liver disease or gastrointestinal bleeding, but high specificity was offset by reduced sensitivity. We conclude that the recommended cut-off score of eight is a reasonable approximation to the optimal for a variety of endpoints. (PMID: 8616463 - [PubMed - indexed for MEDLINE]

167

More detailed interpretation of a patient’s total score may be obtained by determining on which questions points were scored. In general, a score of 1 or more on Question 2 or Question 3 indicates consumption at a hazardous level. Points scored above 0 on questions 4-6 (especially weekly or daily symptoms) imply the presence or incipience of alcohol dependence. Points scored on questions 7-10 indicate that alcohol-related harm is already being experienced. The total score, consumption level, signs of dependence, and present harm all should play a role in determining how to manage a patient. The final two questions should also be reviewed to determine whether patients give evidence of a past problem (i.e., “yes, but not in the past year”). Even in the absence of current hazardous drinking, positive responses on these items should be used to discuss the need for vigilance by the patient. In most cases the total AUDIT score will reflect the patient’s level of risk related to alcohol. In general health care settings and in community surveys, most patients will score under the cut-offs and may be considered to have low risk of alcohol related problems. A smaller, but still significant, portion of the population is likely to score above the cut-offs but record most of their points on the first three questions. A much smaller proportion can be expected to score very high, with points recorded on the dependencerelated questions as well as exhibiting alcohol-related problems. As yet there has been insufficient research to establish precisely a cut-off point to distinguish hazardous and harmful drinkers (who would benefit from a brief intervention) from alcohol dependent drinkers (who should be referred for diagnostic evaluation and more intensive treatment). This is an important question because screening programmes designed to identify cases of alcohol dependence are likely to find a large number of hazardous and harmful drinkers if the cut-off of 8 is used. These patients need to be managed with less intensive interventions. In general, the higher the total score on the AUDIT, the greater the sensitivity in finding persons with alcohol dependence. Based on experience gained in a study of treatment matching with persons who had a wide range of alcohol problem severity, AUDIT scores were compared with diagnostic data reflecting low, medium and high degrees of alcohol dependence. It was found that AUDIT scores in the range of 8-15 represented a medium level of alcohol problems whereas scores of 16 and above represented a high level of alcohol problems. On the basis of experience gained from the use of the AUDIT in this and other research, it is suggested that the following interpretation be given to AUDIT scores: Scores between 8 and 15 are most appropriate for simple advice focused on the reduction of hazardous drinking. Scores between 16 and 19 suggest brief counseling and continued monitoring. Scores of 20 or above clearly warrant further diagnostic evaluation for alcohol dependence. In the absence of better research these guidelines should be considered tentative, subject to clinical judgment that takes into account the patient’s medical condition, family history of alcohol problems and perceived honesty in responding to the AUDIT questions. While use of the 10-question AUDIT questionnaire will be sufficient for the vast majority of patients, special circumstances may require a clinical screening procedure. For example, a patient may be resistant, uncooperative, or unable to respond to the AUDIT questions. If further confirmation of possible dependence is warranted, a physical examination procedure and laboratory tests may be used.

168

Other Screening tools: TCUDS II The Texas Christian University Drug Screen II (TCUDS II) is a 15-item, self-administered substance abuse screening tool that requires 5–10 minutes to complete. It is based in part on Diagnostic Interview Schedule and refers toDiagnostic and Statistical Manual of Mental Disorders, 4 th Edition, Text Revision (DSM-IV-TR; American Psychiatric Association [APA] 2000a) criteria for substance abuse and dependence. TCUDS II is used widely in criminal justice settings. It has good reliability. (Knight 2002; Knight et al. 2002). This screen, along with related instruments, is available at www.ibr.tcu.edu. CAGE CAGE (Ewing 1984) asks about lifetime alcohol or drug consumption. Each “yes” response receives 1 point, and the cutoff point (the score that makes the test results positive) is either 1 or 2. Two “yes” answers results in a very small false-positive rate and the clinician will be less likely to identify clients as potentially having a substance use disorder when they do not. However, the higher cutoff of 2 points decreases the sensitivity of CAGE for women—that is, increases the likelihood that some women who are at risk for a substance problem will receive a negative screening score (i.e., it increases the false-negative rate). Note: It is recommended that a cutoff score of 1 be employed in screening for women. This measure has also been translated and tested for Hispanic/Latina populations. A common criticism of the CAGE is that it is not gender-sensitive—that is, women who have problems associated with alcohol use are less likely than male counterparts to screen positive when this instrument is used. One study of more than 1,000 women found that asking simple questions about frequency and quantity of drinking, coupled with a question about binge drinking, was better than the CAGE in detecting alcohol problems among women (Waterson and Murray-Lyon 1988). The CAGE is “relatively insensitive” with Caucasian females, yet Bradley and colleagues report that it “has performed adequately in predominantly black populations of women” (1998c, p. 170). Johnson and Hughes (2005) conclude that CAGE has similar reliability and concurrent validity among women of different sexual orientations. The CAGE-AID (CAGE Adapted to Include Drugs) modifies the CAGE questions for use in screening for drugs other than alcohol. This version of the CAGE shows promise in identifying pregnant, low-income women at risk for heavier drug use (Midanik et al. 1998).

Substance Abuse Screening and Assessment Among Women •

How screenings and assessments are conducted is as important as the information gathered. Screening and assessment are often the initial contact between a woman and the treatment system. They can either help build a trusting relationship or create a deterrent to engaging in further services.

169

•

Self-administered tools may be more likely to elicit honest answers; this is especially true regarding questions related to drug and alcohol use.

•

Face-to-face screening interviews have not always been successful in detecting alcohol and drug use in women, especially if the counselor is uncomfortable with the questions.

•

Substance abuse screening and assessment tools, in general, are not as sensitive in identifying women as having substance abuse problems.

2. Screening Instruments for Pregnant Women Considering the devastating impact of substances on the developing foetus, routine screening for drug, alcohol, and tobacco use among pregnant women is imperative. Face-to-face screening interviews are not always successful in detecting alcohol and drug use, especially in pregnant women. However, selfadministered screening tools have been found to be more likely to elicit honest answers (Lessler and O’Reilly 1997; Russell et al. 1996; Tourangeau and Smith 1996). Three screening instruments for use with pregnant women are TWEAK, T-ACE, and 5Ps Plus (CSAP 1993; Morse et al. 1997). Women who smoked in the month before pregnancy are nine times more likely to be currently using either drugs or alcohol or both while pregnant (Chasnoff et al. 2001). TWEAK TWEAK (Russell et al. 1991) identifies pregnant women who are at risk for alcohol use. It consists of five items and uses a 7-point scoring system. Two points are given for positive responses to either of the first two questions (tolerance and worry), and positive responses to the other three questions score 1 point. A cutoff score of 2 indicates the likelihood of risk drinking. In a study of more than 3,000 women at a prenatal clinic, the TWEAK was found to be more sensitive than the CAGE and Michigan Alcohol Screening Test (MAST), and more specific than the T-ACE (Russell et al. 1996). The tolerance question scores 2 points for an answer of three or more drinks. However, if the criterion for the tolerance question is reduced to two drinks for women, the sensitivity of TWEAK increases, and the specificity and predictive ability decrease somewhat (Chang et al. 1999). In comparison with T-ACE, TWEAK had higher sensitivity and slightly lower specificity (Russell et al. 1994, 1996). It can also be used to screen for harmful drinking in the general population (Chan et al. 1993).

170

T-ACE The T-ACE is a 4-item instrument appropriate for detecting heavy alcohol use in pregnant women (Sokol et al. 1989). T-ACE uses the A, C, and E questions from CAGE and adds one on tolerance for alcohol. The first question assesses tolerance by asking if it takes more than it used to to get high. A response of two or more drinks is scored as 2 points, and the remaining questions are assigned 1 point for a “yes” response. Scores range from 0 to 5 points. A total of 2 or more points indicates risk drinking (Chang et al. 1999). T-ACE has sensitivity equal to the longer MAST and greater than CAGE (Bradley et al. 1998c). It has been validated only for screening pregnant women with risky drinking (Russell et al. 1994).

In a study with a culturally diverse population of pregnant women, Chang and colleagues (1998) compared T-ACE with the MAST (short version) and the AUDIT. The study found T-ACE to be the most sensitive of the three tools in identifying current alcohol consumption, risky drinking, or lifetime alcohol diagnoses (Chang et al. 1998). Although T-ACE had the lowest specificity of the three tests, it is argued that false positives are of less concern than false negatives among pregnant women.. Prenatal substance abuse screen (5Ps) This screening approach has been used to identify women who are at risk for substance abuse in prenatal health settings. A “yes” response to any item indicates that the woman should be referred for assessment (Morse et al. 1997). Originally, four questions regarding present and past use, partner with problem, and parent history of alcohol or drug problems were used (Ewing 1990). However, several adaptations have been made, and recently a question about tobacco use in the month before the client knew she was pregnant was added (Chasnoff 2001). Chasnoff and colleagues (2001) reported that women who smoked in the month before pregnancy were 11 times more likely to be currently using drugs and 9 times more likely to be currently using either drugs or alcohol or both while pregnant.

In a study evaluating prevalence of substance use among pregnant women utilizing this screening tool, the authors suggest that it not only identified pregnant women with high levels of alcohol and drug use but also a larger group of women whose pregnancies were at risk from smaller amounts of substance use

171

(Chasnoff et al. 2005). For a review on how to improve screening for pregnant women and motivate healthcare professions to screen for risk, refer to the Alcohol Use During Pregnancy Project. At-Risk Screening for Drug and Alcohol Use During Pregnancy •

In screening women who are pregnant, face-to-face screening interviews have not always been successful in detecting alcohol and drug use.

•

Self-administered tools may be more likely to elicit honest answers; this is especially true regarding questions related to drug and alcohol use during pregnancy.

•

While questions regarding past alcohol and drug use or problems associated with self, partner, and parents will help to identify pregnant women who need further assessment, counselors should not underestimate the importance of inquiring about previous nicotine use in order to identify women who are at risk for substance abuse during pregnancy.

•

There are other factors that are associated with at-risk substance abuse among women who are pregnant, including moderate to severe depression, living alone or with young children, and living with someone who uses alcohol or drugs (for review, see Chasnoff et al. 2001).

Not all drugs produce physiological withdrawal; counselors should not assume that withdrawal from any drug of abuse requires medical intervention. Only in the case of opioids, sedative-hypnotics, or benzodiazepines (and in some cases of alcohol), is medical intervention likely to be required. Nonetheless, specific populations may warrant further assessment and assistance in detoxification, including pregnant women, women of color, women with disabilities or co-occurring disorders, and older women. (Review TIP 45 Detoxification and Substance Abuse Treatment, [CSAT 2006a], pp. 105–113.) Specific to women who are pregnant and dependent on opioids, withdrawal during pregnancy poses specific medical risks including premature labor and mortality to the foetus. Note: Women who are dependent on opioids may misinterpret early signs of pregnancy as opioid withdrawal symptoms (review TIP 43 Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs [CSAT 2005a], pp. 211–224). 3. Acute Safety Risk Related to Serious Intoxication or Withdrawal Screening for safety related to intoxication and withdrawal at intake involves questioning the individual and their family or friends (with client’s permission) about current substance use or recent discontinuation of use, along with past and present experiences of withdrawal. If the individual is obviously severely intoxicated, he needs to be treated with empathy and firmness, and provision needs to be made for his or her physical safety. If a client has symptoms of withdrawal, formal withdrawal scales can be used by trained personnel to gather information to determine whether medical intervention is required. Such tools include the Clinical Institute Withdrawal Assessment for Alcohol Withdrawal (Sullivan et al. 1989; and the Clinical Institute Narcotic Assessment for Opioid Withdrawal (Zilm and Sellers 1978). While specific normative data are unavailable, it is important to screen for withdrawal to assess risk and to implement appropriate medical and clinical interventions.

172

Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) Patient:__________________________ Date: ________________ Time: _______________ Pulse or heart rate, taken for one minute:_________________________ Blood pressure:______ NAUSEA AND VOMITING Ask "Do you feel sick to your stomach? Have you vomited?" Observation. 0 no nausea and no vomiting 1 mild nausea with no vomiting 2 3 4 intermittent nausea with dry heaves 5 6 7 constant nausea, frequent dry heaves and vomiting TACTILE DISTURBANCES Ask "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?" Observation. 0 none 1 very mild itching, pins and needles, burning or numbness 2 mild itching, pins and needles, burning or numbness 3 moderate itching, pins and needles, burning or numbness 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations TREMOR Arms extended and fingers spread apart. Observation. 0 no tremor 1 not visible, but can be felt fingertip to fingertip 2 3 4 moderate, with patient's arms extended 5 6 7 severe, even with arms not extended

173

AUDITORY DISTURBANCES Ask "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?" Observation. 0 not present 1 very mild harshness or ability to frighten 2 mild harshness or ability to frighten 3 moderate harshness or ability to frighten 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations PAROXYSMAL SWEATS Observation. 0 no sweat visible 1 barely perceptible sweating, palms moist 2 3 4 beads of sweat obvious on forehead 5 6 7 drenching sweats VISUAL DISTURBANCES Ask "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?" Observation. 0 not present 1 very mild sensitivity 2 mild sensitivity 3 moderate sensitivity 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations

7 continuous hallucinations ANXIETY Ask "Do you feel nervous?" Observation. 0 no anxiety, at ease 1 mild anxious 2 3 4 moderately anxious, or guarded, so anxiety is inferred 5 6 7 equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions

174

HEADACHE, FULLNESS IN HEAD Ask "Does your head feel different? Does it feel like there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity. 0 not present 1 very mild 2 mild 3 moderate 4 moderately severe 5 severe 6 very severe 7 extremely severe AGITATION Observation. 0 normal activity 1 somewhat more than normal activity 2 3 4 moderately fidgety and restless 5 6 7 paces back and forth during most of the interview, or constantly thrashes about ORIENTATION AND CLOUDING OF SENSORIUM Ask: "What day is this? Where are you? Who am I?" 0 oriented and can do serial additions 1 cannot do serial additions or is uncertain about date 2 disoriented for date by no more than 2 calendar days 3 disoriented for date by more than 2 calendar days 4 disoriented for place/or person

Total CIWA-Ar Score ______

Rater's Initials ______

Maximum Possible Score 67 The CIWA-Ar is not copyrighted and may be reproduced freely. This assessment for monitoring withdrawal symptoms requires approximately 5 minutes to administer. Patients scoring less than 10 do not usually need additional medication for withdrawal. Sullivan, J.T.; Sykora, K.; Schneiderman, J.; Naranjo, C.A.; and Sellers, E.M. Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction 84:1353-1357, 1989.

175

4. Assessing Risk of Harm to Self or Others About 80% of all suicides are committed by men. Yet suicidal attempts and parasuicidal behavior (nonfatal self-injurious behavior with clear intent to cause bodily harm or death; Welch 2001) are more prevalent among women. The greatest predictor of eventual suicide is prior suicidal attempts and deliberate self-harm inflicted with no intent to die (Joe et al. 2006). While substance dependence and PTSD are associated with self-harm and suicidal behavior (Harned et al. 2006), the most frequent diagnoses associated with suicide are mood disorders, specifically depressive episodes (Kessler et al. 1999). Considering the prevalence of suicides, suicidal attempts, self-injurious behavior, and depression, employing safety screenings should be a standard practice. From the outset, clinicians should specifically ask the client and anyone else who is providing information whether the client is in immediate danger and whether they have any immediate intention to engage in violent or self-injurious behavior. If the answer is â&#x20AC;&#x153;yes,â&#x20AC;? the clinician should obtain more information about the nature and severity of the thoughts, plan, and intent, and then arrange for an in-depth risk assessment by a trained mental health clinician. The client should not be left alone. No tool is definitive for safety screening. Clinicians should use safety screening tools only as an initial guide and proceed to detailed questions to obtain relevant information. In addition, care is needed to avoid underestimating risk because clients that are using substances may also engage in self-injurious behavior. For example, a woman who is intoxicated might seem to be making empty threats of self-harm, but all statements about harming herself or others must be taken seriously. Overall, individuals who have suicidal or aggressive impulses when intoxicated are more likely to act on those impulses; therefore, determination of the seriousness of threats requires a skilled mental health assessment, plus information from others who know the client very well. Screening tools and procedures in evaluating risk are discussed in depth in TIP 50 Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment (CSAT 2009a). Substance abuse treatment programs need clear mental health referral and follow-up procedures so that clients receive appropriate psychiatric evaluations and mental health care. The American Association of Community Psychiatrists (AACP) developed the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) that evaluates clients along six dimensions and defines six levels of resource intensity. It includes an excellent tool for helping the counselor determine the risk of harm (AACP 2000). The potential risk of harm most frequently takes the form of suicidal intentions, and less often the form of homicidal intentions. The scale has five categories, from minimal risk of harm to extreme risk of harm. It is available at www.comm.psych.pitt.edu/finds/LOCUS2000.pdf and can be easily adapted for use in treatment facilities.

176

Risk indicators for life-threatening self-harm •

Preparation for self-harm: someone who has taken time to plan, considered the consequences of their actions, said goodbye to people or taken precautions to avoid being discovered by others represents a much higher risk than a person who self-harms without much thinking about it (i.e. selfharm as an ‘impulsive’ act).

•

Seriousness of the method used to self-harm: violent methods such as hanging, stabbing or throwing oneself into deep water are considered serious and indicate higher risk.

•

Current mental illness: at least 60% of people who self-harm have some form of mental illness.

•

Factors that reduce self-control: the use of alcohol or other drugs, or having an impulsive personality, reduce self-control and increase the risk of serious self-harm.

•

Presence of ongoing ‘real life’ difficulties: marital problems, financial problems, difficulties at work, or other problems in daily life increase the risk of self-harm.

Screening Tools 1. Level of Care Utilization System (LOCUS) Purpose: To assess immediate service needs (e.g., for clients in crisis); to plan resource needs over time, as in assessing service requirements for defined populations; to monitor changes in status or placement at different points in time. Clinical utility: LOCUS is divided into three sections. The first defines six evaluation parameters or dimensions: (1) Risk of Harm, (2) Functional Status, (3) Medical, Addictive, and Psychiatric CoMorbidity, (4) Recovery Environment, (5) Treatment and Recovery History, and (6) Engagement. A fivepoint scale is constructed for each dimension, and the criteria for assigning a given rating or score in that dimension are elaborated. In dimension IV, two subscales are defined, whereas all other dimensions contain only one scale. Groups with whom this instrument has been used: Adults Administration time: 15 to 30 minutes - Scoring time: 20 minutes Available from: American Association of Community Psychiatrists www.wpic.pitt.edu/aacp/find.html

177

2. University of Oxford Risk assessment for clients with depression Risk factors specific to depression • • • • • • • •

Family history of mental disorder. History of previous suicide attempts (this includes self-harm). Severe depression. Anxiety. Feelings of hopelessness. Personality disorder. Alcohol abuse and/or drug abuse. Male gender.

Other risk factors for consideration • • • • •

Family history of suicide or self-harm. Physical illness (especially when this is recently diagnosed, chronic and/or painful). Exposure to suicidal behaviour of others, either directly or via the media. Recent discharge from psychiatric inpatient care. Access to potentially lethal means of self- harm/suicide.

Possible protective factors • • •

Social support. Religious belief. Being responsible for children (especially young children).

In assessing patients’ current suicide potential, the following questions can be explored: • • • • • • • • •

Are they feeling hopeless, or that life is not worth living? Have they made plans to end their life? Have they told anyone about it? Have they carried out any acts in anticipation of death (e.g. putting their affairs in order)? Do they have the means for a suicidal act (do they have access to pills, insecticide, firearms...)? Is there any available support (family, friends, carers...)? Where practical, and with consent, it is generally a good idea to inform and involve family members and close friends or carers. This is particularly important where risk is thought to be high. When a patient is at risk of suicide this information should be recorded in the patient’s notes. Where applicable, it is important to share awareness of risk with other team members. Regular and pro-active follow-up is highly recommended.

178

3. The PsyCheck Suicide / Self-Harm Risk Assessment Check risk for harm to others following a similar process. A history of violence or aggression towards others indicates a risk for future harm. Other factors associated with harm to others are: • being male • being under 35 years of age • having a criminal history • having a history of using weapons • having a history of child abuse or mistreatment by others Current factors to assess include: • verbal intent to harm others • paranoid thoughts about others • preoccupation with violent images and thoughts • access to lethal means • high levels of anger, frustration or agitation • a lack of problem-solving skills • current role instability (for example changes in work, relationship or accommodation circumstances) A client poses a high risk of harm to others if some of the following are true: •

male under 35 years of age

• • •

previous history of violence or aggression previous use of weapons role instability

•

paranoid thoughts about others

•

increasing anger, frustration or agitation

4. Responding to potential self-harm or harm to others Managing risks If there is no risk: • • • • • • • •

Monitor the client as required. Check at regular intervals, especially if there are potential triggers in the future, or there is as history of self-harm. If the risk is considered to be low: Monitor the client closely. Agree on a verbal or written contract to maintain safety and develop a contingency plan that includes support numbers for out-of-hours counseling services. Ask for a commitment from the client to follow a contingency plan in the event that their suicidal thoughts become more prominent.

If the risk is considered moderate: • • • • • • •

Refer the client for further assessment with a mental health service or other service that offers inpatient facilities in the event of a suicide or self-harm attempt. Agree on a written contract to maintain safety, and a written contingency plan with the client, listing supports to be contacted if feelings escalate. Request the client’s permission to contact their family and/or an emergency mental health service if necessary. Consult a supervisor for a second opinion.

179

If the client is considered to pose a high risk of harm to self or others: • • • •

Make an immediate referral to a place of safety such as a hospital mental health service or emergency mental health team. Call an ambulance or police if necessary. Contact the appropriate person in your service who has designated authority or powers under the Mental Health Act or relevant legislation for advice and support. Inform a supervisor or a senior colleague.

It is a clinician’s duty to warn and protect others if credible threats are made against them. This duty overrides the client’s right to confidentiality. However, in many instances it is reasonable to inform the client that you need to break confidentiality because of concerns about them. 5. Mental Illness Symptoms and Mental Disorders Considering that women are twice as likely as men to experience mood disorders, excluding bipolar and anxiety disorders (Burt and Stein 2002), all women entering substance abuse treatment should be screened for co-occurring mental disorders. If the screening indicates the possible presence of a disorder, a woman should be referred for a comprehensive mental health assessment and receive treatment for the cooccurring disorder, as warranted. Depression, anxiety, eating disorders, and PTSD are common among women who abuse substances (McCrady and Raytek 1993). Because certain drugs as well as withdrawal symptoms can mimic symptoms of mental disorders, the continual reassessment of mental illness symptoms is essential to ensure accurate diagnosis and treatment planning. TIP 42Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005e) contains information on screening and treatment of persons with co-occurring substance use and mental disorders. General mental disorder screening instruments Symptom screening involves questions about past or present mental disorder symptoms that may indicate the need for a full mental health assessment. Circumstances surrounding the resolution of symptoms should be explored. For example, if the client is taking psychotropic medication and is no longer symptomatic, this may be an indication that the medication is effective and should be continued. Often, symptom checklists are used when the counselor needs information about how the client is feeling. They are not used to screen for specific disorders, and responses are expected to change from one administration to the next. Symptom screening should be performed routinely and facilitated by the use of formal screening tools. Basic mental health screening tools are available to assist the substance abuse treatment team. The 18 questions in the Mental Health Screening Form-III (MHSF-III) screen for present or past symptoms of most mental disorders (Carroll and McGinley 2001). It is available at no charge from the Project Return Foundation, Inc., and is reproduced in TIP 42 Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005e), along with instructions and contact information (a Spanish-language form and instructions can be downloaded fromwww.asapnys.org/resources.html). MHSF-III was developed in a substance abuse treatment setting and is referred to as a “rough screening device” (Carroll and McGinley 2001, p. 35). The Mini-International Neuropsychiatric Interview (M.I.N.I.) is a brief, structured interview for more than 20 major psychiatric and substance use disorders (Sheehan et al. 2002). Administration time is 15–30 minutes. Scoring is simple and immediate. M.I.N.I. can be administered by clinicians after brief training

180

and by lay personnel with more extensive training. M.I.N.I. can be downloaded from www.medicaloutcomes.com and used for no cost in nonprofit or publicly owned settings. The Brief Symptom Inventory is a research tool that can be adapted for use as a screening checklist. This tool’s 53 items measure 9 primary symptom dimensions as well as 3 global indices of distress. Respondents rate the severity of symptoms on a 5-point scale ranging from “Not at all” (0 points) to “Extremely” (4 points) (Derogatis and Melisaratos 1983). Depression and anxiety disorders Many formal tools screen for depression, including the Beck Depression Inventory-II (Beck et al. 1996a, b ; Smith and Erford 2001; Steer et al. 1989), the Center for Epidemiologic Study Depression Scale (Radloff 1977), and the General Health Questionnaire—a self-administered screening test to identify short-term changes in mental health (depression, anxiety, social dysfunction, and somatic symptoms)—are available. The U.S. Preventive Services Task Force (2002) recommends two simple questions that are effective in screening adults for depression: 1.

Over the past 2 weeks have you felt down, depressed, or hopeless?

Over the past 2 weeks have you felt little interest or pleasure in doing things?

Programs that screen for depression should ensure that “yes” answers to these questions are followed by a comprehensive assessment, accurate diagnosis, effective treatment, and careful followup. Asking these two questions may be as effective as using longer instruments (U.S. Preventive Services Task Force 2002). Little evidence exists to recommend one screening method over another, so clinicians can choose the method that best fits their preference, the specific population of women, and the setting. Refer to TIP 48 Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery (CSAT 2008) for more guidance in working with clients who have depressive symptoms. Note: Women who are depressed are more likely to report bodily symptoms, including fatigue, appetite and sleep disturbance, and anxiety (Barsky et al. 2001; Kornstein et al. 2000; Silverstein 2002). An example of an instrument that can detect symptoms of anxiety is the 21-item Beck Anxiety Inventory (BAI; Beck 1993; Hewitt and Norton 1993). Among a group of psychiatric patients with a variety of diagnoses, women’s BAI scores indicated higher levels of anxiety than men’s BAI scores. However, the nature of the anxiety reported appears similar for women and men (Hewitt and Norton 1993). 6. Trauma and Posttraumatic Stress Disorder PTSD can follow a traumatic episode that involves witnessing, being threatened, or experiencing an actual event involving death or serious physical harm, such as auto accidents, natural disasters, sexual or physical assault, war, and childhood sexual and physical abuse (APA 2000a). During the trauma, the individual experiences intense fear, helplessness, or horror. PTSD has symptoms that last longer than 1 month and result in a decline in functioning in several life areas, such as work and relationships. A diagnosis of PTSD cannot be made without a clear history of a traumatic event (Figure 4-5 presents sample screening questions for identifying a woman’s history of trauma). General symptoms of PTSD include persistently re-experiencing the traumatic event, numbness or avoidance of cues associated with the trauma, and a pattern of increased arousal (APA 2000a).

181

Historically, women have not been routinely screened for a history of trauma or assessed to determine a diagnosis of PTSD across treatment settings (Najavits 2004). Among women in substance abuse treatment, it has been estimated that 55–99 percent have experienced trauma—commonly childhood physical or sexual abuse, domestic violence, or rape (Najavits et al. 1997; Triffleman 2003). Studies have reported that current PTSD rates among women who abuse substances range between 14 to 60 percent (Brady 2001; Najavits et al. 1998; Triffleman 2003). In comparison to men, women who use substances are still more than twice as likely to have PTSD (Najavits et al. 1997). Brief screening is paramount in not only establishing past or present traumatic events but in identifying PTSD symptoms. Upon identification of traumatic stress symptoms, counselors need to refer the women for a mental health evaluation in order to further assess the presenting symptoms, to determine the appropriateness of a PTSD diagnosis, and to assist in establishing an appropriate treatment plan and approach. Brief screenings are used to identify clients who are more likely to have were not normal and were abusive. Some women do not remember the abuse. Therefore, a negative finding on abuse at an intake screening should not be taken as a final answer. The Substance Abuse and Mental Health Services Administration (SAMHSA)-funded Women, CoOccurring Disorders and Violence Study includes questions about sexual abuse in its baseline interview protocol, presented in Figure 4-6. In addition, SAMHSA’s CSAT has developed a brochure for women that defines childhood abuse and informs the reader of how to begin to address childhood abuse issues while in treatment (CSAT 2003a). TIP 36 Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues (CSAT 2000b) includes detailed information on this topic.

182

Interpersonal violence Studies estimate that between 50 to 99 percent of women with substance use disorders have a history of interpersonal violence (Miller et al. 1993; Rice et al. 2001). In one study focused on sensitivity and specificity of screening questions for intimate partner violence, Paranjape and Liebschutz (2003) concluded that when three simple screening questions were used together, identification of lifetime interpersonal violence was effectively identified for women. This screening tool, referred as the STaT, is presented in Figure 4-7 (p. 72). Along with a sample personalized safety plan, additional screening tools, including the Abuse Assessment Screen (English and Spanish version), Danger Assessment, The Psychological Maltreatment of Women Inventory, and The Revised Conflict Tactics Scale (CTS2), are available in TIP 25 Substance Abuse Treatment and Domestic Violence (CSAT 1997b). Note: It is important to assess for interpersonal violence in heterosexual and homosexual relationships.

STaT: Intimate Partner Violence Screening Tool Source: Paranjape and Liebschutz 2003.

183

Interpersonal violence and disabilities Women with disabilities are at a significantly greater risk for severe interpersonal violence and neglect (Brownridge 2006). As a counselor, additional screening questions tailored to address unique vulnerabilities associated with the specific physical disability may be warranted. For example, •

Has anyone ever withheld food or medication from you that you asked for or needed?

•

Has anyone ever refused to let you use your wheelchair or other assistive devices at home or in the community?

•

Has anyone ever refused to assist you with self-care that you needed, such as getting out of bed, using the toilet, or other personal care tasks?

•

Has anyone used restraints on you to keep you from getting out of bed or out of your wheelchair?

Initial questions about trauma should be general and gradual. While ideally you want the client to control the level of disclosure, it is important as a counselor to mediate the level of disclosure. At times, clients with PTSD just want to gain relief; they disclose too much, too soon without having established trust, an adequate support system, or effective coping strategies. Preparing a woman to respond to trauma-related questions is important. By taking the time with the client to prepare and explain how the screening is done and the potential need to pace the material, the woman has more control over the situation. Overall, she should understand the screening process, why the specific questions are important, and that she can choose not to answer or to delay her response. From the outset, counselors need to provide initial trauma-informed education and guidance with the client. 7. Health screenings, including HIV/AIDS, hepatitis, tuberculosis, and STDs Eating Disorders Eating disorders have one of the highest mortality rates of all psychological disorders (Neumarker 1997; Steinhausen 2002). Approximately 15 percent of women in substance abuse treatment have had an eating disorder diagnosis in their lifetimes (Hudson 1992). Three eating disorders are currently included in the DSM-IV-TR: anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified ( APA 2000a). Compulsive eating, referred to as binge-eating disorder, is not included as a diagnosis in the DSM. Currently, it is theorized that substance use disorders and compulsive overeating are competing disorders, in that compulsive overeating (binge-eating) is not as likely to appear at the same time as substance use disorders. Consequently, disordered eating in the form of compulsive overeating is more likely to appear after a period of abstinence, thus enhancing the risk of relapse to drugs and alcohol to manage weight gain. Be aware that weight gain during recovery can be a major concern and a relapse risk factor for women. Bulimia nervosa, characterized by recurrent episodes of binge and purge eating behaviors, has the highest incidence rates in the general population for eating disorders (Hoek and van Hoeken 2003), and it is the most common eating disorder among women in substance abuse treatment (Corcos et al. 2001; Specker et al. 2000; APA 2000a). For specific information regarding the co-occurring disorders of eating and substance use disorders, counselors should refer to TIP 42 Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005e).

184

Screening for eating disorders in substance abuse treatment is based on the assumption that identification of an eating disorder can lead to earlier intervention and treatment, thereby reducing serious physical and psychological complications and decreasing the potential risk for relapse to manage weight. Eating disorder screenings are not designed to establish an eating disorder diagnosis but instead to identify the need for additional psychological and medical assessments by a trained mental health clinician and medical personnel. The EAT-26 (Garner et al. 1982), or Eating Attitudes Test, is a widely used screening tool that can help identify behaviors and symptoms associated with eating disorder risk (Garner et al. 1998). It is recommended that a two-stage process be employed using the EAT-26: screening followed by a clinical interview. Specifically, if the woman scores at or above a cutoff score of 20 on the EAT-26, she should be referred for a diagnostic interview. For a copy of the screening tool and scoring instructions, refer to Appendix C. Figure 4-8 lists questions that probe for an eating disorder. A woman with an eating disorder often feels shame about her behavior, so the general questions help ease into the topic as the counselor explores the client’s attitude toward her shape, weight, and dieting.

Screening by Healthcare Providers in Other Settings Healthcare providers such as nurse practitioners, physicians, physicians’ assistants, and social service professionals have opportunities to screen women to determine whether they use or abuse alcohol, drugs, or tobacco. The most frequent points of entry from other systems of care are obstetric and primary care; hospital emergency rooms; probation officer visits; and social service agencies in connection with housing, child care, and domestic violence. Our own preconceived images of women who are addicted, coupled with a myth that women are less likely to become addicted, can undermine clinical judgment to conduct routine screenings for substance use. Between 5 and 40 percent of people seeing physicians and/or reporting to hospital emergency rooms for care have an alcohol use disorder (Chang 1997), but physicians often do not identify, refer, or intervene with these patients (Kuehn 2008). Even clinicians who often use the CAGE or other screening tools for certain patients are less likely to ask women these questions because women—particularly older women, women of Asian descent, and those from middle and upper socioeconomic levels—are not expected to abuse substances (Chang 1997). Volk and colleagues (1996) found that, among primary care patients who were identified as “at risk” for alcohol abuse or dependence by a screening questionnaire, men were 1.5 times as likely as women to be warned about alcohol use and three times as likely to be advised to stop or

185

modify their consumption. Women may be less likely to have problems with alcohol or drugs than men (Kessler et al. 1994, 1995); however, when women have substance use disorders, they experience greater health and social consequences. Screening must lead to appropriate referrals for further evaluation and treatment in order to be worthwhile. Missed opportunities can be especially unfortunate during prenatal care. In one study of ethnically diverse women reporting to a university-based obstetrics clinic, 38 percent screened positive for psychiatric disorders and/or substance abuse. However, only 43 percent of those who screened positive had symptoms recorded in their chart, and only 23 percent of those screening positive were given treatment. This low rate of treatment is of great concern, given the untoward consequences of substance use for maternal and infant health (Kelly et al. 2001). To address the disconnection that often happens (beginning with the lack of identification of substancerelated problems of the patient and extending to the failure of appropriate referrals and brief interventions), SAMHSA has invested in the Screening, Brief Intervention, and Referral to Treatment Initiative (SBIRT)â&#x20AC;&#x201D; research, resources development, training, and program implementation across healthcare settings. Although studies have not focused on gender comparisons, SBIRT programs have yielded short-term improvements in individual health (for review, seeBabor et al. 2007). Specifically, some SBIRT programs on the State level have tailored SBIRT to provide assistance to pregnant women (Louisiana Department of Health and Hospitals 2007).

186

Annex 2 : Assessment tools Choosing an Instrument Some instruments are clearly for screening, and others are clearly for assessment. Still others are sometimes used for either purpose. Before choosing an instrument, read its stated purpose, statistical properties (norming and standardization populations, reliability, validity) and know your population of focus and purpose (eligibility determination, screening or assessment). Individualize your choices based upon your population, purposes, and circumstances. On the TA Partnership’s Mental Health Web page, there is a list of Mental Health and Substance Abuse Screening Instruments . The page lists screening instruments, the developer/publisher, purpose, age of the covered population, and where to obtain further information. Mental Health Screening and Women • Women need to be routinely screened for depressive, eating, and anxiety disorders including PTSD. •

Women tend to report higher levels of anxiety and somatic symptoms associated with depression.

•

Explicit details, especially related to traumatic subject matter that may make a woman uncomfortable, are not necessary early in the process.

•

For some women, drugs have had a secondary effect and purpose, i.e., weight management. Be aware that weight gain during recovery can be a concern and a relapse risk factor for women and that clinical and medical issues surrounding body image, weight management, nutrition, and healthy lifestyle habits are essential ingredients in treatment for women.

•

Bulimia nervosa is the most common eating disorder among women in substance abuse treatment, and counselors should become knowledgeable about the specific behavioral patterns associated with this disorder, e.g., compensatory and excessive exercise for overeating, routine pattern of leaving after meals, persistent smell of vomit on the woman’s breath or in a particular bathroom, taking extra food (from dining room), or hoarding food, etc.

•

Be aware that women with bulimia nervosa are usually of normal weight.

The following section reviews core assessment processes tailored for women, including gender-specific content for biopsychosocial histories and assessment tools that are either appropriate or possess normative data for women in evaluating substance use disorders and consequences. It is beyond the scope of this chapter to provide specific assessment guidelines or tools for other disorders outside of substance-related disorders. General Guidelines for Selecting and Using Screening and Assessment Tools •

What are the goals of the screening and assessment?

•

Is the screening and assessment process appropriate for the particular setting?

•

What costs are associated with the screening process; e.g., training, buying the screening/assessment instruments or equipment (computer), wages associated with giving and scoring the instrument, and time spent providing feedback to the client and establishing appropriate referrals?

187

â&#x20AC;˘

What other staff resources are needed to administer and score the instrument, interpret the results, review the findings with the client, arrange referrals, or establish appropriate services to address concerns highlighted in the screening and assessment process?

â&#x20AC;˘

While screening measures can be completed in just a few minutes, positive screenings involve more work. Does staff see a need for and value of the additional work? Did you prepare and train staff? What strategies did you employ to obtain staff or administrative buy-in? What other obstacles have you identified if the screening is implemented? Have you developed strategies to target their specific obstacles?

â&#x20AC;˘

Do you have a system in place to manage the results of the screening and assessment process?

Note: While formal assessment tools are consistently used in research associated with substance use disorders, treatment providers and counselors are less likely to use formalized tools and more likely to only use clinical interviews (Allen 1991). The standardization of formal assessment measures offers consistency and uniformity in administration and scoring. If the implementation of these tools is not cost prohibitive and staff maintain adherence to administration guidelines, formal assessment tools can be easily adopted regardless of diverse experience, training, and treatment philosophy among clinicians. Using psychometrically sound instruments can offset clinical bias and provide more credibility with clients. The focus of the assessment may vary depending on the program and the specific issues of an individual client. A structured biopsychosocial history interview can be obtained by using The Psychosocial History (PSH) assessment tool (Comfort et al. 1996), a comprehensive multidisciplinary interview incorporating modifications of the Addiction Severity Index (ASI) designed to assess the history and needs of women in substance abuse treatment. Investigators have sought to retain the fundamental structure of ASI while expanding it to include family history and relationships, relationships with partners, responsibilities for children, pregnancy history, history of violence and victimization, legal issues, and housing arrangements (Comfort and Kaltenbach 1996). PSH has been found to have satisfactory test-retest reliability (i.e., the extent to which the scores are the same on two administrations of the instrument with the same people) and concurrent validity with the ASI (Comfort et al. 1999). Psychosocial and Cultural History Treatment programs have their own prescribed format for obtaining a psychosocial history that coincides with State regulations as well as other standards set by Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and Commission on Accreditation of Rehabilitation Facilities (CARF). While many States require screening and assessment for women, specific guidelines and specificity in incorporating women-specific areas vary in degree (CSAT 2007). Note: When using information across State standards, the following psychosocial and cultural subheadings should be included in the initial assessment for women, and these areas need to be addressed in more depth as treatment continues. Keep in mind that the content within each subheading does not represent an entire psychosocial and cultural history. Only biopsychosocial and cultural issues that are pertinent to women were included in the list below. Medical History and Physical Health: Review HIV/AIDS status, history of hepatitis or other infectious diseases, and HIV/AIDS risk behavior; explore history of gynecological problems, use of birth control and hormone replacement therapy, and the relationship between gynecological problems and substance abuse; obtain history of pregnancies, miscarriages, abortions, and history of substance abuse during pregnancy; assess need for prenatal care.

188

Substance Abuse History: Identify people who initially introduced alcohol and drugs; explore reasons for initiation of use and continued use; discuss family of origin history of substance abuse, history of use in previous and present significant relationships, and history of use with family members or significant others. Mental Health and Treatment History: Explore prior treatment history and relationships with prior treatment providers and consequences, if any, for engaging in prior treatment; review history of prior traumatic events, mood or anxiety disorders (including PTSD), as well as eating disorders; evaluate safety issues including parasuicidal behaviors, previous or current threats, history of interpersonal violence or sexual abuse, and overall feeling of safety; review family history of mental illness; and discuss evidence and history of personal strengths and coping strategies and styles. Interpersonal and Family History: Obtain history of substance abuse in current relationship, explore acceptance of clientâ&#x20AC;&#x2122;s substance abuse problem among family and significant relationships, discuss concerns regarding child care needs, and discuss the types of support that she has received from her family and/or significant other for entering treatment and abstaining from substances. Family, Parenting, and Caregiver History: Discuss the various caregiver roles she may play, review parenting history and current living circumstances. Childrenâ&#x20AC;&#x2122;s Developmental and Educational History (applicable to women and children programs): Assess child safety issues; explore developmental, emotional, and medical needs of children. Sociocultural History: Evaluate clientâ&#x20AC;&#x2122;s social support system, including the level of acceptance of her recovery; discuss level of social isolation prior to treatment; discuss the role of her cultural beliefs pertaining to her substance use and recovery process; explore the specific cultural attitudes toward women and substance abuse; review current spiritual practices (if any); discuss current acculturation conflicts and stressors; and explore need or preference for bilingual or monolingual non-English services. Vocational, Educational, and Military History: If employed, discuss the level of support that the client is receiving from her employer; review military history, then expand questions to include history of traumatic events and violence during employment and history of substance abuse in the military; assess financial self-reliance. Legal History: Discuss history of custody and current involvement with child protective services, if any; obtain a history of restraining orders, arrests, or periods of incarceration, if any; determine history of child placement with women who acknowledge past or current incarceration. Barriers to Treatment and Related Services: Explore financial, housing, health insurance, child care, case management, and transportation needs; discuss other potential obstacles the client foresees. Strengths and Coping Strategies: Discuss the challenges that the client has faced throughout her life and how she has managed them, review prior attempts to quit substance use and identify strategies that did work at the time, identify other successes in making changes in other areas of her life. Assessment Tools for Substance Use Disorders Addiction Severity Index (ASI): The ASI (McLellan et al. 1980) is the most widely used substance abuse assessment instrument in both research and clinical settings. It is administered as a semi-structured interview and gathers information in seven domains (i.e., drug use, alcohol use, family/social, employment/finances, medical, psychiatric, and legal). The ASI has demonstrated high levels of reliability

189

and validity across genders, races/ethnicities, types of substance addiction, and treatment settings (McCusker et al. 1994; McLellan et al. 1985; Zanis et al. 1994; SeeAppendix C for specific information on the ASI). ASI-F (CSAT 1997c): The ASI-F is an expanded version of ASI; several items were added relevant to the family, social relationships, and psychiatric sections. Additional items refer to homelessness; sexual harassment; emotional, physical, and sexual abuse; and eating disorders. The supplemental questions are asked after the administration of ASI. Psychometric data for ASI-F are limited. Texas Christian University Brief Intake, the Comprehensive Intake, and Intake for Women and Children: These instruments are available electronically and are administered by a counselor. The seven problem areas in the Brief Intake Interview were derived from the ASI: drug, alcohol, medical, psychological, employment, legal, and family/social. Scoring is immediate, and the program generates a one-page summary of the clientâ&#x20AC;&#x2122;s functioning in 14 domains (Joe et al. 2000). The Comprehensive Intake has an online version for women (Simpson and Knight 1997; For review, visit: http://www.utexas.edu/research/cswr/nida/instrumentListing.html). Since women are more likely to experience greater consequences earlier than men, using an instrument that highlights specific consequences of use is crucial. Drinker Inventory of Consequences (DrinC): This measurement is a self-administered 50-item, true-false questionnaire that elicits information about negative consequences of drinking in five domains: physical, interpersonal, intrapersonal, impulse control, and social responsibility (Miller et al. 1995). This instrument has normative data for women, men, inpatient and outpatient, and has good psychometric properties. Since women are more likely to experience greater consequences earlier than men, using an instrument that highlights specific consequences of use is crucial. A version that assesses drug use consequences is also available (Tonigan and Miller 2002). For a copy of the assessment tool, scoring, and gender profile in interpreting severity of lifetime consequences, see Appendix C. Measurements of spirituality and religiousness Spirituality and religion play an important role in culture, identity, and health practices (Musgrave et al. 2002). In addition, people are likely to embrace different coping strategies (including emotional outlets and religion) to assist in managing life stressors (Dennerstein 2001). Practices such as consulting religious leaders or spiritual healers (curanderas, medicine men) and attending to spiritual activities (including sweats and prayer ceremonies, praying to specific saints or ancestors) are common. The consensus panel believes it is important that programs assess the spiritual and religious beliefs and practices of the individual and incorporate this component into their treatment with sensitivity and respect. A challenge in determining the effect of spirituality on treatment outcomes is how to assess the extent and nature of a personâ&#x20AC;&#x2122;s spirituality or religiousness. Several assessment tools are available; however, they are more often used for research. They include, but are not limited to, the Religious Practice and Beliefs measurement (CASAA 2004), a 19-item self-assessment tool that reviews specific activities associated with religious practices; the Multidimensional Measure of Religiousness/Spirituality, an assessment device that examines domains of religious or spiritual activity such as daily spiritual experiences, values and beliefs, and religious and spiritual means of coping (Fetzer Institute 1999); and the Spiritual WellBeing Scale, a 20-item scale that examines the benefits of spirituality for African-American women in recovery from substance abuse (Brome et al. 2000).

190

Health Assessment and Medical Examination with women Because women develop serious medical problems earlier in the course of alcohol use disorders than men, they should be encouraged to seek medical treatment early to enhance their chances of recovery and to prevent serious medical complications. Health screenings and medical examinations are essential in womenâ&#x20AC;&#x2122;s treatment. In particular, women entering substance abuse treatment programs should be referred for mental health, medical, and dental examinations. In many cases, they may not have had adequate health care because of lack of insurance coverage or transportation, absence of child care, lack of time for self-care, chaotic lifestyle related to a substance abuse, or fear of legal repercussions or losing custody of children. The acute and chronic effects of alcohol and drug abuse, the potential for violence, and other physical hardships (e.g., homelessness) greatly increase the risk for illness and injury. Women may practice behaviors that put them at high risk for contracting sexually transmitted diseases (STDs) and other infectious diseases (Greenfield 1996). Testing for HIV/AIDS, hepatitis, and tuberculosis is important; however, it is as essential to have adequate support services to help women process test results in early recovery. Anticipation of the test results is stressful and may place the client at risk for relapse. Residential centers may offer medical exams onsite, but outpatient service providers may need to refer patients to their primary care provider or other affordable health care to ensure that each client has a thorough medical exam. Healthcare professionals may benefit in using the Women-Specific Health Assessment (Stevens and Murphy 1998), which assesses health and wellness and addresses gynecological exams, HIV/AIDS, drug use, STDs, pregnancy/child delivery history, family planning, mammography, menstruation, disease prevention, and protection behaviors.

191

Annex3 : How to deal with an existential crisis

How to Deal with an Existential Crisis WIKIHOW ARTICLE Edited by Bill Young, Krystle C., Imperatrix, Ben Rubenstein and 44 others An existential crisis can occur when the answers to the questions about the meaning and purpose of life (as well as our place in it) no longer provide satisfaction, direction or peace of mind. When you find yourself contemplating life, not knowing what illusory fulfilment you're seeking, it can get pretty mentally hectic. But with a little purpose and determination, it's easy to become all the better for it!

Steps

1. Recognize that you're having an existential crisis. If you're questioning the meaning or purpose of your existence, or if the foundations of your life seem shaky and transient, you might be experiencing a crisis (usually called "existential" because it relates to ideas explored by the philosophical school of existentialism), which may result from: - The sense of being alone and isolated in the world - A new-found grasp or appreciation of one's mortality - Believing that one's life has no purpose or external meaning

192

- Awareness of one's freedom and the consequences of accepting or rejecting that freedom - An extremely pleasurable or hurtful experience that leaves one seeking meaning. 2. Choose the meaning of your life. Existentialism posits that each individual is empowered to choose the parameters of his or her existence. Choosing to add meaning to your life yourself, without the help of anyone else, can ultimately help you resolve an existential crisis. Below are some methods that can help. Method 1 of 2: The Last Messiah Method Norwegian philosopher Peter Wessel Zapffe contends that the human self-conscious is actively engaged in the "repression of its damaging surplus of consciousness," and offers four ways of doing so. They are: 1. Isolation: Dismiss all upsetting or negative thoughts and feelings from your consciousness and actively deny them. 2. Anchoring: Combat feelings of isolation by "anchoring" your consciousness to fixed values or ideals, such as "God, the Church, the State, morality, fate, the laws of life, the people, the future." Focusing your attention on these things (whether you support or contradict them) can help you feel like your consciousness is not adrift, or as Zapffe said, build "walls around the liquid fray of consciousness." 3. Distraction: Keep your thoughts from turning to distressing ideas by filling your life with distractions. Focus all your energy on a hobby, project, job, or other outlet that can consume your thoughts 4. Sublimation: Refocus your energy toward positive creative outlets, such as music, art, literature, or any other activity that you find allows you to express yourself. Method 2 of 2: Other Methods 1. Understand what caused the problem. The issue is not your thoughts â&#x20AC;&#x201D; it is your attachment to the thoughts. Your thoughts (and the language in which you experience them) come from your conditioning, your society, your reaction to experiences. 2. Try to see life and your place in it as it really is. Question everything and attempt to see past all social, political, spiritual and personal conditioning and falsehoods. 3. Acknowledge that this is a common problem. Know that we humans often feel that we are stuck in a game designed and controlled by others who do not have your or humanity's best interests in mind. When you're in crisis, it looks like others succeed through ignorance, fear and the ability to lead you around by the nose. Research the history of civilization and how this rat race began, and how it is perpetuated, then begin to formulate your own understanding as to where it may be heading. 4. Consider how well orchestrated life seems to be. Some type of consistency does appear to exist, at least on a micro level. 5. Stop comparing yourself to others. Your ability to experience joy will grow dramatically when you stop comparing yourself to other people and only compare yourself to yourself, if to anyone at all. In an ironic twist of fate, this can be achieved incrementally by holding a more stoic subjectivity. 6. Don't be afraid to make up your own rules. Remember to let go of "should" â&#x20AC;&#x201D; you are in charge. (This message is a "should", so take it with a grain of salt.) You are the lightning of your values, and don't forget that, ultimately, value is genetically grounded in the body, even if it appears to be emotion. If you feel anxiety about "what to do", now that nobody else is telling you what to do, that's the most exciting

193

part of the journey ... remember childhood? Mystery? Adventure? Smelling new smells and feeling new fabrics? New foods? Do something to improve your experience of joy. 7. Try to voice what your problem is. Some people write full-length sentences to help determine what their issues are. Others start by writing a poem in order to get their thoughts and feelings flowing. Later, you can elaborate in prose. 8. Imagine several different people you like or respect giving you advice.Don't pick anyone abusive. Try Mr. Rogers, your first grade teacher, or that person you had a crush on in 9th grade. They don't help very much, do they? But it's fun talking to them. 9. Imagine giving advice to someone else in your situation. Would you still think this was as big a problem? 10 . Problem solve. If you can't figure out your problem, that means it's legitimate. If your solution involves making big changes, take a few days to think about it. If you can't do anything about your problem right now, accept it. If it's late, go to sleep; if you can't sleep, find something to do that does not involve a television or computer screen (blue light causes insomnia). You'll want to go to sleep later. If it's daytime, get some exercise or finish your job. Be professional. A few successes never hurt anyone. 11. Take what you've learned. If after exhausting research you still feel unsatisfied, you still have gained a lot of insight into the philosophy of the situation. You must know by now that a will to truth is absurd (to use the terminology). Since we truly don't know whether there is meaning to existence or not, we can always fall back on risk assessment. If you put life and death in two columns, and meaningful/meaningless existence into two rows, you will find that living out the rest of your life is the best option (no matter what horror existence may be). 12. Aim to create peace and joy. In whatever situation you find yourself, do no harm to yourself or others; even though sometimes it hurts, it will pass. Find meaning in the simple pleasures of life through your senses. Stop to smell the roses, feel the sunlight, taste the food, see the beauty and listen to your heart calling. You can create your own meaning for yourself and your own life. After all, it is your life, your game, your experiment. Play your game with respect for others, and deal with your circumstances to the best of your ability. To really succeed, respectfully enlist the help of others. 13. Clean whatever room you're in. This will help you clarify your power over the world and give you a few minutes to do some basic problem-solving. Don't just straighten things up, clean. Use a cleaning product. 14. Remember that tomorrow is a new day. It's another opportunity for you to make changes in your life to seek happiness and self-fulfillment. This power is yours â&#x20AC;&#x201D; claim it.

194

Tips •

Breathe deeply through your nose and out through your mouth; shallow breaths through the mouth are a signal of panic.

•

Authors that have dealt with such subjects include Nietzsche and Camus. Depending on who you are, reading these people may make you feel worse or better.

•

Don't be afraid to laugh and make fun of yourself. It's a good way to find out who you really are. This practice gives you a true sense of personal freedom. This is also a good way to clarify what's really important. If you find it difficult to laugh at something, your problem is much bigger than you originally imagined. Accept the things (and people) you cannot change or control.

• • • •

Choose to live, forgive, learn, love and prosper. In fact, don't be afraid at all! No matter how tempting it may be, don't take your insecurity out on others. If you think you suck, that's for you to handle. Tearing other people down isn't going to change how you feel about yourself, no matter how often you try.

•

Take care of your body. Drinking more water can combat headaches and changes in mood and improve brain function. Taking a walk can provide you with a new perspective and a boost of endorphins.

• •

Eat real food, and drink plain filtered water. Meditate.

Warnings •

Don't resort to alcohol or drug abuse to cope with your crisis. Although they might seem to provide momentary relief, these compulsive behaviors will only add to your suffering in the long run and make it considerably more difficult to grow and to improve your life.

•

Whatever you do, don't kill, cut, or maim yourself. Don't make any permanent changes because of temporary problems: destroying the only copy of your novel or getting a facial tattoo is unacceptable. If you want to get in a fight with your parents, dye your hair blue.

•

Respect the existence of others. If there is someone or something stopping you from achieving your goal, it is best to determine a mutually beneficial course of action. In other words, killing, maiming, or otherwise harming people is an unacceptable practice that may lead to your own undoing. Live and let live, baby. Besides, if you think that life stinks, now, you've not been to prison. If you really feel that life is more meaningful through suffering, then simply ignore this tip and get on with it. You'll find some very heavy duty meaning on the inside, certainly.

•

Don't hesitate to call hotlines. They are there for the benefit of people who have similar difficulties. Life is hard. Help others, and ask for help when you need it.

195

Annex4: How to help a friend with depression

How to Help a Friend with Depression WIKIHOW ARTICLE Edited by David J, Versageek, HalfPint9135, TheKnowerOfStuff and 56 others Depression. We've all heard of it. Most of us will come into contact with it at some point in our lives. Depression is a very difficult serious disorder and miserable experience for someone to go through, and it's something that either you or someone you care about will have to deal with. However, it isn't just the victims who are impacted. What about their friends? Victims of depression need steady, supportive friends to rely on in their times of need. If you're the friend of a depression victim and are confused and don't know what to do or how to help them best, then worry no longer. This article is for you.

Steps 1. Acknowledge. Tell the person suffering from depression that you've noticed that they seem down or depressed lately. (Unless they have already told you that they are suffering from depression.) If so, tell them that since you now know that they're sad that you want to help. This will be very reassuring to them. Sometimes the depressed don't even feel like telling anyone because of the stigma associated with depression. Also, make them feel like they are needed. Talk to them when you are upset about something or when you want to vent. Trust them with things that you wouldn't tell just anyone else. This makes them feel very important to you. Depression lies to them and makes them feel like they aren't needed by anyone. This acknowledgment that you know how bad they feel may be the little "push" they need to start talking about it, and maybe even seek help. 2. What not to do: Pretend like it is not there or that this is not a serious condition. This is debilitating for a person. They can't help it. This will make them feel like they are insignificant and that you don't even take their problem seriously. 3. Find out why your friend is depressed. Did they just have a bad break-up or did their parents get divorced? Or are they just simply mad or disappointed with life and the world? Ask them what you can do to help. Ask carefully and gently, and don't get upset if they're slow to tell you. Some people take longer than others to talk. If they do tell you a list of things you can do, then do them. Usually if they answer a question like this in full they absolutely genuinely need those things from you. What not to do is to ask that and they answer and not carry those things out. This will just send them back into a deeper state of their depression because once again, they have been let down. Especially since it would be by someone so close as their best friend, it could be very damaging. 4. What not to do: If they tell you why they are depressed, or why they think they are. (sometimes people don't even know what causes their symptoms.) Be sure to take those reasons seriously. Don't joke around with them. Do not bring them up in a light hearted conversation, because this can cause a wave of emotions associated with that topic, altering their mood for the worst. Do not bring up what they have told you in trust, in front of other people. This is very very damaging to the friendship and to the person.

196

5. Listen. Although you may think that the last thing your friend wants to do is talk to you about depression, you could be wrong. Sometimes a friend just needs someone to talk to. Actively listen to them without judging or giving advice. Depression is an issue that people sometimes feel they must hide, in order to maintain their usual life. Because people see it as a weakness or a cry for attention they feel like not telling anyone. This is wrong though, the depressed person would like nothing better than to feel happy again and be themselves. Either that or they are only just coming to terms with it, let alone the idea of letting other people in on it. However, from time to time, your friend may open up, or express the desire to talk to you. Sometimes they just want to vent. Don't start spitting out possible solutions until you know the full extent of the problem. A good listener can sometimes be vastly more helpful than someone who tries to offer solutions. When this happens, be understanding and kind and willing to listen. This means a lot to them. This also should mean a lot to you because they are trusting you with something so personal that's affecting them. Don't interrupt, don't try to convince them they're wrong, don't give advice and try not to react in horror. It can be difficult to hear about how terrible your friend feels, but remember that they're trusting you. Value this trust, don't break it and keep it close. Just be there to listen. That's the number 1 thing they need right now. 6. What not to do: Don't make jokes when they are talking to you. This makes them feel like you don't see their feelings as legitimate or serious. You may be trying to help by lightening the mood but it is not good for the depressed person. Do not tell them just to "Be happy." Or "Why can't you just be happy for once?" or "Lighten up." "Will you ever stop being like this?" "It's getting annoying." This will not encourage them at all. Once again this makes them feel like you aren't even listening and it makes them feel like their issues don't matter which could lead to them feeling like their whole self doesn't matter to you. Don't tell your friend to stop being depressed or be happier. This is out of their control. Depression is a sickness, not a choice. A depressed mind is the most sensitive mind. Remember that. 7. Try to understand. Every person's story is different, and so it is impossible to completely understand. Depression is a very complex and complicated disease. So it is ok for you not to understand where they are coming from. However, keeping an open mind and putting yourself in your friend's shoes can help you come closer to them. Once you've done your research on depression, you should know a lot more about the disorder. Apply the symptoms and emotions to yourself, and contemplate how you would feel if this was happening to you. Call upon things your friend has done or told you, and try to understand why and what they mean. In times of need, having someone understand or try too, can be all the relief in the world. 8. What not to do. Don't tell your friend that life is still worth living and that this situation will improve and the sadness will get better. This trivializes their pain and will not help. Do not try to make them feel better by reminding them how much better their lives are than other people's. They know that and it makes them feel guilty about their condition because they feel like they should just be able to be grateful for life because they have it better than a lot of people yet they can't seem to do it. Don't ask them to "cheer up" or "snap out of it". People with depression aren't capable of just doing it so simply, so be sensitive to that. It'll only make them feel more guilty about their condition. NEVER tell them that their problems are stupid or that there is nothing to worry about. They'll stop talking. This can lead them to more suicidal tendencies.

197

9. Be There. Most importantly is to just be there for your friend. Be very genuine and don't lie to them. Don't tell them things and not truly mean it. Sometimes they can tell and this will hurt them greatly. This a time when they are their lowest point in life. Especially if they are a teen battling with depression. Because they are wasting away their most precious years, and this also makes them sad and guilty because they feel like they can't just enjoy their life. Things you can do to make them know that you are there is to obviously tell them that. You could say something like "I am here for you and whenever you feel like talking I'll always be willing to listen and to try & understand." Sometimes, the thing they need most is just a simple hug and a "I am here for you. Everything is going to be ok." Also let them know that you value their friendship and that you care about their life. The depression can cause them to feel worthless and not needed. They need to be re-assured that they matter to you and that you want to help them through this. Let them know that they aren't weak or worthless because they may feel like this because of society and it's view on this serious disorder. If you honestly mean it and can do so with an open heart, offer to be there 24/7. Tell them that you welcome their phone calls at all hours. You will rarely, if ever, receive a middle of the night call. But a sincere offer sends a message of support that will be heard. If you see them in public places, make sure to say hi and notice them. Don't pretend like everything is ok though, always remember that. Ask them how they feel today and be sure to pay attention to them from time to time because they feel alienated from people when out in the world. Do these things because they feel completely alone and isolated. This is a major side effect of depression and causes lots of suicidal thoughts and tendencies, especially in teenagers. Hug them, hold their hand, physical contact is good for people that are suffering from depression. It makes them feel better and comforted, and safe, so do those things as often as you can. Tell them that you love them and care for them. Give them a shoulder to cry on. Be there. 10. What not to do: Don't say you will be there for them and then not be there. This will be very damaging to them. Because they have been let down once again. Also, do not ignore them. If they want to talk just to chat or want to talk heart-to-heart, respond! They feel like you don't care in the least when they get nothing from you. If you can't talk or are tired, say that. Don't ever leave them in the dark. This causes them to worry even more than they already are. And takes a toll on their insecurity. Don't do things half-heartedly. One of the main reasons people get depressed is because they seem to feel like they care too much or they love people too hard. And they get sad because they feel like they are the only ones being genuine. So do not do things in vain with them. It will damage them greatly. 11. Be patient. Because depression is heavy, slow moving and unpredictable, it can frustrate and even anger those who are trying to help. Remember that depression is a complex disorder, and try to understand that the depressed person is not herself or himself right now. If your friend doesn't seem to appreciate your efforts, or is pushing you away, don't walk off in a temper. Give them space or give them comfort if they need it, and be there for them, no matter how much they believe you don't need to be. 12. Don't push too hard. If it makes your friend feel worse to face up to their problems, do not force them to continue. Sometimes analyzing a person's past can make them feel worse about themselves and dredge up past traumas. In this case, focus on how they feel now and how they want to be in future, and forget whatever caused them to feel depressed. Leave it in the past until they are ready to either deal with it or let it go. Be gentle. Depression can be dark, confusing and

198

angry, but it can also be tender, hurtful and full of sensitive tears. Don't yell or be rough-keep your voice and body language soft and don't force your friend into anything. 13. Stay in contact. Check in. Call them just to call them. Check up on them occasionally, esp. at night when the depression is at its worst. Text them occasionally just to say you are thinking about them and ask how they feel today. This means the world to them and makes them feel like they matter and re-assures them that you care and causes them to feel more at ease. Support them and ask what you can do to help, of course. When they have severe depression, often times they will confess to you that they sometimes want to just die. But they actually don't. Most of these happen while driving. So asking them a quick "Are you home and ok?" Will make them feel very cared for. You don't want to be that person finding out something terrible just because you aren't worrying about them. Maybe even give them a card or bring them lunch or take them to a movie. This means so much to someone who is depressed. You won't believe how it will uplift their mood. It makes them feel significant. 14. What not to do: Is ignore them or blow them off. If you can't do something tell them. And don't say you will do things and not do it. For example: "I will call you later tonight." and then not. or "I am going to get you something!" and then not. This makes them feel like you are just saying that in the moment and don't even bother to do it later. 15. Take care of yourself. You have to be mindful of yourself and your mind to in helping this friend. It can take a toll especially if they are very needy. If you need to take breaks then tell them that. Remember though, do not ignore them. Go have fun with other friends, and enjoy your life too. But you have to remember that depression is not them. Your friend will eventually come out of this, and become the person you've grown to love and have fun with. Just give them time and have patience. 16. It is ok to have fun! Not everything has to be so serious all the time, even with depression. Especially if they are already on medication. Sometimes they feel completely up to just doing anything and having mindless fun. Just be aware that their mood can alter for no reason, and do not get mad at them for it. They can't help it. Just be there for them if that happens. 17. Encourage your friend not to abuse drugs. People with depression can be much more vulnerable to the negative effects that occur when recreational drugs wear off. If your friend is taking antidepressant or anti-anxiety medication, encourage them not to make any changes without talking to their doctor or psychiatrist. Taking more than they were prescribed can be dangerous, and going off the medication suddenly may make them feel much worse. Avoid alcohol as well nobody is going to conquer depression with a hangover. 18. Advise them to seek professional help. They may deny that they need it, or tell you that "it's okay" or they'll be "fine". If they react this way, stop pestering them about it for a while. Over time, the idea might grow on them. Depression is not something that goes away by itself after a while. This is probably the most difficult step. Be sensible. If you friend is sounding like they are harming themselves or are thinking of suicide, you need to alert somebody. Listen out for suicidal like comments when they are talking to you. Such as " I wish I were dead." or "I don't want to live anymore. I feel useless." I'm not good enough. These should be taken seriously.

199

19. Depression is complicated. This is a lot to take in. But if you use this as a tool to help your best friend in need, you will be surprised at how much little steps and things you can do for them will greatly affect their disorder. When they make it out of their depression, they will be so grateful that you played a part in help guiding them out of it.

Tips •

Do not try to make them feel better by reminding them how much better their lives are than other people's.

•

When your friend is confiding in you with their feelings, don't start bringing up your own problems. This might make them feel like their depression isn't as important as your own problems and make things worse.

•

Keep them talking, talking helps but give them ways to work out their problems privately too, don't force them to be dependent on you.

•

People can and do recover from depression. Never lose sight of that, and without pushing it in the depressed person's face, make sure they remember it too.

•

Sometimes venting to them might not be wise, as they're already in a dark place and might not be able to handle someone else's troubles on top of their own. Follow the advice presented under No.1 with caution.

• •

Try not to give them advice, try to just guide them. If you honestly mean it and can do so with an open heart, offer to be there 24/7. Tell them that you welcome their phone calls at all hours. You will rarely, if ever, receive a middle of the night call. But a sincere offer sends a message of support that will be heard.

•

Be patient. Don't involve other peers unless the person is happy with you involving other people. And above all remind them that you will always be there for them. And if you say it, mean it. Don't ask them to "cheer up" or "snap out of it". People with depression aren't capable of just doing it so simply, so be sensitive to that. It'll only make them feel guilty about their condition. A lot of times depressed people just want to be alone, so don't push. If you can, try to get them interested in going out with friends and doing things again. Even getting them to be happy again for a couple hours means there is still hope!

• •

Warnings •

Don't tell you friend to stop being depressed or be happier. This is out of their control.

• •

Many people with depression will turn down your offer of assistance. Don't take it personally. Never tell them that their problems are stupid or that there is nothing to worry about. They'll stop talking.

•

Many suicide attempts happen when people begin to feel slightly better, rather than in their very deepest depression. When someone is at rock bottom they may not have enough energy to do anything; when their energy starts to return, that is when they may take action.

•

Self-harm could be the precursor to thoughts of suicide, so watch them closely and continue to provide gentle encouragement and reassurance. However, self-harming does not definitely mean

200

• •

that a person will become suicidal, it usually indicates that a person has significant personal problems and may simply be a cry for help. If your friend does any of the following things, you should call the National Suicide Prevention Lifeline for referrals [1-800-273-TALK(8255)] or seek immediate help. Talks about "wanting to die," or "wishing it was all over."

•

Begins stockpiling medication, buys guns or gets them out of safety lockers, or does anything else to make a suicide attempt easier.

•

Begins giving away possessions.

•

Writes notes to try to "tie things up," even if they are not explicitly talking about a potential attempt.

•

Begins abusing drugs or alcohol, or eating dramatically less.

•

Depression is very serious. It often takes a professional to take care of it.

If you believe your friend may be at risk of harming themselves or others, take them to their doctor or a drop-in accident and emergency center.

201

Sources: Crisis Training Manual – Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS), 710 James Robertson Parkway Nashville, TN 37243 By The TDMHSAS Crisis Workgroup: Trish Wilson, Phillip Earhart, Liz Ledbetter, Mary Shelton, TDMHSAS Staff Melissa Sparks, Director of Crisis Services, Division of Mental Health Services, Mary Dillon, Assistant Director of Crisis Services, Division of Mental Health Services, Bob VanderSpek, Office of Consumer Affairs (Retired), Becki Poling, Director, Office of Hospital Services, Marthagem Whitlock, Assistant Commissioner, Division of Planning, Research, and Forensics, Lygia Williams, Division of Mental Health Services and Cindy Sneed, former President of Crisis Management Group, Inc. The Crisis Curriculum, a Mental Health Manual, By Larraine Pierce, Minnesota Department of Human Services http://cebmh.warne.ox.ac.uk/csr/clinicalguide/riskassessment.html Centre For Suicide Research - University of Oxford World Health Organization - The Alcohol Use Disorders Identification Test - Guidelines for Use in Primary Care – Audit By Thomas F. Babor, John C. Higgins-Biddle, John B. Saunders and Maristela G. Monteiro http://www.wikihow.com/Volunteer-at-a-Crisis-Hotline http://www.reddit.com/r/AskReddit/comments/1s2jx8/serious_suicide_hotline_operators_of_reddit_what/ http://www.reddit.com/r/IAmA/comments/l4di8/iama_phone_operator_at_a_suicide_hotline_amaa/ http://www.mayoclinic.com/health/support-groups/MH00002 http://www.mindtools.com/stress/Brn/IntroPage.htm http://www.ncbi.nlm.nih.gov/books/NBK83253/ National Center for Biotechnology Information, U.S. National Library of Medicine 8600 Rockville Pike, Bethesda MD, 20894 USA http://www.tapartnership.org/content/mentalHealth/faq/01screening.php www.cisresponse.com – www.icisf.org - Critical Incident Stress Management (CISM) Program Canada Border Services Agency - Pacific Region By Mitchell, J.T. PhD, and Everly, G.S. PhD, Critical Incident Stress Debriefing: CISD An Operations Manual for the Prevention of Traumatic Stress Among Emergency Service and Disaster Workers. Ellicot City, Maryland: Chevron Publishing Corporation 2nd Edition Revised - ICISF Internet Site - A Primer on Critical Incident Stress By Janelle & Associates - Canada Customs CISM Training and Development Consultant – www.drjohnmurphy.com ©2013 John Murphy UCA Box 4915 Conway, AR 72035-0001 Ph: 501-450-5450 email: jmurphy@uca.edu By John Murphy http://www.drphil.com/articles/article/13 - grieving

202

http://www.drphil.com/articles/article/205 - moving past a moment of crisis http://www.drphil.com/articles/article/204 - Common signs and symptoms of PTSD (By Glory) http://www.mdjunction.com/bipolar/articles/common-signs-and-symptoms-of-ptsd TOAC Web Site - powered by bravenet.com http://www.newdaynewlesson.com/the-best-way-to-empower-someone-is-to-show-them-their-strengths/ By Susie http://www.wikihow.com/Empower-People By DifuWu, Daniel Bauwens http://tinybuddha.com/blog/empower-others-and-make-a-positive-difference-in-their-day/ Empower Others and Make a Positive Difference in Their Day By Asnat Greenberg - Helping Hand http://www.lifeoptimizer.org/2010/03/10/empower-people/ By Mark Foo of 77 Success Traits Posted by Donald Latumahina http://www.lifecoachingstudio.com/acom13.htm The Coaching Clinic: Jerome Shore - tel 416-787-5555 or coach@coachingclinic.com - (www.coachingclinic.com ). http://betterlifecoaching.wordpress.com/2011/06/17/5-tips-for-building-rapport/ dandkpoke@bigpond.com.au http://www.ehow.com/how_2060519_develop-collaboration-skills.html#ixzz1qbT2HejN How to Develop Collaboration Skills | eHow.com http://www.reliableplant.com/Read/18500/a-to-z-strategies-for-building-collaboration By Carol Kinsey Goman. Carol Kinsey Goman, Ph.D., is a keynote speaker and author of 10 business books. Her latest is “The Nonverbal Advantage: Secrets and Science of Body Language at Work”. Contact: editorial@troymedia.com http://www.collaboration.me.uk/HOW2_BUILD_COLLABORATION.php www.befrienders.org © The Royal College of Psychiatrists 1997 Bereavement Information Pack By Kate Hill, Keith Hawton, Aslog Malmberg and Sue Simkin How to Cope With Emotional Pain By Doris Ann (DEE) 12 Canadian Journal of Connselling / Revue canadienne de counseling / 1998, Vol. 32:1 An Empowerment Model of Counsellor Education By Ellen Hawley McWhirter - University of Oregon

203

Ellen Hawley McWhirter, Ph.D., is an assistant professor in the counselling psychology program at the University of Oregon in Eugene. Her research and scholarly interests include the career development of adolescents of color and applications of the construct of empowerment in counselling. Address correspondence to: Ellen Hawley McWhirter, Ph.D., Counseling Psychology Program, DABCS, College of Education, 5251 University of Oregon, Eugene, OR 97403 5251. Serving sexual assault survivors in the academic library: Using the tools of crisis intervention and empowerment counseling in the reference interview by Wendy S. Wilmoth Georgia Library Quarterly spring 2008 - Georgia Library Association Empowering conversations: A Resource Guide for Team Building Between Families and Professionals to Support Action Planning for Young Children By Laura Beard, Lead Family Contact; Michelle Dipboye Sames, Early Childhood Empowerment Specialist, Kentucky’s System to Enhance Early Development, Kentucky Partnership for Families and Children, Inc. Empowering Language http://seizetruth.com/EmpoweringLanguage.html Comm 2399: Special Topics in Communication: Listening Nine Tools of Empowered Listening http://faculty.stedwards.edu/teriv/COMM%202399%20Listening/McCalls_9_Tools_of_Listening.pdf By Teri L. Varner, Ph.D. Assistant Professor of Communication and Dr. Carol McCall Sobell and Sobell, ©2008 Motivational Interviewing Strategies and Techniques: Rationales and Examples Lay Counselling: A Trainer’s Manual, developed by the Danish Cancer Society, the War Trauma Foundation in the Netherlands, the University of Innsbruck, Austria and the Reference Centre for Psychosocial Support of the International Federation of Red Cross and Red Crescent Societies, based in Copenhagen, is based on evidence-informed practice over many decades in lay counselling and psychosocial work, and has been researched and field-tested before publication. It is available online at http://www.pscentre.org , where you will find lots of other interesting materials to extend knowledge about best practice in lay counselling and which will be useful to you and your organisation. The recovery coach manual - The McShin Foundation - A Recovery Resource Foundation J. Daniel Payne Executive Director - John Shinholser President 2300 Dumbarton Road Richmond, VA 23228 (804) 249-1845 info@mcshin.org - www.mcshin.org http://mcshinfoundation.org/sites/default/files/pdfs/Recovery%20Coach%20Manual%20-%207-222010.pdf

204

205

206