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This learner guide has been designed for students who are engaging in the units: CHCCM503-DEVELOP FACILITATE & MONITOR ALL ASPECTS OF CASE MANAGEMENT. Elements: 1.1, 2.1, 2.2, 2.3, 3.1, 3.2, 3.3, 3.7, CHCCS500A- CONDUCT COMPLEX ASSESSMENT AND REFFERAL Elements: 1.1, 1.3, 1.4, 1.5, 2.2, 2.3, 2.5, 2.6, 2.7, 3.1, 3.3, 3.4, 3.5, 4.1, 4.2, 4.4, 4.5, and 4.6. This guide would be useful for students to improve their questioning skills prior to a role-play assessment. This guide also focuses strongly on working with clients with a substance use/abuse issue. It is expected that students have already acquired knowledge of active listening and other verbal and non-verbal communications. This learner guide also includes a range of learning activities for which the answers can be found on page 34. This guide also includes an assessment that is divided into three parts: ASSESSMENT ACTIVITY 1 CREATE YOUR OWN CASE STUDY. Write a fictional story of around 500 words that begins with the words: My name is.. The story must include the issue of substance abuse and at least two other issues of your choosing. This story must also contain two strengths (positives). Include the persons original motivation for using. Is the motivation the same today? How did they feel when they used? How do they feel now when they use? How has it affected their lives with regard to relationships and employment? What does a normal day look like for them? What sorts of emotions do they experience? What would they like to achieve in the future? Try to be creative and put yourself into the shoes of someone who is in a situation that your future clients may find themselves in. However keep a reasonable amount of realism, as you will need this case study in other sections of the assessment. Do not finish the story with a happy ending as the issues should be on-going. ASSESSMENT ACTIVITY 2 Create your own holistic assessment form that poses all of the required questions as briefly and unobtrusively as possible. Remember to include all personal details and an explanation and acceptance of confidentiality to begin with. Then try to pose the questions in a logical and polite manner. You probably would not begin with Mental Health, for example. 2

Once each pair has completed their holistic assessment questionnaire, using the case studies you created in Assessment Activity 1 conduct an informal role-play. One student will assume the role of the character they created, and the other will take on the role of a case manager, who will utilise their verbal and nonverbal communication skills to conduct a holistic assessment using the assessment questionnaire. Make sure that you fill in the answers. Once completed swap over and repeat the task. ASSESSMENT ACTIVITY 3 Formal Role-Play. Now that you have fulfilled the case management stages of: ENTRY/SCREENING, and ASSESSMENT, It is time to meet up with the client again and to begin the PLANNING process. For this task you will be required to use your questioning techniques toolbox as previously discussed. You are not required to adhere to one particular theory of technique. Rather, try to use strategies and questions from each as you fell would be most useful to achieve a positive outcome. For example you might begin with Egans first stage of: Whats going on? Your client maybe stuck in a stage of ambivalence, or has a lack of direction or motivation because they cannot see change as a realistic possibility. In this situation perhaps Egans second stage of brainstorming (What do I want?), Could be appropriate. Or perhaps a more solution focused approach of asking the miracle question. Motivational interviewing would also be useful in this situation. Maybe you might look at the positive aspects received by the client for the use of a substance or the continuation of behaviour, and then the less positive aspects. You may ask them what someone close to them might say are their best personal qualities. And then ask them how a stranger in the street may see them. You might ask them: What did they imagine they would be doing today when they were 15? (Adjust age appropriately) Then have they achieved any goals towards that? What do they think has held them back from achieving those goals? You could ask them how badly they want to achieve change on a scale from 10-to10. And then ask them: What would it take to achieve a higher grade. Feel free to create your own variations of these techniques and try to pose them in a logical order. At the same time do not forget to apply your verbal and non-verbal communication micro-skills. 3

By the end of the role-play, hopefully you have identified both areas of immediate need as well as some goals to work towards into the future. Once you have concluded the role-play you can begin to write up your case notes. Now you are ready to research appropriate agencies and programs to put a case-plan together for presentation to your client. Remember that the best case plans not only address issues of immediate need but also include activities directed at social, future vocational and emotional needs. Try to make it as enjoyable as possible. Before attempting these assessment tasks work through this learner guide and ask your trainer for assistance and clarification. Students are encouraged to read further on the subject. Many good references are given at the end of this guide.

After workers have conducted an intake and holistic assessment of the clients issues, it can often seem clear to the worker what we believe might be a restrictive or negative element in the clients life. However this may not be the case for the client. We must remember that it is the clients life and that only they can choose to make changes in their life, or not. Clients may also be conscious or semi-conscious that change is necessary but maybe ambivalent, or may lack the motivation or self-belief required for positive change. Thats where we as Community Workers come in! This guide will examine the theories of: Motivational Interviewing, Egans 3 stages theory, Solution Focused Therapy Questioning techniques put forward by: Rollnick, Miller and DeJong, as well as others mentioned in the Reference Section. Helping clients to set goals is an important part of the case management process. However, before we can get to that point we have to assist in the illumination of what the client would like to change or achieve. This is not always easy as clients are not always able to express, or are not yet conscious of what they believe needs to change or even how they would like their future to look like. As an exercise, write down five personal or professional goals that you would like to achieve in the future. 1. 2. 3. 4. 5. As you can see understanding what you want to achieve is not always straightforward, it is however necessary if we are to set goals and achieve them. Egan's skilled helper model This 3-stage model or framework offered by Egan is useful in helping people solve problems and develop opportunities. The goals of using the model are to help people 'to manage their problems in living more effectively and develop unused opportunities more fully', and to 'help people become better at helping themselves in their everyday lives.' (Egan G., 'The Skilled Helper', 1998, p7-8). Thus there is an emphasis on empowerment. Also the person s own agenda is central, and the model seeks to move the person towards action leading to outcomes, which they choose, and value. This model is not based on a particular theory of personality development, or on a theory of the ways difficulties develop. It is a framework for conceptualising the 5

helping process, and is best used in working on issues in the recent past and the present. As with any model, it provides a map, which can be used in exploring, but which is not the territory itself. The Egan model and mentoring are not synonymous; the model can be used in many kinds of helping relationships, and mentoring/comentoring can be done using other models, (or none!). The model can and should be used flexibly. The model works best if attention is paid to Rogers' 'core conditions'. (genuineness, realness, or congruence, unconditional positive regard and empathic understanding). For more details on this subject, check out the following linkhttp://garethmartin.hubpages.com/hub/The-core-conditions-which-Carl-Rogersconsidered-essential-for-effective-counselling The helpers approach to the speaker being based on genuineness, respect, and empathy, and if principles of good active listening are remembered throughout. The Egan model aims to help the speaker address 3 main questions: 1. 'What is going on?' 2. 'What do I want instead?' 3. 'How might I get to what I want?' Not everyone needs to address all 3 questions, and at times people may move back into previously answered ones. For simplicity, we'll look at the model sequentially. However, the skilled helper will work with the speaker in all or any of the stages, and move back and forward, as appropriate.

Diagram of the Model

STAGE 1 STAGE 2 Preferred Scenario STAGE 3

Current Scenario

Action Strategies

2a Possibilities 3a - Possible actions 1a - The story (What's going on?) (Ideally, what do I want instead?) (How many ways are there?) 2b - Change Agenda (SMART goals)

1b - Blind spots (What's really going on?)

3b - Best fit strategies (What will work for me?)

1c - Leverage (Focusing/prioritizing)

2c - Commitment (Check goals are right)

3c Plan (What next and when?) Action Leading to Valued Outcomes 6

STAGE 1 - What's going on? Stage 1 is about providing a safe place for the speaker to tell their story in their own way, and to be fully heard and acknowledged. It is about a space where a person can hear and understand their own story. It is also about gently helping them lift their head to see the wider picture and other perspectives, and to find a point from which to go forward with hope. 1a - an expansive part The helper encourages the speaker to tell their story, and by using good active listening skills and demonstrating the core conditions, helps them to explore and unfold the tale, and to reflect. For some, this is enough, for others it is just the beginning. .... as you summarised what I said, all the jumble began to make sense." Skills in Stage 1a: - active listening, reflecting, paraphrasing, checking understanding, open questions, summarising. Useful Questions: How do/did you feel about that? What are/were you thinking? What is/was that like for you? Keep them open! What else is there about that? 1b - a challenging part Since they are in the situation, it can be difficult for the person speaking to see it clearly, or from different angles. With the help of empathic reflections and challenges, the speaker uncovers blind spots or gaps in their perceptions and assessment of the situation, of others and of themselves - their patterns, the impact of their behaviour on the situation, their strengths. "I'd never thought about how it might feel from my colleague's point of view."

Skills: Challenging; different perspectives, patterns and connections, shoulds and oughts, negative self-talk, blind spots (discrepancies, distortions, incomplete awareness, things implied, what's not said), ownership, specifics, strengths. Useful Questions: o How do others see it/you? o Is there anything you've overlooked? o What does he/she think/feel? o What would s/he say about all this? o What about all of this is a problem for you? o Any other way of looking at it?

1c -Focussing and moving forward People often feel stuck; that is why they want to talk. In this stage, the helper seeks to move the speaker from stagnation to hope by helping. Then choose an area that they have the energy to move forward on, that would make a difference and benefit them. "I see now the key place to get started is my relationship with K" 7

Skills: Facilitating focussing and prioritising an area to work on. Useful Questions: o What in all of this is the most important? o What would be best to work on now? o What would make the most difference? o What is manageable?

Stage 1 can be 5 minutes or 5 years; it may be all someone needs.

Stage 2 - What do I want instead? People often move from problem to action, or problem to solution, without reflecting on what they really want, or in what way their problems might be opportunities. Stage 2 is about this, about helping the speaker to open up a picture of what they really want, and how things could be better. This stage is very important in generating energy and hope. 2a - a creative part The helper helps the speaker to brainstorm their ideal scenario; 'if you could wake up tomorrow with everything just how you want it, like your ideal world, what would it be like?' The speaker is encouraged to broaden their horizon and be imaginative, rather than reflect on practicalities. For some people this is scary, for some liberating. "At first it was really difficult but after a while I Jet my imagination go and began to get really excited about what we could achieve in the department".

Skills: Brainstorming, facilitating imaginative thinking, i.e. o Quantity vs. Quality Anything goes - have fun o Write down ideas verbatim, don't analyse or judge o Keep prompting - 'what else?' o Don't hurry, allow lots of time Useful Questions: o What do you ideally want instead? o What would be happening? o What would you be doing/thinking/feeling? o What would you have that you don't have now? o What would it be like if it were better / a bit better?

2b - a reality testing part From the creative and visionary brainstorm, the speaker formulates goals, which are specific, measurable, achievable/appropriate (for them, in their circumstances), realistic (with reference to the real world), and has a time frame attached, i.e. SMART goals. Goals, which are demanding yet achievable, are motivating. "It feels good to be clear that I want a clear understanding with my colleagues about our respective rules and responsibilities."

Skills: facilitating selecting and reality checking with respect to internal and external landscape. Useful Questions: o What exactly is your goal? o How would you know when you've got there? o What could you manage/are you likely to achieve? o Which feels best for you? o Out of all that, what would be realistic? o When do you want to achieve it by?

2c - moving forward This stage aims to test the realism of the goal before the person moves to action, and to help the speaker check their commitment to the goal by reviewing the costs and benefits to them of achieving it. Is it worth it? "It feels risky but I need to resolve this."

Skills: facilitation of exploring costs and benefits, and checking commitment to goal. Useful Questions: o What will be the benefits when you achieve this? o How will it be different for you when you've done this? o What will be the costs of doing this? Any disadvantages/downsides to doing this?

Stage 3 - How will I get there? This is the 'how' stage... how will the person move towards the goals they have identified in Stage 2? It is about possible strategies and specific actions, about doing something to get started, whilst considering what/who might help and hinder making the change. 3a - another creative part! The speaker is helped to brainstorm strategies - 101 ways to achieve the goal again with prompting and encouragement to think widely. What people, places, ideas, organisations could help? The aim is to free up the person to generate new and different ideas for action, breaking out of old mind-sets. "There were gems of possibilities from seemingly crazy ideas".

Skills: Facilitation of brainstorming Useful Questions: o How many different ways are there for you to do this? o Who/what might help? o What has worked before/for others? o What about some wild ideas?

3b - focussing in on appropriate strategies What from the brainstorm might be selected as a strategy that is realistic for the speaker, in their circumstances, consistent with their values? Force field analysis can be used here to look at what internal and external factors (individuals and organisations) are likely to help and hinder action and how these can be strengthened or weakened respectively. "I would feel comfortable trying to have a conversation with him about how he sees things".

Skills for Stage 3b: Facilitation of selecting and reality checking. Useful Questions: o Which of these ideas appeals most? o Which is most likely to work for you? o Which are within your resources/control?

3c - moving to action The aim is to help the speaker plan the next steps. The strategy is broken into bitesize chunks of action. Here the speaker is doing almost all the work, producing their action plan. The helper works with them to turn good intention into specific plans with time scales. Whilst being encouraging, it's also important not to push the speaker into saying they'll do things to please the helper. "I will make sure we have time together before the end of the month. I will book a meeting, so that we can be sure of quiet uninterrupted time. I will organise this before Friday".

Skills: Facilitation of action planning. Useful Questions: o What will you do first? When? o What will you do next? When?

If the end point of producing an action plan has been reached, the experience of trying it out could be the starting point for a follow-up mentoring/co-mentoring session. The work would start in stage I again, telling a new story. If an action plan had not been reached, that's fine too, and the model can be used over a series of sessions. The key in using the model, as with any theory or model, is to keep the speakers agenda central, the individual in the foreground and theory in the background, and to use the model for the person, rather than vice versa.

Reference: 'The Skilled Helper - a problem management approach to helping' by Gerard Egan. Brooks Cole, 6"' edition 2010

10

Activity 1. In your own words write down what the 3 stages are, and how the strategies employed could be beneficial to the helping process.

Activity 2. We all have things in our lives we would like achieve, improve or devote more, or less time to. Find a partner, classmate, housemate or family member. Working through Egans Stages interview each other one at a time and identify and record 3 goals that each person would like to achieve.

Motivational interviewing.
When working with clients a skilled worker will employ a range of counseling techniques depending on the situation and the client. Try to imagine a tool - box filled with different skills and questioning techniques. Motivational interviewing was a step away from labeling people and focusing on the behaviors. Counselling techniques and characteristics Drug and alcohol problems are seen by many as something unusual that needs to be handled in a special way and best left to the 'experts'. This is not the case. The skills used by counsellors and health and welfare workers in their day-to-day work are the skills utilised by a drug and alcohol worker/counsellor. The counsellor/worker:

11

Needs to develop trust and understanding with the client Should not impose his/her views on the client Needs to help the client address issues the client sees as problematic.

Motivational interviewing is one way of exploring the issues that concern the client with a view to behavioural change. If you are going to conduct a motivational interview it is necessary to develop or consolidate your knowledge of some basic counselling skills. Many of these skills can only be developed with practise, particularly telephone counselling, which requires highly developed listening skills. Many people talk of feeling embarrassed, confused, stupid, worried, and vulnerable, of feeling a failure. These can be strong emotions so naturally if you were feeling this way you would want the person you are seeking help from to respond in an appropriate manner. Consider how you were thinking and feeling when you asked someone for help.

Activity 3. Take some time to consider and write down the characteristics that you believe a good counselor should have.

What is motivation? Most people would agree that they think motivation is a good thing, but motivation means different things to different people. How might you describe motivation?

Most people regard motivation as behaviour, which is positive. The underpinning theory of motivational interviewing is that all human behaviour is motivated. We often hear welfare workers, teachers and counsellors describing a student or client as unmotivated, when really that person is simply motivated to behave in a 12

manner other than the one the teacher or welfare worker wants. The person has not become unmotivated as a result of his/her drug use but rather is motivated toward drug use.

Motivation can be intrinsic,

Inherent Essential Belonging naturally,

Or it can be extrinsic,

Not inherent Not essential Not belonging naturally.

It is important that you consider the implications of the differences of the two and how they might impact on motivational interviewing. Ambivalence Being ambivalent (in two minds) about a particular behaviour is normal. If people are ambivalent about a particular behaviour and can think of many costs but also many benefits for that behaviour, then change is unlikely. If in doubt do nothing. Motivational interviewing attempts to free people from the trap of ambivalence.

Activity 4.

Create a caption for each of these characters that might describe their motivations.

13

Activity 5. Think about a behaviour, which you are ambivalent about then, design, a decision matrix with these headings.

Benefits of maintaining my current behaviour are Benefits of changing my behaviour are Negatives of maintaining my current behaviour Negatives of changing my behaviour are

When you have completed the matrix, consider if you will change your current behaviour. Don't be surprised if you have decided not to. Activity 6. People use substances for a range of reasons. See if you can name 5.

ASSESSMENT ACTIVITY 1
CREATE YOUR OWN CASE STUDY. Write a fictional story of around 500 words that begins with the words: My name is.. The story must include the issue of substance abuse and at least two other issues of your choosing. This story must also contain two strengths (positives). Include the persons original motivation for using. Is the motivation the same today? How did they feel when they used? How do they feel now when they use? How has it affected their lives with regard to relationships and employment? What does a normal day look like for them? What sorts of emotions do they experience? What would they like to achieve in the future? 14

Try to be creative and put yourself into the shoes of someone who is in a situation that your future clients may find themselves in. However keep a reasonable amount of realism, as you will need this case study in other sections of the assessment.

Motivational interviewing Continued.

Miller and Rollnick identified general principles of motivational interviewing that are necessary to achieve a successful result. They are: Express empathy. Empathy involves seeing the world through the client's eyes, thinking about things as the client thinks about them, feeling things as the client feels them, sharing in the client's experiences. Expression of empathy is critical to the MI approach. When clients feel that they are understood, they are more able to open up to their own experiences and share those experiences with others. Having clients share their experiences with you in depth allows you to assess when and where they need support, and what potential pitfalls may need focused on in the change planning process. In short, the counsellors accurate understanding of the client's experience facilitates change.

Develop discrepancy. This guides therapists to help clients appreciate the value of change by exploring the discrepancy between how clients want their lives to be vs. how they currently are (or between their deeply-held values and their day-to-day behaviour). MI counsellors work to develop this situation through helping clients to examine the discrepancies between their current behaviour and future goals. When clients perceive that their current behaviours are not leading toward some important future goal, they become more motivated to make important life changes. Techniques used can include decisional balance sheets.

Roll with resistance. In MI, the counsellor does not fight client resistance, but "rolls with it." Statements demonstrating resistance are not challenged. Instead the counsellor uses the client's "momentum" to further explore the client's views. Using this approach, resistance tends to be decreased rather than increased, as clients are not reinforced for becoming argumentative. MI encourages 15

clients to develop their own solutions to the problems that they themselves have defined. In exploring client concerns, counsellors may invite clients to examine new perspectives, but counsellors do not impose new ways of thinking on clients. Rolling with resistance allows therapists to accept client reluctance to change as natural rather than pathological. Support self-efficacy. This guides therapists to explicitly embrace client autonomy (even when clients choose to not change) and help clients move toward change successfully and with confidence. As clients are held responsible for choosing and carrying out actions to change in the MI approach, counsellors focus their efforts on helping the clients stay motivated, and supporting clients' sense of self-efficacy is a great way to do that. One source of hope for clients using the MI approach is that there is no "right way" to change, and if a given plan for change does not work, clients are only limited by their own creativity as to the number of other plans that might be tried.

The main goals of motivational interviewing are to establish rapport, elicit change talk, and establish commitment language[2] from the client. For example, change talk can be elicited by asking the client questions, such as "What makes you think this is a problem for you?" or "How does ______ interfere with things that you would like to do?" It is important to keep in mind that client behavioural issues are common in the process of motivational interviewing. Change often takes a long time, and the pace of change will vary from client to client. Knowledge alone is usually not sufficient to motivate change within a client, and relapse behaviours should be thought of as the rule, not the exception. Ultimately, therapists must recognize that motivational interviewing involves collaboration not confrontation, evocation not education, autonomy rather than authority, and exploration instead of explanation. Effective processes for positive change focus on goals that are small, important to the client, specific, realistic, and oriented in the present and/or future. While there are as many variations in technique as there are clinical encounters, the spirit of the method, however, is more enduring and can be characterized in a few key points:[1] 1. Motivation to change is elicited from the client, and is not imposed from outside forces 2. It is the client's task, not the counsellors, to articulate and resolve his or her ambivalence 3. Direct persuasion is not an effective method for resolving ambivalence 4. The counselling style is generally quiet and elicits information from the client 5. The counsellor is directive, in that they help the client to examine and resolve ambivalence 6. Readiness to change is not a trait of the client, but a fluctuating result of interpersonal interaction 7. The therapeutic relationship resembles a partnership or companionship 16

 ^ a Miller, W.R., Zweben, A., DiClemente, C.C., Rychtarik, R.G. (1998) 'Motivational Enhancement Therapy Manual. Washington, DC:National Institute on Alcohol Abuse and Alcoholism ^ Amrhein, Paul C.; Miller, William R.; Yahne, Carolina E.; Palmer, Michael; Fulcher, Laura (2003). "Client commitment language during motivational interviewing predicts drug use outcomes". Journal of Consulting and Clinical Psychology 71 (5): Also remember to avoid argumentation. Arguments are counterproductive Defending breeds defensiveness Resistance by the client is a signal for the counsellor to change strategies Labelling is unnecessary.

How does Motivational interviewing differ from other methods of counselling when working with clients experiencing drug and alcohol issues? Approaches to working with AOD clients. The points listed below outline two approaches that have been used in working with clients who use alcohol and other drugs. The confrontation/denial approach has traditionally been used in America and does not acknowledge the reasons behind the clients' behaviour. It is not seen to be effective in working towards supporting change. Motivational Interviewing, with its client-centred approach and acknowledgement of the Stages of Change is seen to be more effective in supporting clients to reflect upon their substance use and to make their own decision to change. Confrontation/denial approach

Heavy emphasis on acceptance of self as having a problem, acceptance of diagnosis is seen as essential for change. Emphasis on personal make-up, which reduces personal choice, judgement and control. Therapist presents perceived evidence of problems in an attempt to convince the client to accept the diagnosis. Resistance is seen as 'denial', a trait or characteristic requiring confrontation. 17

Resistance is met with argument and correction. Goals of treatment and strategies for change are prescribed for the client by the therapist; the client is seen as in denial and incapable of making sound decisions.

Motivational interviewing approach

De-emphasis on labels; acceptance of 'alcoholism' or other label is not seen as necessary for change to occur. Emphasis on personal choice and responsibility for deciding future behaviour. Therapist conducts objective evaluation but focuses on eliciting the client's own concerns. Resistance is seen as an interpersonal behaviour pattern influenced by the therapist's behaviour. Resistance is met with reflection. Treatment goals and change strategies are negotiated between client and therapist based on data and acceptability; client's involvement in and acceptance of goals are seen as vital.

Attending behaviours Attending behaviours are behaviours, which demonstrate to the client that you are there mentally as well as physically. This can be demonstrated by:

Non-verbal behaviour

Whilst it is important for the counsellor to be focused and to use appropriate questioning, reflecting and summarising skills, we should never underestimate the power of non-verbal communication. It has been suggested that as much as 70% of communication is non-verbal. Non-verbal communication is sent via posture, proximity, use of space facial expression, gaze, eye contact, gestures and body movement, clothing, physical layout of the space, objects. Some non-verbal communication is deliberate and conveys messages we intend to give. However, we must become aware of non-verbal behaviour, which can convey messages we do not intend to send. We might smile and make appropriate eye contact but send signals of our irritation by a tapping foot or strained voice. Egan (2007) summaries how our body language sends a message to the client that we are attending to him/her, with the following acronym. 18

S face the client Squarely O adopt an Open position L Lean towards the client E maintain good Eye contact (being mindful of cultural differences) R be Relaxed

Good listening skills. Listening, like all acts of perception, is an active not a passive process. We need to attend to what is being said and to observe the non-verbal communication, then interpret the messages or signals we are receiving. Carl Rogers, a psychotherapist and counsellor who developed a client centered therapy method, stated that to really listen we need to have empathy with the clients. We should attempt to understand what the client is saying without filtering it through our beliefs and life experiences. He suggests that to develop this skill, the counsellor should use the client's own words to repeat what the client has said, to the client's satisfaction, before the counsellor replies.

Roadblock/Barriers to communication A key element of reflective listening is how the counsellor responds to what the client says. Thomas Gorden (1995) has outlined 12 kinds of responses that block or inhibit two-way communication. These responses are called roadblocks as they block the client's efforts to communicate. If the client wants to keep going he/she has to go around the obstacles placed in his/her way. Ordering, directing or commanding Response: You need to stop drinking now. Warning or threatening Response: If you don't stop using heroin you will be dead within six months. Giving advice, making suggestions, or providing solutions Response: The best thing you can do is tell your mother that... Persuading with logic, arguing or lecturing Response: You may think that but experts tell us differently. Moralising or preaching Response: You must realise that you cannot be a good mother when you are drinking like this. 19

Disagreeing, judging, criticising Response: No matter how strong the cravings are there is no excuse for stealing. Agreeing, approving or praising Response: It is very hard for you; your father had a drink problem so naturally you drink heavily. Shaming, ridiculing or labelling Response: Your children are suffering as a result of your drinking. Why won't you stop? Interpreting or analysing. Response: It seems to me that your wife is behaving like that to get a reaction from you. Reassuring, sympathising or consoling Response: Don't worry we will sort everything out. Inappropriate questioning Response: This may be a question that is not relevant to the intervention and thereby limiting client willingness to respond. Withdrawing, distracting, humouring or changing the subject Response: I think most of us drink in excess of the guidelines on occasions. Did you have any luck in finding a job? Empathy Empathy shows the client that you are trying to understand what it is like to stand in his/her shoes and see the world through his/her eyes. It is important that you do not filter what the client is saying through your own values and beliefs system. This skill can be demonstrated by:

displaying a non-judgemental attitude reflecting and validating what the client has said respecting and acknowledging the strengths and resources of the client.

It is important to try to demonstrate that you have a genuine interest in the client and his/her issues. This can be done by:

having an ability to recognise and understand the client's problems and concerns showing sincerity and warmth being able to reflect understanding of and interest in the issues being aware of your own strengths, limitations and boundaries. 20

Paraphrasing and clarifying Paraphrasing shows the client that you are listening to him/her and provides an opportunity for the client to hear your understanding of what he/she has said and to respond to that. It is important that you don't add anything. Clarifying goes a little further. It provides an opportunity for the counsellor to admit that he/she is a little confused and to explain the counsellor's understanding of what is being said and to clarify or to ask for another example of what the client is trying to say. 'Was that for yourself or both of you?' 'What you seem to be saying is...' Reflecting During a counselling session a client may convey many feelings and emotions, some obvious and others not so obvious. For many of us, expressing feelings and emotions can be very difficult. We have often spent years trying to mask both our feelings and emotions. Clients should be encouraged to express their emotions and accept them for what they are. The counsellor needs to reflect the client's feelings by picking up on all the messages he/she is sending and then reflecting and clarifying the feeling. To do this the counsellor may respond with a statement such as: 'It seems that you are feeling...'

Questions The counsellor should use his/her skills to ask appropriate questions and guide the session. Counsellors should also have skills in delivering specific educational information and facilitating the client's self-confrontation. Closed Questions Closed questions are designed to curtail or close the client's response. They are often answered with one or two words and don't allow exploration. They can be useful when you need specific information, especially in the early stage of an interview. If they are overdone, closed questions can lead to a counsellor-controlled session in which the client feels interrogated. If a lot of information needs to be gathered a pre-interview questionnaire can be useful. Open Questions Open questions should be used to provide opportunity for elaboration, clarification and illustration. Open questions allow a more detailed response. Open questions often start with words such as what, where, when, how or phrases such as 'I would like to hear a little more about that', or, 'Tell me what concerns you?' 21

Activity 7. With a classmate/friend/or relative ask them a range of questions that do not allow them to give a one-word response. More difficult than you would think?

Getting Down To Business.

Opening structure If it is the first time you have met you will need to introduce yourself and say a little about your role within the agency. You may also need to gather a few personal details by use of closed questions, especially if the client has not completed a preinterview questionnaire. It may be possible however, to wait until later in your meeting to get these details. 'Hello. It's good to see you again; I hope you have not been waiting long. I believe you want to talk about your use of...' OR 'Last time we spoke you mentioned that you thought your use of cannabis had increased and this sometimes concerns you. If it's okay with you I would like to spend a little time today to explore this issue a little further.'

Discuss the good things

A useful strategy in reducing defensiveness is to ask the client what they enjoy about their drug use. People who use alcohol and other drugs do so for a reason. Asking about the good things will indicate the role of substances in the clients life. Many clients' experience of talking about drugs is the focus on the negative aspects, to talk about the good things, or positives supports your engagement with a client. You are trying to understand their use of alcohol and other drugs from their perspective. It shows you do not think he/she is mad, you know there must be some 'good things' about the drug use. It is important for you as the counselor to know what the client perceives as being the 'good things' as these may be the basis of the client's conflict about changing his/her behavior. So ask them directly: 'What are the good things about your use of...?' 'What do you enjoy about using...?' It can be a good idea to list them in a notebook or on a whiteboard, as a visual record can be a powerful tool when summing up the benefits and costs of drug use. Make sure you acknowledge and summarise all the good things about the client's drug use.

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Counsellor `Can you tell me some of the good things about your amphetamine use?' Client 'It gives me loads of energy, I feel alive.' Counsellor 'So you enjoy feeling more energetic?' Client 'Yes I get more done, I work as a waitress and when I finished work I never felt like going out. I was too tired. Now I just have a bit of speed and off I go. (Pause). I also like the fact I can have a few drinks and I don't get drunk.' Counsellor 'So your use of speed has very real benefits. You have the energy to go out and when you drink alcohol you don't feel like you are getting drunk. Is there anything else you like about using speed?'

Examine the less good things

This is an opportunity for the client to express some of the negative things associated with use. This time when he/she raises an issue you are going to explore it in more detail and try and find out how it affects the client personally. For example, the client needs to talk about the direct relevance to his/her life. It is important that you don't assume that just because the client has mentioned a negative aspect of drug use that it is a problem. Remember today nearly everyone knows smoking cigarettes is linked to cancer and yet it does not motivate smokers to stop. Counsellor 'You have told me why you enjoy using speed and it sounds as if it has some real benefits for you. Now let's look at the other side of the coin. What are some of the less good things about your use?'

Summarising

Once you have talked about the good things and explored the less good things, summarise what has been said. Try to use the client's words as much as possible. You might say something like, 'So on one hand you're your use of amphetamine is enjoyable because... and on the other hand it ...' Rather than just listing the less good things focus on the aspects that the client thought was cause for concern. The aim is to help the client see that concerns outweigh the positives. Allow the client time to react or comment on the summary you have made before you move on to other strategies.

Life satisfaction

To help raise issues or concerns it can be useful to look back to when the client was 18 and ask how he/she imagined life would be, and how that fits with life now. Ask then how the client sees himself/herself in two years time if he/she carries on as things are now. Ask the client how he/she feels about that. Would the client like to make changes? What is stopping him/her? 23

The timescales need to be appropriate to the concerns mentioned and the client's age. With a younger person you may focus more on the immediate future and talk in terms of months rather than years.

User versus self

Another useful strategy is one which Saunders, Wilkinson and Allsop call the psychological squirm. It encourages the client to think about discrepancies between himself/herself as an individual and the client as a drug user. To do this you ask the client to describe his/her best qualities or to tell you what qualities his/her best friend, wife, child or mother would say the client has. Explore what the client says, use reflective listening and then summarise. Ask the client how he/she would describe him/herself as a drug user. Explore the responses and again summarise before asking, 'How do these two images fit together?'

Ask for a decision

You may find the client says he/she wants to change or the client will indicate that he/she wants to do something. Ask the client directly if he/she has made a decision about what he/she wants to do. If the client has not reached a decision, ask if there is anything you can do which might help to make a decision. If the client decides to remain the same, give the client information and tell the client that if he/she wants to talk to you again, you are available.

Stages of Change Model

People go through a series of stages when they change health behavior. The stages are cognitive and behavioral. In the early phases, people tend to focus on thinking about change-whether change is something they need to consider. In later stages, people are actively doing things to change or maintaining the changes that they have been able to make. The Stages of Change Model describes seven stages of readiness and provides a framework for understanding the change process. By identifying where a person is in the change cycle, interventions can be tailored to the individual's "readiness" to progress in the recovery process. Interventions that do not match the person's readiness are less likely to succeed and more likely to damage rapport, create resistance, and impede change. Anything that moves a person through the stages toward a positive outcome should be regarded as a success. Motivation is multidimensional. Motivation is multidimensional and not easily assessed. In addition to readiness to change, workers should also consider the key factors of "importance" and "selfefficacy." Importance is determined by what value a person places on making the 24

5$% "#$% 3-+4$! &'()$*+,-).'(! change. Self-efficacy is the belief or confidence in one's ability to achieve change.
When individuals think that change is beyond their capabilities, they may not try. People who are high on importance but low on confidence need encouragement that change is possible. They also need specific ideas about how to do it. This 3-+4$! &'()$*+,-).'(! approach promotes engagement and allows greater self-efficiency and identifies the person's greatest needs and goals. The stages of change model is a useful tool for both clients and workers. It helps workers to tailor an appropriate strategy and helps clients identify at which stage they are at. This realization can accelerate the changing process and it also can be ",-((.(/! of comfort to2-.()$(-(1$!has re-lapsed, as they can view the process as cyclic an individual who and on going.

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3-+4$!

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Pre-Contemplation Stage: A state of unawareness where the user has no concerns about the consequences of their alcohol or drug use. Teenagers are generally in this stage and some people may be stuck here for years. "Denial" might describe this stage for people who have a long history of alcohol or drug use but insist they can handle it. 25

Contemplation Stage: The stage where the person has become aware that there are problems associated with their substance use, has begun to think about the issue, but is not yet ready to deal with it. The consequences are not yet so bad that they feel the need to take action; or the consequences are serious, but the person feels that getting control of the situation is just too hard. Preparation Stage: The stage where the client is beginning to try things such as going to AA, looking at the options, and making a plan to stop or cut down. The preparation stage is perhaps the most important in the process. If you move too quickly and stop using without a proper plan or without putting the necessary support in place, the chances of long-term success are not great. Finding the right support is the key to success in any significant personal change. Action Stage: The stage where the person is actively attending counselling or AA/NA or both, and has committed to an attempt to cut back or stop using (preferably on a certain date.) Maintenance Stage: The stage where the person uses 'relapse prevention' strategies to ensure new behaviors are maintained. Strategies in this stage might include: On-going counselling Attending a support group such as AA or NA Telling friends and family of their plan Avoiding friends they used to "use" with Self-esteem building processes Finding replacement activities

Lapse: The process of learning to cope with a "slip" to prevent it turning into a full-blown relapse. Few people are able to get on top of substance abuse or dependence without a "slip", where they start using again. However some of the best learning comes from having a slip which is brought under control before the user relapses completely. In the process of stopping quickly, new skills are learnt which then become part of the user's relapse prevention repertoire. 26

Relapse: Unfortunately a slip, often becomes a full re-lapse. However all is not lost as both the client and the worker can reflect on what strategies worked and what went wrong. These lessons are invaluable to achieving success in the future. The client need not go through all seven stages again as they can begin to plan a soon as possible.

Activity 8. Watch the Oasis movie. The film can be viewed here: http://www.theoasismovie.com.au/watch/watch-film.php Identify 5 of the main characters, and answer the following questions: What are their issues?

At the films conclusion, at which stage of change, would you say that they are experiencing?

Do the clients appear to have a lot of issues in common?

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Check out these clips on You Tube: http://www.youtube.com/watch?v=cj1BDPBE6Wk http://www.youtube.com/watch?v=EJ6A7C3pcHE http://www.youtube.com/watch?v=K7m9vCFa6H8&feature=related Then have a look at this power point presentation. http://www.risen.org.au/HealthProfessional/Docs/Motivation.pdf

Activity 9 In pairs write down as many of the motivational interviewing and solution focussed techniques as you can. Then write down what is the perceived benefit or hoped intention of asking each question.

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Checklist for undertaking a motivational interview

Begin with an opening/welcoming statement. Focus on one aspect of ambivalence. Ask about the positive/benefits of the client's substance use - ask the client to be specific, individualise the importance. Ask about the less good things: o be specific o individualise using reflection and amplified reflection o probe to find out how the client feels (just because something is less good does not mean the client sees it as a problem).

Components of a Motivational Interview A motivational interview consists of the worker using the following skills and strategies throughout. It is not a linear process, more of a weaving process, where the worker uses reflective listening and open questions to elicit self-motivational statements. Affirming and summarizing are used appropriately throughout the interview.

Summarise the positives and less positive aspects of behaviour - let the client hear the dilemma again. Ask about life goals: o how the client sees himself/herself in a year if things work out well o how he/she sees the future if he/she maintains current behaviour. Ask the client to describe his/her good qualities through the eyes of a partner of friend. Then ask how the client would describe himself/herself as a user. Ask for a decision, but remember, people can be in contemplation for a long time. They may not be ready to change. They may want to discuss things further, or they may want to remain the same. If so, investigate harm reduction strategies. They may want to make changes but don't know where to start or they feel there are barriers they need to overcome. If so you would assist them with problem solving and goal setting.

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Solution Focused therapy.

The essence of solution focused brief therapy is the client is the expert and it is the client's goals that are important. Solution focused brief therapy focuses on the solution the client wants, not the problem. Solution focused brief therapy focuses on what can be done, not what cannot be changed. Solution focused brief therapy is about here and now, not what happened in the past. Solution focused brief therapy is about what is possible, and whatever works, get done more. Solution focused brief therapy believes that current solutions are the problem, doing more of the same is wrong, that change, any change is success. The therapist's job is identify what can be changed and to change it. Solution focused brief therapy aims to get the client to imagine change, to imagine the future. The Miracle Question is instant therapy. The Miracle Question focuses your mind on exactly how to achieve what you want. Focusing on your future goals is the essence of Solution Focused Therapy. Solution focused therapy ignores what is past, what has happened, the history of the problem. Solution focused therapy gets the client to focus on what they want to become and how they will get there. Solution focused therapy stops you thinking about past failures and makes you focus only on what you want to be. It takes people out of the problem situation and into the solution space. The Miracle Question lets the client focus on his own solution, and come up with exactly what he wants, not what the therapist wants. You can tailor the question to something that either you feel more comfortable with, or to one that you believe the client will identify better with. Here is one example: Suppose you woke up one morning and by some miracle everything you ever wanted, everything good you could ever imagine for yourself, had actually happened - your life had turned out exactly the way you wanted it. Think about it now. What will you notice around you that let you know that the miracle had happened? What will you see? What will you hear? What will you feel inside yourself? How would you be different? The key to success is knowing what you want. In fact, when asked, most people cannot answer the miracle question, except in very general terms. They have been so busy going over the past and how bad their present problems are, they have never really thought about what their ideal future would look like. They do not have a clear idea of what success would mean for them. They cannot visualize success. And because of that, they will never achieve it. 30

The Miracle question forces you to think about exactly what it is you want from life. Until you get a clear idea of what you want you will drift through life. You must know what you want first before you can have any chance of getting it. The miracle is that if you do know what you want, decide what you want, and visualize it clearly, that will start to motivate you, and you will achieve it. The Miracle Question is your test of whether you are really serious about wanting success. Unless you can answer the question immediately with exact details of what your ideal outcome would be, you are not yet in a position to take charge of your life. The Miracle Question is the starting point for effective solution focused therapy. So how do you work out what you really want? The Dare Question may have an answer for you. Suppose somebody said you could have anything you wanted in the world, anything at all, how would you know what to choose? One way is to ask yourself the Dare question: "What would you do if you knew you could not fail?" Most people in fact have never really thought about what they want, what they might be capable of, because they are so focused on the daily routine that they just don't take the time to think about their own future. And not knowing what you want is the route to a wasted life.

ASSESSMENT ACTIVITY 2.
By now you should have some idea about the intake and assessment stages of case management. Think for a moment about holistic assessments. What areas of a persons life need to be explored to gain a holistic picture? What sorts of issues might one of our clients encounter? In pairs create a comprehensive list of all the subjects or potential issues one would have to ask about to gain a holistic picture of a clients situation. How many did you come up with? You should have at least 10. Now that you have your lists, think about what you need to know about each issue to establish a holistic picture. For example: the issue of Mental Health. We would need to know if: They had ever suffered a mental illness, If so when? Did they seek treatment? Have, or do they take medication for a mental illness? If anyone in their family had suffered a mental illness, Now that you have thought about what needs to be asked. 31

Create your own holistic assessment form that poses all of the required questions as briefly and unobtrusively as possible. Remember to include all personal details and an explanation and acceptance of confidentiality to begin with. Then try to pose the questions in a logical and polite manner. You probably would not begin with Mental Health, for example. Once each pair has completed their holistic assessment questionnaire, using the case studies you created in Assessment Activity 1 conduct an informal role-play. One student will assume the role of the character they created, and the other will take on the role of a case manager, who will utilise their verbal and nonverbal communication skills to conduct a holistic assessment using the assessment questionnaire. Make sure that you fill in the answers. Once completed swap over and repeat the task.

ASSESSMENT ACTIVITY 3
Formal Role-Play. Now that you have fulfilled the case management stages of: ENTRY/SCREENING, and ASSESSMENT, It is time to meet up with the client again and to begin the PLANNING process. For this task you will be required to use your questioning techniques toolbox as previously discussed. You are not required to adhere to one particular theory of technique. Rather, try to use strategies and questions from each as you fell would be most useful to achieve a positive outcome. For example you might begin with Egans first stage of: Whats going on? Your client maybe stuck in a stage of ambivalence, or have a lack of direction or motivation because they cannot see change as a realistic possibility. In this situation perhaps Egans second stage of brainstorming (What do I want?), Could be appropriate. Or perhaps a more solution focused approach of asking the miracle question. Motivational interviewing would also be useful in this situation. Maybe you might look at the positive aspects received by the client for the use of a substance or the continuation of behaviour, and then the less positive aspects. You may ask them what someone close to them might say are their best personal qualities. And then ask them how a stranger in the street may see them. You might ask them: What did they imagine they would be doing today when they were 15? (Adjust age appropriately) 32

Then have they achieved any goals towards that? What do they think has held them back from achieving those goals? You could ask them how badly they want to achieve change on a scale from 10-to10. And then ask them: What would it take to achieve a higher grade. Feel free to create your own variations of these techniques and try to pose them in a logical order. At the same time do not forget to apply your verbal and non-verbal communication micro-skills. By the end of the role-play, hopefully you have identified both areas of immediate need as well as some goals to work towards into the future. Once you have concluded the role-play you can begin to write up your case notes. Now you are ready to research appropriate agencies and programs to put a case-plan together to present to your client. Remember that the best case plans not only address issues of immediate need but also include activities directed at social, future vocational and emotional needs. Try to make it as enjoyable as possible.

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Activity Answers.
Activity 1. In your own words write down what the 3 stages are, and how the strategies employed could be beneficial to the helping process 1. 'What is going on?' This stage is about listening to the clients story. Using all of yourmicroskills, understanding and establishing rapport. Also reflecting and carefully challenging possible false perceptions and maladaptions. It is about clarifying areas where we can focus, and move forward with.

2. 'What do I want instead?' Is about taking the time to examine what the client really wants. This is a creative exercise that allows the client to step out of themselves and initially imagine limitless possibilities. This can be very useful as it can inject an amount of hope and positivity into the situation. This section then examines practical ways to achieve their goals, financially, practically and emotionally.

3. 'How might I get to what I want?' This section is about how to achieve the goals. Where to start, who can help, and what might hold the client back from achieving progress. It is also a creative part of the process as it calls on the client to think of all the possible avenues of support, and opportunities. At the end of this section an action plan should be complete and as time to review progress set. Often clients are stuck in their situation and find the possibility of positive change to be out of reach. Encouraging them to explore their desires through the brainstorming of ideas both realistic and unrealistic gives them an opportunity to step outside of themselves for a moment and experience some positive energy, often for the first time in a long time.

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This positivity can be capitalised upon by breaking the ideas up into S.M.A.R.T achievable goals. For example if a client expressed that they wanted to become a rock star. You might suggest that they begin to take some music lessons. Whether or not the initial goal is achieved is insignificant as the positive action of the activity can be extremely beneficial to the client and can serve as a distraction from other less productive negative behaviours.

Activity 2. Answers will vary according to students individual situations.

Activity 3. Take some time to consider and write down the characteristics that you believe a good counselor should have. Answers will vary, however could include: empathy, non-judgmental, patients, and listening skills, questioning skills.

Activity 4. Create a caption for each of these characters that might describe their motivations. Answers will vary one possible example might be: User I enjoy smoking. It relaxes me and gives me a buzz. I feel more creative and have been getting back into my art. Users parentsBrian spends all of his time in his bedroom and is completely unmotivated. He wont get up in the mornings, and he never spends time with us Counsellor-

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When working with clients it is important to ascertain the direction of their motivation. That is we wish to understand, and for the client to understand exactly what benefits they receive from continuing with their use or behaviours.

Activity 5. Think about a behaviour, which you are ambivalent about then, design, and a decision matrix with these headings. Answers will vary according to students individual situations.

Activity 6. People use substances for a range of reasons. See if you can name 5. There are many reasons people use substances, some examples would be: To get high, Peer pressure/to fit in, Escapism/dealing with trauma, Self-medication for mental or physical illness, Boredom/risk taking behaviour Activity 7. With a classmate/friend/or relative ask them a range of questions that do not allow them to give a one-word response. More difficult than you would think? Answers will vary according to the questions asked. Activity 8. The Oasis Movie. Answers may vary. Here are some examples. Halley- Planning stage, as she has planned to de-tox numerous times but has failed to engage the service. She has substance abuse issues, accommodation; financial was a victim of physical abuse and neglect. Owen- Maintenance stage. Substance abuse issues, mental health, accommodation, financial, was a victim of emotional and physical abuse. Emma & Trent- Maintenance stage. Substance abuse, accommodation, financial, was a victim of abuse. 36

Tommy- Contemplation/Planning stage, as he has identified his drinking as being an issue and has ideas of activities that could replace his behaviours. He has substance abuse, behavioural, legal issues. His child hood is not spoken about, so we do not know if he was a victim of abuse, or not. Beau- Maintenance stage. Mental health issues. His child hood is not spoken about, so we do not know if he was a victim of abuse, or not. Activity 9. In pairs write down as many of the motivational interviewing and solution focussed techniques as you can. Then write down what is the perceived benefit or hoped intention of asking each question. When employing motivational interviewing techniques the speaker would always pay homage to the four elements: Express empathy, Develop discrepancy, Roll with resistance, and Expressing empathy is essential, not only to the motivational interviewing process, but to welfare work in general. Expressing empathy accelerates the clarity of understanding and it also helps the client to feel understood and more comfortable to open up and explore their issues in a more relaxed and reflective fashion. Developing discrepancy helps the client to identify a discrepancy between who they believe they are, what they value, and where they want to be, and their current lifestyles and behaviours. Rolling with resistance allows the worker to pose empathetic responses to statements of resistance. For example: if the client made a statement such as: My drinking is not really an issue. The worker might respond with: Oh so your saying everything is going pretty well at the moment? Not arguing with the client in this situation gives the client an opportunity to correct the worker. In this situation they might say something like: Well actually not, the doctor says I have liver damage. Supporting self-efficacy allows the client to feel a sense of control over the decisions they make and the direction they will take. It is the workers role to support the decisions of the client, encouraging them and trying to keep them motivated. If a client expresses that they are not ready for change then the worker would support that decision and let the client know that help will still be available in the future if they change their minds. The worker would also employ their micro-skills, such as active listening summarising and reflective responses. Reflective listening is the key to this work. The best motivational advice we can give you is to listen carefully to your clients. They will tell you what has worked and what hasn't. What moved them forward and shifted them backward. Whenever you are in doubt about what to do, listen. But remember this is a directive approach. Unlike Rogerian therapists, you will actively guide the client towards certain materials. You will focus on their change talk and provide less attention to nonchange talk. For example, "You are not quite sure you are ready to make a change, but you are quite aware that your drug use has caused concerns in your relationships, effected your work and that your doctor is worried about your health." (Miller, W. R., & Rollnick, S. 1991 ) Reframing Reframing is a strategy in which you invite clients to examine their perceptions in a 37

new light or a reorganized form. In this way, new meaning is given to what has been said. For example, if a client reports a spouse or loved one as saying, "You really need to get in treatment and deal with these problems," the client may view this as "she's such a nag" or "he is always telling me what to do." The counselor can reframe this as "this person must care a lot about you to tell you something he (or she) feels is important to you, knowing that you will likely get angry with him (or her)." Open-ended questions are those therapist utterances that client's cannot answer with a "yes", "no" or "three times in the last week". Most people begin treatment sessions with an open-ended question - "What brings you here today?" or "Tell me about what's been happening since we last met?" An open-ended question allows the client to create the impetus for forward movement. Although close-ended questions have their place - indeed are necessary and quite valuable at times - the open-ended question creates a forward momentum that we wish to use in helping the client explore change. For example, "So what makes you feel that it might be time for a change?" Affirmations are statements of recognition about client strengths. We side firmly with Carlo Di Clemente that many people who come for our assistance are failed self-changers. That is, they tried to alter their behavior and it didn't work. As a result, clients come to us demoralized or at least suspicious of the assertion that change is possible. This condition means that as therapists, we must help clients feel that change is possible and that they are capable of implementing that change. One method of doing this is to point out client strengths, particularly in areas where they observe only failure. We often explore prior attempts at change. For example, "So you stayed sober for a week after treatment. How were you able to stay sober for that week?" We also use resistance as a source for affirmations. For example, "You didn't want to come today, but you did it anyway. I'm not sure, but it seems like that if you decide something is important enough, you are willing to put up with a lot just to do it." (Miller, W. R., & Rollnick, S. 1991 ) Looking at the pros and cons of continuing with using a substance or continuing with a certain behaviour can be a powerful tool. Beginning with a look at what benefits the client receives from using the substance/behaviour gives some legitimacy to the clients actions. This helps them feel more comfortable as it is understood that there are advantages received from the use/behaviour and that they are not stupid or crazy. It is also useful information for the worker in later stages of the process, as they in conjunction with the client look at other means of achieving those benefits. For example: If the client suggested that they use to relax the worker might suggest other forms of relaxation to see if something interested the client. Looking at the less good things, or cons can be an opportunity for the client to verbalise their concerns with their use/behaviour often for the first time. This can be, in some cases a shocking realisation that if things continue, as they are that they will encounter serious consequences. Writing them down and reflecting on each point can provide considerable motivation to change. Scaling questions can also be very useful. Asking the client to give a score between 1 & 10 how committed to making a change they are, and then asking them what would have to change to achieve a higher score. Or the same style of question could be asked with reference to how important certain positive, or negative aspects of their life are. This can be of great assistance in clarifying the clients priorities for both worker and client. 38

Showing the client a visual representation of the stages of change model can also be useful. The client may have been previously unaware of the cyclic nature of dependency. It could be of comfort to them to see that they are not the only one who has experienced these cycles. It can also help them to conceptualise at which stage of the cycle they are at, and it can in some cases accelerate the decision process to make a change. It is also very useful for the worker to know as they can develop a more relevant treatment plan that has a far better chance of success. Psychological squirm. As a worker you could try many different variations of this question. One example would be to ask the client to describe what they believe a loved one would describe as being their best qualities. Take time to respond reflectively and summarise. Then ask the to describe how a stranger might describe them who has observed them on an average day doing the things they have to maintain their lifestyle. Again reflect and summarise, then ask them if they can see a discrepancy between the two. If the client does identify a discrepancy the uncomfortable feeling can be a powerful motivator to make a change. Life satisfaction. Another way to develop discrepancy is to ask the client to think back to a time before they were using, like their teenage years. (Age appropriate). At that time: How did they imagine their lives would look like today? If the client can observe a decided difference between their previous ambitions and the reality of today, the worker could ask them: What do they believe held them back from achieving their goals? Or: What is holding them back from achieving said goals now? This can be a useful tool in helping the client to identify and verbally acknowledge what has been, or is a restrictive issue in their lives. For the worker it is also useful as it highlights the issues that the client believes is holding them back, but also lets the worker know exactly what the more positive goals are for the client. This will aid greatly when tailoring a treatment plan that not only looks at the issues of concern, but also behaviour replacement activities that bring the client closer to achieving goals previously held. Summarising and asking reflective questions are useful in establishing a clear understanding and a better rapport with the client. The client feels understood and is more likely to open up further. A reflection of emotion statement like: It sounds like your fed up with the lifestyle that goes along with your use. Can be used in three ways. Firstly it may be used as a summary to reinforce a clarity of understanding, or it may be used encourage the client out of the state of ambivalence. Finally it maybe used in a false way to encourage the client to correct you, to better understand or to accelerate the acknowledgment of an issue. For example, if the client is in a state of denial the worker might suggest that: So it sounds like you are pretty happy with the way things are going at the moment If the client then corrects the worker the situation can be explored in a more productive fashion. Ask for a decision. Asking for a decision can help the client to make their mind up, or if they are not yet ready it lets them know that help will be available when they are ready. The Miracle Question. This strategy can be beneficial in many ways. Firstly it allows the client to step out of their current reality and to imagine a life free of all of the worries and issues that are holding them back. This can inject a significant amount of motivation, energy and positivity into the situation. Asking this questions, or variations of it also helps the client to understand more clearly the direction they would like to go. When exploring their response further the worker can ask how badly do they want to achieve these things, with the hope that the desire is strong 39

enough to consider changing some of the less positive behaviors. Finally this question helps the worker to understand the direction the client would ultimately like to take which is essential knowledge when constructing a holistic case plan. Another variation is the: Dare question. -"What would you do if you knew you could not fail?" Often, when asked people struggle to identify exactly what it is they would like to achieve. Posing this question can take the weight of the situation off the clients shoulders and get the process moving.

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REFERENCES.
Connors, G J, DiClemente, C, Donovan, D, 2004, Guilford Press New York USA. Substance Abuse Treatment and the Stages of Change: Selecting and Planning Interventions

De Jong, P., & Kim Berg, I. (2002). Interviewing for solutions. (2nd ed). Pacific Grove, CA: Wadsworth.
Egan, G 1998, 2010, 2007 Brooks/ Cole Cengage Learning Belmont USA The Skilled Helper: A Problem-Management and Opportunity-Development Approach to Helping Eve, L 2002 The Guilford Press New York USA Beyond Technique in Solution-Focused Therapy: Working with Emotions and the Therapeutic Relationship Gordon, T & Sterling, E 1995,1997 Greenwood Publishing Group USA Making the Patient Your Partner: Communication Skills for Doctors and Other Caregivers Leukefeld, G Platt, J, Frank, F Tims, M 2001 Yale University Press USA Relapse and recovery in addictions Miller,W & Heather, N 1998 Plenum Press Ney York USA Treating addictive behaviors. Miller, W & Rollnik, S !991 The Guilford Press New York USA Motivational Interviewing, Preparing People to Change Addictive Behaiviour

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Web Pages
http://garethmartin.hubpages.com/hub/The-core-conditions-which-Carl-Rogersconsidered-essential-for-effective-counselling http://www.theoasismovie.com.au/watch/watch-film.php http://www.risen.org.au/HealthProfessional/Docs/Motivation.pdf http://www.youtube.com/watch?v=cj1BDPBE6Wk http://www.youtube.com/watch?v=EJ6A7C3pcHE http://www.youtube.com/watch?v=K7m9vCFa6H8&feature=related Client commitment language during motivational interviewing predicts drug use outcomes. . PC Amrhein, WR Miller, CE Yahne Clinical Psychology, 2003 - psycnet.apa.org

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