Leader’s Guide

Drug Addiction and Basic

Counselling Skills

Treatnet Training Volume B, Module 1: Updated 13 February 2008 1

 Volume B: Elements of Psychosocial Treatment

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

Workshop 1 Workshop 1 Workshop 1

Workshop 2 Workshop 2 Workshop 2

Workshop 3 Workshop 3 Workshop 3

Workshop 4
Module 1: Training goals

1. Increase knowledge of the biology of

drug addiction, principles of treatment,
and basic counselling strategies
2. Increase skills in basic counselling
strategies for drug addiction treatment
3. Increase application of basic
counselling skills for drug addiction
treatment activities

3
Module 1: Workshops

Workshop 1: Biology of Drug Addiction

Workshop 2: Principles of Drug Addiction
Treatment
Workshop 3: Basic Counselling Skills for
Drug Addiction Treatment
Workshop 4: Special Considerations when
Involving Families in Drug
Addiction Treatment

4
Icebreaker: If I were the President 15 Min.

If you were the President (King, Prime

Minister, etc.) of your country, what 3
things would you change related to
drug policies, treatment, and / or
prevention?

5
Workshop 1: Biology of Drug Addiction

6
Pre-assessment 10 Min.

Please respond to the pre-assessment

questions in your workbook.

(Your responses are strictly confidential.)

7
Training objectives

At the end of this workshop you will be able to:

l Understand the reasons people start drug
use
l Identify 3 main defining properties of drug
addiction
l Identify 3 important concepts in drug
addiction
l Understand characteristics and effects of
major classes of psychoactive substances
l Understand why many people dependent on
drugs frequently require treatment
8
 Introduction to
Psychoactive Drugs

9
What are psychoactive drugs? (1)

“…Any chemical substance which, when taken

into the body, alters its function physically
and/or psychologically....”
(World Health Organization, 1989)

“…any substance people consider to be a drug,

with the understanding that this will change
from culture to culture and from time to time.”
(Krivanek, 1982)

10
What are psychoactive drugs? (2)

 Psychoactive drugs interact with the

central nervous system (CNS) affecting:
 mental processes and behaviour
 perceptions of reality
 level of alertness, response time, and
perception of the world

11
Why do people initiate drug use? (1)

Much, if not most, drug use is

motivated (at least initially) by the
pursuit of pleasure.

12
Why do people initiate drug use? (2)

Key Motivators & Conditioning Factors

 Forget (stress / pain amelioration)
 Functional (purposeful)
 Fun (pleasure)
 Psychiatric disorders
 Social / educational disadvantages
Also, initiation starts through:
 Experimental use
 Peer pressure

13
Why do people initiate drug use? (3)

After repeated drug use, “deciding” to use

drugs is no longer voluntary because

DRUGS CHANGE THE BRAIN!

14
 What is
Drug Addiction?

15
What is drug addiction?

Drug addiction is a complex illness

characterised by compulsive, and at
times, uncontrollable drug craving,
seeking, and use that persist even in the
face of extremely negative
consequences.

16
Characteristics of drug addiction

 Compulsive behaviour
 Behaviour is reinforcing (rewarding or
pleasurable)
 Loss of control in limiting intake

17
Important terminology

1. Psychological craving
2. Tolerance
3. Withdrawal symptoms

18
Psychological craving

Psychological craving is a strong desire or

urge to use drugs. Cravings are most
apparent during drug withdrawal.

19
Tolerance

Tolerance is a state in which a person

no longer responds to a drug as they
did before, and a higher dose is
required to achieve the same effect.

20
Withdrawal

 The following symptoms may occur when drug

use is reduced or discontinued:
 Tremors, chills
 Cramps
 Emotional problems
 Cognitive and attention deficits
 Hallucinations
 Convulsions
 Death

21
 Drug
Categories

22
Classifying psychoactive drugs

Depressants Stimulants Hallucinogens

Alcohol Amphetamines LSD, DMT

Benzodiazepines Methamphetamine Mescaline

Opioids Cocaine PCP

Solvents Nicotine Ketamine
Barbiturates Khat Cannabis (high
doses)
Cannabis (low Caffeine Magic mushrooms
doses)
MDMA MDMA
23
Alcohol

24
Alcohol: Basic facts (1)

Description: Alcohol or ethylalcohol

(ethanol) is present in varying amounts in
beer, wine, and liquors

Route of administration: Oral

Acute Effects: Sedation, euphoria, lower

heart rate and respiration, slowed reaction
time, impaired coordination, coma, death

25
Alcohol: Basic facts (2)

Withdrawal Symptoms:
 Tremors, chills
 Cramps
 Hallucinations
 Convulsions
 Delirium tremens
 Death

26
Long-term effects of alcohol use
 Decrease in blood cells leading to
anemia, slow-healing wounds and other
diseases
 Brain damage, loss of memory,
blackouts, poor vision, slurred speech,
and decreased motor control
 Increased risk of high blood pressure,
hardening of arteries, and heart disease
 Liver cirrhosis, jaundice, and diabetes
 Immune system dysfunction
 Stomach ulcers, hemorrhaging, and
gastritis
 Thiamine (and other) deficiencies
 Testicular and ovarian atrophy
 Harm to a fetus during pregnancy

27
Tobacco

28
Tobacco: Basic facts (1)

Description: Tobacco products contain nicotine

plus more than 4,000 chemicals and a dozen
gases (mainly carbon monoxide)
Route of administration:
Smoking, chewing
Acute Effects: Pleasure; relaxation; increased
concentration; release of glucose; increased
blood pressure, respiration, and heart rate

29
Tobacco: Basic facts (2)

Withdrawal Symptoms:
 Cognitive / attention deficits
 Sleep disturbance
 Increased appetite
 Hostility
 Irritability
 Low energy
 Headaches

30
Long-term effects of tobacco use

 Aneurysm
 Cataracts
 Cancer (lung and other types)
 Chronic bronchitis
 Emphysema
 Asthma symptoms
 Obstructive pulmonary diseases
 Heart disease (stroke, heart attack)
 Vascular disease
 Harm to a fetus during pregnancy, low
weight at birth
 Death

31
Cannabinoids

Marijuana Hashish
32
Cannabis: Basic facts (1)

Description: The active ingredient in cannabis is delta-

9-tetrahydrocannabinol (THC)
 Marijuana: tops and leaves of the plant Cannabis
sativa
 Hashish: more concentrated resinous form of the
plant
Route of administration:
 Smoked as a cigarette or in a pipe
 Oral, brewed as a tea or mixed with food

33
Activity 1

Think of all the names for marijuana in your

community and how this drug is consumed.

Share your thoughts with the rest of the group.

34
Cannabis: Basic facts (2)

Acute Effects:
 Relaxation  Reduced nausea
 Increased appetite  Increased blood
 Dry mouth pressure
 Altered time sense  Reduced cognitive
capacity
 Mood changes  Paranoid ideation
 Bloodshot eyes
 Impaired memory

35
Cannabis: Basic facts (3)

Withdrawal Symptoms:
 Insomnia
 Restlessness
 Loss of appetite
 Irritability
 Sweating
 Tremors
 Nausea
 Diarrhea

36
Long-term effects of cannabis use

 Increase in activation of stress-

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

37
Stimulants
METHAMPHETAMINE
CRACK

COCAINE

38
Types of stimulants (1)

Amphetamine Type Stimulants

(ATS)
 Methamphetamine
Speed, crystal, ice, yaba, shabu
 Amphetamine
 Pharmaceutical products used for
ADD and ADHD
Methamphetamine half-life: 8-10 hours

39
Types of stimulants (2)

Cocaine
 Powder cocaine
(Hydrochloride salt)
 Smokeable cocaine
(crack, rock, freebase)

Cocaine half-life: 1-2 hours

40
Activity 2

What stimulants are used in your community and

how are they consumed?

Share your thoughts with the rest of the group.

41
Stimulants: Basic facts (1)

Description:
Stimulants include: (1) a group of synthetic drugs
(ATS) and (2) plant-derived compounds (cocaine)
that increase alertness and arousal by stimulating
the central nervous system

Route of administration:
Smoked, injected, snorted, or administered by mouth
or rectum

42
Stimulants: Basic facts (2)

Acute effects:
 Euphoria, rush, or flash
 Wakefulness, insomnia
 Increased physical activity
 Decreased appetite
 Increased respiration
 Hyperthermia
 Irritability
 Tremors, convulsions
 Anxiety
 Paranoia
 Aggressiveness
43
Stimulants: Basic facts (3)

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

44
Long-term effects of stimulants

 Strokes, seizures, headaches

 Depression, anxiety, irritability, anger
 Memory loss, confusion, attention problems
 Insomnia, hypersomnia, fatigue
 Paranoia, hallucinations, panic reactions
 Suicidal ideation
 Nosebleeds, chronic runny nose, hoarseness,
sinus infection
 Dry mouth, burned lips, worn teeth
 Chest pain, cough, respiratory failure
 Disturbances in heart rhythm and heart attack
 Loss of libido
 Weight loss, anorexia, malnourishment,
 Skin problems

45
Methamphetamine use leads to severe tooth decay

“Meth Mouth”

(New York Times, June 11, 2005) 49

Opioids

50
Opioids

 Opium
 Heroin
 Morphine
 Codeine
 Hydrocodone
 Oxycodone
 Methadone
 Buprenorphine
 Thebaine

51
Opioids: Basic facts (1)

Description:
Opium-derived or synthetic compounds that
relieve pain, produce morphine-like addiction,
or relieve symptoms during withdrawal from
morphine addiction.

Route of administration:
Intravenous, smoked, intranasal, oral, and
intrarectal

52
Opioids: Basic facts (2)

Acute effects:
 Euphoria
 Pain relief
 Suppresses cough reflex
 Histamine release
 Warm flushing of the skin
 Dry mouth
 Drowsiness and lethargy
 Sense of well-being
 Depression of the central nervous system
(mental functioning clouded)

53
Opioids: Basic facts (3)

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

54
Long-term effects of opioids

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

55
Other drugs

 Inhalants
 Petroleum products, glue, paint, paint removers

 Aerosols, sprays, gases, amyl nitrite

 Club drugs (MDMA-ecstasy, GHB)
 Hallucinogens (LSD, mushrooms, PCP, ketamine)
 Hypnotics (quaaludes, mandrax)
 Benzodiazepines (diazepam / valium)
 Barbiturates
 Steroids
 Khat (Catha edulis)
56
Activity 3

Working individually or in small groups, think of the

drugs that are consumed in your area and the way
they are consumed both by youth and adults:

Share your thoughts with the rest of the group.

57
 Introduction to
Addiction and the Brain

58
Addiction = Brain Disease

Addiction is a brain disease that is

chronic and relapsing in nature.

59
60
How a neuron works

61
62
The reward system

Natural rewards
 Food
 Water
 Sex
 Nurturing

63
How the reward system works

64
65
Activating the system with drugs

66
The brain after drug use (1)

Control Methamphetamine

(Source: McCann et al. (1998). Journal of Neuroscience, 18, 8417-8422.) 67

 Partial Recovery of
Brain Dopamine Transporters in
Methamphetamine (METH) Abuser
After Protracted Abstinence
3

ml/gm

Normal Control METH Abuser METH Abuser

(1 month detox) (24 months detox)
The brain after drug use (2)

DA = Days Abstinent

69
Drugs change the brain

After repeated drug use, “deciding” to use

drugs is no longer voluntary because

DRUGS CHANGE THE BRAIN!

70
 ? ? ?
Questions?

Comments?

71
Thank you for your time!

End of Workshop 1

72
Workshop 2:
Principles of Drug Addiction Treatment

73
Training objectives

At the end of this workshop you will be able to:

1. Identify 3 basic components of
comprehensive treatment for substance
abuse
2. Identify 2 individual factors that help people
stay in treatment
3. Identify 3 factors within a programme that
help people stay in treatment
4. Understand and identify 5 basic principles of
effective treatment
74
Comprehensive
Treatment

75
Addiction treatment goals

The goals of addiction treatment are to help

the individual:
 Stop or reduce the use of drugs

 Reduce the harm related to drug use

 Achieve productive functioning in their family,

at work, and in society

76
 Why is comprehensive addiction treatment
needed?
 Addicted individuals usually suffer from
mental health, occupational, health, or
social problems that make their addictive
disorder difficult to treat
 For most people, treatment is a long-
term process that involves multiple
interventions and attempts at abstinence

77
Components of comprehensive drug abuse
treatment
Activity 1: Your organisation 20 Min.

Using the previous graphic, think about all the

services that your organisation provides.
 What services do your clients most often
need?
 What services could your organization add to
meet your clients’ needs?

79
Treatment duration

Individuals progress through drug

addiction treatment at various speeds, so
there is no predetermined length of
treatment.

In general, longer treatment duration

results in better outcomes.

80
Treatment compliance (1)

Client factors that affect treatment

compliance are
 Readiness to change drug-using
behaviour
 Degree of support from family and friends

 Pressure to stay in treatment from the

criminal justice system, child protection
services, an employer, or family members
81
Treatment compliance (2)

Factors within the program that affect

treatment compliance are
 A positive therapeutic relationship between the
counsellor and client
 A clear treatment plan, which allows the client to
know what to expect during treatment
 Medical, psychiatric, and social services
 Medication available when appropriate
 Transition to continuing care or “aftercare”

82
Drug addiction treatment

Drug addiction treatment is offered in

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

83
Activity 2: Group activity 15 Min.

Identify factors within your program (or

others’ programs) that may do the following:

1. Help clients to comply with their treatment plan

2. Interfere with clients’ compliance with their
treatment plan

84
Principles of Addiction Treatment

85
Principles of effective treatment (1)

1. NO single treatment is APPROPRIATE FOR ALL

2. Treatment needs to be READILY AVAILABLE
3. Effective treatment attends to MULTIPLE NEEDS,
not just to drug use problems
4. The treatment plan must be ASSESSED
CONTINUALLY and MODIFIED AS NECESSARY to
insure that it meets the client’s changing needs
5. Remaining in treatment for an ADEQUATE PERIOD
OF TIME is critical for treatment effectiveness.

Continued
86
Principles of effective treatment (2)

6. Counselling (individual and/or group) and other

behavioural therapies are CRITICAL
7. Medications are IMPORTANT elements of
treatment for many clients, especially when
combined with behavioural therapy
8. People with coexisting mental disorders should
be treated in AN INTEGRATED way
9. Detoxification is only the FIRST STAGE of
addiction treatment and by itself does little to
change long-term drug use.

Continued
87
Principles of effective treatment (3)

10. Treatment does NOT need to be voluntary to be

effective
11. Possible drug use during treatment must be
MONITORED continuously
12. Treatment programs should provide assessment
for HIV/AIDS and other infectious diseases as well
as counselling to help clients change behaviours
that place themselves or others at risk of infection
13. Recovering from drug addiction can be a LONG-
TERM PROCESS and frequently requires multiple
episodes of treatment

88
Categories of
Treatment

89
Categories of treatment

Research treatment components include:

 Detoxification
 Pharmacological treatment
 Residential treatment
 Outpatient Treatment

90
Medical detoxification

 Detoxification is a process where

individuals are treated for withdrawal
symptoms upon discontinuation of
addictive drugs

 Detoxification treatment is conducted

under the care of a physician in an
inpatient or outpatient setting

91
Pharmacological treatment

 Medications to reduce the severity and risk of

withdrawal symptoms
 Medication to reduce relapse to illicit drug use
 Agonist maintenance treatment for opiates
(methadone, buprenorphine)
 Antagonist treatment for opiates (naloxone,
naltrexone)

92
Residential treatment

Residential treatment programs provide

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

93
Residential treatment models

 Therapeutic community (TC):

 Highly structured treatment (6-12 months)
 Focus on re-socialization
 Developing personal accountability
 Residential (“rehab”) program
 Typically 30 days long
 Aftercare includes counselling and / or peer
support

94
 Outpatient treatment

Recommended elements of outpatient treatment

include the following:
 Weekly sessions for around 90-120 days
 Family involvement
 Positive reinforcement approaches
 Cognitive-behavioural materials
 12-step meetings or support group participation
 Urinalysis and breath alcohol testing
 Medication as appropriate

95
 Ethical and
Legal Issues

96
Ethical guidelines

Ethical Values:
Be good!
Do good!
And above all: Do no harm!

97
Ethical and legal issues

Ethical guidelines are Legal guidelines are

 A set of professional  Determined by laws
standards  Implemented if ethics are
 A set of principles to consistently violated
guide professional  Often enforced by civil or
behaviour criminal penalties
 Often a matter of opinion
and cultural context
 Not always a legal
concern

98
Professional and ethical issues

Treatment professionals should have a

copy of the following:

 Relevant ethical guidelines or code of conduct

for your region
 Laws or regulations affecting their clinical
professions

99
Professional boundaries

Maintain a professional relationship with a

client at all times
 Avoid dual relationships with clients

 Avoid sexual relationships with clients

 Avoid personal relationships with clients

100
Confidentiality (1)

 The client’s rights and the limits of

confidentiality should be explained at the
beginning of treatment
 The relationship with any client should be
private and confidential
 Client information should not be communicated
outside of the treatment team
 Information should only be released with the
client’s or guardian’s permission

101
Confidentiality (2)

Confidentiality must be maintained at all

times, except when to do so could result in
harm to the client or others.

102
Activity 3: Case study 15 Min.

Discuss in small groups the following cases:

A) A young man tells his clinician that he intends to
kill his former girlfriend just as soon as she
returns from an out-of-town trip.
B) A client’s employer comes to you asking for
information on your client’s test results.
How should the clinician act in cases A and B?

103
Additional principles of counselling

 An addiction treatment professional should

 Respect the client
 Be a role model
 Control the therapeutic relationship
 Emphasise the client’s personal responsibility for
recovery
 Provide direction and encourage self-direction
 Be conscious of his or her own issues

104
 ? ? ?
Questions?

Comments?

105
Thank you for your time!

End of Workshop 2

106
Workshop 3:
Basic Counselling Skills for
Drug Addiction Treatment

107
Training objectives (1)

At the end of this workshop you will be able to:

l Identify a minimum of 4 counselling strategies
useful in drug abuse treatment
l Conduct a minimum of 3 counselling strategies
l Structure a regular counselling session
l Understand the importance of clinical supervision
l Conduct a minimum of 3 listening strategies and 3
responding and teaching strategies to be used in
counselling for drug abuse treatment

108
Introduction to
Counselling

109
What is counselling? (1)

 Counselling involves the following:

 Interactive relationship
 Collaboration
 Set of clinical skills & teaching techniques
 Positive reinforcement
 Emotional support
 Formal record

110
What is counselling? (2)

The purpose of counselling is to

establish:
 Goals of treatment
 Treatment modality
 Treatment plan
 Scheduling of sessions
 Frequency and length of treatment
 Potential involvement of others
 Termination of treatment

111
Basic Counselling
Skills

112
BASIC COUNSELLING SKILLS
ACTIVE
LISTENING

PROCESSING

RESPONDING

TEACHING

Active Listening
Active listening

Active listening by the clinician

encourages the client to share
information by providing verbal
and nonverbal expressions of
interest.

114
Active listening skills

Active listening includes the following skills:

 Attending

 Paraphrasing

 Reflection of feelings

 Summarising

115
Attending (1)

Attending is expressing awareness

and interest in what the client is
communicating both verbally and
nonverbally.

116
Attending (2)

Attending helps the clinician

 Better understand the client through careful
observation

Attending helps the client

 Relax and feel comfortable
 Express their ideas and feelings freely in their own
way
 Trust the counsellor
 Take a more active role in their own sessions

117
Attending (3)

Proper attending involves the following:

 Appropriate eye contact, facial expressions
 Maintaining a relaxed posture and leaning
forward occasionally, using natural hand and
arm movements
 Verbally “following” the client, using a variety
of brief encouragements such as “Um-hm” or
“Yes,” or by repeating key words
 Observing the client’s body language

118
Example of attending

I am so tired,
but I cannot
sleep…so I
Um-hm. drink some
wine.

…When I wake
Please up…it is too late
continue... already…

I see. Too late for

work…my
boss fired me.

119
Activity 1: Case study 15 Min.

“The client asked the clinician about the

availability of medical help to deal with his
withdrawal symptoms. The clinician
noticed that the client is wringing his
hands and looking very anxious.”

Discuss how the clinician should respond.

120
Paraphrasing (1)

Paraphrasing is when the clinician

restates the content of the client’s
previous statement.
 Paraphrasing uses words that are similar
to the client’s, but fewer.
 The purpose of paraphrasing is to
communicate to the client that you
understand what he or she is saying.

121
Paraphrasing (2)

Paraphrasing helps the clinician

 verify their perceptions of the client’s statements
 spotlight an issue
Paraphrasing helps the client
 realise that the counsellor understands what they
are saying
 clarify their remarks
 focus on what is important and relevant

122
Example of paraphrasing

My mom irritates me. She

picks on me for no reason
at all. We do not like each
other.

So…you are having

problems getting along
with your mother. You
are concerned about
your relationship with
her.
Yes!

123
Reflection of feelings (1)

Reflection of feelings is when the

clinician expresses the client’s feelings,
either stated or implied. The counsellor
tries to perceive the emotional state of
the client and respond in a way that
demonstrates an understanding of the
client’s emotional state.

124
Reflection of feelings (2)

Reflection of feelings helps the clinician

 Check whether or not they accurately
understand what the client is feeling
 Bring out problem areas without the client
being pushed or forced
Reflection of feelings helps the client
 Realise that the counsellor understands what
they feel
 Increase awareness of their feelings
 Learn that feelings and behaviour are
connected

125
Example of reflection of feelings
When I get home in the
evening, my house is a
mess. The kids are dirty…
My husband does not care
about dinner...I do not feel
like going home at all.
You are not satisfied
with the way the house
chores are organized.
That irritates you.

Yes!

126
Summarising (1)

Summarising is an important way for the

clinician to gather together what has
already been said, make sure that the client
has been understood correctly, and prepare
the client to move on. Summarising is
putting together a group of reflections.

127
Summarising (2)

Summarising helps the clinician

 Provide focus for the session
 Confirm the client’s perceptions
 Focus on one issue while acknowledging the
existence of others
 Terminate a session in a logical way

Summarising helps the client

 Clarify what they mean
 Realise that the counsellor understands
 Have a sense of movement and progress

128
Example of summarising

We discussed your relationship with

your husband. You said there were
conflicts right from the start related to
the way money was handled, and that
he often felt you gave more
importance to your friends. Yet on the
whole, things went well and you were
quite happy until 3 years ago. Then
the conflicts became more frequent
and more intense, so much so that he Yes, that
is it!
left you twice and talked of divorce,
too. This was also the time when your
drinking was at its peak. Have I
understood the situation properly?

129
Processing

130
Processing (1)

Processing is the act of the clinician

thinking about his or her observations
about the client and what the client has
communicated.

131
Processing (2)

Processing allows the counsellor to

mentally catalogue the following data:
 Client’s beliefs, knowledge, attitudes, and
expectations
 Information given by his or her family

 Counsellor’s observations

132
Responding

133
Responding

Responding is the act of

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

134
Expressing empathy

Empathy is the action of understanding,

being aware of, being sensitive to, and
vicariously experiencing the feelings,
thoughts, and experiences of another.

135
Example of expressing empathy
I am so tired,
but I cannot
sleep… So I
drink some
I see. wine.

When I wake
up…I am
I understand. already too late
I am sorry for work.
about your job. Yesterday my
boss fired me…

...but I do not
have a
drinking
problem!

136
Probing (1)

Probing is the counsellor’s use of a

question to direct the client’s attention to
explore his or her situation in greater
depth.

137
Probing (2)

 A probing question should be open-ended

 Probing helps to focus the client’s attention on a
feeling, situation, or behaviour
 Probing may encourage the client to elaborate,
clarify, or illustrate what he or she has been saying
 Probing may enhance the client’s awareness and
understanding of his or her situation and feelings
 Probing directs the client to areas that need
attention

138
Example of probing

I was always known to be a

good worker. I even received
Work problems an award. Lately I had some
related to drug issues…my husband is just
use? not helping…that is why I am
always late.

Tell me about the

problems you have
been having at the
work place?

Actually I have
had lots of
problems, not
only being late.
139
Interpreting (1)

Interpreting is the clinician’s

explanation of the client’s issues after
observing the client’s behaviour,
listening to the client, and considering
other sources of information.

140
Interpreting (2)

Effective interpreting has three

components:
1. Determining and restating basic messages
2. Adding ideas for a new frame of reference
3. Validating these ideas with the client

141
Example of interpreting

You say you had difficulty in getting

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

142
Silence

Silence can encourage the client to reflect

and continue sharing. It also can allow the
client to experience the power of his or her
own words.

143
Activity 2: Now it’s your turn! 35 Min.

Rotating Roles

This role-play gives you and your colleagues an

opportunity to practise as clinicians and clients.
 Role-play with one of your partners the new counselling skills
you have learned. A third partner will be an observer. After 10
minutes switch roles (30 minutes total).
 Each observer will provide feedback at the end of each role-
play (5 minutes).

144
Teaching Clients New Skills
145
Teaching clients new skills

Teaching is the clinician’s transfer of skills

to the client through a series of techniques
and counselling strategies.

146
Use repetition

Repetition entails counsellors

restating information and clients
practising skills as needed for
clients to master the necessary
knowledge and skills to control their
drug use.

147
Encourage practise

Mastering a new skill requires time and practise.

The learning process often requires making
mistakes and being able to learn from them. It is
critical that clients have the opportunity to try
new approaches.

148
Give a clear rationale

Clinicians should not expect a client to

practise a skill or do a homework assignment
without understanding why it might be
helpful.
Clinicians should constantly stress how
important it is for clients to practise new
skills outside of the counselling session and
explain the reasons for it.

149
Activity 3: Script 1
“It will be important for us to talk about and work on new
coping skills in our sessions, but it is even more important
to put these skills into use in your daily life. It is very
important that you give yourself a chance to try new skills
outside our sessions so we can identify and discuss any
problems you might have putting them into practise.
We’ve found, too, that people who try to practise these
skills tend to do better in treatment. The practise
exercises I’ll be giving you at the end of each session will
help you try out these skills.”

150
Activity 3: Case study 10 Min.

Script 1
Discuss in groups the teaching strategies employed by the
clinician.

151
Monitoring and encouraging

Monitoring: to follow-up by obtaining information

on the client’s attempts to practise the
assignments and checking on task completion.
It also entails discussing the clients’ experience
with the tasks so that problems can be
addressed in session.
Encouraging: to reinforce further progress by
providing constructive feedback that motivates
the client to continue practising new skills
outside of sessions.

152
Use the assignments

Use the information provided by the clients

in their assignments to provide
constructive feedback and motivation.
Focus on the client’s:
Coping style
Resources
Strengths and weaknesses

153
Explore resistance

Failure to implement skills outside

of sessions may be the result of a
variety of factors (e.g., feeling
hopeless). By exploring the specific
nature of a client’s difficulty,
clinicians can help them work
through it.

154
Praise approximations

Counsellors should try to shape the

patients’ behaviour by praising even
small attempts at working on
assignments, highlighting anything
they reveal as helpful or interesting.

155
Activity 4: Case study 10 Min.

Script 2
Discuss the teaching strategies employed by the
counsellor in the following example:
“I noticed that you did not fully complete your homework, but I am
really impressed with the section that you have completed. This is
great…in this section you wrote that on Monday morning you had
cravings but you did not use. That is terrific! Tell me a little more
about how you coped with this situation. In this other section, you
wrote that you used alcohol. Tell me more about it…let’s analyse
together the risk factors involved in this situation.”

156
Develop a plan (1)

A plan for change enhances your client's

self-efficacy and provides an opportunity
for them to consider potential obstacles
and the likely outcomes of each change
strategy.

157
Develop a plan (2)

 Offer a menu of change options

 Develop a behaviour contract or a

Change Plan Worksheet
 Reduce or eliminate barriers to action

158
Activity 5: Role-playing 30 Min.

This role-play gives you and your colleague another

opportunity to practise as counsellors and clients.
 Observe the role-playing
 Complete the Change Plan Worksheet form and ask
each other the following questions:
 “When do you think is a good time to start this
plan for change?”
 “Who can help you to take action on this plan?”

159
 ? ? ?
Questions?

Comments?

160
Thank you for your time!

End of Workshop 3

161
Workshop 4: Special Considerations when Involving
Families in Drug Abuse Treatment

162
Training objectives

At the end of this workshop you will be able to:

1. Understand the importance of involving a client’s family in
the treatment process
2. Identify a minimum of 4 family feelings and reactions to their
relative’s drug dependence
3. Identify strategies to insure that the client’s confidentiality is
maintained when you are working with relatives
4. Understand the basics of child protection
5. Identify a minimum of 3 strategies for engaging families in
treatment
6. Conduct a minimum of 2 strategies for engaging families in
treatment.

163
Introduction to Family
Support

164
Family support

The family is a powerful source of assistance and

support.
Families and significant others can effectively
participate in the treatment process if the client
consents.

165
The goals of involving the family

Involving the family

 Helps family members understand
and cope with the client’s addiction
 Helps achieve the recovery goals of
the drug-dependent person

166
Working with
Families

167
First contact with your client

At the point of first contact with a client,

counsellors should ask questions such as:
 Who is important in your life at this moment?
 How do they support you?
 Do they know that you are getting treatment?
 Would they support you in getting treatment?
 Would you like them to be involved in
treatment and, if so, in what way?

168
Family reactions (1)

Family members usually experience the

following feelings and reactions in
response to their relative’s drug problems:
 Denial
 Shame
 Self-blame
 Anger
 Confusion
Continued
169
Family reactions (2)

 Preoccupation
 Making changes in themselves
 Bargaining
 Controlling
 Disorganisation

170
Activity 1:
Identify maladaptive reactions 10 Min.

Discuss the maladaptive reactions of Anna’s husband

in the following scenario:

Anna has been in treatment for alcoholism for 3 months. Anna’s

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

171
How to engage the family (1)

To effectively engage family members:

 Recognize their perceptions of the situation
 Provide a range of service options for families to
choose from
 Actively engage family members (follow-up with
phone calls and letters)
 Don’t give up easily
 Deliver flexible services

Continued
172
How to engage the family (2)

To effectively engage family members:

 Make sure that the family's greatest need is the
one addressed first
 Be responsive to a crisis
 Insure that the service offered is what the family
wants
 Present clear information
 Insure that promises and commitments are met
 Promote strengths-oriented conversations

173
 Building Positive
Communication
Between the Client
and the Family

174
Communication problems

Frequently, a client’s addiction can

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

175
Positive communication skills

Positive communication skills include the

following:
 Avoid assuming what the other is thinking
 Communicate directly instead of hinting
 Avoid double messages
 Admit mistakes
 Use “I” statements

176
Avoid assuming what the other is
thinking

Nancy asked her husband Pete, “Will you

be coming home right after work?” Pete
exploded, “You don’t have to check up on
me every 5 minutes! Do you want a urine
sample, too?” Nancy responded angrily,
“Well, you’ve sure given me enough
reasons to check up on you.”

177
Communicate directly instead of
hinting
Ricardo, a 17-year-old in recovery, was playing a
video game when his mother, Rosa, walked by
and said, “Ricardo, the kitchen trash can is
getting full.” Ricardo responded, “Uh huh,” and
continued playing his game. Half an hour later,
Rosa noticed that Ricardo hadn’t emptied the
trash. She angrily confronted Ricardo for not
taking the trash out right away. Ricardo
responded to her anger by loudly saying, “Hey, I’ll
do it when I’m ready to do it!”

178
Avoid double messages

Tanya asked her husband, Andre, “Do you mind if

I go fishing with Sharonne Saturday?” Andre had
been planning to spend time with Tanya on the
weekend and didn’t want her to go with Sharonne.
However, he replied, “Sure, go ahead.” As he said
this, his arms were stiffly crossed across his
chest and he didn’t look directly at Tanya. Tanya
felt uneasy and said, “You’re really OK with it?”
Andre responded angrily, “I said I was, didn’t I?
The discussion escalated into an argument.

179
Admit mistakes

Bob forgot that it was his and Catherine’s 5th wedding

anniversary. A coworker invited him to bowl a few frames after
work, and he accepted. When he arrived home, he discovered
the table set for two and Catherine in tears. When she
confronted Bob about being so late, he responded defensively.
“You know I have trouble remembering these things. You
should have reminded me! How am I supposed to know you
were planning a special dinner?” Catherine responded, “How
could you forget our anniversary?” Bob was feeling guilty at
this point, but not wanting to admit he was wrong, defensively
replied, “Listen, Catherine, we’ve been married for 5 years now.
What’s the big deal?” Catherine locked herself in the bedroom.

180
Use “I” statements

Pam, a senior in high school, was out on a date.

Her curfew was midnight, and she was already
late. When Pam arrived home at 1 a.m., her
mother, Emily, was extremely worried. Emily
greeted Pam at the door saying, “You’re late! You
could have picked up a phone and called. You’re
always so inconsiderate!” Pam responded angrily,
“I am not always inconsiderate!” A fight ensued.
.

181
Activity 2: How to engage the family 15 Min.

Take time to think about strategies to

involve the family and how you would
implement them in your organisation.
Share your ideas with the rest of the
group.

182
Confidentiality

183
Confidentiality

It is the right of the client to determine to

whom they or others disclose details of
their treatment.

No information regarding a person's

treatment should be disclosed without the
client's explicit consent in writing.

184
Organisations’ confidentiality policy

Organisations should have policies and

procedures in place to assist practitioners in
insuring confidentiality for the client and
their records. These policies should include:
 Having an agreement with the client and
informed consent before releasing any
information regarding treatment
 Having a signed “release of information” form
from the client
 Clarifying to the client the purpose and types of
case records and what happens to them

185
Precautions

Written consent should be obtained before

disclosing:
1. Details of a client's treatment to any family
member
2. Information about the client’s attendance

186
If in doubt …

 Ask your client if it is OK to talk about it

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

187
 Support and
Information for Clients
who have Children

188
Support and information for clients who have
children

Clinicians should identify the needs of clients

with children. These might include:
 Referral to a specialist in parenting or family support
programs
 Attention to child safety issues within the physical
environment of the agency
 Provision of “child-friendly” areas within the clinic,
including toys and resources for children, posters, and
other aids to establish a welcoming and age-
appropriate environment
 Provision of information on a range of welfare, child
care, and family recreation services available in the
local area

189
Child protection

Organisations should have policies and procedures in

place to assist practitioners in responding to
suspicions of child abuse and neglect such as:
 Access to immediate supervision from an experienced
practitioner
 Knowledge of what constitutes risk
 Knowledge of the child protection system
 Training in how to discuss concerns about safety with
clients

190
 ? ? ?
Questions?

Comments?

191
Post-assessment 10 Min.

Please respond to the post-assessment

questions in your workbook.

(Your responses are strictly confidential.)

192
Thank you for your time!

193