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Workbook
Provide support strategies for addiction service users with co-existing problems in mental health and addiction services
US 27078
Level 5 Credits 8
Name:
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Contents
Before you start ................................................................................................................ 4
Addiction and co-existing problems .................................................................................. 7
Wellbeing as a goal ........................................................................................................ 10
The strengths model of case management .................................................................... 11
CEP as a management model ....................................................................................... 14
Policy and procedures for CEP ...................................................................................... 43
Evaluating effectiveness of the support strategy ............................................................ 44
Suggested answers to learning activities ....................................................................... 48
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Before you start
Welcome to this workbook for unit standard 27078:
Provide support strategies for addiction service users with co-existing problems
in mental health and addiction services.
For this unit standard you will have:
this workbook.
an assessment.
In this workbook you will learn more about:
working with people affected by both addiction and co-existing mental health
problems.
the prevalence of co-existing mental health problems.
models of treatment management and strategies to improve wellbeing.
the development of a treatment management plan for those affected by co-existing
mental health problems.
How to use this workbook
This is your workbook to keep. Make it your own by writing in it.
Use highlighters to identify important ideas.
Do the learning activities included throughout this workbook. Write your answers in
the spaces provided.
You might find it helpful to discuss your answers with colleagues or your supervisor.
Finish this workbook before you start on the assessment.
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Workbook activities
Learning activity
You will come across learning activities as you work through this
workbook. These activities help you understand and apply the
information that you are learning.
When you see this symbol, you are asked to think about what you
know. This may include reviewing your knowledge or talking to a
colleague.
When you see this symbol, it gives you a hint, tip or definition.
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Check your knowledge
Think about co-existing mental health problems
Think about any people in your life with co-existing problems (which may be yourself).
A co-existing problem is when a person has a mental health problem and an addiction.
How much does the mental health problem affect the addiction problem?
How much does the addiction problem affect the mental health problem?
Is it best to offer help for those problems one at a time or together?
A new client turns up clearly affected by alcohol to your gambling treatment service.
What would you do? Choose an answer and explain why you chose that.
A Require that he gets treatment for his alcohol problem before you begin treating his
gambling problems.
B Ask the client to come back when they are sober, and when they do, ask them to
consent to an assessment for alcohol problems.
C Carry on with your assessment for gambling problems.
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Addiction and co-existing problems
Addiction is a term that can cover both the use of drugs, including alcohol and tobacco,
as well as problem gambling. Addiction is defined as:
“. . . a maladaptive pattern of substance use or problem gambling that leads to a clinically
significant impairment or distress…. (and) are characterised by dyscontrol, tolerance,
withdrawal and salience, and are considered chronic relapsing conditions.”
Reference: Let’s get real: Real skills for people working in mental health and addiction.
Ministry of Health. 2008
Addictions can develop because of a complex interaction between the person’s biological
makeup, psychological factors, and social or environmental factors that can increase the
behaviour despite growing costs it may have on the person’s life.
These addictions can result in moderate to severe consequences for both the person
and their whanau. What is becoming clearer is that addictions can be more likely to
develop because of other pre-existing health problems, as well as the addiction creating
new, additional, mental health problems as it becomes more severe.
Addiction is itself a mental health condition, however because of historical reasons,
addiction treatment has often been provided through separate services to other mental
health conditions. Research shows that addiction and co-existing mental health problems
are commonplace, and that those with addictions as a rule have other mental health
problems.
What are ‘co-existing problems’?
The term ‘co-existing problems’
refers to the co-existence of a
mental health disorder with an
alcohol or other drug problem.
Several other terms are used
interchangeably including dual
diagnosis, dual disorder,
co-existing, concurrent disorders
and co-morbidity.
Co-existing problems are called
CEP for short. Overseas, CEP is
often referred to as ‘co-occurring
disorders’.
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Substance use addictions and pathological gambling are themselves recognised mental
health disorders, so sometimes the separation can be a little artificial in these
circumstances. However, the term CEP can also include co-existing mental health
problems that may or may not meet the criteria of a disorder, but will interact
problematically with the addiction. When CEP occurs, affected people are less likely to
improve their wellbeing, their conditions may be more severe, and their being at risk for
self-harm increases.
The CEP approach is to integrate treatment between addiction and other mental health
conditions where these services are in the same place.
Who is at risk for CEP?
Co-existing mental health problems are common amongst those who attend alcohol and
drug treatment services. Research identified that 74% of those seeking help for alcohol
and/or drug (AOD) problems in community services were currently affected also by a
mental health disorder.
Co-existing mental health/addiction problems (Adamson, et al 2006)
Mental health disorder % co-existing with AOD
Any mental health disorder 74%
Anxiety disorder (any)
Social phobia
Posttraumatic stress disorder
65%
31%
31%
Mood disorder (any)
Major depressive disorder
Bipolar I disorder
53%
34%
11%
Anti-social personality disorder 27%
Pathological gambling 11%
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The American Psychiatric Association (2000) found that pathological gambling, a
recognised mental health disorder that is often described as gambling addiction, is
associated with other mental health problems. Kessler and colleagues (2008) identified
that 55.6% of pathological gamblers had been affected by mood disorders, such as
depression, 60.3% by anxiety disorders, and 42.3% by substance use disorders.
Addictions and mental health problems interact to increase the impact they have on each
other. These more severe impacts raise the risk for several negative outcomes including:
increased likelihood of violence, offending and imprisonment.
increased likelihood of suicide.
more severe mental health symptoms and increased relapses.
increased financial problems, homelessness and housing problems.
lower family support.
poorer overall health.
lower help-seeking, lower treatment compliance and staying in treatment,
compounded by treatment providers not identifying the existence of both addiction
and co-existing mental health problems.
CEP can include problem gambling as a co-existing
mental health problem that is identified with a
person’s alcohol or other drug addiction.
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Wellbeing as a goal
In the past there has been a focus on resolving health problems as a goal of treatment.
This has the unfortunate emphasis upon negative aspects of someone’s life rather than
looking at them in terms of their potential, and the goal may only be the absence of the
problem. In many cases the problem doesn’t go away, but the person’s quality of life can
be improved. The term ‘recovery’ looks at the process from a strengths perspective, and
is often explained as: ‘living well in the presence or absence of mental health.’
Wellbeing as a goal incorporates both the treatment of problems as well as enhancing
the person’s positives in their life, resulting in a positive outcome in which they have an
empowering role in decision-making about their own health. This focus upon wellbeing
rather than disorders is more in line with both Māori and Pacific models of health.
Integrated treatment
In the past, some treatment providers considered that where someone was affected by
both addiction and other mental health problems, one may have to be treated first before
starting to address the other. It may have been considered right to resolve an alcohol
problem before addressing co-existing depression, with the client being required to follow
what was recommended. This ‘serial’ approach viewed the addiction and co-existing
mental health problems as separate issues that nevertheless interfered with each other
in treatment.
An alternative approach would be to treat both these issues at the same time (a ‘parallel’
model of treatment) but with separate services that don’t work together.
The approach considered to be the best is an integrated model of treatment. The
integrated model occurs when both the addiction and mental health issues are
addressed at the same time, preferably at the same treatment setting, if necessary with
health professionals working together using similar approaches. Ideally, but
understandably it’s not always possible, integration of services refers to the treatment of
the addiction and mental health issues at the same time, in the same service by the
same health professionals.
This may indicate that future skills and knowledge for a health professional working in the
CEP field will become more wide-ranging in respect of mental health assessment and
brief intervention for addiction workers, as well as addiction assessment and brief
intervention for those working in the mental health field.
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The strengths model of case management
The strengths model is an evidence-based model developed by Charles Rapp in the
early 1980s. It is a social work practice theory that emphasises people’s
self-determination and their strengths, rather than illness and the pathology of illness.
In the strengths model, the client’s quality of life is mostly defined by what the client
wants to achieve, and these goals are individual to the client. They may include having
relationships and resources outside of the mental health system, feeling as though they
are ‘normal’, and having employment, friends, and independent living options. This may
be experienced as an improved quality of life.
The six principles in the strengths model of case management are:
1 Individual strengths are the focus, not the client’s pathology.
2 The relationship between the client and the health professional as their case
manager is both very important and essential.
3 Self-determination by the client is the main focus.
4 The client’s community contains many resources beyond traditional health
services.
5 Positive assistance or aggressive outreach is the best approach.
6 Those affected by severe mental illness can learn, grow and change, and can be
assisted to do this.
Clients are assisted in normal community settings rather than in services separated from
the community; and where necessary, integrated services from a single team is preferred
to separate treatment services being brokered by the case manager.
Remember
There are better outcomes for the client when co-existing
problems are managed together.
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Assessment in a strengths model
An assessment using this model would identify client strengths, their coping style, where
they were in their recovery (eg in crisis, preparing to change, building on change), what
social or family networks they have, what community resources they have (eg church),
and what deficits (impairment) they have and whether these are accepted or can be
reversed.
Roll out
The case manager helps in an active way to assist with the client needs, goals and
aspirations. Case managers are trained to identify client skills and strengths, and provide
positive feedback to clients for all goal success steps achieved, however small. Case
managers support the client themselves to access community resources, only taking that
role when it is in the long-term interest of the client that the case manager provides the
support to access the resource. Gradually, the case manager disengages from the case
management, changing and adapting the plan with the client where necessary, focussing
always on the confidence and the strengths the clients have to solve problems
themselves and to monitor their own progress.
Strengths model and CEP
With the strengths model, little attention is paid to the mental health symptoms or illness,
and the role of the case manager as a health professional has less emphasis or
importance.
The CEP and wellbeing goal approach is consistent with the strengths model in many
ways, but there is consideration of the mental health and addiction symptoms in the CEP
approach. Integrated approaches are recommended for both models, although the CEP
model may be more flexible in what is included in ‘integrated’. For both models, the focus
is upon clients with severe mental health conditions. Supporters of both models believe
that, for severely affected mental health clients, each model is the best approach.
Mandatory treatment that may be required as a result of legislation can restrict the
flexibility of goals for many clients, while offending rates are often high for those with
CEP. This mandated treatment may be less consistent with the strongly client-centred
approach of the strengths model.
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Learning activity
What actions could you take using the strengths model support
strategy?
Gerry, 19, is affected by both moderate/severe depression and alcohol problems. He is
about to be evicted from his flat because he has not paid his rent for a month following the
loss of his job as a mechanic due to redundancy. He is entitled to a benefit but feels too
ashamed to apply for that or an accommodation allowance, or to ask for help from his
parents. He doesn’t want to take up your time because you are busy and he has been
diagnosed in the past with major depression and alcohol abuse, yet has not changed his
behaviour.
NOTE: See suggested answers at the back of this workbook.
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CEP as a management model
Te Ariari o te Oranga highlights the seven key principles that should be considered in
regard to any approach when working with an addicted person. These key principles are:
1 Cultural needs and values of clients must be considered throughout treatment.
2 Wellbeing is the outcome focus or goal rather than removing dysfunction, with
problems seen as barriers to wellbeing.
3 Engagement with the client is critical and must be maintained and if possible
improved throughout treatment – engagement established with the client’s
case manager, the management plan, and with the treatment service as well.
4 Motivation must be actively improved throughout treatment.
5 Assessment to begin with screening for common addictions and mental health
problems. If positive on a screen, clients are then comprehensively assessed and
weight given to diagnoses of disorders, current issues, and possible causes, for
example, relationship problems; strengths and resources are assessed as well
as problems.
6 Management plans will include reaching an opinion (or formulation) of what has
caused the client’s problems; treatment for the range of problems may need to be
integrated with some prioritised, eg suicidal thoughts may be prioritised over
addictions, but addictions must be addressed in the medium term to reduce
suicidal thoughts.
7 Integrated care refers to the drawing together of help for the goal of client
wellbeing. This will include helping with needs in addition to mental health and
addiction such as social relationships, educational and work needs, cultural
needs, working with the justice system for them, and assisting them to build upon
their strengths. This does not require that all of these needs are met by the CEP
service, but that others involved in the case management have a consistent goal
of improved wellbeing rather than treatment of disorders.
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Learning activity
Think about the seven key principles that should be considered in
regard to any approach when working with an addicted person.
How do these CEP key principles relate to the strengths model of case management?
Are they similar?
How do they differ?
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Cultural needs and values
A cultural advisor providing advice on language, processes and interventions may help
with ensuring that cultural safety is maintained and effective case management provided.
Special considerations for Māori
The different and complex ways that Māori can relate to their cultural identity can have
difficulties for health professionals in identifying appropriate interventions.
Let’s Get Real highlights the importance of providing information in te reo, as well as
English, having an option of a support person speaking on behalf of the client, the
importance of whakawhanaunga (connections: where do you come from), and the
importance of Māori identity for recovery.
Let’s Get Real also highlights self-determination (tino rangatiratanga), spiritual practises
(wairua), caring and nurturing and enhancing the mana of others (manaakitanga), and
the importance of tapu (sacredness, to be managed by protocol, ritual and karakia), and
mana. A treatment approach that reduces the client’s mana may be regarded as
worsening wellbeing, which emphasises the importance of protocol in the treatment of
Māori.
Māori have higher rates of substance use disorders, mood and anxiety disorders than
pakeha, with likely higher rates for CEP. Under models of Māori health, positive
approaches that support wellbeing are focussed upon, not just removal of health
problems. The approach for Māori will be to address addiction and mental health as one.
Mental health issues may present to health professionals as physical and spiritual
problems. Shame (whakama) may present as depression or anxiety-like symptoms,
while breaches of ritual or being cursed may result in symptoms like mental health
problems. Addressing these issues may be through spiritual approaches or massage,
and may be combined with western health approaches. Having access to cultural
specialists (kaumatua) for assessment and treatment processes may assist in ensuring
cultural safety.
It is important to respect and respond to cultural issues relevant to Māori such as:
traditional models of healing.
language.
accurate communication.
different concepts of wellbeing.
reluctance to disclose or shame of disclosure.
tolerance and management of risk.
involvement of family/whānau and hapu/iwi.
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Whare tapawha (Durie, 1994)
Identity for many Māori may be derived from a collective culture, with identity coming
from relationships within their whānau (extended family). Family members may have
roles which may differ from pakeha, for example, grandparents may have significant
parenting roles.
There are several well-known Māori models of mental health wellbeing including Te Pae
Mahutonga and Tu Wheke. Te Whare Tapa Whā is probably the best-known model of
wellness for Māori.
The literal translation of ‘Te Whare Tapa Whā’ is ‘the four sides of the house’. The
essence of the approach is that wellbeing sits within the four cornerstones of health,
which are all interlocking and essential. If one wall falls, the house will fall.
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Special considerations for Pacific people
The Pacific community in New Zealand consists of several distinct languages and
cultural groups.
The Samoan community is the largest of the Pacific ethnic groups (nearly 49%), followed
by the Cook Islands community (21%), the Tongan community (20.5%), Niuean (8%),
Fijian, Tokelauan and other communities. (Statistics New Zealand 2013 Census).
Each of these communities have their own history, culture and social experiences, which
make their encounters with risk factors such as alcohol, other drugs and gambling
problems distinct. There may also be differences in needs between Pacific people born
in New Zealand and those who were born in the Pacific Islands.
For Pacific people, the following cultural issues should be taken into consideration:
language and accurate communication.
the influence of religion.
different concepts, for example in relation to family.
disclosure of problems.
the use of kava and kava drinking traditions, where kava drinking in groups is
continued until the kava is finished.
The best-known overarching Pacific model of wellness is the fonofale.
This is based on a Samoan fale
(house), where the foundation or
floor, four pou (posts) and roof
all have symbolic meanings.
These elements are presented in
a circle, expressing the
philosophy of holism and
continuity.
Fonofale is a dynamic model, in
that all elements have an
interactive relationship.
Real Skills, Plus Seitapu (2009), identifies three key themes in working with Pacific
peoples - family, language and tapu.
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Family
The treatment provider aims to establish and maintain strong relationships with the client,
their family, and the service. Being aware of the dynamics of family roles assists clients
to meet their obligations and minimise conflicts, tensions or breach of tapu.
Sense of identity for Pacific peoples is strongly connected with their family, and their
obligations to care for and protect family. Involvement of the family in a person’s
treatment in a holistic approach may be necessary as the mental health of the individual
and that of their family is strongly linked. Each role within the family comes with its
obligations and expectations. The head of the extended family has responsibility for the
wellbeing of the whole family and may be a key for marshalling the family’s resources to
provide help. As these family structures can vary, especially with the influence of
adaptation with New Zealand cultures, the case worker must be able to assess these
family dynamics.
Time to ensure sufficient cultural engagement, rather than clinical engagement with the
family, is essential. Preparing for the initial meeting through knowledge of the person and
their language, ie which island does the person identify with, is English spoken or is an
interpreter required, and where were they born (New Zealand or a Pacific Island) greatly
assists in building rapport. Patience, humility, respect, being supportive and caring are all
positive qualities for client and family meetings.
Language
Correct pronunciation and showing respect is important. Knowing where specialist
language skills can be accessed will also be important. Language is both verbal and
non-verbal. Language and actions must be consistent, for example, an apology in a
raised voice would be inconsistent and may be seen as insincere. Humility is valued, for
example, walking past a seated person with your head bowed forward can build rapport.
Be aware that there are different languages and levels of languages, and that these may
vary depending upon the formality of the situation, and whether the client and their family
are traditional or New Zealand born.
Tapu
Tapu refers to the sacred bonds between people. Spirituality is an important element in
care, alongside the other usual elements of physical, mental and social aspects of
wellbeing. As wellbeing is collective rather than individual, mental illness can affect the
family as a whole. Breach of tapu, such as isolation from family when tradition is
challenged across generations, can affect wellbeing and result in mental illness.
Spirituality can include both Christian and older spirituality which can co-exist. Being
open-minded when considering cultural, spiritual, relationships and beliefs, is essential
for effective case-work with Pacific people affected by mental health.
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Learning activity
Read the following scenario and answer the question.
Mele is a 20 year-old Fijian who was born in Fiji but came to New Zealand with his family
when he was 10 years-old. He has lost all his savings gambling and borrowed much
more from friends saying that he needed a loan to buy a house for his parents. He is now
drinking heavily ‘to forget’, and had his car impounded for a second drink/driving offence.
He says he has disgraced his family who have now found out about his debts and
offending, and says he has also lost his girlfriend who is tired of his daily drinking. He
says he cries all the time and feels that this is not manly. He wants to stop it all
happening.
His brother comes with him to your service and says he is very worried about his brother,
but also angry with him, as are the rest of the family. He says the family feels ashamed
and wants to know what to do with him to stop him embarrassing them.
Describe the CEP strategies that take into account Mele’s cultural needs.
NOTE: See suggested answers at the back of this workbook.
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Special considerations for Asian people
Asian immigration to New Zealand has increased significantly in the last decade and they
are now the third largest ethnic group in New Zealand. According to the 2013 Census,
Asians make up 12 percent of the population and comprise 23.1% of the Auckland
region’s total population.
The New Zealand Asian population is made up of peoples from around 28 countries, and
they bring to New Zealand many different cultures, beliefs and social experiences. Due
to the increases in migration to New Zealand, the majority have been born overseas. The
largest Asian group in New Zealand is Chinese (36.3%), followed by Indian (32.9%) and
Korean (12%). (Statistics New Zealand 2013 Census).
We know that Asians in New Zealand do not tend to utilise existing services, which can
convey the message that they are a ‘model minority’. But in fact, we know very little
about the general wellbeing of Asians living in New Zealand. Adjusting to a new country
brings language barrier issues and adaptation problems for individuals and families and
more research in needed to understand these communities.
It may be inappropriate with Asian people to use direct questioning about intimate health
issues and their age. However, problematically, for some Asian people choice and
empowerment may be interpreted as the health professional’s lack of authority.
Traumatisation may also be more likely, especially with refuges, and physical symptoms,
rather than emotional symptoms, may present with those affected by mental illness
(possibly as being more acceptable). Some Asian cultures accept hallucinatory
experiences as normal.
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Wellbeing
Wellbeing is care that not only reduces problems, but also improves positive assets of
the client. Removal of mental health and addiction problems are important and will
improve wellbeing, however improving existing strengths and qualities of the client is also
important. Both of these approaches are necessary for a person’s wellbeing, as treating
the problem first to achieve wellbeing, or assuming wellbeing will happen automatically
because the problem has been treated, are both incorrect. Many clients with chronic
problems can still achieve high levels of wellbeing.
Wellbeing improvement can therefore start early in case-management and not be
dependent upon first solving the problem. The World Health Organisation (WHO) has
equated health with wellbeing and defined health as ‘a state of complete physical, mental
and social wellbeing and not merely the absence of disease or infirmity’. Included in
defining wellbeing is good social functioning, and fulfilment of potential and spiritual
satisfaction. For cultures that value family and larger social units, such as Māori, Pacific
and many Asian cultures, it may be more appropriate to view wellbeing as applying to
this group as a whole, and to consider the group’s wellbeing as a goal, rather than the
individual’s. Wellbeing may involve three important aspects:
helping the client to establish their goals of treatment by targeting barriers to
wellbeing.
enhancing engagement, motivation and integration through not only addressing
problems, but the client’s hopes and aspirations, and in so doing increasing their
motivation and their sense of being understood through linking treatment with their
goals.
active treatment that builds recovery from mental illness, resilience against relapse,
and enhanced quality of life.
Setting goals one step at a time can help clients to experience quick success and so
raise their hope and optimism for wellbeing.
Wellness
Barriers
Substance Use
Accommodation
Finance Employment
Mental Illness
Family
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Engagement
Engagement, particularly in the early stages of getting help, is very important.
Engagement includes engagement with the health professional and their organisation,
and engagement with the treatment that is being suggested. Engagement can include
involvement with many issues that may not appear to be directly associated with
treatment. Engagement can be enhanced through:
assisting with food needs and housing.
helping with legal issues.
helping with budgeting and benefits.
helping with distressing mental health issues.
working to improve family needs.
assertive outreach, for example, going out to see people who will help your client.
Engagement, which continues as an important goal throughout treatment, has three
important factors:
1 the client’s motivation and their readiness to change.
2 the quality of the client’s relationship with their health professionals.
3 the quality of and continued participation, collaboration and effort in treatment.
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Motivation
Both readiness for treatment and motivation to change the addiction are important, not
only for engagement in treatment, but also in making sure there is a positive outcome in
improving the addiction and other mental health problems. Research supports the use of
motivational interviewing (MI) as being very helpful in improving the engagement CEP
clients have with their support worker and the plan throughout treatment. However there
is less evidence of MI in reducing substance use or symptoms of mental health.
CEP clients may have different levels or types of motivation. They may have little
motivation to change their behaviour at all, often because it may not be important to
change, or they may not feel confident of success, or changing their behaviour may
appear not to be relevant to their goals. Motivation, when it exists, may be because of
external pressures (extrinsic motivation), which although often enough to make change
happen, may not be as effective in change occurring than if the motivation was accepted
for the person’s own reasons (intrinsic motivation). Self-determination theory states that
motivation is likely to move from low or external motivation to internal motivation as the
treatment demonstrates to the person that they have the ability to succeed, that they
have control or choice around the goals of the treatment, and any change in their
behaviour has relevance to achieving their goals in life.
Transtheoretical model
The transtheoretical model of change is widely accepted as to the stages of change and
processes that occur in improving motivation to change behaviour, especially for CEP
clients.
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Motivation is considered to develop through stages, and is considered to be something
that is created, rather than a trait or a characteristic that people may or may not have.
The six stages of motivation in the model are:
1 pre-contemplation stage, where the person is unmotivated or resistant to change,
and are not particularly aware that they need to change their behaviour.
2 contemplation stage, where some awareness has arisen that there is a problem
and consideration has been given to change. The reasons for change aren’t as
strong though as the reasons to continue the behaviour; often these people are
seen as stuck.
3 preparation stage is where an intention to change has been made, and they are
preparing to put the change process into action, usually within the next month
4 action stage is where changes to behaviour have started, or have been made.
5 maintenance stage is where changes have been made, the new behaviour is
becoming normal, and prevention strategies to avoid slips are made.
6 relapse or recycling stage is where a person recycles to an earlier stage, and the
process continues.
The model notes that recycling, (the preferred term, rather than the negative term
‘relapse’) is normal and behaviour changes often, or may require recycling at an earlier
stage. This is sometimes referred to as a ‘slip’. However, the recycling will not revert to
the precontemplation stage as once the realisation has happened that a problem may
exist, it is difficult to go back to not knowing. Reminding the person that it is a slip and
that it is a learning experience is a good way of motivating them when they have gone
back to contemplating the problem and what to do about it.
Once the new behaviour has become normal and coping strategies have been put in
place against a relapse, perhaps after six months or so of the new behaviour, the person
will exit the behaviour change cycle.
With clients affected by CEP, motivation may be specific to a particular behaviour. CEP
clients may have several problem behaviours, which may fluctuate both in intensity and
in readiness to change. Asking clients to rate the importance of each behaviour may be
an important early step.
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Motivation and CEP
Zuckoff and colleagues (2007) have developed a specific interview incorporating
motivational interviewing principles and strategies designed to enhance engagement.
Zuckoff says that although some CEP clients may be ready to change they may not be
ready for treatment, or they may be ready for treatment but not for change.
Motivational interviewing is a person-centred approach which encourages people to
identify their own reasons for needing to change by looking at the consequences of not
changing. This way of working acknowledges that people are the experts on their own
lives. Motivational interviewing recognises that people can be extremely ambivalent
about change for many reasons. For some people their behaviour is a coping strategy
that is difficult to replace.
Motivational interviewing supports people to make changes through three key concepts:
1 collaboration (rather than confrontation) with the client.
2 drawing-out (rather than imposing on) the ideas of the client.
3 autonomy of the client (rather than authority being assumed over the client).
For example, some CEP clients may not wish to change their behaviour, and use the
addiction as a way to ‘self-medicate’ their mental health symptoms. Alcohol may reduce
stress, may make them feel like they fit in, and be pleasurable while intoxicated.
Stopping use of the addiction may result in the return of undesirable mental health
symptoms, loss of social life (with other users), boredom and the return of unwanted
memories. They may however not want the problems that come with the addiction.
Alternatively, CEP clients may want to change their behaviour but find that transport to,
or maintaining appointments with, their case worker is difficult to manage. Attitudes and
stigma around treatment may also make it difficult for people to want to go along for help.
Zuckoff emphasises that two considerations must be taken into account with CEP clients.
These are:
there may be thought or brain limitations that may affect ability to understand
information offered, affect memory, ability to stay attentive, and to concentrate.
For this reason language should be simplified, choices offered, clear links provided
between new statements and past ones, increase of the reflecting, summarising
used in motivational interviewing, repeat of important points frequently, and
provision of written summaries of the session and reminders of agreed points.
CEP clients may have less tolerance of intense emotions. This may require moving
away from these issues when they arise with less focus upon what is happening
with psychosis when the client is affected by this, instead focussing upon concrete
meanings to important points. Where the client feels change is hopeless, change
the point you are discussing, and reframe it in a more positive way.
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Learning activity
Read the following scenario, choose the best answer, and write why you
chose that answer.
Jenny is affected by methamphetamine addiction and major depression disorder. When
you ask about how her addiction affects her relationship with her family she becomes
very agitated, saying she’ll never be forgiven for stealing from them to buy drugs, and
they just stared at her in Court from the public gallery.
Do you:
A tell her it will get easier to bear over time.
B reframe it as, they may have been worried for her, otherwise they wouldn’t have
even come to Court.
C ignore her statement and change the subject.
When you finish the session with Jenny, she says she probably won’t remember half of
what was said, but it was all helpful.
Do you:
A tell her that she will probably remember later when she thinks back on the
session, and not to worry.
B summarise again, using simple language.
C offer to write the main points down for her to look at later.
NOTE: See suggested answers at the back of this workbook.
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Assessment
Assessment generally has two purposes:
1 to engage and motive a client to work towards wellbeing.
2 to obtain enough information to identify the client’s problems. These may all be
related to each other so that it is possible to suggest appropriate ways to improve
wellbeing.
There are three main levels of assessment.
1 Screening – a brief questionnaire to identify whether a problem exists, and if the
screen is positive, a more intensive or comprehensive assessment put in place if
needed.
2 Brief assessment – this is a more targeted discussion that may take more time
than a screening, and gains a wider understanding of the problem. Less severe or
complicated problems may then be followed by a brief intervention, which can
include information, awareness and motivation raising, or arranging help from a
professional.
3 Comprehensive assessment – this is where a broad understanding of all
appropriate problems of the client (and family in cultural approaches) is formulated,
and may include a diagnosis.
Screening
Engagement is an important step before offering a screen. When clients feel safe to talk
about difficult problems, and understand the relevance of answering them, then screens
are more likely to be answered truthfully.
Screening, though, is not a substitute for a more comprehensive assessment, but does
identify likely risk. As brief assessments of the likelihood of problems existing, they need
to be as accurate as possible, appropriate for the people being screened, and be brief
and easily scored. Positive screens should warrant further assessment and if possible a
diagnosis.
For client at risk of CEP, screens should cover a range of addictions and mental health
problems. An example of a brief screen that covers a range of addiction, mental health,
as well as some lifestyle problems, is the ‘case finding and help assessment tool’ (CHAT)
screen.
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CHAT (Case Finding and Help Assessment Tool)
What we do and how we feel can sometimes affect our health. To help us assist you to reach and maintain a healthy and enjoyable lifestyle, please answer the following questions to the best of your ability.
How many cigarettes do you smoke on an average day? none less than 1 a day 1-10 11-20 31 or more
Do you ever feel the need to cut down or stop your smoking? (tick no if you don’t smoke) no yes
If yes, do you want help with this? no yes but not today yes
Do you ever feel the need to cut down on your drinking alcohol? no yes
In the last year, have you ever drunk more alcohol than you meant to? no yes
If yes to either or both questions do you want help with this? no yes but not today yes
Do you ever feel the need to cut down on your non-prescription or recreational drug use?
(If you do not use other drugs, just tick no). no yes
In the last year, have you ever used non-prescription or recreational drugs more than you meant to? no yes If yes to either or both questions do you want help with this? no yes but not today yes
Do you ever feel unhappy or worried after a session of gambling?
(If you do not gamble, just tick no). no yes
Does gambling sometimes cause you problems? no yes
If yes to either or both questions do you want help with this? no yes but not today yes
During the past month have you often been bothered by feeling down, depressed or hopeless? no yes
During the past month have you often been bothered by having little interest or pleasure in doing things? no yes
If yes to either or both questions do you want help with this? no yes but not today yes
During the past month have you been worrying a lot about everyday problems? If so how often? none less than 1 a day 1-10 11-20 31 or more
What aspects of your life are causing you significant stress at the moment? none relationship work home life money health study
other (specify) ………………………………………………………………..………………
Is there anyone in your life whom you are afraid of or who hurts you in any way? no yes
Is there anyone in your life who controls you and prevents you doing what you want?
no yes
If yes to either or both questions do you want help with this? no yes but not today yes
Is controlling your anger sometimes a problem for you? no yes
If yes, do you want help with this? no yes but not today yes
As a rule, do you do more than 30 minutes of moderate or vigorous exercise (such as walking or a sport) on 5 days of the week? no yes
If no, do you want help with this? no yes but not today yes
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SCORING CHART
Questions Response options Positive
How many cigarettes do you smoke on an average day?
none / less than 1 a day / 1-10 / 11-20 / 31 or more
More than 10 cigarettes a day
Do you ever feel the need to cut down or stop your smoking?
no / yes yes
Do you want help with your smoking? no / yes but not today / yes yes but not today, or yes
Do you ever feel the need to cut down on your drinking alcohol?
no / yes yes
In the last year, have you ever drunk more alcohol than you meant to?
no / yes yes
Do you want help with your drinking? no / yes but not today / yes yes but not today, or yes
Do you ever feel the need to cut down on your non-prescription or recreational drug use?
no / yes yes
In the last year, have you ever used non-prescription or recreational drugs more than you meant to?
no / yes yes
Do you want help with your drug use? no / yes but not today / yes yes but not today, or yes
Do you ever feel unhappy or worried after a session of gambling?
no / yes yes
Does gambling sometimes cause you problems? no / yes yes
Do you want help with your gambling? no / yes but not today / yes yes
During the past month have you often been bothered by feeling down, depressed or hopeless?
no / yes yes
During the past month have you often been bothered by having little interest or pleasure in doing things?
no / yes yes
Do you want help with this? no / yes but not today / yes yes but not today, or yes
During the past month have you been worrying a lot about everyday problems?
no / yes yes
Do you want help with this? no / yes but not today / yes yes but not today, or yes
What aspects of your life are causing you significant stress at the moment?
none / relationship / work / home life / money / health / study/ other
Is there anyone in your life whom you are afraid or who hurts you in any way?
no / yes yes
Is there anyone in your life who controls you and prevents you doing what you want?
no / yes yes
Do you want help with this? no / yes but not today / yes yes but not today, or yes
Is controlling your anger sometimes a problem for you? no / yes yes
Do you want help with this? no / yes but not today / yes yes but not today, or yes
As a rule, do you do more than 30 minutes of moderate or vigorous exercise (such as walking or a sport) on 5 days of the week?
no / yes no
Do you want help with this? no / yes but not today / yes yes but not today, or yes
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Brief assessment
Although brief assessments can be very appropriate for mild and moderate levels of
addictions, when CEP issues are present this may indicate higher risk for later severe
addiction. Mild addictions and CEP, however, are often effectively addressed through
brief interventions particularly in primary care settings, which is often the first point of
contact for people. Brief interventions can result in reducing the addiction to controlled or
manageable levels, and in reducing the symptoms of the co-existing mental health
problems.
Examples of brief interventions for mild to moderate
alcohol problems may include:
feedback on the positive alcohol screen.
feedback and advice on safe drinking levels.
goal setting.
strategies when drinking with others, for example,
low-alcohol drinks, setting of appointments to leave
earlier, reduced speed of consumption, alternating
alcoholic drinks with soft drinks.
Examples of brief interventions for problem gambling may include:
feedback on positive gambling screen.
identification of risk times and situations, for
example paydays, when stressed, when out with
friends who gamble and establishing alternative
actions at these times.
leaving credit or debit cards at home.
taking only a set amount of cash and treat as an
entertainment cost.
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Comprehensive assessment
When comprehensively assessing clients, and especially those affected by CEP, all
important problems are covered, including those areas where the client is not managing
well, their physical problems, as well as their strengths and level of wellbeing. Obtaining
additional information from others, with the client’s consent, can often provide additional
important knowledge that the client may not be aware of.
A comprehensive assessment will usually comprise key steps. These are:
data collection – this is information told to you by the client including history and
screening for commonly co-occurring problems, what you observe about the client’s
mental health and motivation, cultural identity, spirituality and family dynamics, risk
assessment for self-harm, and relationships between the addiction/s and CEP.
forming an opinion about mental disorders, including addictions, what problems
and strengths currently exist, why the problems have developed, and how they may
be interacting. A tool that may help in forming these opinions following a logical
step-by-step process is a 4x4 grid that lists biological, psychological, social and
spiritual factors into categories of vulnerabilities, recent triggers for the problems,
factors which cause the problems to persist, and strengths. Factors can often be in
two or more boxes.
analysing the interaction of these factors, which may fit into more than one
category, is also a key part of opinion-forming. This opinion can then be discussed
with the client and an agreement reached as to development of the management
plan to reach the client’s goals.
formulation of the opinion above will inform the treatment or management goals,
and these will lead to the management plan. This opinion will assist the treatment
provider to inform the client and their family about the likely or possible treatment
outcome if the plan is maintained, and its connection to the client’s goals around
wellbeing.
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Learning activity
Read the following scenario, and then complete the table below. Put the
information into the appropriate boxes to help form an opinion about a
management plan that Paula may agree with to help her reach her goals.
Some of Paula’s factors may fit in more than one box, while other boxes
may be empty.
Paula, a solo parent aged 22, uses cannabis daily, and has become very paranoid,
finding it hard to control her temper, resulting in her 5-year old daughter being taken into
care last week. Her parents live in Australia, and she only has one friend who lives
nearby. Paula tells you she gets headaches if she doesn’t use cannabis, but also knows
she didn’t have these headaches, or feel paranoid, before she started using it. She says
she is a good mother and will do anything to get her daughter back. She says she feels
understood by you and feels hopeful.
Vulnerabilities Triggers Persisting
factors
Strengths
Biological
Psychological
Social
Spiritual
NOTE: See suggested answers at the back of this workbook.
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Management
Before meeting the client, if some details are known, thought may be given as to which
service and person may be the best to see the client. Cultural knowledge or expertise
may be appropriate beforehand in order to best meet their needs.
Case management can be approached in several ways, which will determine what
competencies a case manager should have.
The least involved approach is described as ‘brokerage’ where a case manager, after
assessing the needs of a client, refers the client to other services to address those
needs, while the case manager retains the overall role of coordinating the treatment.
From a CEP perspective, this has some potential problems. Integration of interventions,
a critical aspect of CEP, is not often delivered because of the number of services
requiring coordinating, and because some interventions may require several approaches,
are difficult to arrange or see the need for, from a distance.
Assertive community treatment (ACT) is where the case manager is in fact one of a
team of managers with different skills, usually provided ‘in-house’ rather than referred
out, and is an alternative approach where these competencies and resources are
available in the service.
Intensive case management (ICM) is an option where a single case manager provides
an intensive management of the client’s treatment, and can be useful where there is a
need for an assertive outreach for a client often several times weekly, and the CEP client
remains difficult to engage in treatment.
Both ACT and ICM have high resource requirements with case managers often having
fewer than ten to fifteen clients. This is often viewed as overly costly and without strong
evidence of efficient and effective case management that compensates for this cost.
A less intensive and less resource-demanding case management approach is called
clinical case management. This is where the case manager also delivers several of the
interventions. This case management approach is often preferred for CEP clients as
being cost-effective and resource appropriate. Because clinical case managers are
required to address a range of client problems, these case managers need to have a
comprehensive range of skills, such as ability to fully assess a client’s needs, provide
motivation, relapse prevention, monitor psychiatric conditions, management planning and
education of family members.
Within the CEP treatment framework, support workers will work with case managers to
engage CEP clients and retain them in treatment, support the client’s family, assist
clients with strategies to attain wellbeing, and provide assistance to the case manager
whose workload will be higher because of the complex needs and treatment integration
requirements of the CEP client.
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An example
Jane, a support worker, contacts Mary, a client affected by both problem gambling and
depression, and offers her assistance in getting her to attend a budgeting services
person as agreed in her management plan. Mary advises that she doesn’t think she
needs budgeting now as she hasn’t gambled for two weeks and her partner has agreed
to manage her benefit. She thinks that is a good compromise because her partner can
be very tough, and asks Jane what she thinks.
Jane tells Mary that the issue is outside of her expertise, and that she can see some
things for and against it, but that it may have important consequences for her
management plan. Her next counselling appointment is not until the following week, so
Jane tells Mary she will talk with the clinical case manager and get back to her as soon
as she can, with some feedback. The clinical case manager, Robin, is aware that Mary
often has aggressive arguments with her partner, and that this reliance on her partner
may not be a good idea. Robin suggests that Jane should encourage Mary to attend the
budgeting services appointment, just to see what the alternative would be like, and that
Mary gives Robin her informed thoughts next week at the session.
Rollout of the treatment plan
Initial treatment process for CEP clients should be:
ensuring that the client is safe – identify if there is a risk for self-harm, harm or
violence to others.
stabilising any issues that otherwise might affect the client’s ability to engage in
treatment if not addressed, or cause them to leave treatment, for example,
homelessness, legal issues.
As initial treatment priorities are looked after, the next steps are:
working to reduce the harm from the effects of the addiction.
focus upon what may be required to improve the client’s wellbeing.
continuing to motivate the client to stay in treatment and succeed with their
treatment plan.
As treatment progresses into later stages, the focus may be upon:
relapse prevention for the addiction/s through development of coping skills,
organising social supports and activities, and keeping to the agreed mental health
treatment plans.
building up family support and contact with friends.
helping the client to be part of their community.
work on engagement and motivation throughout treatment until the person can take
full control over skills to manage their own continued wellbeing without the need for
the addiction and mental health services.
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This treatment of addiction and mental health issues is not about managing the addiction
issues first, but should be addressed in an integrated way, for example, identify how
each may impact upon the other, and try to minimise risk. The management plan is not
set in stone and should be reviewed as more information becomes available.
A possible structure for the management plan
1 Setting – treatment should be provided in a safe, supportive environment. If their
safety is at risk from the effects of either addiction or mental health problems, then
mandatory steps may be the safest approach, eg under the Alcoholism and Drug
Addiction Act or the Mental Health (Compulsory Assessment and Treatment) Act.
2 Gaining information – from significant others to add to the information that may
assist with the formulation of the treatment plan. However, as Rule 2 of the Health
Information Privacy Code requires information to be collected directly from the
client, subject to listed exceptions (for example, consent given by the client, or acute
mental illness makes this difficult), care must be taken to comply with the Code
when collecting this additional information.
3 Need for involving medical health professionals – for example, a GP or a mental
health case worker. If the client has a mental health case worker then their inclusion
in the treatment plan formulation may be important, especially if medication is
necessary or may be necessary to address psychosis.
4 Psychotherapy or counselling – to address CEP problems, including family therapy
and self-directed strategies, for example, twelve-step meetings for addictions;
support groups for CEP.
5 Family, social, and cultural support is enhanced.
6 Assistance with work goals, if required.
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Integrated care
Integrated care for the client and their family includes, in addition to mental health and
addiction; strengths, relationships needs, spiritual needs, cultural needs, justice needs,
employment needs, housing and physical health needs. The goal for all of these is to
develop them in an integrated approach, for the enhanced wellbeing of the client and
their family.
Integration has not occurred when an issue is treated first in one service, then the client
is transferred to another service for treatment of another issue (serial treatment); neither
does integration occur when two issues are treated at the same time in two separate
services (parallel treatment). Problems that occur include treating problems, rather than
clients, conflicting approaches, for example, abstinence and harm minimisation, and lack
of working together, which can de-motivate clients and cause them to think about leaving
any treatment.
Addiction and co-existing mental health problems are to be expected rather than an
exception to the rule, with no single intervention being correct.
Learning activity
Remember the exercise you did in the section on cultural needs about
Mele. The client’s alcohol symptoms may indicate an alcohol problem
exists alongside their presenting problem.
How might you address this in an integrated way?
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The ideal approach
A current ‘gold standard’ model of an integrated treatment programme is (CSAT 2007):
the same health professional team treats both addiction and mental health issues.
addiction treatments are modified to suit clients with CEP, such as harm reduction
goals rather than abstinence, reducing anxiety, and modified MI approaches.
where appropriate, medication is included in the treatment plan.
matching strategies to the client’s stage of readiness to change.
assertively outreaching, such as assertive community treatment (ACT) where the
emphasis is on engagement and maintaining contact with the client, shared
caseloads within the treatment team, a highly coordinated intensive service with
wide client accessibility to the team, with most interventions provided in the client’s
community.
providing a wide range of therapy options in addition to individual therapy, such as
group work, family work and connection to twelve-step support groups.
a wide range of lifestyle issues also addressed in the treatment plan, including
increasing the client’s social support, assisting with work and social skills, and
rehabilitation.
This ‘gold standard’ may be difficult to establish and maintain because of the high
resources required to sustain it, with few services in New Zealand large enough to
provide all components. When mental health or other problems are outside of the
expertise of the treatment provider that the client presents to, a 2x2 matrix may provide a
guide to involving other specialists within the management plan.
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Although this matrix model has its flaws, in reaching a decision about CEP clients and
the need for an integrated association with either specialist addiction or mental health
services, the matrix suggests:
where the client presents to primary health care with mild addiction and mental
health problems the service should be competent to address both (quadrant 1).
where the client has more severe addiction problems and less severe mental health
problems, for example, pathological gambling and mild depression, this would be
treated in, or connected with a specialist addiction service (quadrant 3).
where the client has more severe mental health problems and less severe addiction
problems, for example, post-traumatic stress disorder and cannabis abuse, this
would be treated in, or connected to a specialist mental health service (quadrant 2).
where the client was affected by both severe addiction and mental health problems,
both specialist mental health and addiction services should work within the
treatment plan (quadrant 4).
Learning activity
Mark in the box, which quadrant would be appropriate for each of these
scenarios, and what other services, if any, you would involve.
A The patient has a mild to moderate cannabis use problem and is also affected by
bi-polar depression.
B You are a practice nurse in a primary health clinic. A patient presents with alcohol
abuse (mild/moderate) and feeling anxious (moderate).
C A client presents to a problem gambling treatment service with severe gambling and
moderate depression.
D The patient is affected by schizophrenia and has a severe alcohol problem.
3
4
1
2
NOTE: See suggested answers at the back of this workbook.
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Brief interventions
Brief interventions are ‘opportunistic’ and can in some cases be as a simple as a
conversation between a concerned family member or friend or a service provider with the
person with the addiction. This may be sufficient to motivate a person to change their
addictive behaviour.
Brief interventions are characterised by the following:
they are not formal therapy sessions.
they work better when the problem has not become advanced, but they can also
work with severe problems.
they focus on motivating a person to change their addictive behaviour.
they aim to trigger a commitment to make a change.
Addiction treatment research has found that relatively brief interventions of one to three
sessions are comparable in impact to more extensive treatments for alcohol problems.
Other research has shown that brief interventions are substantially more effective in
‘curing’ the problem and far more successful than leaving the problem untreated in the
hope that the person will give up their addiction.
Although clients with moderate to severe AOD and mental health problems are best
helped by more intensive interventions rather than brief interventions, brief intervention
strategies can still be used to engage with these clients and provide options for these
needs, and perhaps help support them to attend more formal treatment services.
Additional assistance can also include housing, twelve step support groups such as
Alcoholics Anonymous, employment assistance, and crisis services.
The principle underlying brief interventions is Hester and Miller’s FRAMES mode. This
has been identified by many researchers as being very important in a brief intervention
scenario to help motivate people with an addiction to ‘look at themselves’ and change
their behaviour.
FRAMES =
Feedback
Responsibility
Advice
Menu of strategies
Empathy
Self-efficacy
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The anagram FRAMES stands for the following.
Feedback – the feedback you provide gives the person with the addiction the
opportunity to think about where they are at. Screens are very useful for this.
Responsibility – the person is responsible for taking responsibility for their own
behaviour change.
Advice – providing clear advice, as and when appropriate.
Menu – by providing several options (menu) as a way forward will enhance a
person’s ability to take control and make a choice. The fact that they have chosen
a course of suggested action themselves means it is much more likely to be
successful.
Empathy – empathising with a person is a good way to motivate them to make a
behavioural change.
Self-efficacy – by instilling a belief in their own ability to make an effective change,
and that they can have hope in changing and be optimistic, is a powerful factor in
reaching successful change.
Example of a brief intervention
Your flatmate says that he is not feeling well this morning, and you strongly suspect that
he has a hangover. He feels and acts like this every weekend morning and some
weekday mornings as well. Your response could include some of these approaches.
Feedback, for example: “Oh, any idea why you’re not feeling so well? I did notice
that you were smelt of booze again when you got home last night.”
Responsibility, for example: “It’s good that you’re talking to me about this.”
Advice, for example: “How about starting to think about how much you’re drinking?
Would you consider talking to anyone else about it?”
Menu of options, for example: “Maybe get something to eat before you go out? And
have a glass of water between each drink.”
Empathy, for example: “I know you’ve got a lot going on and it’s been really hard.
You’re not alone and I’m here for you.”
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An acceptable integrated approach
Lesser levels of integration can still be worthwhile when multiple services work together
in any of the key areas of screening, assessment, treatment planning and provision and
ongoing care. This can include issues and needs outside of addiction and mental health.
An integrated approach works with the view that addiction and CEP are both of primary
importance, that a client-centred approach is best, and uses empathy and encourages
hope in the client for reaching their goals. A linkage between services that may address
components of a client’s problems is important and essential, but may not necessarily
include an integrated approach to treatment.
Steps between the client and the treatment provider that are important in an integration
approach are:
1 collecting information from a range of sources, for example, family, mental health
providers, justice, which can be viewed within a common approach, will assist with
an integrated approach.
2 seeking a broad history from the client in order to understand their view of
wellbeing for themselves. Addiction use, cultural factors, their strengths, mental
health, family and spiritual health, educational and work history will all contribute to
an integrated approach to treatment.
3 formulation of an opinion as to how the client’s problems have contributed to, or
caused their current situation.
4 reaching an agreement with the client that the formulation is accurate.
5 working with the client to agree to a management plan to attain their goals. Often
clients and treatment providers can have differing views about what is important,
achievable, and useful. Often organisations may be focussed upon outputs of the
service rather than outcomes or quality of life improvements for the client, and this
may be a barrier to integration.
6 having a team of treatment providers, with a range of necessary skills, and with a
common purpose and approach that is prioritised by the organisation’s managers.
This will enhance engagement of the client in the plan, with the team, and with the
organisation/s providing the treatment. This may include working closely with other
organisations outside of the main team. Screening tools to identify a range of likely
problems will assist with integration, especially if these can be provided in a single
setting.
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Policy and procedures for CEP
Many service providers for CEP clients will have both policies and procedures for
meeting the complex needs of CEP clients. These policies and procedures may include:
screening of all clients in order to identify CEP clients. There may be specific
screens that are approved by the service as valid and efficient for this purpose, and
these should be used rather than being reliant upon individuals’ ability to perceive
CEP problems without screens, or using unapproved screens.
all staff working with clients to be trained to use these screens, provide feedback to
the client, and motivate participation in an assessment where required.
identification of which CEP issues will be addressed ‘in house’ and by whom, and
which ones will be addressed by referral to other organisations.
requirements for regular team meetings of staff working with CEP clients, to review
progress of treatment plans and additional resources or reviews required to address
issues and needs.
the development and maintenance of relationships with other services to ensure an
integrated approach to treatment and wellbeing goals.
Because of the increased needs, risk and competencies required by professional bodies
– for example, DAPAANZ, legal requirements, Health and Disability regulations, the
Health Practitioner Competency Assurance Act, and funders of health services – policies
and procedures in health service organisations are a critical resource, particularly for
those working in the field of treatment for CEP clients.
An example
Peter, a support worker for an alcohol and other drugs treatment service, has assisted
Roland who is affected by bipolar depression, to attend his doctor and then attend
counselling at the service. Roland, who has a good relationship with Peter, discloses that
over the last week he has seriously considered ending his life, and after a heavy drinking
session following his running out of medication had worked out a plan for suicide. He
now feels ashamed about the drinking slip, and says he no longer has any thoughts of
self-harm. He says he has learnt his lesson, won’t drink again, and prefers you didn’t
mention it to his counsellor.
Peter knows, from his service’s policies and procedures manual, that this is an important
event that must be discussed with the case manager, and the treatment team. To ensure
the safety of Roland, and to comply with the service’s policies and procedures,
safeguards must be promptly put in place. He explains to Roland how important the
information that he’s been given is, and how it can be used to protect him from future
risk. In Roland’s presence, he passes on that information to the case manager, and then
promptly records the information for the review.
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Evaluating effectiveness of the support strategy
Evaluation of the outcome of management plans with CEP clients is an important
strategy, especially as new information becomes available and the needs of the client
change. Clients may change their goals, especially as they respond to treatment,
whether positive or not, adjusting what they may desire as necessary for their wellbeing.
In addition, interventions may not achieve client’s goals and may require further
resources or changes in approach. Reasonable outcomes from treatment may involve
more than simply reduction in the addiction problems affecting clients; recovery involves
longer term goals than immediate goals of reducing addiction symptoms, and in the long
run involves additional improvements in health and functioning in society.
The main outcomes to be achieved that have been regarded as important for both the
client and society have been:
reduction in the addictive behaviour.
increases in the health (including mental health) of the client.
improvement in social functioning of the client; this includes employment
improvements, family and other social relationships, and engagement with the
community.
reductions in threats to public health and safety. These include reduction in
offending that may be driven by the addiction and CEP.
McLellan et al 2005
Whereas the importance to be placed upon each of these outcome goals will depend
upon the negotiated goals of the management plan with the client affected by CEP, these
are important overall goals of any treatment and each provides a ‘domain’ against which
treatment can be evaluated for effectiveness.
There are several approaches, or models of evaluation.
The post-treatment follow-up model of evaluation
The ‘gold standard’ model of treatment effectiveness is the ‘baseline’ assessment of the
client’s conditions (using standardised screens followed by assessment where positive)
when first presenting for treatment, followed by an assessment after treatment. By
comparing the two (before and after) measures, there can be a conclusion drawn about
whether the treatment was effective, and how effective it has been.
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The performance monitoring model of evaluation
In this model, data is collected during treatment (rather than after treatment) and regular
reporting back to those involved in the management plan. This performance feedback
enables both the clinician and administrators in the service or services to know if the
service is providing a measurable improvement for patients overall. Examples of
measures are: whether clients are satisfied with the service, whether waiting times are
too long, and if treatment is appropriate to the client. This approach is often referred to as
continuous quality improvement, and enables changes to be made, and repeated
measures occur during treatment to monitor the effectiveness of the service. Overall, the
focus of this evaluation process is on whether the service is operating efficiently and less
directly on the client or their management plan.
Client-focussed evaluation
This approach includes many of the steps in the first two models. At the beginning of
each session, information is collected to immediately see if previous sessions and
‘homework’ has improved the wellbeing of the client. The counsellor evaluates this
information and gives immediate feedback to the client. The feedback is based upon the
client’s symptoms of their addiction and CEP problems (whether they are improving or
worsening), whether relationships are improving, and whether their social roles, for
example, meeting their role in their family, have improved since the last session. This
information may be used to change the management plan in order to better achieve
goals.
Concurrent recovery monitoring evaluation
The concurrent recovery monitoring evaluation (CRM) approach combines many of the
steps of all three above models (McLellan et al 2005), providing immediate evaluation of
treatment and guiding what future care may be required. CRM increases the monitoring
both throughout treatment and post-treatment, providing greater opportunities for
relevant information and increased informed clinical supervision of clients. Information is
often gathered in a standardised manner, to ensure that all issues are covered in a
similar way for both effectiveness, and to enable comparisons to be made and policies
developed for good clinical practice.
An example would be, once a month (or more often if the CEP client was experiencing
ongoing serious negative effects) before a session started, collecting brief information
about symptoms, relationships, and social role performance, in a way that can be made
available to the client for feedback, and to others involved in the management plan
(including service administration).
Careerforce – Issue 1.0 – Jul 2014 US27078 Provide support strategies for addiction service users with CEP . . . 46
An example of CRM evaluation
Conduct a baseline screening/assessment of clients addiction, CEP problems,
relationships status, and social role functioning. The service’s policy and procedures
will provide a standardised approach to be provided to all clients.
A management plan is negotiated and support workers’ roles discussed.
At least monthly, clients will provide information to their counsellor about the
symptoms of their addiction and CEP problems, and information collected by the
counsellor of their relationships and social functioning.
Feedback is provided to the client immediately and used in clinical planning; support
needs are reviewed and addressed.
Information is then provided to the clinical supervisor for safety and clinical
direction.
Management team meetings, including support workers, review client programmes.
Processes are reviewed in supervision.
Discussions with client as to changes to management plan and goals.
Information is collected over time and provided to service administrators for policy
guidance, and for funding audit.
Post-treatment gathering of information on the main outcomes above on a regular
basis over, say, 12 months (not just the once or twice used in post-treatment), and
support worker provides information to case manager, management team and
administration.
Motivation of client to re-enter treatment, if required.
Review of post-treatment information by management team to guide clinical and
service programmes.
The CRM evaluation process appears to have particular relevance for CEP clients.
Because it doesn’t just focus upon post-treatment outcomes, it can provide timely
attention on the needs of CEP clients for medications, therapies, service needs (for
example, support needs), to help clients to achieve their wellbeing goals. These regular,
relevant review processes emphasise the need for structured processes (for example,
screens to use, all clients’ screened/assessed, regular consultation and supervision,
review of plans, regular and prompt client feedback).
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Learning activity
Read the scenario below and answer the questions.
Fai is a first generation Tongan female aged 56 who has an anxiety disorder and is
addicted to benzodiazepines. She has been getting her prescription drugs from three
doctors using different names as her need for stronger doses increased, and she was
unable to tolerate her anxiety. Police have diverted her to your addiction treatment
centre. Fai is both ashamed and anxious about her ability to survive on the now reducing
medication. She is the mother of four children, and grandmother to five grandchildren.
The family is strongly religious and feels that she has shamed them in the church. The
grandchildren ask her if she is going to jail and this makes her cry. Her children want to
help but her husband won’t come with them, feeling he now has to assume her role too
as the only family head.
What support strategies would be appropriate using the strengths model of
management?
What support strategies would be appropriate under the CEP model?
What integrated approach would you use under the CEP model to address both Fai’s
drug dependence and her anxiety disorder?
NOTE: See the suggested answers at the end of this workbook.
Careerforce – Issue 1.0 – Jul 2014 US27078 Provide support strategies for addiction service users with CEP . . . 48
Suggested answers to learning activities
Learning activity - Gerry
Answers could include:
Aggressive outreach or positive assistance such as assisting him to apply to WINZ for an
emergency benefit, negotiating with the landlord or representative to delay eviction, and with his
consent, reconnecting him to his parents for help.
Relationship prioritisation such as assuring Gerry that you have the time to ensure he receives the
help he needs and that you will accompany him if necessary to get that help.
Raising his awareness of his strengths such as being a qualified mechanic, and that redundancy
unfortunately is commonplace in a recession; that changes don’t occur without often multiple attempts
to change, and his presenting again is both normal and indicates his determination despite the
setbacks he has experienced.
Self-determination – he has a range of aims or choices that you can assist him with and it is entirely
his decision as to which aim he would like you to assist with.
Learning activity - Mele
Actions could include:
Discussing the amount of family involvement he wants over and above the involvement of his brother.
Explaining to Mele why it may be helpful to involve his family, and that the wellness of the whole family
may be an appropriate goal for treatment. With Mele’s consent, explain to the family why they could be
involved in his treatment. Identifying Mele’s role in the family before the problems, and how he may
again meet that or another acceptable role. Alongside this, finding out what role, if any, he wants his
girlfriend to have in the treatment.
Assessing Mele’s alcohol use, level of dependence, and discussing with him what options may be
available. Assessing his gambling, and how it fits with his alcohol use. Discussing and agreeing to
strategies to address the harm from both gambling and alcohol use.
Asking Mele whether he wishes to involve an elder or matua as an advisor in his treatment.
Identifying what further help he needs in respect of his traffic offences.
Learning activity - Jenny
Model answer
Reframe it, for example, they may have been worried for her, otherwise they wouldn’t have even come
to Court.
Summarise again, using simple language.
Offer to write the main points down for her to look at later.
Careerforce – Issue 1.0 – Jul 2014 US27078 Provide support strategies for addiction service users with CEP . . . 49
Learning activity - Paula
Vulnerabilities Recent
triggers
Persisting
factors
Strengths
Biological Age (22)
Headaches
Cannabis use
triggers anger
and paranoia
Headaches
Psychological History of
cannabis use
Cannabis use
triggers anger
and paranoia
Cannabis use
Paranoia
Temper and
dyscontrol
Engagement with you
Desire and commitment to
get daughter back
Awareness cannabis use
may be related to
headaches and paranoia
Social Solo parent
Parents overseas
Only one friend
Daughter taken
into care
Your support
Has a friend who
potentially can support her
Spiritual Belief in herself as a good
mother
Feels hopeful
Learning activity
Quadrant 3
Addiction care
C Severe gambling and moderate depression
(could also consider integrated assistance with GP
for depression (quadrant 1))
D Schizophrenia and severe alcohol problem
integrated work between AOD service (quadrant 3)
and MH service (quadrant 2)
Quadrant 4
Shared care
Quadrant 1
Primary care
B Alcohol abuse and moderate anxiety
Quadrant 2
Mental health care
A Mild/moderate cannabis and bipolar depression
D Schizophrenia and severe alcohol problem –
integrated work between AOD service (quadrant 3)
and MH service (quadrant 2)
Careerforce – Issue 1.0 – Jul 2014 US27078 Provide support strategies for addiction service users with CEP . . . 50
Learning activity - Fai
Support using a Strengths approach
develop strong support relationship with client.
convey and build belief in her ability to enjoy a drug free life and regain her role as the maternal
head of her family.
contact her family (with client’s consent) and explain how normal benzodiazepine addiction is
during use, and loss of control with use, and how drug-seeking can be a common reaction. Ask
them to participate in treatment. Especially outreach to her husband with this approach.
assure client ability to overcome her anxiety, and that you have seen this many times before.
emphasize her family, her church, and her culture is a formidable strength.
Support using a CEP approach
Prepare and maintain cultural safety with client and her family using appropriate humility and
language; involve matua or church elder if necessary in preparation and, if acceptable, in treatment.
Understand the importance of tapu and the spirituality for the client and family as a whole.
Involve family in treatment, and try to include her husband, with her consent, spending time to fully
engage.
Encourage family to accept her as maternal head, explaining how her behaviour became controlled by
the addiction.
Identify what outcome she wants (her wellbeing goals, not just a drug-free and anxiety-free goal).
Maintain engagement with the client and family, with you as therapist, the agreed treatment plan when
decided, and the service.
Assess for level of anxiety and drug dependence, or involve a competent assessor, identify why these
may have arisen (why benzodiazepine was prescribed; what reason may have caused this underlying
condition), and her strengths to overcome these.
Reach an agreed treatment plan with her that includes her family, after you have given her feedback
of why this has arisen, and what the likely outcome will be if she maintains the plan.
Integrated approach under CEP for both drug dependence and anxiety disorder:
Involve a GP if her anxiety is elevated, or any further mental health risk arises that requires more skill
than you are able to provide. Involve such a service when required and your client’s needs exceed
your competence; integrate these in your approach with other help engaged, such as the matua, or an
interpreter if required.
If the anxiety is severe, and her needs exceed the resources of a GP, consider help from a mental
health specialist service. A benzodiazepine support group may also be appropriate.
Careerforce – Issue 1.0 – Jul 2014 US27078 Provide support strategies for addiction service users with CEP . . . 51
Completion and assessment
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You have come to the end of the workbook. Please check over all the activities in this
workbook to make sure you have completed them.
Your assessment is next.
You need to complete the assessment successfully to be credited with this unit standard.
Acknowledgements
Careerforce thanks the people who have contributed to this workbook by:
researching and validating content.
providing advice and expertise.
testing the activities.
sharing personal experiences.
appearing in photographs.
The images contained in these workbooks are visual illustrations only and are not representative of
actual events or personal circumstances. Image on page 31 courtesy of marin / FreeDigitalPhotos.net
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Careerforce – Issue 1.0 – Jul 2014