Workbook - Careerforce · 2018-07-01 · Careerforce – Issue 1.0 – Jul 2014 US27078 Provide support strategies for addiction service users with CEP . . . 4 Before you start Welcome

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:

Careerforce – Issue 1.0 – Jul 2014 US27078 Provide support strategies for addiction service users with CEP . . . 3

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


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.


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.


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.


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’.


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%


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.


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.


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.


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.


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.


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.


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?


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.


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.


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.


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.


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.



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.


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


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.


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.


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.


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.


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.



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.


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


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


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


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


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


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


Is controlling your anger sometimes a problem for you? no / yes 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



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.


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.


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



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.


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.


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.


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?


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.


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



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


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.”


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.


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.


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.


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).


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).


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.


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.


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)


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.


Completion and assessment

Congratulations!

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

Creative Commons

This work is licenced under a Creative Commons Attribution-NonCommercial Licence. You are free to

copy, distribute and transmit the work and to adapt the work. You must attribute Careerforce as the

author. You may not use this work for commercial purposes. For more information contact Careerforce

www.careerforce.org.nz

Careerforce – Issue 1.0 – Jul 2014

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Workbook - Careerforce · 2018-07-01 · Careerforce – Issue 1.0 – Jul 2014 US27078 Provide support strategies for addiction service users with CEP . . . 4 Before you start Welcome