week 6 issues with treatment Flashcards
Understand engagement and rapport building – the importance of therapeutic alliance
Theraputic alliance
Bordin, goals, tasks, bonds
Engaging and retaining drug use clients in therapy is a significant issue (Meier et al., 2005). Retention is commonly used as a measure of treatment success (Carroll, 1997. Client-related characteristics that impact retention include the client’s:
Level of psychopathology;
Level of social support;
Distance from place of residence to treatment facility/service; and
Level of motivation (Carroll, 1997).
Therapist-related characteristics found to influence client retention include the therapist’s:
Level of training and clinical experience;
Competence in treatment delivery; and
Level of openness to working with individuals with substance or behavioural addiction issues (Carroll, 1997).
A supportive therapeutic alliance may enhance client engagement and retention, making it more likely that clients can achieve successful treatment outcomes.
a strong therapeutic alliance may enhance client engagement and retention and provide a role model for positive relationships outside the context of therapy
Clear expectations of treatment, including goals, purpose and practicalities, and of the roles of therapist and client are important to developing a strong therapeutic alliance. A recent study has found that clients with a substance use disorder in group therapy who experienced consistency between their expectations and experience of therapy reported a more positive therapeutic alliance
The quality of the therapeutic alliance has consistently been shown to predict client engagement and retention (e.g., Meier et al., 2005; Ruglass et al., 2012). Regardless of the specific treatment type, therapists who are able to develop a positive alliance with their clients have clients who remain in treatment longer and more actively contribute to treatment process compared to those with low therapeutic alliance.
Assessing therapist involvement: therapists’ self-awareness of their tendency to either over-identify with clients’ vulnerabilities and presenting issues or set unrealistic and rigid boundaries. Either has the potential to interfere with alliance and treatment progress.
Treatment agreement developed collaboratively with the client about the expectations of both client and therapist during treatment, and includes the goals, purpose, and practical arrangements of treatment. This indicates the shared responsibility both therapist and client has for treatment.
Therapist awareness of the negative reactions clients may trigger, learning how to manage and use these reactions effectively in therapy.
Use of incentives or rewards.
Enlisting the support of family and friend
Understand why the worker may need to play an advocacy role for a service user
Advocacy is the process of standing alongside an individual and speaking out on their behalf in a way that represents the best interests of that person. The aim of advocacy is to bring about beneficial outcomes in a way that enables each client to retain as much control as possible over how it is carried out. An advocate can provide information and advice in order to assist a person to take action or might take a more active role in representing the person’s rights.
People need advocates for all sorts of reasons. Many clients can successfully advocate on their own behalf, however there are some people who may experience difficulty speaking up for themselves. In these instances, an advocate may:
Assist the client to access services
Assist the client to change services
Ensure that the service chosen is appropriate
Communicate with the service provider
Negotiate suitable resolutions where a complaint or dispute has arisen.
Advocacy may involve speaking, acting or writing on behalf of an individual (or group) who has limited ability to exercise his/her rights. Advocacy is a mechanism to facilitate client rights, and you may be requested to support the client in exercising his/her rights. Examples of rights you could be asked to support include:
he right to privacy and confidentiality;
The right to respect and dignity;
The right to quality services;
The right to information to inform decision making;
The right to choice and control;
The right to make and resolve complaints;
The right to non-discriminatory service; and
The right to protection of legal and human rights, and freedom from abuse and neglect.
Advocacy differs from mediation and negotiation. Mediation and negotiation processes aim to reach a mutually acceptable outcome between parties. The role of the advocate is not impartial, as he or she has an obligation to operate entirely from the perspective of the service user in negotiating an outcome. Advocacy is concerned with genuine major needs, and aims to protect the interests and welfare of the client (Centacare CQ, 2015).
Additional elements have been identified for improving the alliance, including:
Supporting client goals
Developing a liking for the client
Helping the client who needs support to hold on to vital defences and activities that maintain their level of functioning
Communicating hope
Rewarding progress
Acknowledging areas of competence
Encouraging some clients to express themselves
Describe the concepts of harm reduction and abstinence
Kellehear et al. (1998) describe harm minimisation as “an evolving approach to drug use [that] attempts to reduce . . . the harmful consequences that arise from the use of drugs” (p. 136). Rumbold and Hamilton identify the major advantages of harm minimisation as:
a value-neutral view of drug use;
a value-neutral view of users;
a focus on problems or harmful consequences resulting from use;
an acceptance that abstinence is irrelevant; and
a belief that the user has and should continue to have an active role in making choices and taking action about their drug use.
The defining features of harm minimisation are the focus on the prevention of harm, rather than on the prevention of drug use itself, and the focus on people who continue to use drugs
It is based on the recognition that many people throughout the world continue to use psychoactive drugs despite even the strongest efforts to prevent the initiation or continued use of drugs. Harm reduction accepts that many people who use drugs are unable or unwilling to stop using drugs at any given time.
Abstinence:
Severity of dependence is a key factor when setting goals of controlled drinking or abstinence. Controlled drinking is usually more appropriate with lower levels of dependence, while higher levels of dependence indicate abstinence as the best option. Controlled drinking may be attempted after a period of abstinence of at least 3-6 months for such individuals.
It was found that outcomes for abstinence vs controlled drinking strategies were virtually equivalent and did not differ significantly. Most heavily dependent people ended up choosing abstinence, and key findings highlighted some key issues (Sobell, 1995):
The notion that treatment goals are determined by service providers seems an illusion.
Neither specific encouragement nor skills training facilitates a moderation outcome.
Outcomes are strongly related to other life circumstances often associated with severe dependence (e.g. lack of social support, poor vocational history).
The attractiveness of various approaches to potential clientele matters.
Although problem-free drinking may be a rare outcome for severely dependent alcohol abusers, it is an equally effective entry to the treatment pathway
Understand the approach to comorbidity in treatment seeking populations
stimates ranging from 38% to 59% of people with a lifetime addictive disorder also have a lifetime mental health disorder (Kessler et al., 1995; Regier et al., 1990). These disorders tend to be anxiety and depression but other diagnoses such as bipolar disorder and psychotic disorders are also common. It is often said that comorbidity – that is, the concurrent mental health and addiction problems, is the norm rather than the exception.
Despite these figures, only about one in seven Australians with a substance use disorder had sought assistance from a health professional in the past 12 months, with a general practitioner being the most frequently seen. Women (21%) were more likely to have sought treatment than men (12%) for a substance use disorder. While the presence of symptoms does not necessarily indicate treatment is required, there was a striking lack of professional help-seeking, with approximately 65% of persons with a mental health disorder not obtaining professional help.
Describe self-management and reflective practice
In the field of addiction, it is extremely common for clients to present with trauma histories (or current ongoing trauma experiences), suicidality and self-harm, and complex interpersonal presentations. The ability of the therapist to maintain objectivity, productivity, manage countertransference, and cope with such stressful and emotionally-laden presentations on a weekly or daily basis is therefore extremely important.
Therapists need to maintain awareness of their reactions to client presentations and the content discussed, reflect on why such reactions have been experienced and how they are/may impact on the therapists’ well-being, and the strategies available to enhance coping ability and resilience. Staying attune to such factors can help the therapist maintain resiliency in both professional and personal spheres, identify when further supervision is needed, and alert them to the risk of burnout.
Burnout has been defined as a syndrome of emotional exhaustion which results from the “chronic emotional strain of dealing extensively with other people, particularly those experiencing problems”
The risk of burnout can be reduced through the maintenance of effective self-care strategies (Derthick et al., 2015), and through maintaining an active awareness (through self-reflection) of your coping ability and resilience.
Helpful strategies include mindfulness (i.e., Christopher et al., 2011), making time for exercise and/or leisure activities, having massages or attending to personal self-care (i.e., hair appointments), leaving work at the office (i.e., not discussing work at home), sticking to planned work-life balance, calling friends or other supports, making time for hobbies, and, importantly, engaging in regular clinical supervision and debriefing. By having a range of effective coping strategies at your disposal, you can be better prepared to identify and manage indicators of burnout, and experience enhanced well-being in both your professional and personal life.
