Empowering Interventions

Guide for Empowering Coaching and Crisis Interventions Composed by Dean Amory

Empowering Interventions

Guide for Empowering Coaching and Crisis Interventions Composed by Dean Amory

Title: Empowering Interventions Guide for Empowering Coaching and Crisis Interventions Composed b : !ean "mor !ean#"mor $hotmail%com &ublisher: Edgard "driaens' (elgium edd adriaens$ ahoo%com I)(*: + Cop right 2,-3' Edgard "driaens' (elgium' . "ll /ights /eserved%

This boo0 is a compilation of information freel available in the &ublic !omain and gathered and composed b !ean "mor % It has been composed based on the contents of trainings' information found in other boo0s and using the internet% It contains a number of articles and coaching models indicated b T1 or + or containing a reference to the original author% 2henever ou cite such an article or use a coaching model in a commercial situation' please credit the source or chec0 with the I& .owner% If ou are aware of a cop right ownership that I have not identified or credited' please contact me at: edd adriaens$ ahoo%com

When I invite you into my confidence my secret places introduce you to my devils my ancestors my way of being Show me this much: that you will tread lightly over the graves yield to my wisdom now me as creator! lover! ma er of my life amidst this ruc us"

Ellen 4awle 1c2hirter

Inde#: Introduction %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 7 Chapter - %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 8 Goals of this Guide%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 8 The goals of empowering intervention services %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 8 Chapter 2 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -, !efinition of 9&ersonal Crisis:%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -, T pes of personal crisis %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -, Chapter 3 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -Empowering Intervention Components %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% --% Importance of the first contact %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -)ample of a telephone script for the correct handling of incoming calls %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -2 2% The &ersonal Crisis Intervention )ervices )"/E 1odel%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -3 -% )creening %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -3 2% "ssessment %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -3 3% (uilding /apport %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 24% Empowering %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 36 3% ;oundations of Empowering Interventions%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 72 -% (rief )olution ;ocused Counseling%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 72 2% Cognitive (ehavioural Counselling%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 78 3% Empowering <anguage%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% --, 4% )ample ;ormats for )essions%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% --2 Chapter 4 %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% --5 The Intervention &rocess%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% --5 2hat is involved in the crisis intervention process=%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% --5 "ctive <istening %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% --5 The five stages of grief are:%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -24 Identif ing a ma>or problem%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -26 E?ploring possible alternative solutions %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -3, Evaluating %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -3, Chapter 3%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -32 Critical Incident )tress 1anagement @CI)1A %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -32 1oving &ast a 1oment of Crisis%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -37 &ost.Traumatic )tress !isorder:%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -37 "pprehension "m I )tressed But%%%=%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -4, Critical Incident )tress: Tips on 4ow to /ecover from a Critical Incident %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -45 Critical Incident )tress Tips to Colleagues and ;amil %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -47 Chapter 5%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -48 4arm "ssessment @)uicide' 4omicide' In>ur to self or othersA %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -48 2hat should a responder 0new about suicide= %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -48 2hat ma0es depression and alcoholCdrug abuse important=%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -34 "ssessing dangerousness to others%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -36 "nne? -: )creening %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -54 "nne? 2 : "ssessment tools%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -76 "nne?3 : 4ow to deal with an e?istential crisis %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -82 "nne?4: 4ow to help a friend with depression %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% -85 )ources: %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% 2,2

Introduction Therapists' Counsellors' Coaches' <ifeline Dolunteers' /ecover Coaches' Crisis Intervention Bperators' %%% ever da ' man people provide support to other people that are passing through a diffult phase in their lifes or are affected b crisis' disaster or other critical events' such as loss or serious illnesses' depression' burn out' living in isolation or being stigmatised' %%% "lthough ever bod concerned with responding to human suffering' will find man useful techniEues in this manual' the main purpose of the guide is to help la counsellors' relatives and friends of people in need to discover empowering techniEues to support the people around them that find themselves afflicted b crisis% The shoulder and ear of a friend or a lifeline volunteer' the ps chosocial support the provide' should never replace professional counselling where this is needed and one of the responsibilities of an bod assisting people in need without having a professional mental health bac0ground or formal degree in counselling' is to refer the people who turn to them for support and advice to Eualified officials' when this is deemed useful or reEuired% Fet' not all people affected b crisis need or want professional help' and even though at times the intervention of a professional counselor or therapist will be absolutel necessar for the individual see0ing help' at other times the input of a peer: a fellow >ourne er or trusted friend or relative' will suffice to ma0e the difference and help the person affected b crisis to get bac0 on his feet% "lso' to all the people that are going through a phase of personal crisis and are treated in an ambulant wa ' it will ma0e a huge difference when the can fall bac0 to friends and relatives who master empowering intervention s0ills' allowing them to provide better support during the time the spend together% )ince all of us will find ourselves sooner or later in a situation in which relatives or friends need our help and support' we ma as well prepare ourselves for the occasion% The s0ills reEuired of a la counsellor will differ depending on the situation and the setting in which the are wor0ing% ;or e?ample' counselling on a phone line for people at ris0 of suicide will be different from helping in the immediate aftermath of a disaster' which will again differ from counselling grieving or depressed people or people living with serious illnesses% 4owever' certain s0ills appl to all these situations% I am convinced that the techniEues >oined in this manual provide for a basis that will prove of utmost importance in an 0ind of coaching or crisis intervention% !ean "mor

Chapter $ Goals Goals of this Guide " primar goal of this guide is to offer an empowering basic approach for coaches and providers of personal crisis services aimed at providing support to the distressed and suicidal and' more in general' all people going through a phase of personal crisis in their lives% "nother goal of this guide is to increase awareness and understanding that a personal crisis often is a situation defined as such b the perception of the individual e?periencing it% "n outcome of appl ing the techniEues set forth in this guide is increased awareness and utiliGation of the most appropriate and motivating instruments available to encourage empowerment and recover of individuals served% %he goals of empowering intervention services The goals of empowering intervention services include' but are not limited to: -% &romote the safet and emotional stabilit of individuals e?periencing a personal crisis% 2% 1inimiGe further deterioration of these individuals% 3% &rovide sufficient information to clients for them to learn how to ma0e their own decisions' encouraging them to re.ta0e control of their lives and decision ma0ing power 4% "ssist individuals in rebuilding self.confidence and developing or enhancing better coping s0ills' better problem solving s0ills and a natural support s stem% 3% 4elp individuals find and obtain ongoing support' care and treatmentH 5% Getting the client to see himself as the agent of change' capable of using the 0nowledge and s0ills of others in furthering their own interest and creating responsible social change% 6% Encourage the use of the best techniEues available to meet the individualIs needs%

Chapter & Definition of '(ersonal Crisis) " personal crisis is defined as an intensive behavioral' emotional' or ps chiatric situation which' if left untreated' could result in an emergenc situation' in the placement of the person in a more restrictive' less clinicall appropriate setting' including' but not limited to' inpatient hospitaliGation or at the ver least' significantl reduce levels of functioning in primar activities of dail living% J" personal crisis can be thought of as a s stem out of balance% *ormall ' all of us maintain our state of eEuilibrium on a da .to.da basis without too much trouble% Bbstacles are overcome because weIve learned good coping s0ills to re.establish eEuilibrium after some event has temporaril 0noc0ed us off balance% &ersonal crises occur when the balance cannot be regained' even though we are tr ing ver hard to correct the problem%: %ypes of personal crisis %wo Different types of personal crisis occur" Bne is a developmental crisis' li0e a >ob change' retirement' having a bab ' our bab turns -4% The other is a situational crisis li0e rape' robber ' sudden death' or being diagnosed with a chronic or terminal disease% 2ith regards to a situational crisis' the cause is often defined as a 'Critical Incident:% " Critical Incident is an event that has an impact sufficient enough to overwhelm the usuall effective coping s0ills of either an individual or even a group% Critical incidents are t picall sudden' powerful events that are outside of the range of a personKs ordinar e?periences% (ecause the are so sudden and unusual' the can have a strong emotional effect% If the critical incident is e?treme in nature' it ma serve as the starting point for the ps chiatric disorder called 9&ost.traumatic )tress !isorder%: Critical Incident )tress services help mitigate this possibilit % Critical Incident )tress @CI)A or traumatic stress is an unusuall strong emotional reaction that has the potential to prevent the individual from maintaining their normal duties and responsibilities within their wor0' social and famil environments% The reaction ma be immediate or dela ed% 1ost personal crises however occur because a person is >ust overloaded% " reprimand from a supervisor ma be accepted without issue one da % 4owever' if it happens when ou alread have several stressors using up our reserve of coping abilit ' it ma be the event or precipitator that pushes ou off balance% In other words' the person is pushed enough off balance that he or she needs assistance to rebalance his or her s stem% This definition focuses on the needs of a person who is being stressed rather than the cause that evo0es this response%

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Chapter * Empowering Intervention Components $" Importance of the first contact In a crisis situation' each component of wor0ing is important' however the first few minutes of a contact could determine if the individual will continue to see0 out assistance or not% "ssuring a supportive' therapeutic interaction right from the ver first moment of contact will therefore be ver important in the outcome of the situation% If the first contact is made over the phone' normall ' within seconds' the caller is forming an opinion of the people the ma interact with and the possible services the ma receive% The service provider answering the telephone must ensure the initial contact is a positive one' setting the stage for a successful e?perience and instilling confidence in the professionalism of the service Eualit % "s each service component is reviewed throughout this manual' it is important to understand that although one person ma present with a crisis situation' famil members andCor significant others are also affected b the crisis situation% It will often be important to engage famil members andCor significant others for information and clarit of the crisis situation to the e?tent appropriate% "lthough this concept is not directl stated through out this manual' it is implied and should alwa s be practiced% What are crisis telephone answering s ills+ Bften' the first contact with the individual e?periencing a personal crisis' will occur through a telephone call to a crisis service provider or crisis line% The manner in which the crisis telephone is answered sets the tone for the contact% "ll telephone calls are reEuired to be answered in a uniform' courteous' and professional manner to be followed b all telephone operators on answering incoming calls %he following are a few tips to assure these re,uirements are met: 1. "nswer the telephone as soon as possible' but preferabl within at least three @3A rings% 2. "ll telephone calls are to be answered Jlive:% *o answering machines or other electronic mechanisms are allowed to field crisis calls% 3. "ll telephone operators of hotlines should answer the telephone in a standardiGed and courteous wa % ;or e?ample' JGood morning, Lifeline Services, how may I help you?J

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Sample of a telephone script for the correct handling of incoming calls -% 2elcome Goodmorning' <ifeline )ervices% This is L1 nameM spea0ing% 2% Caller Identification In case we are accidentall disconnected could I please have - Four full name= - Four telephone number= - The address from which ou are calling= - "nd our Email address=% 3% )creening C Establishing the purpose of the call 4ow can I help ou toda = 4% Commence "ssessment C Troubleshooting C Empowering Can ou describe the nature of the difficult 3% Conclusion of the call Is there an thing else I can help ou with toda = 1 name is L1 nameM% If ou have an further difficulties please do not hesitate to call again% Than0 ou for calling <ifeline )ervices% 4ave a good da ' goodb e% ou are e?periencing=

General call behaviour rules -% "lwa s as0 for permission before ou put caller on hold 2% &rovide an estimate of how long the ma e?pect to be on hold E?ample . 9would ou mind if I place ou on hold for a few minutes while I chec0 some of our s stems=: 3% If a caller is placed on hold' chec0 bac0 with the caller ever minute to give himCher feedbac0 regarding the status of the call% 4% 2hen ou return from placing the customer on hold sa : 9than0 ou for holding: 3% If ou need to tal0 to other staff' press the mute button% - !o not place the person on a spea0er telephone% - This ma ma0e them feel there is no privac in the conversation and ma prevent them from telling ou important information% - Nsing a spea0er telephone ma also compromise the confidentialit of the callerIs right to protect their private health information%

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&" %he (ersonal Crisis Intervention Services SA-E .odel %he SA-CE mnemonic stands for: $" &" *" 0" Screen Assess /uild -apport Empower

$" Screening &rior to initiating an crisis assessment service' some sort of screening of the potential crisis situation must be conducted% The screening ma be formal or informal' occur through a telephone call to a crisis line' an appointment with the personal crisis service provider or through information obtained from a third part @famil member' friend or othersA% The screening determines the problem and needs of the individual as well as provides guidance for crisis prevention andCor earl intervention% This screening information @which ma be incomplete or from an untrained personA can help to determine if a formal crisis assessment service is warranted% The screening should not be more intrusive than necessar % It should be done before an details of the problem are elicited and the caller should be told the reason for the Euestions upon reEuest% What is included in a crisis intervention screening+ The screener must gather basic demographic information' determine whether a crisis situation ma e?ist' identif parties involved' and determine an appropriate level of response% The screener must use active and supportive listening s0ills to determine if a crisis intervention is reEuired' and which service intervention would best address the personIs needs and circumstances% The initial screening must consider all available services to determine% ;or some individuals' information about services or a referral to a local service provider would be an appropriate and sufficient intervention% Bthers ma need telephone or a face.to.face intervention% (ased on the information gathered to this point' the screener must determine whether a crisis reEuires further assessment% It should be noted that disruptions in life that ma not create a crisis situation for one person at an given time might create a crisis situation for another person% "lternatel ' disruptions that might not have posed a challenge during one time ma cause significant turmoil at other times in the personIs life% If the person believes that he or she is e?periencing a personal crisis' it is best to honor that belief% 2henever we screen and identif specific needs' we have an ethical responsibilit to either provide the necessar ne?t steps @assessment or interventionA or refer to an appropriate source for follow up% )creening processes alwa s should define a protocol or procedure for determining which clients need further assessment @i%e%' screen positiveA for a condition being screened and for ensuring that those clients receive a thorough assessment% That is' a professionall designed screening process establishes precisel

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how to score responses to the screening tools or Euestions and what constitutes a positive score for a particular possible problem @often called a 9cutoff: scoreA% The screening protocol details the actions ta0en after a client scores in the positive range% In a professional conte?t' it also provides the standard forms for documenting the results of the screening' the actions ta0en' the assessments performed' and that each staff member has carried out his or her responsibilities in the process% )creening alone is not sufficient to diagnose a situational' developmental' behavioral' or health concern% It is one piece of information that ma indicate the need for further evaluation b a Eualified professional% If the screening raises concerns' then the screened individual should be referred to a Eualified professional who will perform further evaluation% If the person is eligible' the Eualified professional will lead the development of an IndividualiGed )ervice &lan and coordinate services "lthough a screening can reveal an outline of a clientKs situation and needs' it does not result in a diagnosis or provide details of how previous e?periences have affected the clientKs life% Appropriate Screening %ools )creening procedures and tools should be: - <inguisticall appropriate% 2hen possible' the screening tool should be in the individualKs primar language - "ge and developmentall appropriate% - Culturall appropriate% )ome developmental s0ills ma loo0 different depending on the culture and bac0ground of the individual screened% 2hen possible' use a screening tool or procedure that ta0es into account the personKs cultural conte?t% 2hen a culturall and linguisticall appropriate screening tool is not available' information from families is even more critical to ensure validit % - Dalid' reliable' and standardiGed when available to ensure that the tool gives information about the how a person is developing relative to a larger group of their peers% - Identified as screening tools% )creening tools might inform ongoing assessment' but a tool created for assessment would not be appropriate for screening%

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&" Assessment %he Difference /etween Screening and Assessment The purpose of screening is to determine whether a person needs assessment% The purpose of assessment is to gather the detailed information needed for an action plan that meets the personal needs of the individual% )creening involves as0ing Euestions carefull designed to determine whether a more thorough evaluation for a particular problem or disorder is warranted% 1an screening instruments reEuire little or no special training to administer% )creening differs from assessment in the following wa s:

Screening is a process for evaluating the possible presence of a particular problem% The outcome is often a simple es or no% Assessment is a process for defining the nature of that problem' determining a diagnosis' and developing specific treatment recommendations for addressing the problem or diagnosis%

Assessment The assessment e?amines a clientKs life in far more detail so that accurate diagnosis' appropriate treatment placement' problem lists' and treatment goals can be made% Nsuall ' a clinical assessment delves into a clientKs current e?periences and her ph sical' ps chological' and socio.cultural histor to determine specific treatment needs% Nsing Eualified and trained clinicians' a comprehensive assessment enables the treatment provider to determine with the client the most appropriate treatment placement and treatment plan @C)"T 2,,,cA% *otabl ' assessments need to use multiple avenues to obtain the necessar clinical information' including self.assessment instruments' clinical records' structured clinical interviews' assessment measures' and collateral information% /ather than using one method for evaluation' assessments should include multiple sources of information to obtain a broad perspective of the clientKs histor ' level of functioning and impairment' and degree of distress% "ssessment is a process that is much more comprehensive than the screening.process% It includes the famil ' and assesses the individual in all life domains including evaluating strengths and famil % "n assessment should be conducted as soon as possible after the screening results have determined its necessit % - 2hereas a screening is alwa s necessar ' an assessment will onl be conducted in the individual needs a more thorough evaluation' empowering guidance or counselling and when conditions permit: o "lmost alwa s during face to face meeting at the clientKs home or in the premises of the service provider o 2hen the client is cooperative' that is: able and willing to answer the Euestions in a calm and rational manner o 2hen the time and the will to achieve a more thorough evaluation is present with all parties%

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In case of an inta0e' it usuall ta0es place within 3, da s of inta0e and screening and contains such components as: - It should be conducted b a Eualified individual with the appropriate credentials reEuired b the licensing authorit % - The assessment should be culturall and linguisticall appropriate for the individual and the famil ' ta0ing into consideration the famil Ks level of acculturation and assimilationH their cultural world views of healthCwellness' illness' and treatmentH and their values' traditions' beliefs' rituals' and practices% In addition' it should be conducted in the preferred language and in a setting that is conducive to the most cooperation from' and ease for both the individual and the famil % In general' assessment must be individualiGed to meet the needs and identif the strengths of the person assessed% "s with all interventions' informed consent must be sought and properl documented% %he Assessment Interview To provide an accurate picture of the clientKs needs' a clinical assessment interview reEuires sensitivit on the part of the counselor and considerable time to complete thoroughl % 2hile treatment program staff ma have limited time or feel pressure to conduct initial ps chosocial histories Euic0l ' it is important to portra to clients that ou have sufficient time to devote to the process% The assessment interview is the beginning of the therapeutic relationship and helps set the tone for treatment% Initiall ' the interviewer should e?plain the reason for and role of a ps chosocial histor % It is eEuall important that the counselor or inta0e wor0er incorporate screening results into the interview' and ma0e the appropriate referrals within andCor outside the agenc to comprehensivel address presenting issues% ;or instance: the notion that a personKs substance use is not an isolated behavior but occurs in response to' and affects' other behaviors and areas of their lifes is an important concept to introduce during the inta0e phase% This information can easil disarm a clientKs defensiveness regarding use and conseEuences of use% General Guidelines of Assessment

)imilar to the screening process' the individual assessed should 0now the purpose of the assessment% To conduct a good Eualit assessment' counselors need to value and invest in the therapeutic alliance with the client% Challenging' disagreeing' being overl invested in the outcome' or vocaliGing and assuming a specific diagnosis without an appropriate evaluation can Euic0l erode an potential for a good wor0ing relationship with the client% The assessment process should include various methods of gathering information: clinical interviewH assessment tools including rating scalesH behavioral samples through e?amples of previous behavior or direct observationH collateral information from previous treatment providers' famil members' or other agencies @with client permissionAH and retrospective data including previous evaluations' discharge summaries' etc% "ssessment is onl as good as the abilit to follow through with the recommendations% "ssessments need to incorporate socio.cultural factors that ma influence behavior in the assessment process' interpretation of the results' and compliance with recommendations%

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The assessment process should e?tend be ond the initial assessment% "s the assessed person becomes more comfortable' additional information can be gathered and incorporated into the revised assessment% )ubseEuentl ' this new information will guide the reevaluation of presenting problems' treatment priorities' and treatment planning with input and guidance from the client% /eassessments help monitor progress across the continuum of care and can be used as a barometer of effective treatment% 1oreover' the presenting problems and s mptoms ma change as recover proceeds%

1oo ing at strengths ;ocusing on strengths instead of deficits improves self.esteem and self.efficac % ;amiliarit with the individualKs strengths enables the counselor to 0now what assets the can use to help them during recover % The use of good self.assessment wor0sheets that focus on individual strengths are to be recommended% In addition to assessing strengths' coping st les and strategies should be evaluated @see /ogers 2,,2A% What is included in a crisis assessment+ " crisis assessment evaluates an immediate need for emergenc services and' as time permits' the personIs: current life situationH sources of stress and acuit levelH mental health problems and s mptomsH )trengthsH cultural considerationsH identifiable and realistic support networ0H drug and alcohol useH current medication useH vulnerabilitiesH and current functioning%

What is a personal crisis intervention service+ J&ersonal crisis intervention serviceJ refers to an isolated intervention or to a series of interventions which ma be face.to.face or telephonic short term' intensive conversations initiated during a personal crisis or emergenc to help the person cope with immediate stressors' identif and utiliGe available resources and strengths' and begin to return to the personIs baseline level of functioning% Intervention settings ma include the personIs home' the home of a friend or famil member' the service providerKs premises' a hospital or emergenc room' >ail or other communit settings% &ersonal intervention services can ta0e place at an time or da of the wee0% &ossible determinants indicating the need for a face.to.face intervention include: e?treme d sphoria @deep sadness' an?iet and restlessnessA' severe depression' suicidal intent' homicidal intent' acute ps chosis

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Bthers include: hopelessness' helplessness' e?treme tearfulness' and e?treme detachment or withdrawalCisolation If the crisis assessment determines that crisis intervention services are needed' the intervention services must be provided as urgent or emergent% Who may conduct a crisis assessment intervention+ 2hereas mental health crisis interventions should be alwa s conducted b trained' credentialed andCor approved mental health personnel and professionals who have a licensed ps chiatrist or ph sician e?perienced in ps chiatr available for consultation' ever bod will live through moments in life when the circumstances reEuire of them that the act to help and support people going though a personal crisis% What is the function of hotlines in this conte#t+ 4otlines are designed to help individuals to handle crisis situations% 4otlines cannot operate alone% The rel on a networ0 of other organisations that offer professional health and counselling services 4otline telephone operators can: - <isten to people without >udgingH support them in their >ourne b showing empath for them and their problems - &rovide basic information - Connect people to available resources where the ma find practical help - &rovide limited emotional support 4otline telephone operators cannot do the following: - Tell &eople what to do - &rovide e?tensive counselling or emotional support - &rovide medical care or services directl ;or all hotline telephone operators and first line service providers in a professional environment' a structured approach providing the necessar administrative' educational and emotional support must be put into place: information and training should be made available to all operators' including up to date referral lists and resources for callers' training in communication techniEues' assertiveness' setting personal boundaries and personal stress reduction strategies' as well as offering an outlet to tal0 about their feelings and a chance to discuss difficult calls% )upervisors should e?press appreciation for a >ob well done% &ositive feedbac0 is important for operators to feel the are doing a good >ob% J!ebriefingJ' Jcase reviewJ or Jps chological first aidJ are terms used b mental health professionals to describe interventions that should be available when a crisis service provider e?periences a completed suicide or traumatic event that involves a service recipient% The goal of these interventions is to allow a crisis service provider to e?press their personal reactions to the event and to identif steps that might relieve stress s mptoms related to their e?posure to the event% In some cases' emergenc mental health interventions ma include staff members outside of the crisis service provider% "n of these interventions should be conducted b ' or in consultation with' a trained mental health professional in the area of emergenc mental health services%

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!ebriefing occurs preferabl in a structured manner' occurs immediatel after a shift' and is mainl supportive and not as formal as supervision% ( ta0ing place immediatel following a shift' operators can discuss feelings about upsetting calls and deal with responding to other issues' prior to the ne?t shift% 1a0ing a difference in someoneIs life' helping individuals improve their lives and find solutions to their problems' can be e?tremel challenging and satisf ing for those who en>o seeing the positive results of their direct action% "nother benefit reported b those wor0ing in this field is the level of camaraderie that often e?ists within these organiGations% It can be inspiring and invigorating to see what people can accomplish when the gather for the sole purpose of helping others live better lives% 4owever' while this wor0 can be highl satisf ing' it can also be emotionall draining and full of frustrations% Bne of the reported difficulties of providing services within some bureaucratic s stems is the amount of paperwor0 often reEuired% ;or people who enter this field because of their desire to help people' this can be a significant challenge% In addition' this wor0 can be frustrating because change often happens in a slow' sometimes almost undetectable wa ' and seeing the benefits of our wor0 ma ta0e a long time% ;or people who are committed to helping others' accepting the fact that there is alwa s more to do than could ever be done' can be difficult% Bne of the greatest challenges for people who see themselves as 9helpers: is to balance giving with 0nowing when ou have done enough% 2or0ing as a hotline operator is a great responsibilit and should never be ta0en lightl % "s a hotline operator' ou donIt want to wing it with people whose lives are hanging b a thread% Fou should onl use established procedures and training to get the person bac0 from the brin0% "s a hotline operator' it is important not to place too much pressure on ourself% Fou are there to help people ou canIt diagnose or advise them' so rel on our training and people s0ills to help them find the right people who can help and to ma0e their own choices% &reventing burn.out b setting personal boundaries is critical to longevit and success in the social service field% %hings you may need to learn if you want to become a hotline are: - Emergenc procedures . what to do if things arenIt going well with a caller% - )tate laws concerning the operation of a crisis center . these concern the liabilities and restrictions that are important to 0now' even as a volunteer% - The range of help available out in the communit to direct callers to' from financial and legal to rehabilitation or deto? help% - Counseling techniEues . getting people who are reall hurt to tal0 to ou openl or even at all can be difficult% FouIll need to learn the wa s of helping people to open up and how ou can demonstrate trust% "lso' most crisis hotlines will teach ou that our role is to facilitate the callerIs own decision.ma0ing process through prompts and guides% Fou donIt ma0e the decisions for the caller' nor do ou counsel% 2ow soon must o crisis intervention plan be developed+ "s part of the crisis intervention services' the crisis services provider must develop a crisis intervention plan during the initial face.to.face assessment% The plan must address the needs and problems noted in the crisis assessment and refer to identified services to reduce or eliminate the crisis% What if the personal crisis service provider determines that the person re,uires e#tra services+ If the crisis service provider determines that the person reEuires mental health crisis stabiliGation services' such as crisis respite or crisis stabiliGation' the crisis services provider must arrange for the provision of

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these services either directl or through other resources' depending on his professional Eualifications and the circumstances at hand% - Crisis stabiliGation services are designed to assist the person in returning to his or her prior functional level or improved level of functioning' if possible% - 1ental health stabiliGation services are individualiGed mental health services that are provided to a person following a crisis assessment

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*" /uilding -apport 2e all 0now that 9" man convinced against his will' remains of the same opinion still %%: That is wh ever sales. or h pnosis course and ever article about dating will tell ou that ou need to start with creating as much rapport as possible% Bnl after ou have created sufficientl emotional connection and trust' will the other person feel comfortable enough to actuall listen to ou' and accept and emotionall respond to images that ou are describing% 2ow to create rapport+ Creating rapport is about establishing a tangible and harmonious lin0 b getting on the same wavelength with another person% Fou 0now there is rapport when ever thing clic0s and feels right' when it is as if ou 0now and understand each other and our ideas are s nchroniGed% 2hen there is rapport' ou feel bonded' connected and en>o time together% <in0 ourself with people and things the other person 0nows about and li0es% 1a0e them tal0 about sub>ects that are familiar and en>o able to them% )earch for common ground% If the li0e gardening and ou do too' then tell and show hem how much ou en>o gardening% -% Fou can develop rapport faster b pa ing attention to bod language' mirroring and matching and empathic listening% /ody language /eading bod language correctl enables ou to identif the individualKs emotions and discomfort% Nsing bod language appropriatel ' including e e.contact and touch' helps ou to get the attention desired and can create a positive perception%

(e conscious of our bod language% 2hen meeting people for the first time' itKs obviousl important that ou appear rela?ed and open in our stance and that ou ma0e good e e contact% "s the conversation goes on' it can also help to mirror the bod language of the person ouKre spea0ing to' not in an obvious wa ' but in a wa that gives the impression that ouKre 9in s nch: with each other% 1a0e sure as well that ouKre focused on the person that ouKre tal0ing to' not loo0ing around the room' which can give the impression that ouKre loo0ing for someone more interesting to tal0 to% .irroring and matching "C 1irror our listenerKs bod language That is: their posture' movements' breathing rh thm and ph sical state% 2h = Cop ing their behavior causes them to feel similar to ou' which in turn will lead to our listener starting to cop ou in response The idea is to align our movements and bod image with the other personKs demeanour% 1irroring or reflecting is not the same as imitating' but b presenting similar demeanours as the other personKs' the will subconsciousl feel that ou have much more in common with them than ma actuall be the case% Fou can mirror or match language' including rate of speech and vocabular used' breathing' voice' moods' movements' energ level' O

2-

(C Confirm and match our listenerKs inner world% That is: their values' perceptions' beliefs' emotions' ideas and assumptions% 2h = when ou cop our listenerKs wa of seeing the world @visual' audio OA' their wa of e?pressing themselves @words and e?pressions he usesA' repeat their values' accept them as the are and confirm them in their beliefs and opinions' the will listen to ou' accept what ou are sa ing and start to li0e ou because the will see ou as ver similar to themselves and will appreciate the respect ou show them% "fter all' ou are confirming them in what and how the are and what ou are telling' is the truth' such as the too perceive it% 2ere is how to do it: -% 1atch the persons sensor modalit 2hat I mean here is to match and mirror the wa that the thin0 and tal0% /emember when we were tal0ing about visual' auditor and 0inesthetic modalities= 2ell' this is about putting it into practice% <isten for the indicator words that the person is using and use wordsCphrases from the same modalit % "lso' loo0 out for e e movements to spot thin0ing patterns% 2% 1irror the persons &h siolog ( cop ing the persons posture' facial e?pressions' hand gestures' movements and even their e e blin0ing' will cause their bod to sa unconsciousl to their mind that this person is li0e meP 3% 1atch their voice Fou should match the tone' tempo' timbre and the volume of the personIs voice% Fou should also ma0e use of matching the 0e words that the use a lot% E?amples of this ma be: J"lrightJ' J"ctuall J' JFou 0now what I meanJ 4% 1atch their breathing Fou should match the persons breathing to the same pace% 1atching the in and out breath% 3% 1atch how the deal with information Fou should match persons C4N*Q )IRE of how the deal with information% ;or e?ample are the detailed or do the tal0 and thin0 in big pictures% If ou get this wrong ou will find it ver difficult indeed to build rapport as the detailed person will be earning for more information and the big picture person will soon be awningP 5% 1atch common e?periences "fter all' what are ou going to tal0 aboutP This is all about finding some commonalit to tal0 about% 1atching e?periences' interests' bac0grounds' values and beliefs% Bne point to bare in mind is that ou need to be subtle when ou are matching and mirroring% !onIt go over the topP T picall however' the other person will be focussing so much on what the have to sa that the will not even notice%

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/rea ing the mirror There are two sides to ever coin% If ou feel the need to create distance or to brea0 the s nchroniGation because ou want the other person to get out of their comfort Gone' or in order to show disagreement: stop mirroring and behave differentl from the individual% Empathic listening Empathic listening or "ctive listening basicall is ac0nowledging the indivualKs feelings and reflecting them% The sub>ect is treated more in detail in the ne?t chapter of this boo0% The basis of empathic listening is validating the other person and incorporating their words into our answers and conversations 2% Bther techniEues include Agree! (raise and Confirm 9B%0%' right' e?actl m idea: 9 ou are great' smart' good' O:

3alidate the persons4 concerns! struggles! perceptions! and feelings *o wonder ou feel that wa O *o wonder ouKre so frustrated and stressed out @validating feelingsA% FouKve struggled with this problem for a long time' and it ma0es sense to me that ouKre wondering whether itKs best to %%% or %%% @validating concerns and e?perience of the problemA%

Compliment people on their courage! resilience! and other attributes "fter ever thing ouKve been through' IKm impressed that ouKre still hanging in there and tr ing to ma0e things better for ourself% 2here do ou find the courage and strength to sta at it instead of giving up= @complimenting courage and resilienceA= 4ow did ou manage to get through the whole da = improvementAH IIm reall glad ou brought that up% I thin0 what ou are doing is reall difficult% IIm reall proud to be wor0ing with ou on this% )o man people avoid see0ing help% It sa s a lot about ou that ou are willing to ta0e this step% 2hat have ou noticed about ourself in the past few months since ou started coming here= @This Euestion is designed to prompt the client to self.affirm%A @giving credit for resilience and

*ote on compliments: Compliments can be direct: commenting directl on a personKs actions: 9Fou did a great >ob on this assignment: Indirect: folding compliments into Euestions: 94ow did esterda =: ou get ourself to wor0 on time

or attribution.based: referring to positive characteristics of the person: 9FouKre a caring person:

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/e curious 5vs" all6 nowing7: "s0 a lot of Euestions% &eople trust people who are interested in them% The reason for this is that people tend to feel isolated as life gets more complicated% "nd when someone pa s attention to us we feel safer and less isolated% Thin0 of the car bu ing situation with the car salesperson being ou% The salesperson who focuses on finding out the customerKs needs before tr ing to close the sale will do much better than the salesperson who focuses on the product% 2hen someone tries to sell us something' whether a car or an idea' if we feel the 0now us' we will feel safer and be more open to what the have to sa % "s a crisis service provider the more ou use curious information gathering to build rapport the more li0el it is that the individual ou want to help will trust ou and be coachable% 9I wonder what would happen ifO: As 5vs" tell7: 92hat might change when %%%=: J4ow are things going=J J2hat is most important to ou right now=J J4mm%%% Interesting%%% Tell me more%%%J J4ow did ou manage that in the past=J J4ow would ou li0e things to be different=J J2hat will ou loseCgain if ou give up SSS=J J2hat do ou want to do ne?t=J J4ow can I help ou with that=J

8ffer options! not solutions 8verall empathic interaction "ct as if the other person is our whole world% ;ocusing intentl on them will build rapport% It will ma0e them feel important and ma0e it easier for them to trust ou and this trust will ma0e them more s mpathetic to our coaching% In order to focus intentl on them' if possible' get into a Euiet space% This should be awa from distractions% 1a0e it eas on ourself to focus% ;or e?ample' avoid places where there is a lot of action going on% If necessar ' face a wall with the individual in front of ou to ma0e it eas on ourself% If ou are distracted during the intervention' it is li0e sa ing that the other person is of less importance than what is distracting% 2hat does it sa to answer a phone while listening to another person= Copy patterns of speech! words and images used To ma0e someone ouKre tal0ing to feel comfortable it is helpful to mirror their demeanour% If the are slow and deliberate the will feel most comfortable if ou are the same wa % If ouKre in a hurr the will feel uncomfortable and less safe% 2hen tr ing to mirror someone loo0 for their language pattern% Is it deliberate or fast= Tr to measure their breathing pattern in the same wa % Is it fast or slow= /eflect it% 2atch out for their

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bod language% If the are rela?ed' donKt lean in aggressivel % (eing fle?ible in how ou act around our intervention% In order to obtain a deep contact and influencing power with the other' ou must let them help ou to find the correct wa s to achieve our goal% Tuning in to them will help ou build rapport b including their feelings of safet and their receptiveness to our suggestions% %ell about similar e#periences Bne other wa to build rapport is let the other person 0now that ou understand where the are coming from% 2hen ou ac0nowledge them' that is ou sa and demonstrate that ou understand' it doesnKt mean ou agree it >ust means that ou have heard them% This creates an absence of vulnerabilit because people want to 0now that the have been heard% That ma0es them feel important and ma0es it easier to trust% To demonstrate that ou understand let them 0now that their words ma0e sense to ou and' when possible' that ou have had similar e?periences and thoughts% This might be done b telling them about a personal e?perience that is li0e theirs% If that is not possible sa that ou understand or as0 them to e?plain further in a wa that lets them 0now ou are interested in their e?perience% (eing heard is a building bloc0 of trusting% 9I have that same feeling all the time%: 9I was >ust about to sa e?actl the same thing: 9I couldnKt agree more: As for advice 94ow would ou O = 2hat would ou do if O =:

Insert pauses between phrases! tal slowly! whisper 2hen ou as0 a Euestion' deliberatel pause to let the person ouKre as0ing answer% This is a sign of respect' which builds feelings of safet and trust% Imagine if ou had an audience with the &ope% 2ould ou as0 a Euestion and then >ump in while he was answering= *o' not at all% Fou would respectfull wait for the answer% It is the same in building rapport% To build trust ou must patientl provide an empt space for the answer to fill% &atient open space listening produces respect' an absence of vulnerabilit and rapport% Smile I 0now that this oneKs obvious' but weKre much more approachable when we smile% "lternativel ' a greeting without a smile lac0s warmth and ma0es it difficult for us to connect with others% A solid handsha e " good handsha0e isnKt ver memorable' but a bad one is% 1a0e sure that our handsha0e is firm @without brea0ing fingersA and doesnKt go on for too long% 4anging our hand out li0e a dead fish comes across as insipid and lac0ing in confidence' a bad start to an relationship and to be avoided% 2hilst ou ma have used the same handsha0e for our whole life so far' itKs never too late to change' so if ouKre conscious that ou sometimes donKt come across well in this area' start practicing%

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Get! and use! their name To assist ou to build rapport with others' getting their name earl in the interaction is crucial% ItKs >ust as important to use it a few times' ma0ing the conversation more personal and increasing the li0elihood that ouKll remember it the ne?t time ou meet them% 9ind common interests! but eep it about them &eople li0e people who share interests with them' so as0ing Euestions about their famil ' wor0' bac0ground' even favourite sporting teams can assist ou to find common ground with the other person% 4owever' when ouKve found one or two points of affiliation' donKt ta0e that as permission to tal0 too much ourself% "s0 Euestions to get the other person tal0ing' enabling them to feel more comfortable and confident with ou% /uilding -apport: (aving the road to Collaboration /uilding " supportive relationship alwa s demands giving our full attention to the other person% ( doing so' ou ma0e it easier for them to tell their stor and enable them to loo0 at wa s that will allow them to handle their problems better or even solve them% Giving attention includes listening activel ' being genuine and showing respect% In other words: totall being there for the individual% Fou tune into the other% Fou tune into his use of language' words' intonation' attitude' movements and emotions% !o this unobtrusivel % If ou tune into them' it will become easier for ou to imagine what it would be li0e being him and having his problems% Bn the other hand' the person ou want to help will also feel more at ease with ou% This can be called 1irroring% Bne of the active ingredients that ma0es supportive relationships wor0 is /apport% 1ore rapport between two people will t picall ma0e the e?change and acceptance of ideas go more Euic0l % <ess rapport will ma0e it less effective% 2hat this means is that more time spent b activel listening to the other and mirroring his actions' thoughts and feelings up front will lead to less effort later to produce results% <ess effort up front to create rapport will mean more effort is needed later to stimulate the other to right action% Fou should therefore alwa s ta0e the time to establish rapport if our aim is to influence somebod else% Establishing /apport will ma0e our intervention more efficient and more successful% In e?treme circumstances the rapport building might need to be 88T of the relationship% )o what is rapport% The dictionar definition spea0s of mutual trust% 1 favourite definition of trust is Uan absence of vulnerabilit %K )o rapport could be considered a Umutual absence of vulnerabilit %K (uilding rapport is ta0ing steps to create trust b creating an absence of vulnerabilit % This is done b helping the other to feel safe% )teps to ta0e include being curious' creating an open space for answers to Euestions' mirroring the demeanour of the other' giving the individual our total attention and ac0nowledging that the are being heard% ItKs all about being an e?cellent listener% /apport is the ultimate tool for producing results with other people and thus it is so vital for effective communications% 2hen ou bear in mind that 83T of all communication is down to the tonalit of our voice and our bod language' building rapport is far more than >ust tal0ing about common e?periences% ItIs an important point to remember but people li0e people when the are li0e themselves and when the are not it so much more difficult to have an sort of relationship with that person never mind an effective oneP

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2ow to develop collaboration building - : (repare to compromise" 2hen wor0ing with a team' it is impossible for ever one to get their wa ' so compromise is imperative% !onIt consider it a blow to our ego' simpl a necessit when ou develop collaboration s0ills and put them to use% 2 : Avoid ta ing it personally% 2hen collaborating with a group' there is alwa s a chance of getting our feelings hurt b insensitive team members or group decisions% /emember that decision.ma0ing should not be personal' it is >ust a natural part of the process% 3 : 9ocus on the well6being of the pro:ect% In order to full develop collaboration s0ills' it is important to 0eep our e e on the tas0 at hand% ;ocusing our efforts on the success of a pro>ect removes the urge to get our own wa and helps a group sta on tas0% 4 : Communicate effectively% 2ithout communication all sorts of problems are li0el to pop up% ( communicating in thoughtful wa s and remaining mindful of othersI feelings and motivations' ou will be more li0el to collaborate successfull % 3 : Identify challenges% If ou have trouble developing collaboration s0ills' ta0e some time to reflect on our difficulties% ( pinpointing the hurdles in our wa and the causes of our discomfort' ou can map out wa s to overcome them% 5 : (articipate in team building activities% There are a number of team building wor0shops and activities that are easil accessible online or in person% Ta0e the time to participate in team building activities as a wa to Euic0l and efficientl develop collaboration s0ills% A6to6; strategies for building collaboration in organi<ations 1ost people agree that effective collaboration is more important than ever in toda Ks turbulent environment% In a 9do.more.with.less: realit ' it ta0es ongoing teamwor0 to produce innovative' cost. effective' efficient and targeted solutions% In fact' the ultimate success of our intervention ma depend on how well ou and the other person can combine our potential and the Eualit of the information the possess with our abilit @and willingnessA to share that 0nowledge % )o' whatKs to be done= 4ere' from " to R' are the most successful strategies to tear down fences' reduce conflicts and increase collaboration% A" 9ind ways to AC=>8W1EDGE collaborative contributors" /ecogniGe and promote people who learn' teach and share% "nd' penaliGe those who do not% In all best.practices companies' those hoarding 0nowledge and failing to build on ideas of others face visible and serious career conseEuences% In those top companies' emplo ees who share 0nowledge' teach' mentor' and wor0 across departmental boundaries are recogniGed and rewarded% (" Watch your /8D? 1A>G@AGE% "ll leaders e?press enthusiasm' warmth and confidence as well as arrogance' indifference and displeasure through their facial e?pressions' gestures' touch and use of space% If leaders want to be perceived as credible and collaborative' the need to ma0e sure that their verbal messages are supported @not sabotagedA b their nonverbal signals% C% 9ocus on the C1IE>%% *othing is more important in an organiGation whether itKs a for.profit compan or a non.profit group than sta ing close to the end.user of the service or product ou offer% 2hen ou build collaborative relationships with our customers' ou give them power and co.ownership of our organiGationKs success%

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!% DI3E-SI%? is crucial to harnessing the full power of collaboration% E?periments at the Nniversit of 1ichigan found that' when challenged with a difficult problem' groups composed of highl adept members performed worse than groups whose members had var ing levels of s0ill and 0nowledge% The reason for this seemingl odd outcome has to do with the power of diverse thin0ing% Group members who thin0 ali0e or are trained in similar disciplines with similar 0nowledge bases run the ris0 of becoming insular in their ideas% Instead of e?ploring alternatives' a confirmation bias ta0es over and members tend to reinforce one anotherKs predisposition% !iversit causes people to consider perspectives and possibilities that would otherwise be ignored% E% E1I.I>A%E the barriers to a free flow of ideas% Ever one has 0nowledge that is important to someone else' and ou never 0now whose input is going to become an essential part of the solution% 2hen insights and opinions are ridiculed' criticiGed or ignored' people feel threatened and 9punished: for contributing% The t picall react b withdrawing from the conversation% Conversel ' when people are free to as0 9dumb: Euestions' challenge the status Euo and offer novel even biGarre suggestions' then sharing 0nowledge becomes a collaborative process of blending diverse opinion' e?pertise and perspectives% ;% %o enhance collaboration! analy<e and learn from 9AI1@-E% The goal is not to eliminate all errors' but to anal Ge mista0es in order to create s stems that more Euic0l detect and correct mista0es before the become fatal% G% Collaboration ta es G@IDA>CE b managers who 0now how to harness the energies and talents of others while 0eeping their own egos in chec0% )uccessful organiGations reEuire leaders at all levels who manage b influence and inclusion rather than b position% 4% Eliminate 28A-DI>G by challenging the ' nowledge is power) attitude% Qnowledge is no longer a commodit li0e gold' which holds @or increasesA its worth over time% ItKs more li0e mil0 fluid' evolving and stamped with an e?piration date% "nd' b the wa ' there is nothing less powerful than hanging on to 0nowledge whose time has e?pired% I% 9ocus on I>>83A%I8>" Creativit is triggered b a cross.pollination of ideas% It is in the combination and collision of ideas that creative brea0throughs most often occur% 2hen an organiGation focuses on innovation' it does so b bringing together people with different bac0grounds' perspectives and e?pertise brea0ing down barriers and silos in the process% V% A8I> the social media revolution" NtiliGe 2eb technologies tools and processes that allow people to share opinions' insights' e?periences and perspectives in order to collaborate and to self organiGe% Q% -eali<e that there are two inds of =>8W1EDGE in your organi<ation: E?plicit 0nowledge can be transferred in a document or entered in a database% Tacit 0nowledge needs a conversation' a stor ' a relationship% 1a0e sure ou are developing strategies to capture both% <% 1EADE-S at all levels of an organi<ation can nurture collaboration within their own wor group or staff" The most successful of these leaders do so b ta0ing the time and effort necessar to ma0e people feel safe and valued% The emphasiGe peopleKs strengths while encouraging the sharing of mista0es and lessons learned% The set clear e?pectations for outcomes and clarif individual roles% The help all members recogniGe what each of them brings to the team% The model openness' vulnerabilit and honest % The tell stories of group successes and personal challenges% "nd most of all' the encourage and respect ever oneKs contribution%

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1% .IB it up by rotating personnel in various >obs and departments around the organiGation' create cross.functional teams' and invite managers from other areas of the organiGation to attend @or leadA our team meetings% *% Employees with multiple >E%W8-=S throughout the organi<ation facilitate collaboration" Fou can accelerate the flow of 0nowledge and information across boundaries b encouraging wor0place relationships and communities% Nse a tool li0e )ocial *etwor0 "nal sis @)*"A to create a visual model of current networ0s so ou can reinforce the connections and help fill the gaps% B% Insist on 8(E> and transparent communication" In an organiGation' the wa information is handled determines whether it becomes an obstacle to or an enabler of collaboration% Emplo ees toda need access to information at an time from an place% &% Collaboration is a (A-%>E-S2I(% "s one savv leader put it' 9To ma0e collaboration wor0' ouKve got to treat people the wa ou want to be treated% ItKs prett simple' reall % Treat all emplo ees as our partners% (ecause the are%: W% As the right C@ES%I8>S% "t the beginning of a pro>ect' as0: 2hat informationC0nowledge do we need= 2ho are the e?perts= 2ho in the organiGation has done this before= !o we have this on a database= 2ho else will need to 0now what we learn= 4ow do we plan to shareChand off what we learn= /% %he success of any organi<ation or team D its creativity! productivity and effectiveness D hinges on the strength of the -E1A%I8>S2I(S of its members% Collaboration is enhanced when emplo ees get to 0now one another as individuals% )o' when ou hold offsite retreats' organiGation.wide celebrations or wor0place events with 9social: time built in' be sure to provide opportunities for personal relationships to develop% Ta0ing time to build this 9social capital: at the beginning of a pro>ect increases the effectiveness of a team later on% )% Collaboration is communicated best through S%8-IES of successes' failures' opportunities' challenges' and 0nowledge accumulated through e?perience% ;ind those stories throughout our organiGation% /ecord them% )hare them% T% %-@S% is the foundation for collaboration" It is the conduit through which 0nowledge flows% 2ithout trust' an organiGation loses its emotional 9glue%: In a culture of suspicion people withhold information' hide behind ps chological walls' withdraw from participation% If ou want to create a networ0ed organiGation' the first and most crucial step is to build a culture of trust% N% Combating silo mentality re,uires @>I9?I>G goals% (usiness unit leaders must understand the overarching goals of the total organiGation and the importance of wor0ing in concert with other areas to achieve those crucial strategic ob>ectives% D% The incentive to collaborate is the 3A1@E of the e#change to both the organi<ation and the individual" 2hen the assets and benefits of productive collaboration are made visible' silos melt awa % 2% ?our W8-=(1ACE layout encourages or impedes the way the organi<ation communicates" To facilitate 0nowledge sharing' ou need to create environments that stimulate both arranged and chance encounters% "ttractive brea0.out areas' coffee bars' comfortable cafeteria chairs' even wide landings on staircases all of these increase the li0elihood that emplo ees will meet and linger to tal0% S% %a e a tip from BE-8B" It discovered that real learning doesnKt ta0e place in the classroom or in an formal setting% In fact' people were found to learn more from comparing e?periences in the hallwa s than from reading the compan Ks official manuals' going online to a 0nowledge repositor or attending training sessions%

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F% Collaboration is crucial for ?8@- success" 2eKve witnessing the death of 9The <one /anger: leadership model' where one person comes in with all the answers to save the da % 2e now 0now that no leader' regardless of how brilliant and talented' is smarter than the collective genius of the wor0force% R% 9orget about reaching the ;E>I%2" Collaborative cultures are learning cultures and 0nowledge sharing is an ongoing process' not an end point% (ractical collaboration building IItIs amaGing how much can be done when it doesnIt matter who gets the creditI% @attributed to George C% 1arshalA This page contains principles that when put into practice will produce results% Start with a unifying purpose: The purpose ma need to be broad enough to bring in enough people with energ ' imagination' commitment' resources' and creativit ' to generate success% @;or e?ample' a communit council interested in famil and children issues or a business opening a new mar0et%A )ometimes the purpose ma also be ver specific and narrow when the energ ' imagination' commitment' and creativit ' are sufficient% )tart with two or three or a small group of people who have passion for the purpose% @;or e?ample' drug prevention%A This apparent conflict between broad and specific or narrow collaborations can sometimes be resolved b creating an umbrella committee with a more broad purpose and mission and subcommittees with more narrow and specific missions and purposes% @;or e?ample' a communit council supporting famil and children issues and a subcommittee dealing specificall with drug prevention or a committee wor0ing on absentee issues and a subcommittee dealing specific with drug prevention andCor treatment or even a business tr ing to recreate itself with a number of subcommittees%A Start with the End in .ind: Create' maintain' and update' simple and practical 1ission and Dision statements% Create short and concise 1ission and Dision )tatements' and possibl a strategic plan% (e willing to update and change as the need arises% Qeep the 1ission and Dision statements in full view of all of the participants at ever meeting% )ome organiGations place their mission and vision statement at the top of each agenda% )tic0 with it%%%%%%%%however' If it doesnIt fit an more' change it% !o it b consensus @unless a specific and different level of authorit communicated% has been clearl

)ometimes it can be helpful to create b .laws% (e careful that ou do not get caught in the minutia and loose trac0 of the priGe @goalA% Consider creating and displa ing a value statement% Set goals and ob:ectives" Goals are where ou want to go% Bb>ectives are how ou are going to get there% Goals should be measurable and observable% The should have specific achievable steps @ob>ectivesA with built in accountabilit for accomplishment%

3,

Goals should be built upon a consensus and can develop and adapt as the process matures% )ome goals should be met Euic0l and easil ' others should stretch ou and the organiGation% Celebrate and advertise success% EmphasiGe both process and product% !ocument baselines to which ou can compare% Evaluate how our results compare with the results of others wor0ing on similar goals% (e willing to learn from the success of others% "lwa s strive for improvement' evaluate' solicit feedbac0' and ad>ust our course as needed% /elieve in what you are doing and the people who are doing it" JIf ou thin0 ou can do a thing or thin0 ou canIt do a thing' ouIre right%J @4enr ;ordA /adiate and spea0 Bptimism% E?pect )uccess E?pect the best from people that ou are wor0ing with% 1eadership J2hat ou are thunders so loudl in m ears that I cannot hear what ou sa %J @Emerson A )omeone needs to be responsible for facilitating' moderating' and managing the meeting and discussion% Dalue.based dedicated leadership is essential for an thing lasting' significant' and positive' to be accomplished% (e supportive' consistent' and dependable% )et high standards of e?cellence% True collaboration reEuires shared leadership% Cultivate leadership in others% <eadership must value an inclusive' collaborative' process% Coordinate 6 8rgani<e )eating can be ver important% )itting behind tables can have the advantage of giving people a place to write and providing emotional protection% It also creates an atmosphere conducive to getting down to business and wor0ing% &referabl ' tables should allow ever one to see each other @circle' semicircle' rectangle' or sEuareA% Der small groups can often do well sitting on something comfortable such as two or three couches andCor other comfortable chairs that face each other% Der large groups can sit in a circle or semicircle% These formats will increase communication% "void rows of people% This cuts down on interaction and communication% 4old regular' consistent @same place and same timeA' mutuall beneficial' constructive' profitable' informative' and brief meetings% Ta0e notes from the meeting and provide them to ever one in the collaboration% 2hen there is a discussion' write down what is said% 2riting on a board or flip chart where ever one can see is often preferred% @In some settings' writing on a board or flip chart can seem pretentious%A "ccuratel write what people sa % "lwa s have an agenda% In most cases it is better to send it to ever one ahead of time% )tic0 to the schedule% /espect ever oneIs time% 2hen someone brings something up that is not on the agenda' write it down where the can see it% (e sure and address it at a later time' such as at the end of the meeting' after the meeting' or during another meeting% <et ever one 0now ahead of time what the process will be for addressing

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items brought up during the meeting' but not on the agenda% Bccasionall in some urgent situations' items will need to be addressed immediatel ' this should be rare% Stic to your mission statement" ;or communit collaboration regularl nominate and vote for officers or set a s stem for rotation% Even when this is a committee' within a single organiGation' this can have value% )mall subcommittees or groups can often accomplish specific technical wor0 or complete pro>ects more Euic0l than a larger group' committee' or collaboration% These smaller groups can receive direction or report to the larger group% /emember to 0eep <evels of "uthorit clear%)how /espect for &eople and Time% "s0 for help% )a please and than0 ou% !emonstrate common courtes % "pologiGe when warranted @0now when itIs warranted' be humble enough to appologiGe' at times' even when itIs not%A 7 a%m% is often a good time for meeting with participants from "gencies and )chools% <unch time can also be a good time% Evenings and wee0ends are usuall best for Church' ;amil ' *eighborhood' and General Communit 1eetings% I am aware of one communit coalition which meets at 4:3, &%1%' to ma0e it easier for teachers to attend% If our goal is to involve outh' be sure to meet at a time and place convenient to outh% 2hen there is a meeting for a wor0 group with different organiGationsCagencies who have a mandate for the collaboration' the time is usuall more fle?ible% "lwa s start and end on time% (e consistent% Consider logistical needs of others Consider par0ing' transportation' acoustics' and child care' when reEuired% "ccess and comfort should also be considered% disabilities% (e sure there are adeEuate restrooms' water' et% etc% /e 8pen6minded E Share 8wnership" E Empower others E Share 1eadership" (e willing to accommodate others' when possible and appropriate% Concentrate on the areas that ou have in common with others who are involved% " lifetime of good ma be accomplished in the areas that ou agree% )ometimes wor0ing together towards positive goals can be more important than our specific agenda% "s ou wor0 together and develop relationships ou will li0el come to a greater unit of purpose% Encourage and help our organiGation to grow and change as the need arises% 2hen others feel ownership and empowerment in the organiGation' the become more committed' creative' and lo al% ;or man people the process is as important' and sometimes even more important' than the results% Ever one needs to be heard% 1anageC<ead the process' donIt control it% @The process does not belong to an one individual' and usuall does not belong to an one organiGation' or agenc A% "ccommodate needs of individuals with

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"llow for conflict and disagreement% Create a health atmosphere for disagreement and discussion% "s much as possible' resolve conflict and support the solution% 1embersC&articipants need to clearl understand and respect each otherIs values' 0nowledge' and s0ills% Qnowledge needs to be shared in order to increase the capacit of all the members' which in turn e?tends the capacit of the organiGationCcollaboration% Qnowledge shared is more powerful than 0nowledge 0ept% Enthusiasticall support other peopleIs successive or intermittent appro?imations of the goal% @"s much as possible' let it be someone elseIs idea%A If their bandwagon is headed in the general direction of where ou want to go' >ump in and cheer it on% Nse genuine compliments and recognition% "t times it is wise to put it in writing and ma0e it public% "t times it is wise to ma0e it private% (e specific about the behavior that ou are complimenting% 2hen appropriate encourage volunteers% &rovide ever one who wants it' something meaningful to do% /emember that what is meaningful to ou ma not be meaningful to another% 2hen ever possible' encourage and support others in their interests% )hare and rotate leadership responsibilities% )upport and encourage leadership in others whenever possible% <earn and practice critical thin0ing s0ills%%%without being critical% /uild relationships "llow time before and after meetings for visiting% This can often be as important as the meeting itself% Ta0e time to build friendships with members of the organiGation outside of the meeting times% )erving light refreshments or snac0s can help to build relationships and ease conversation% Bccasionall ou ma want to send a simple greeting card or than0 ou note to participants% This can help to build relationships% )ometimes a hand written note is greatl appreciated% Get to 0now and as much as possible understand the needs' issues' and passions of all the members of the coalition and sta0e holders in and out of the coalition% Fou are more li0el to have positive influences over a friend' than an enem % EmphasiGe both process and product% Communicate ;or man people the process is as important' and sometimes even more important' than the results% Ever one needs to be heard% )erving refreshments or light snac0s can open help to rela? people and open communication% Nse common language% Bne of the most important building bloc0s of collaboration and consensus is communication% )ometimes our differences are magnified in the words we choose when we come together% "t times this is because we get used to using certain words' phrases' or acron ms @words formed from the first letter of each word in a phrase such as N)"A' with our

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peers' because these words save time and helps us feel li0e we fit into a group% 2hen we come together with other people from different bac0grounds' we sometimes forget that others ma not understand some of the language that we use% )ometimes' some people ma use words' phrases' or acron ms' that others ma not understand on purpose% This can be a wa to appear superior to others or to hide behind language as a wa of self.protection% It is important to understand that we all have fears and concerns and that part of the purpose of this process is to overcome and move be ond fears and concerns together% 2hen meeting together' use words' and phrases that all will understand% "void acron ms% @Common language can include words' phrases' e?amples' and stories' which are familiar%A )ometimes people donIt feel comfortable sharing ideas in a group% Ta0e time to solicit opinions and ideas one on one% Nse surve s% (rea0 into smaller groups to increase participation% Go around the group as0ing each person for an idea or their opinion% "s people become more comfortable and feel safer with each other' participation will li0el increase% <et ever one 0now that their opinion and contribution is valuable% &romote and encourage open dialogue% /emember that language is more than >ust the spo0en or written word% It is also the wa words are spo0en' timing' bod language' and the wa silence is used% Nse the media and other communication tools to communicate with sta0e holders outside of the collaboration% )ome times members of the media are great additions to the collaborationCcoalition% )end letters' e.mails' agendas' notes' fl ers' et% Etc% to other members of the coalition on a regular basis% 1a0e phone calls and when possible personal visits to other members of the coalition to build relationships' 0eep people involved' and communicate% 1aintain strong and consistent communication with sta0e holders outside of the coalitionCcollaboration% J/eal listening shows respect% It creates trust% "s we listen' we not onl gain understanding' we also create the environment to be understood% "nd when both people understand both perspectives' instead of being on opposite sides of the table loo0ing across at each other' we find ourselves on the same side loo0ing at solutions togetherJ% @)tephen /% Cove A .otivate ;ind the commonalities and common passions% ;ind out what motivates the members of the coalitionCcollaboration and the sta0e holders% /emember that what motivates ou' ma not motivate them% "ppreciate and respect the differences% Nnderstanding each otherIs <ove <anguages ma be helpful% Ta0e responsibilit and give credit% Give credit for success to ever one else involved with that success% Ta0e responsibilit for mista0es' and when the occur' failures that ou have an part in% ;ind and ta0e opportunities to compliment and celebrate the success of others% "s collaboration matures' both responsibilit and success will be shared more evenl %

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Stic with it"""(ersevere"" Wor " JThe onl place ouIll find success before wor0 is in the dictionar J% 1ar (% )mith JThat which we persist in doing becomes eas to do% *ot that the nature of the thing has changed' but the power to do had increasedJ% 4eber V% Grant (uilding Collaboration reEuires substantial and sustained effort' often without recognition or eEual distribution of responsibilit % Qeep our passion alive% 4elp others to find and harness their own passions% Complete and encourage the completion of assignments' provide accountabilit % 1et Go! 9orgive" (e willing to Jlet go'J forgive' and loo0 past the shortcomings in others% 2hen ou do this' the will be more li0el to do it for ou% )ometimes ou have to hear before ou will be heard% @This does not mean that ou allow ourself or an one else to be abused%A Ever one must be treated with dignit and respect% "llow for mista0es and even failure% <oo0 for feedbac0 from failure% !onIt worr perfection% too much about perfection% &articipation is sometimes more important then

<et go of preconceptions% Continuity D Consistency 6 Dependability Even though the organiGation or collaboration ma evolve over time' it is important to demonstrate consistenc and dependabilit in values and character% There should be a continuit in programs and message% Changes in direction should be openl discussed' understood' and consensual% (e honest and trustworth % Four influence will be greatl dependent upon how dependable and trustworth ou and the organiGation are over time% Evaluate 6 9eedbac !evelop ongoing evaluations' feedbac0' and course correction' for continuous Eualit improvement% Collect and present data which is accurate' relevant' and easil understood% ;ind the feedbac0 in failure when it occurs% Eliminate 5or at least decrease7 9inancial Dependency )table resources are essential for an thing enduring% Consider creating an endowment fund% )ometimes e?traordinar results can be accomplished through volunteer efforts and limited funds% Qeep good' clear' financial records% Create sustainabilit %

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Celebrate Success <oo0 for success% <earn to recogniGe success% Celebrate small successes% Celebrate big successes% Celebrate publicl and privatel % "c0nowledge and reward success% !onIt go overboard' find out what people reall appreciate' ma0e it genuine% /e fle#ible /emember that there are often e?ceptions% Show gratitude )how gratitude for gifts of ever 0ind% -emember -obert4s -ules of 8rder" There are times when a more formal process can be helpful and times when it can be an encumbrance and times in.between when some formalit might help% 2hen some or a lot of formalit might be helpful ou ma want to consider incorporating all or some of /obertIs /ules of Brder% Nnderl ing these rules' alwa s remember three fundamental principals% -% Ever one needs to be treated with dignit and respect% 2% Ever one needs to be heard% 3% "ll of the information needs to be clear for ever one%

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0% Empowering JEmpowerment means increased assertiveness and self.management s0ills% It is associated with positive human growth and change processes @1c2hirter' -88-A% "s helping professionals' counsellors are committed to the growth' healing' and development of the clients the serve% Nnfortunatel ' the intention to help does not alwa s guarantee that counsellors are helpful% )ome have argued that counselling and ps chotherap can actuall serve to oppress rather than empower clients% ;or e?ample' )teinboc0 @-877A argues that helping relationships is oppressive to the e?tent that helpees embrace a view of themselves as need and dependent on the helper for solutions to their problems% ;urther' he contends that problem resolution focuses on the individual rather than the s stems that create the problems' resulting in a ver low li0elihood of constructive' preventative change @)teinboc0' -877A% &rilleltens0 @-878A argues that interventions based on traditional approaches to ps chotherap serve to perpetuate the 0inds of s stemic problems and ineEualities that lead clients to see0 ps chological services' preserving rather than transforming an un>ust status Euo% Caplan @-882A argues persuasivel that feminist therap ' e?plicitl created to address womenIs oppression' is also vulnerable to reflecting and preserving the gender ineEuities of societ % These critiEues warrant serious consideration% In societies marred b ineEualit and in>ustice' racism and se?ism' economic stratification and violence' all counselling relationships are vulnerable to subtl and even overtl reflecting these and other forms of oppression @"mold' -886A% ( virtue of our training and education' counsellors are in a position of relative privilege that' une?amined' can contribute to maintaining the presence of oppressive social influences within the counselling relationship% ;or e?ample' counsellors who fail to ac0nowledge the roles that racism and classism pla in creating the environment of a low income client of color ma blame the victimJH counsellors ascribing to the values of the dominant culture without e?amining the influence of their values in counselling ma define client problems and engage in interventions that are inappropriate for their clients @e%g%' "rnold' -886H QatG' -873H )ue X )ue' -88,A% Empowerment Coaching Empowering F mobili<ing strengths for change" The concept of empowerment was described as the process of helping clients discover personal strengths and capacities so that the are able to ta0e control of their lives% The foundation for empowerment in counselling is the belief that clients are capable and have a right to manage their own lives% Thus' an empowerment attitude focuses on the capacities and strengths of clients% Empowerment values and methods challenge counsellors to forgo an need to control clients b ta0ing on an 9e?pert: role that puts clients in positions of dependenc % Giving priorit to empowerment constrains counsellors from hiding behind professional >argon% 1oreover' counsellors who empower dem stif the counselling process through open and non.>argonistic discussion with clients of their methods and assumptions% )elf.determination' an important component of client empowerment' is promoted b helping clients recogniGe choices and b encouraging them to ma0e independent decisions% Counsellors should not do for clients what clients can and should do for themselves% 2hen empowerment is the priorit ' clients become the e?perts' and there is 9collaboration and shared decision ma0ing within the professional relationship @)heafor X 4ore>si' 2,,7' p% 68A% 1c2hirter @-88-A asserts that the potentiall empowering aspects of counselling include 9an underl ing belief in basic human potential and in clientsK abilit to cope with their

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life problems' a collaborative definition of the problem and therapeutic goals' s0ill enhancement and development' recognition and anal sis of s stemic power d namics and an emphasis on group and communit identit : @p% 225A% Bften clients come from disadvantaged and marginaliGed groups where the 9have been Ubeaten downK b oppression' povert ' abuse' and other harmful life e?periences% The want better lives for themselves and their families' but the feel powerless to ma0e the necessar changes% )ome clients have a pervasive sense of failure and feel different from and re>ected b other people: @)heafor X 4ore>si' 2,,7' p% 422A% )ometimes powerlessness arises from negative self.evaluation and low self.esteem or from lac0 of confidence in oneKs abilit to alter oneKs life' but sometimes the s stems that are set up to assist clients are themselves oppressive and contribute to powerlessness% !escribing the welfare s stem' Carniol @-883A observes' 9"s for the clients' evidence shows that the often find themselves blamed for the problems the face% The find the donKt get the help the need or the donKt get nearl enough to ma0e a differenceYor the get Ucut offK : @p% 3A% /acism and other pre>udices ma also den clients access to >obs and resources such as adeEuate housing' a realit which reminds counsellors that the have some responsibilit to advocate for progressive s stem and social polic changes% (en Carniol' a Canadian social wor0 educator' offers this challenge: 9)ocial and economic and environmental >ustice demands a transformation of power' including a basic democratiGation of wealth.creating activitiesYso that the practice of democrac comes within the reach of ever one' rather than being manipulated b those who now dominate the heights of our political and social structures: @-883' p% -37A% Client self.determination is enhanced when clients have more choices% This perspective draws counsellors into broader activities' including wor0ing to identif and remove gaps and barriers to service and encouraging more humane and accessible policies and services% In addition' as 1c2hirter @-88-A argues' empowerment reEuires that clients 9gain some degree of critical awareness of s stemic power d namics: @p% 223A% Bne wa counsellors can achieve this end is to provide clients with information on groups and organiGations whose efforts are directed toward changing problematic elements of the s stem% The counselling process itself offers empowerment to clients% The beginning phase offers man clients a uniEue opportunit to e?plore their situation and their feelings% "ctive listening s0ills help clients bring long.forgotten or misunderstood feelings to the surface% Dentilation of feelings can energiGe clients' and it can lead to spontaneous insight into new wa s of handling problems that seemed insurmountable% ;or some clients the wor0 of counselling is finished at this phase% Empowerment and Change : %he (urpose of Counselling .otivation and the stages of change Clients ma have made conscious decisions to change and their motivation ma be high' but the ma also have mi?ed feelings about replacing established behaviour with new wa s of behaving% )ometimes change involves a 9selling: >ob' but the results are better when clients' not counsellors' do the selling% Clients need to convince themselves that the benefits of change outweigh the ris0s' and the need to develop positive attitudes and beliefs about their capacit for change% Counsellors with a strengths

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perspective believe in the capacit of their clients to change' and this belief in them can be a powerful motivating factor% .otivation initiates and drives the change process% Vohnson' 1cClelland' and "ustin @2,,,A identif three factors important for motivation: 9the push of discomfort' the pull of hope that something can be done to relieve the problem or accomplish a tas0' and internal pressures and drives toward reaching a goal: @p% -33A% Thus' not onl must clients want to change' but the must also believe in their capacit for change% Change is stressfulH it reEuires ris0 and energ to give up established patterns of behaviour and thin0ing% Clients differ in the e?tent to which the have the s0ill or energ to ta0e the associated ris0s% The following are the essential elements of high motivation: $" willingness to engage in the wor0 of counselling &" commitment to devote energ and resources to the change process *" capacit to sustain effort over time and in the face of obstacles 0" sufficient self.esteem to sustain the courage to change @)hebib' -886' p% 232A Counsellors can assess clients based on these four elements' and then design appropriate strategies to meet each clientKs particular need% These four elements suggest two ma>or motivational tas0s for counsellors: engaging clients to commit to change and supporting and energiGing clients as the deal with the stresses of obstacles to change% The concept of secondar gain is a useful wa of understanding wh some people resist change despite the obvious pain or losses involved in maintaining their current situation% Secondary gain refers to the benefits that people derive from their problems% These benefits ma include 9increased personal attention' disabilit compensation' and decreased responsibilit ' as well as more subtle gratifications' such as satisf ing the need for self.punishment or the vengeful punishment of others who are forced to ta0e responsibilit : @*icoli' -877' p% -3A% )ome clients can be e?ceptionall difficult and frustrating to wor0 with% )ometimes itKs hard to do' but we should discipline ourselves to be non>udgmental regarding motivation% "lthough it might be tempting to label some clients as unwilling' passive or laG ' we should remember that the ma have given up for good reason% &erhaps societ has not provided the resources or support the need for change% Clients ma have given up to protect themselves from the further damage to their self.esteem that would come from repeated failure% In this wa their behaviour ma be seen as adaptive% ItKs normal for counsellors to lose patience with them and give up' but itKs important to remember that thatKs precisel what the did to themselvesYgive up% ThatKs one of the reasons the need counselling% Stages of Change The stages of change model @&rochas0a X *orcross' 2,,-A is based on the notion that people go through different motivational stages' each of which reEuires different counsellor strategies for success% The stages of change model' also 0nown as the transtheoretical model @&rochas0a X *orcross' 2,,-A' has received a great deal of attention in the literature since its inception in the -87,s% In this model five stages of change are recogniGed: precontemplation' contemplation' preparation' action' and maintenance% "s well' change is viewed as progressive and developmental in this model' with success at an phase dependent on the success of previous phases% There is no orderl progression from one phase to another%

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In realit clients ma progress through stages and then drop bac0 to an earlier stage @relapseA before starting again% "n essential assumption is that counselling interventions need to be selected to meet the needs and motivation of the particular stage the are in% 4owever' a client ma be at different stages of change for different problems% ;or e?ample' a client ma be precontemplative @not interested in changingA regarding his drin0ing' but read to ta0e action with respect to his failing marriage% !iscussing strategies for cutting down his drin0ing with this client is li0el to meet with failure' but he is li0el to respond positivel to e?ploring strategies to improve his marriage% (recontemplative Stage: 'I DonGt 2ave a (roblem") Clients at this stage have no intention of changing% These clients do not perceive themselves as having a problem' despite the fact that their behaviour is problematic for themselves or others in their lives% These clients are not thin0ing about change' and the ma rationaliGe their problems' minimiGe the conseEuences of their actions' or blame others% ;or these clients empathic and sensitive listening that encourages them to e?amine their situation and its conseEuences can be ver helpful% Counsellors can provide information' offer feedbac0' or encourage reflection with Euestions such as 9Is what ouKre doing now wor0ing to meet our needs=: Counsellors should proceed slowl when confronting denial' and the should remember that denial ma be a defence mechanism that enables people to cope' perhaps b shielding them from feelings of hopelessness @George' in 1c*eece X !i*itto' -887A% !iClemente and DelasEueG @2,,2A observe that 9)ometimes the reluctant client will progress rapidl once he or she verbaliGes the reluctance' feels listened to' and begins to feel the tension between the reluctance to change and the possibilit of a different future: @p% 2,3A% !iClemente and DalasEueG offer a counterargument Y that the natural tendenc is to do more when the ris0 is higher: Clinicians often believe that more education' more intense treatment' or more confrontation will necessaril produce more change% *owhere is this less true than with precontemplators% 1ore intensit will often produce fewer results with this group% Contemplative Stage: '.aybe I Should Do Something About It") "t the contemplative stage clients 0now the have a problem and are thin0ing about change' but the have not developed a plan or made a commitment to ta0e action% Contemplative clients ma be ambivalent and ma vacillate between wanting to alter their lives and resisting an shifts in their behaviour or lifest le% "t this stage clients ma be open to new information as the self.assess their problems and the advantages and disadvantages of change% E?ample: "gnes has been in an abusive relationship for ears% )he wishes that she could leave and start over% In fact' she has left her husband twice in the past' but each time she has returned within a few wee0s% Contemplative.stage clients li0e "gnes are 9burnt out: from previous unsuccessful attempts at change% The are often in a state of crisis with considerable associated stress% "lthough the desire change' the doubt it will happen and the believe that if change is to occur' it will be be ond their control% The also lac0 self.esteem and believe that the do not have the s0ill' capacit ' or energ to change% E?ample: &eter @33A has been unemplo ed for almost two ears' but he has not loo0ed for a >ob in months% 4e sa s' 9ThereKs no wor0 out there% (esides' who is going to hire a man of m age=: )eligmanKs @-863A concept of learned helplessness is a useful perspective for understanding these clients% &eople with learned helplessness come to believe that their actions do not matterH as a result' the are unli0el to e?tend an effort to change since the believe that the have no control over their lives and that what happens to them is a result of chance% The believe in a 9luc0 ethic: rather than a 9wor0 ethic%: Their beliefs are reflected in statements such as the following:

4,

Z 9Fou have to be at the right place at the right time to succeed%: Z 9If IKm successful' itKs because the tas0 was eas %: Z 9It doesnKt matter if I wor0 hard%: Z 9ThereKs nothing I can do about it%: The 0e to wor0ing with people with learned helplessness Y indeed' most clients at the contemplation stageYis to assist them 9in thin0ing through the ris0s of the behaviour and potential benefits of change and to instill hope that change is possible: @!iClemente X DelasEueG' 2,,2' p% 2,8A% 1an people with low self.esteem and learned helplessness are in fact Euite capableH it is the wa the thin0 and feel about themselves that is problematic% ConseEuentl ' it is important that counsellors loo0 for wa s to counter the clientKs self.depreciating remar0s @e%g%' encourage clients to see their past failures as deficits 9in the plan': not deficits in themA% "s well' counsellors can encourage clients to see elements of success in previous efforts @e%g%' partial goal achievement' lessening of problem severit ' short.term achievementA% Cognitive behavioural techniEues' discussed later in this chapter' have also proven to be effective% Confrontation should be used cautiousl % It ma be useful as a wa to help clients understand incongruities between what the believe and the wa the actH selfdefeating wa s of thin0ing and behavingH behaviour that is harmful to self or othersH blind spotsH blaming behavioursH and communication problems% "s well' confrontation can also target unrecogniGed or discounted strengths% "s a rule' confrontation is most effective when it is invited in the conte?t of a collaborative relationship% (reparation Stage: 'IGm Going to Do It >e#t Wee ") 2hen clients reach this third phase' the have made a decision to change and motivating them is no longer the principal tas0% 4owever' counsellors need to sustain the energ for change through support' encouragement' and empathic caring% The principal tas0 for the counsellor is to assist the client to develop concrete goals and action plan strategies% 2ithout concrete' s stematic plans' change efforts can be Euic0l frustrated and abandoned li0e soon.forgotten *ew FearKs resolutions% The essence of good planning consists of setting concrete goals' identif ing and evaluating alternative wa s of reaching goals' selecting an action plan' and anticipating potential obstacles% ;or clients with learned helplessness' setting small' achievable goals is crucial for establishing and maintaining a climate of success and hope% E?ample: Iris' a oung single parent' is e?cited about the possibilit of returning to school% )he sees a school counsellor for assistance with enrollment in the high schoolKs special program for teen moms' but she has not et considered issues li0e da care% Nsing a strengths approach' counsellors can assist preparation.stage clients to draw from their past e?periences @proven success strategies and lessons learnedA% "s well' clients can learn about strategies that have wor0ed for others% ;inall ' it is ver important to coach these clients to anticipate potential obstacles and to plan strategies for addressing them' including the emotional stress of the change process% Action Stage: 'IGm Changing") "t this stage clients are activel involved in the change process% The are wor0ing on the goals and implementing the plans developed in the preparation stage% !iClemente and DelasEueG @2,,2A offer this perspective on counsellor strategies for this stage: Clients in action ma still have some conflicting feelings about the change% The ma miss their old lifest le in some wa s and be struggling to fit into this new behaviour% Careful listening and affirming clients that the are doing the right thing are important in this stage% It is also important to chec0 with the client to see if he or she has discovered parts of the change plan that need revision%

4-

2hen clients encounter anticipated obstacles' counsellors can remind them of previousl developed contingenc plans% If there are unanticipated obstacles' counsellors can assist with interventions to support clients as the deal with these potential setbac0s% .aintenance Stage: 'IGve Done It" I >eed to =eep Doing It) In the final stage the challenge for the client is to maintain the changes that have been made and to deal with relapses' which ma occur for a number of reasons @e%g%' une?pected temptation' personal stress' letting down oneKs guardA% 1oreover' sometimes people are 9activel sabotaged b others in their lives who were threatened b the changes: @Qottler' -883' p% 7-A% "chievement of goals does not guarantee that there will be no relapse% 9This is particularl true if the environment is filled with cues that can trigger the problem behaviour% 2e all 0now [of situations\ where an individual who has stopped drin0ing relapses >ust when ever one thin0s the problem is finall resolved: @!iClemente X DelasEueG' 2,,2' p% 2-3A% Counsellors can help clients accept that relapses' while undesired' are part of the change process and do not signif complete regression or failure% In fact' counsellors can help clients to reframe the relapse as an opportunit for better success ne?t time% 9;reEuentl ' people who do relapse have a better chance of success during the ne?t c cle% The have often learned new wa s to deal with old behaviours' and the now have a histor of partial successes to build on: @!iClemente X DelasEueG' 2,,2' p% 2-3A%

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.otivational Interviewing 5.I7 1otivational interviewing @1iller X /ollnic0' 2,,2A is a tool for helping clients to deal with the ambivalence that 0eeps man of them from ma0ing desired and successful changes% Cognitive behavioural counselling is a collaborative @counsellor and clientA approach to helping clients ma0e changes in the three ma>or ps chological domains: thin0ing' behaviour' and emotions% 1otivational Interviewing @1iller X /ollnic0' 2,,2A is an empiricall validated strateg for helping people overcome ambivalence to change% 1otivational interviewing reEuires a collaborative' nonconfrontational relationship% It assumes that motivation and capacit for change are within the client% ConseEuentl ' it honours the clientKs right to self.determination regarding whether change is to ta0e place as well as the ultimate goals of an change process% 91I allows clients' both mandated and voluntar ' to discover their own reasons for ma0ing change% 1I allows the impetus to change to emerge from within a client' thus honoring the clientKs uniEue circumstances and worldview: @CapuGGi X )tauffer' 2,,7'A% StageHGoal Strategy Choices (recontemplative Stage @Client without desire to changeA ] <isten empathicall % ] &rovide information and feedbac0 @if contractedA or intention to change ] Encourage clients to see0 information and feedbac0 from others% Counselling Goal Increase awareness ] 4elp clients become aware of attractive alternatives% ] Nse thought.provo0ing Euestions of need for change% ] "void directive and confrontational techniEues% ] Nse films' brochures' boo0s' and self.assessment Euestionnaires as tools to increase client insight% ] 2ith involuntar clients' e?plore feelings concerns openl ' self.disclose our own feelings about being forced' give clients choices' involve them in decision ma0ing' and encourage client.initiated goals% Contemplative Stage 5Clients who are arguing in favour of change' which tends to thin0ing about changeA ] !iscuss ris0s and benefits of change' but avoid to ma0e clients argue against change% Counselling Goal /esolve ambivalence depreciating remar0s @e%g%' reframe past failures to engage in the as learning e?perienceA% ] 4elp clients understand and manage self.change process% ] Identif elements of success in previous change efforts% ] E?plore deficits in previous change plans @emphasiGe failure of plans' not failure of clientsA% ] Nse support groups% ] Conve hope%

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(reparation Stage ] @Clients who are committed to changeA ] )et goals% ] &lan s stematic action% ] "ssembleCmobiliGe resources to support change% Counselling Goals !evelop concrete strategies for action% ] 1a0e contingenc plans @anticipate obstaclesA% Action Stage ] /eward @praise' support' ac0nowledgeA change efforts% Counselling Goals Implement change and sustain momentum% ] "ssist clients to manage anticipated and unanticipated obstacles% .aintenance Stage ] "ssist client to deal with periodic obstacles andCor relapses Counselling Goals% )ustain change% 9our broad principles define the application of motivational interviewing: Z E?press empath % Z !evelop discrepanc % Z /oll with resistance% Z )upport self.efficac % @1iller and /ollnic0' 2,,2' p% 35A E#press Empathy Empath and other active listening s0ills create an interview climate where clients are free to e?plore their values' perceptions' goals' and the implications of their current situation without >udgment% 1otivational interviewing accepts ambivalence and reluctance to change as predictable and normal% "ctive listening increases intrinsic motivation for natural change% Conversel ' 9confrontational counselling has been associated with a high dropout rate and relativel poor outcomes: @1iller X /ollnic0' 2,,2' p% 6A% Develop Discrepancy The overall goal of motivational interviewing is to help people get unstuc0% The method is to initiate 9change tal0: b ta0ing advantage of naturall occurring opportunities in the interview to embellish client statements that suggest differences between the wa their life is and the wa the would li0e their lives to be% )impl focusing on a clientKs goals and aspirations can often help people appreciate how their current lifest le is inhibiting their ideals% 1otivational interviewing uses a number of strategies to evo0e change tal0' including the following:

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Z as0ing evocative Euestions about disadvantages of the status Euo' advantages of change' optimism about change' and intention to change Z using scaling EuestionsYfor e?ample' 9Bn a scale of - to -,' where are ou in terms of satisfaction with our life=: Z e?ploring the positive and negative conseEuences of the status Euo Z using elaboration s0ills @e%g%' as0ing for clarification' e?amples' description' and further informationA to elicit further change tal0 Z Euer ing e?tremes' such as' 9)uppose ou donKt ma0e an changes% 2hat do ou thin0 might be the conseEuences of this in the worst.case scenario=: Z loo0ing bac0 to help clients remember how things were before and compare with the current situation Z loo0ing forward b as0ing clients to describe their hopes and goals for the future Z e?ploring goals and values to target discrepancies between important goals and current behaviour @1iller X /ollnic0' 2,,2' pp% 6773A Z helping clients understand their ambivalence to change using the metaphor of a seesawYwhen the costs of continuing present behaviour and the benefits of change outweigh the costs of change and benefits of continuing present behaviour' change will occur% -oll with -esistance -olling with resistance reEuires that counsellors not engage in power struggles with clients' with counsellors arguing for change and clients resisting it% Client resistance is seen as a message that the counsellor needs to do something different% &ower struggles are li0el when counsellors: Z offer unsolicited advice from the e?pert role Z tell clients how the should feel Z as0 e?cessive Euestions Z order' direct' warn' or threaten Z preach' moraliGe' or shame Z argue for change Z blame' >udge' or criticiGe Success %ip 9"s long as our clients are going to resist ou' ou might as well encourage it: @1ilton Eric0sonA% -adical acceptance is a strateg that involves encouraging e?pression of statements that ou tend to disagree with or philosophicall oppose' for e?ample: Client: I donKt see the point% The onl reason I came toda is the fact that if I didnKt show up' IKd be cut off welfare% Counsellor: IKm ver glad ou brought this up% 1an people share views such as ours but wonKt spea0 up' so I appreciate our willingness to be honest% Amplified reflection is a techniEue that e?aggerates what a client has said with the hope that the client will present the other side of ambivalence% 4owever' as 1iller and /ollnic0 @2,,2A stress' 9This must be done empathicall ' because an sarcastic tone or too e?treme an overstatement ma itself elicit a hostile or otherwise resistant reaction: @p% -,-A%

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Client: I donKt see what the problem is% 2hatKs the harm in having a few drin0s after a hard da Ks wor0= Counsellor: )o' ouKre sa ing that drin0ing hasnKt caused an problems or given ou an reason for concern% Client: 2ell' I wouldnKt go that far% Support Self6Efficacy To begin and sustain change' clients must believe in their capacit for change% ;or their part counsellors can have an enormous impact on outcome if the believe in their clientKs abilit to change and when the ta0e steps to enhance client confidence% Bne choice is to help clients identif past success% "nother is encouraging clients to ma0e an inventor of their strengths and resources% 2or0ing on small achievable goals often starts a change process that gathers momentum% Counsellors can also loo0 for opportunities to affirm their clientsK efforts' strengths' and successes% The goals of empowerment coaching include providing sufficient information to clients for them to ma0e their own informed decisions' encouraging them to re.ta0e control of their lives and decision.ma0ing power' providing assistance in obtaining the 0nowledge and learning the s0ills that rebuild self. confidence' and creating responsible social change%

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.otivational Interviewing Strategies and %echni,ues: -ationales and E#amples

Sobell and Sobell, 2008

AS=I>G (E-.ISSI8> -ationale: Communicates respect for clients% "lso' clients are more li0el to discuss changing when as0ed' than when being lectured or being told to change% E#amples of As ing (ermission Do you mind if we talk a out [insert behavior\?! "an we talk a it a out your [insert behavior\?! I noticed on your medical history that you have hypertension, do mind if we talk a out how different lifestyles affect hypertension?! @)pecific lifest le concerns such as diet' e?ercise' and alcohol use can be substituted for the word 9lifest les: in this sentence%A

E1ICI%I>GHE38=I>G C2A>GE %A1= -ationale: Change tal0 tends to be associated with successful outcomes% This strateg elicits reasons for changing from clients b having them give voice to the need or reasons for changing% /ather than the therapist lecturing or telling clients the importance of and reasons wh the should change' change tal0 consists of responses evo0ed from clients% ClientsK responses usuall contain reasons for change that are personall important for them% Change tal0' li0e several 1otivational Interviewing @1IA strategies' can be used to address discrepancies between clientsK words and actions @e%g%' sa ing that the want to become abstinent' but continuing to useA in a manner that is nonconfrontational% Bne wa of doing this is shown later in this table under the Columbo approach% Importantl ' change tal0 tends to be associated with successful outcomes% Cuestions to ElicitHEvo e Change %al #hat would you like to see different a out your current situation?! #hat makes you think you need to change?! #hat will happen if you don$t change?! #hat will e different if you complete your pro ation%referral to this program?! #hat would e the good things a out changing your [insert ris0 Cproblem behavior\?! #hat would your life e like & years from now if you changed your [insert ris0 Cproblem behavior\?! #hy do you think others are concerned a out your [insert ris0 Cproblem behavior\?!

ElicitHEvo e Change %al 9or Clients 2aving Difficulty Changing: ;ocus is on being supportive as the client wants to change but is struggling% 'ow can I help you get past some of the difficulties you are e(periencing?! If you were to decide to change, what would you have to do to make this happen?!

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ElicitHEvo e Change %al by (rovo ing E#tremes: ;or use when there is little e?pressed desire for change% 4ave the client describe a possible e?treme conseEuence% Suppose you don$t change, what is the 2B/)T thing that might happen?! #hat is the (E)T thing you could imagine that could result from changing?!

ElicitHEvo e Change %al by 1oo ing 9orward: These Euestions are also e?amples of how to deplo discrepancies' but b comparing the current situation with what it would be li0e to not have the problem in the future% If you make changes, how would your life e different from what it is today?! 'ow would you like things to turn out for you in ) years?!

EB(18-I>G I.(8-%A>CE A>D C8>9IDE>CE -ationale: "s motivational tools' goal importance and confidence ratings have dual utilit : @aA the provide therapists with information about how clients view the importance of changing and the e?tent to which the feel change is possible' and @bA as with other rating scales @e%g%' /eadiness to Change /ulerA' the can be used to get clients to give voice to what the would need to do to change% E#amples of 2ow to E#plore Importance and Confidence -atings #hy did you select a score of [insert ^\ on the importance%confidence scale rather than[lower ^\?! #hat would need to happen for your importance%confidence score to move up from a [insert ^\ to a [insert a higher ^\?! #hat would it take to move from a [insert ^\ to a [higher ^\?! 'ow would your life e different if you moved from a [insert ^\ to a [higher ^\?! #hat do you think you might do to increase the importance%confidence a out changing your [insert ris0 Cproblem behavior\?!

8(E>ED6E>DED C@ES%I8>S -ationale: 2hen therapists use open.ended Euestions it allows for a richer' deeper conversation that flows and builds empath with clients% In contrast' too man bac0.to.bac0 closed. or dead ended Euestions can feel li0e an interrogation @e% g%' 9'ow often do you use cocaine?! 'owmany years have you had an alcohol pro lem?! 'ow many times have you een arrested?!*+ Bpen.ended Euestions encourage clients to do most of the tal0ing' while the therapist listens and responds with a reflection or summar statement% The goal is to promote further dialogue that can be reflected bac0 to the client b the therapist% Bpen.ended Euestions allow clients to tell their stories%

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E#amples of 8pen6Ended Cuestions ,ell me what you like a out your [insert ris0 Cproblem behavior\+! #hat$s happened since we last met?! #hat makes you think it might e time for a change?! #hat rought you here today?! #hat happens when you ehave that way?! 'ow were you a le to not use [insert substance\ for [insert time frame\?! ,ell me more a out when this first egan+! #hat$s different for you this time?! #hat was that like for you?! #hat$s different a out -uitting this time?!

-E91EC%I3E 1IS%E>I>G -ationale: /eflective listening is the primar wa of responding to clients and of building empath % /eflective listening involves listening carefull to clients and then ma0ing a reasonable guess about what the are sa ingH in other words' it is li0e forming a h pothesis% The therapist then paraphrases the clientsK comments bac0 to them @e%g%' 9It sounds like you are not ready to -uit smoking cigarettes+!A% "nother goal in using reflective listening is to get clients to state the arguments for change @i%e%' have them give voice to the change processA' rather than the therapist tr ing to persuade or lecture them that the need to change @e%g%' So, you are saying that you want to leave your hus and, and on the other hand, you worry a out hurting his feelings y ending the relationship+ ,hat must e difficult for you+ 'ow do you imagine the two of you would feel in . years if things remain the same?!A% /eflections also validate what clients are feeling and doing so communicates that the therapist understands what the client has said @i%e%' It sounds like you are feeling upset at not getting the /o +!*+ 2hen therapistsK reflections are correct' clients usuall respond affirmativel % If the guess is wrong @e%g%' It sounds like you don$t want to -uit smoking at this time+!A' clients usuall Euic0l disconfirm the h pothesis @e% g% 90o, I do want to -uit, ut I am very dependent and am concerned a out ma/or withdrawals and weight gain%:A% E#amples of -eflective 1istening 5generic7 It sounds like1+! #hat I hear you saying1! So on the one hand it sounds like 1+ And, yet on the other hand1+! It seems as if1+! I get the sense that1+! It feels as though1+!

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E#amples of -eflective 1istening 5specific7 It sounds like you recently ecame concerned a out your [insert ris0 Cproblem behavior\+! It sounds like your [insert ris0 Cproblem behavior\ has een one way for you to [insert whatever advantage the receive\+! I get the sense that you are wanting to change, and you have concerns a out [insert topic or behavior\+! #hat I hear you saying is that your [insert ris0 Cproblem behavior\ is really not much of a pro lem right now+ #hat you do think it might take for you to change in the future?! I get the feeling there is a lot of pressure on you to change, and you are not sure you can do it ecause of difficulties you had when you tried in the past+!

>8-.A1I;I>G -ationale: *ormaliGing is intended to communicate to clients that having difficulties while changing is not uncommon' that the are not alone in their e?perience' or in their ambivalence about changing% *ormaliGing is not intended to ma0e clients feel comfortable with not changingH rather it is to help them understand that man people e?perience difficult changing% E#amples of >ormali<ing A lot of people are concerned a out changing their [insert ris0 Cproblem behavior\+! 2ost people report oth good and less good things a out their [insert ris0 Cproblem behavior\+! 2any people report feeling like you do+ ,hey want to change their [insert ris0 Cproblem behavior\, ut find it difficult+! ,hat is not unusual, many people report having made several previous -uit attempts+! A lot of people are concerned a out gaining weight when -uitting+!

DECISI8>A1 /A1A>CI>G -ationale: !ecisional balancing strategies can be used an time throughout treatment% " good strateg is to give clients a written !ecisional (alance @!(A e?ercise at the assessment session and as0 them to bring the completed e?ercise to their first session% " sample of a completed e?ercise is shown in "ppendi? 4%-,b% The !( e?ercise as0s clients to evaluate their current behaviors b simultaneousl loo0ing at the good and less good things about their actions% The goal for clients is two fold: To realiGe that @aA the get some benefits from their ris0 Cproblem behavior' and @bA there will be some costs if the decide to change their behavior% Tal0ing with clients about the good and less good things the have written down on their !( can be used to help them understand their ambivalence about changing and to move them further toward wanting to change% <astl ' therapists can do a !( e?ercise with clients b simpl as0ing them in an open ended fashion about the good and less good things regarding their ris0 Cproblem behavior and what it would ta0e to change their behavior%

3,

E#amples of 2ow to @se a Decisional /alance E#ercise #hat are some of the good things a out your [insert ris0 Cproblem behavior\? [Client answers\ 3kay, on the flipside, what are some of the less good things a out your [insert ris0 Cproblem behavior\+!

"fter the clients discuss the good and less good things about their behavior' the therapist can use a reflective' summar statement with the intent of having clients address their ambivalence about changing% C81@./8 A((-8AC2 -ationale: The Columbo approach can also be characteriGed as deplo ing discrepancies% The goal is to have a client help the therapist ma0e sense of the clientKs discrepant information The approach ta0es its name from the behavior demonstrated b &eter ;al0 who starred in the -86,s television series "olum o% The ColumboesEue approach is intended as a curious inEuir about discrepant behaviors without being >udgmental or blaming and allows for the >u?taposing in a non.confrontational manner of information that is contradictor % In other words' it allows the therapist to address discrepancies between what clients sa and their behavior without evo0ing defensiveness or resistance% 2hen deplo ing discrepancies' when possible' as shown in the e?ample below tr to end the reflection on the side of change as clients are more li0el to elaborate on the last part of the statement% It sounds like when you started using cocaine there were many positives+ 0ow, however, it sounds like the costs, and your increased use coupled with your girlfriend$s complaints,have you thinking a out -uitting+ #hat will your life e like if you do stop?!

E#amples of 2ow to @se the Columbo Approach: 2hile the following responses might sound a bit uns mpathetic' the idea is to get clients who present with discrepancies to recogniGe them rather than being told b their therapists that what the are sa ing does not ma0e sense% 93n the one hand you$re coughing and are out reath, and on the other hand you are saying cigarettes are not causing you any pro lems+ #hat do you think is causing your reathing difficulties?! So, help me to understand, on the one hand you say you want to live to see your 4)5year old daughter grow up and go to college, and yet you won$t take the medication your doctor prescri ed for your dia etes+ 'ow will that help you live to see your daughter grow up?! 'elp me understand, on the one hand I hear you saying you are worried a out keeping the custody of your children+ 6et, on the other hand you are telling me that you are using crack occasionally with your oyfriend+ Since you also told me you are eing drug screened on a random asis, I am wondering how using cocaine might affect your keeping custody of your children+!

S%A%E.E>%S S@((8-%I>G SE196E99ICAC? -ationale: Eliciting statements that support self.efficac @self.confidenceA is done b having clients give voice to changes the have made% (ecause man clients have little self.confidence in their abilit to change their ris0 Cproblem behaviors' the ob>ective is to increase their selfconfidence that the can change% )elf.

3-

confidence statements can be sought from clients using scaling techniEues @e% g' /eadiness to Change /uler' Importance and Confidence related to goal choiceA% ;or e?ample' when using a /eadiness /uler' if clientsK readiness to change goes from a lower number @pastA to a higher number @nowA' therapists ma follow.up b as0ing how the were able to do that and how the feel about their change% E#amples of Eliciting Statements Supporting Self6Efficacy It seems you$ve een working hard to -uit smoking+ ,hat is different than efore+ 'ow have you een a le to do that?! Last week you were not sure you could go one day without using cocaine, how were you a le to avoid using the entire past week?! So even though you have not een a stinent every day this past week, you have managed to cutyour drinking down significantly+ 'ow were you a le to do that?! 97ased on your self5monitoring logs, you have not een using canna is daily+ In fact, you onlyused one day last week+ 'ow were you a le to do that?! ;ollow.up b as0ing' 9'ow do you feela out the change?!

"fter as0ing about changes clients have made' it is important to follow.up with a Euestion about how clients feel about the changes the made% 'ow do you feel the changes you made?! 9'ow were you a le to go from a [^ 5 months ago\ to a [^ now\?! [Client answers\ 'ow do you feel a out those changes?!

-EADI>ESS %8 C2A>GE -@1E-ationale: "ssessing readiness to change is a critical aspect of 1I% 1otivation' which is considered a state not a trait' is not static and thus can change rapidl from da to da % Clients enter treatment at different levels of motivation or readiness to change @e%g%' not all are read to changeH man are ambivalent about changingA% In this regard' if therapists 0now where clients are in terms of their readiness to change' the will be better prepared to recogniGe and deal with a clientKs motivation to change% The concept of readiness to change is an outgrowth of the )tages of Change 1odel that conceptualiGes individuals as being at different stages of change when entering treatment% 2hile readiness to change can be evaluated using the )tages of Change 1odel' a simpler and Euic0er wa is to use a /eadiness to Change /uler @"ppendi? 4%6A% This scaling strateg conceptualiGes readiness or motivation to change along a continuum and as0s clients to give voice to how read the are to change using a ruler with a -,. point scale where - _ definitel not read to change and -, _ definitel read to change% " /eadiness /uler allows therapists to immediatel 0now their clientKs level of motivation for change% !epending on where the client is' the subseEuent conversation ma ta0e different directions% The /eadiness to Change /uler can also be used to have clients give voice to how the changed' what the need to do to change further' and how the feel about changing% E#amples of 2ow to @se a -eadiness to Change -uler ] Therapist @TA: 3n the following scale from 4 to 48, where 4 is definitely not ready tochange and 48 is definitely ready to change, what num er est reflects how ready you are at the present time to change your [insert ris0 Cproblem behavior\?! Client @CA: Seven+! T: And where were you 9 months ago?!

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C: ,wo+! T: So it sounds like you went from not eing ready to change your [insert ris0 Cproblem behavior\ to thinking a out changing+ 'ow did you go from a :)$ 9 months ago to a :;$ now?! 'ow do you feel a out making those changes?! #hat would it take to move a it higher on the scale?!

Clients with lower readiness to change @e%g%' answers decreased from a 93: 5 months ago to a 92: nowA So, it sounds like you went from eing am ivalent a out changing your [insert ris0 Cproblem behavior\ to no longer thinking you need to change your [insert ris0 Cproblem behavior\+ 'ow did you go from a :.$ to a :)$?! #hat one thing do you think would have to happen to get you to ack to where you were 9 months ago?!

A99I-.A%I8>S -ationale: "ffirmations are statements made b therapists in response to what clients have said' and are used to recogniGe clientsK strengths' successes' and efforts to change% "ffirmative responses or supportive statements b therapists verif and ac0nowledge clientsK behavior changes and attempts to change% 2hen providing an affirmation' therapists should avoid statements that sound overl ingratiating @e%g%' #ow, that$s incredi le<! or ,hat$s great, I knew you could do it<!A% 2hile affirmations help to increase clientsK confidence in their abilit to change' the also need to sound genuine% E#ample of Affirmative Statements 6our commitment really shows y [insert a reflection about what the client is doing\+! 6ou showed a lot of [insert what best describes the clientKs behaviorYstrength' courage' determination\ y doing that+! It$s clear that you$re really trying to change your [insert ris0 Cproblem behavior\+! 7y the way you handled that situation, you showed a lot of [insert what best describes the clientKsK behaviorYstrength' courage' determination\+! #ith all the o stacles you have right now, it$s [insert what best describes the clientKs behaviorY impressive' amaGing\ that you$ve een a le to refrain from engaging in [insert ris0 Cproblem behavior\+! In spite of what happened last week, your coming ack today reflects that you$re concerned a out changing your [insert ris0 Cproblem behavior\+!

AD3ICEH9EED/AC= -ationale: " freEuentl used 1I strateg is providing advice or feedbac0 to clients% This is a valuable techniEue because clients often have either little information or have misinformation about their behaviors% Traditionall ' therapists and other health care practitioners have encouraged clients to Euit or change behaviors using simple advice [e%g%' If you continue using you are going to have @insert health conseEuence*+!\% /esearch has shown that b and large the effectiveness of simple advice is ver limited @e%g%' 3T to -,T of smo0ers are li0el to Euit when simpl told to Euit because smo0ing is bad for their

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healthA% The reason simple advice does not wor0 well is because most people do not li0e being 9told what to do%: /ather' most individuals prefer being given choices in ma0ing decisions' particularl changing behaviors% 2hat we have learned from 1I is that how information is presented can affect how it is received% 2hen relevant' new information should be presented in a neutral' non>udgmental' and sensitive manner that empowers clients to ma0e more informed decisions about Euitting or changing a ris0 Cproblem behavior% Bne wa to do this is to provide feedbac0 that allows clients to compare their behavior to that of others so the 0now how their behavior relates to national norms @e%g%' percentage of men and women drin0ing at different levelsH percentage of population using cannabis in the last earH see "ppendices 4%2c and 4%2d for e?amples of such feedbac0A% &resenting personaliGed feedbac0 in a motivational manner allows clients to evaluate the feedbac0 for personal relevance @I guess I drink as much as my friends, ut may e we are all drinking more than we should+!*+ 2hen therapists as0 clients what the 0now about how their ris0 Cproblem behavior affects other aspects of their life @e%g%' healthYh pertensionA clients t picall sa ' #ell not much! or the might give one or two brief facts% This can be followed.up b as0ing if the are interesting in learning more about the topic and then being prepared to provide them with relevant advice feedbac0 material that the therapist has prepared or has available% <astl ' whenever possible' focus on the positives of changing% " good e?ample of providing positive information about changing is evident with smo0ing% 2ithin 2, minutes of stopping smo0ing an e?.smo0erKs bod begins a series of changes ranging from an immediate decrease in blood pressure to -3 ears after Euitting the ris0 of coronar heart disease and death returns to nearl that of those who have never smo0ed [http:CCwww%lungusa%orgCsiteCpp%asp=c_dv<NQ8B,EXb_33357\% 2hat is interesting with this e?ample is that man smo0ers are not aware of the multiple benefits that occur soon after Euitting% In this regard' therapists can as0' #hat do you know a out the enefits of -uitting smoking?! and follow. up with as0ing permission to tal0 about the clientKs smo0ing @Do you mind if we spend a few minutes talking a out your smoking?!A% /emember that some clients will not want information% In these cases' if the therapist uses scare tactics' lectures' moraliGes' or warns of disastrous conseEuences' most clients are not li0el to listen or will pretend to agree in order to not be further attac0ed% E#amples of 2ow to (rovide AdviceH9eedbac @often this can start b as0ing permission to tal0 about the clientKs behaviorA Do you mind if we spending a few minutes talking a out1+? [;ollowed b \ #hat do you know a out1+?! [;ollowed still b \ Are you interested in learning more a out1++?!

["fter this clients can be provided with relevant materials relating to changing their ris0 Cproblem behavior or what affects it has on other aspects of their life%\ #hat do you know a out how your drinking affects your [insert health problem\?! #hat do you know a out the laws and what will happen if you get a second drunk driving arrest?! 3kay, you said that the legal limit for drunk driving is 8+8=>+ #hat do you know a out how many drinks it takes to get to this level?! So you said you are concerned a out gaining weight if you stop smoking+ 'ow much do you think the average person gains in the first year after -uitting?!

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I$ve taken the information a out your drinking that you provided at the assessment ,calculated what you report drinking per week on average, and it is presented on this form along with graphs showing levels of drinking in the general population+ #here do you fit in?! 3n one of the -uestionnaires you filled out, the Drug A use Screening ,est, you scored a ;+ ,his form shows how scores on that measure are related to drug pro lem severity+ #here do you fit in?!

S@..A-IES -ationale: )ummaries are used >udiciousl to relate or lin0 what clients have alread e?pressed' especiall in terms of reflecting ambivalence' and to move them on to another topic or have them e?pand the current discussion further% )ummaries reEuire that therapists listen ver carefull to what clients have said throughout the session% )ummaries are also a good wa to either end a session @i%e%' offer a summar of the entire sessionA' or to transition a tal0ative client to the ne?t topic% E#amples of Summaries: It sounds like you are concerned a out your cocaine use ecause it is costing you a lot of money and there is a chance you could end up in /ail+ 6ou also said -uitting will pro a ly mean not associating with your friends any more+ ,hat doesn$t sound like an easy choice+! 3ver the past three months you have een talking a out stopping using crac0, and it seems that /ust recently you have started to recogni?e that the less good things are outweighing the good things+ ,hat, coupled with your girlfriend leaving you ecause you continued to use crack makes it easy to understand why you are now committed to not using crack anymore+!

%2E-A(E@%IC (A-AD8B -ationale: &arado?ical statements are used with clients in an effort to get them to argue for the importance of changing% )uch statements are useful for clients who have been coming to treatment for some time but have made little progress% &arado?ical statements are intended to be perceived b clients as une?pected contradictions% It is hoped that after clients hear such statements clients would see0 to correct b arguing for change @e%g%' 7ill, I know you have een coming to treatment for two months, ut you are still drinking heavily, may e now is not the right time to change?!*+ It is hoped that the client would counter with an argument indicating that heCshe wants to change @e%g%' 0o, I know I need to change, it$s /ust tough putting it into practice+!A% Bnce it is established that the client does want to change' subseEuent conversations can involve identif ing the reasons wh progress has been slow up to now% 2hen a therapist ma0es a parado?ical statement' if the client does not respond immediatel b arguing for change' the therapist can then as0 the client to thin0 about what was said between now and the ne?t session% )ometimes >ust getting clients to thin0 about their behavior in this challenging manner acts as an e e.opener' getting clients to recogniGe the have not made changes% Therapeutic parado?es involve some ris0 @i%e%' client could agree with the parado?ical statement rather than arguing for the importance of changeA' so the are reserved for times later in treatment when clients are not ma0ing changes and ma or ma not be aware of that fact% )uch clients often attend sessions regularl but ma0e no significant progress toward changing the ris0 Cproblem behavior for which the sought treatment% "nother reason for caution is such statements can have a negative effect on clients% <astl ' the therapist must be sure to sound genuine and not sarcastic%

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2hen using the therapeutic parado?' the therapist should be prepared that clients ma decide that the do not want to change at this time% In such cases the reasons can be discussed' and the therapist can suggest that perhaps it might be a good idea to ta0e a 9vacation: from treatment% In such instances' therapists can tell clients that the will call them in a month or so to see where the are in terms of readiness to change% "nother wa to thin0 about what a therapeutic parado? is doing is reflecting the personKs behavior in an amplified manner% E#amples of 2ow to @se a %herapeutic (arado# 2ay e now is not the right time for you to make changes+! 6ou have een continuing to engage in [insert ris0 Cproblem behavior\ and yet you say that you want to [insert the behavior ou want changeYe%g%' get our children bac0H get our driverKs license returnedH not have our spouse leave\+ 2ay e this is not a good time to try and make those changes+! So it sounds like you have a lot going on with trying to alance a career and family, and these priorities are completing with your treatment at this time+!

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%here are five ,uestions that are central to empowerment coaching:

$" What would a good situation loo li e+ &" What would need to change+ *" What are the steps necessary to ma e the change+ 0" What help would you need to ta e these steps+ I" Who could provide you with support as you ta e these steps+
These five Euestions can be used as the centerpiece of a successful reference interview as well as a successful coaching intervention% The first Euestion' as0ing for the definition of a good or right situation' ma address what the patron e?pects to get out of the reference session% The obvious assumption is that the good or right situation would be having complete and accurate information to accomplish the intended tas0% The client survivor' however' might be loo0ing for something in addition to this' such as a sense of empowerment that comes from >ust having information about the issue and 0nowing that she is not alone% The second Euestion' concerning desired changes' is also applicable to both the coaching situation and the reference interview% 2hen a patron see0s reference service' it can be assumed that he or she is loo0ing to change something% Changes ma include ma0ing a research paper better' getting a better >ob' etc% The client' however' ma be loo0ing for an entirel different 0ind of change' such as getting awa from an abusive situation' finding coaching to regain her mental health or finding support from peers% ;or this reason' the reference interview must be 0ept as confidential as possible% )he might be e?tremel sensitive to even being seen in a librar as0ing about options% " librarian should ma0e ever effort to get the client into a private area for the reference interview% The third Euestion concerns the steps that are needed to reach the intended 9good: situation% This is where the librarianKs research s0ills are essential% )omeone who has been a victim of violence ma have no idea what to do and ma simpl want to 0now' 92hat do I do now=: It is recommended that ever librar investigate services for survivors in the local area and 0eep a list of services and contact information near the des0' including national or state hotline numbers% The survivor ma see the librarian as a 0ind' helpful professional and tr to use them as a coach% "t this point' it is important to gentl remind the patron that the librarian is not a coach and cannot give advice on how to proceed but will be glad to help her loo0 for information on all of the options% The fourth Euestion involves the 0ind of help that is needed in order to ma0e the change% " librarian should be able to locate resources that discuss all of the options available% It is ver important not to give the patron advice such as 9 ou should go to the police': but to ma0e sure she has information about all of the options so that she can leave with the necessar tools to ma0e an informed choice% It is a good idea to have some free materials such as pamphlets @a local crisis center ma be able to provide theseA that the patron can ta0e with her% ;ree materials that do not need to be returned are an e?cellent resource for survivors who ma have ta0en a great personal ris0 to come to the librar % The fifth Euestion involves help and support% " survivor of a se?ual assault ma be as0ing for help without actuall voicing a Euestion% It is a good idea for a librarian to give an patron who as0s about se?ual assault contact information for a helping resource' such as the number of a rape crisis hotline% *ot onl can these organiGations assist survivors' the can also provide e?cellent information to researchers%

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In empowerment coaching' the coach is advised not to use Euestions that as0 or impl 9wh %: !ewdne and 1ichell advised against e?cessive use of 9wh : Euestions in the reference interview% The e?plained that the librarian and patron ma view a 9wh : Euestion differentl % The librarian ma be loo0ing for a motivation for the patronKs Euer in order to give a more complete or relevant answer' but the patron ma view the Euestion as suspicious' intrusive or confusing% !ewdne and 1ichell further suggested that these feelings on the part of the patron ma lead to hostilit and a brea0down of the reference transaction% There is' however' an additional reason to avoid the use of 9wh : Euestions with @se?ualA assault survivors% 2hen as0ing 9wh ': one is loo0ing for a reason or motivation% If a reference librarian were to sa 9wh are ou loo0ing for information on se?ual assault coaching=: a survivor would be faced with two choices: reveal sensitive information or lie% *o one should be forced into that dilemma b someone who purportedl is serving her% "dditionall ' a self.revelation might lead to Euestions about the abusive event or situation% 2hen one as0s a Euestion li0e 9wh did he rape ou=: the Euestion implies that he must have had a reason' and this reason ma be the responsibilit of the victim% It is imperative that an one in a service role' whether librarian' coach or even friend' avoid 9wh : Euestions that ma sound li0e victim blaming% Empowerment in the conte#t of counselling has been defined as follows: Empowerment is the process b marginaliGed: which people' organiGations' or groups who are powerless or

@aA become aware of the power d namics at wor0 in their life conte?t' @bA develop the s0ills and capacit for gaining some reasonable control over their lives' @cA which the e?ercise' without infringing upon the rights of others' and @dA which coincides with supporting the empowerment of others in their communit % @1c2hirterA @aA In fact' powerful s stemic and structural influences including racism' se?ism' hetero.se?ism' inaccessible environments' and ageism ma be reflected within the counselling relationship as well' thus' the counsellors critical awareness of power d namics within the counselling relationship and in the clientIs larger social conte?t is prereEuisite to facilitation of client awareness% @bA !evelop the s0ills and capacit for gaining some reasonable control over their lives refers to s0ill acEuisition as well as the motivation and self.efficac e?pectations reEuired to e?ercise those s0ills% Counsellors often pla an important role in facilitating the acEuisition of new s0ills% It is important to 0eep in mind' however' that counsellors are often trained in s0ill building e?ercises rooted in European "merican values' worldviews' and norms% Thus the nature of each s0ill' as well as the manner and conte?t in which the s0ill is practiced' must be shaped in accord with the clients concerns as well as other salient client characteristics such as personal and sociopolitical histor ' culture' interpersonal st le' level of acculturation' and preferences% ;urther' counsellors must not overloo0 the vital resources with which the client enters the counselling relationship: specific coping mechanisms' attitudes' 0nowledge' and e?periences that sustained the client through life thus far% @cA 2hich the e?ercise without infringing upon the rights of others addresses the fundamental nature of empowerment as integrative power or Jpower with othersJ @4agberg' -874A rather than power over others' or power Jto do toJ others% The e?ercise of s0ills that violate the human rights of others is fundamentall incompatible with empowerment% @dA Coinciding with supporting the empowerment of others in their communit can range from interpersonal behaviours such as providing encouragement and support to communit consciousness.

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raising efforts such as participating in marches or helping to organiGe cultural and educational events% The role of the counsellor is to facilitate and support the clients connections with communit ' and to enhance the clients abilit to support the empowerment of others as appropriate for the clients current situation% These elaborations should ma0e clear that empowerment is not a linear process' nor one that concludes with the achievement of a particular JempoweredJ state% 1an clients will not be read for or interested in the empowerment of others. in the form of interpersonal relationships or communit participation . when the terminate the counselling relationship% This must not be considered a failure on the part of the client or the counsellor to JachieveJ the goal of empowerment% The counsellors role is to meet clients where the are in the empowerment process and wor0 to support increasing' enhancing' or otherwise promoting empowerment in additional wa s that are consistent with the clientIs goals% Critical components of an empowerment model can be represented in terms of J;ive CsJ: Collaboration' Competence' Conte?t' Critical Consciousness' and Communit % Collaboration" JCollaborationJ refers to the d namic relationship between counsellor and client% The relationship should be characteriGed b collaborative definition of problematic issues' goals' and development of interventions and strategies for change or growth% These interventions and change strategies are consistent with the clientIs values' goals' s0ills' e?periences' and abilities% The client is viewed a la &aulo ;reire @-86-A as an active member of a team rather than a passive recipient of services% Competence: "ll clients have e?isting s0ills' resources' and a wealth of e?perience to contribute to the counselling process% To overloo0 these resources is li0el to reinforce neediness' to foster dependenc ' to discourage esteem.building' and is generall contrar to the goals of empowerment and to good counselling% Counsellor recognition and authentic appreciation of client resources is essential% 4onest counsellor feedbac0 regarding s0ill deficits or personal wea0nesses is also part of supporting client competence% The vast ma>orit of clients understand that the have wea0nesses @which the often perceive to be more serious than does the counsellorA and counsellor avoidance of constructive feedbac0 is li0el to ma0e it hard for clients to believe positive feedbac0% )o too with counsellors themselves: the must learn to identif their own strengths and wea0nesses' grow in their understanding of how to utiliGe their strengths more effectivel ' and how to enhance areas of wea0ness% Counsellors are unli0el to trul appreciate the strengths of others if the are unable to appreciate their own competencies' >ust as the are unli0el to accept others wea0nesses without accepting their own% Conte#t" The d namics of power and privilege shape the clients conte?t as well as the conte?t in which we provide counselling services% This conte?t includes larger social forces @e%g%' ageism' racism' se?ism' classism' homophobia' able.bodied assumptionsA and the effects of these assumptions on care providers' families' and individuals' as well as on facult members' departments' educational institutions' and individual students% Conte?t also includes s stems such as families' social networ0s' neighborhoods' ethnic groups' professional and wor0 groups' and faith communities% Integration of the conte?t component into counselling means that we ac0nowledge the role of conte?t in the clients current situation or problem' including how the conte?t serves to maintain or e?acerbate problems' while at the same time ac0nowledging the clients options and responsibilities related to change%

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The conte?t component of empowerment is directl dependent upon the critical consciousness component That is' without critical consciousness' efforts to address conte?t are li0el to be ineffective' because understanding conte?t reEuires the development of critical consciousness% Critical Consciousness" )upporting the empowerment process reEuires that counsellors engage in an ongoing attempt to facilitate client awareness of conte?t through the process of consciousness raising in a manner consistent with the clients situation' needs and abilities% Counsellors cannot engage in consciousness.raising without developing their own understanding of the power d namics affecting both clients and themselves% Critical consciousness can be increased through two overlapping processes: power anal sis and critical self. reflection% &ower anal sis refers to e?amining how power is distributed in a given situation in terms of raceC ethnicit ' gender' disabilit status' se?ual orientation' age' e?perience' famil position' etc% @1c2hirter' -884A % E?ample: To illustrate power anal sis' a facult member might engage students in e?ploring the personal and professional repercussions of the program C department C universit Is adherence to medical' economic' or sociopolitical models of disabilit @4ahn' -877A% "ccording to 4ahn @-877A' the medical model defines disabilit in terms of individual limitations' while the economic model focuses on the individuals functional limitations% ( contrast' the sociopolitical model defines disabilit as a multifaceted product of the interaction between the individual and the environment' and emphasiGes disabling features of the environment% The economic and medical models of disabilit arise out of modem da cultural assumptions regarding disabilit ' such as: Jdisabilit J eEuals Jneeding helpJH disabilit is a fact of biolog aloneH and people with disabilities' as victims of biological in>ustice rather than social in>ustice' must change their personal behaviour rather than their social conte?t @;ine X "sch' -877A % E?ploration of the e?tent to which these models are represented in the department' and the implications of each model for counselling students with disabilities' would engage students in thin0ing criticall and concretel about one important aspect of power d namics% In addition to raising awareness' such a discussion could lead to actions that improve the departmental environment for students with disabilities% Critical self.reflection overlaps with power anal sis in the sense that counsellors must understand how the contribute to specific power d namics in their behaviours' assumptions' and interactions with others% In addition' critical self.reflection involves developing awareness of privilege' and of how counsellors have benefitted from privilege at the e?pense of those who are not privileged% The vast ma>orit of counsellors en>o privilege at multiple levels' such as age' racialCethnic group membership' se?ual orientation' socioeconomic status' disabilit status' education level' and gender% This is not to sa that most counsellors are oung' white' straight' middle or upper class' able.bodied males' but to sa that most counsellors are members of more than one of these categories of privilege% Bne wa to e?plore privilege is to e?amine the common assumptions or things that people ta0e for granted b virtue of membership in a privileged group% @Bf course' these will not be true for all members of that privileged group%A European Canadians' for e?ample' usuall assume that ever one does @or shouldA spea0 their language @EnglishA' are far less li0el to be hated or JtoleratedJ b persons with greater power because of their ethnicit ' and generall e?perience higher teacher e?pectations than persons of color% 4eterose?uals can engage in public displa s of affection without their actions

5,

representing a political actH the also e?perience freedom from fear of losing their >obs on the basis of se?ual orientation' and freedom from the threat of being outed or targeted b anti ga hate crimes% 1ales are less li0el to be interrupted' more li0el to be >udged on the basis of characteristics be ond purel ph sical characteristics' and are far less li0el to be raped b strangers' acEuaintances' or famil members' than are females% "n e?ploration of wor0s enumerating these aspects of privilege ma serve as a point of departure with students' for e?ample' the wor0 of 4enning.)tout @-884A ' ;reire @-86-A ' and others% Community" Communit ma be defined in terms of ethnicit ' famil ' friends' place of residence' faith' se?ual orientation' common organiGational affiliation' or other bonds% " communit is a source of strength and hope' identit and histor ' support and challenge' interaction and contribution% Communit is fundamental to empowerment in two wa s% ;irst' the communit can provide resources' support' and affirmation for clients% )econd' the clients mutual contribution bac0 to that communit is essential in furthering the empowerment process% Counsellors wor0 with clients to develop an understanding of the clients sense of communit ' the resources available' and the e?tent and Eualit of client interactions with the identified communit % Bften clients will not e?perience a sense of communit with an others in their environment' or ma belong to communities that undermine their resources and abilities% Thus' counsellors must also be aware of potential new sources of communit ' and assist clients in accessing or fostering communit % This ma include helping clients develop s0ills for drawing upon the communit Ks support% ;inall ' counsellors can assist clients in identif ing wa s to support the empowerment of others in their communit % )ource: E?cerpt of article published in the Canadian Vournal of Connselling C /evue canadienne de counseling C -887' Dol% 32:- . "n Empowerment 1odel of Counsellor Education ( Ellen 4awle 1c2hirter . Nniversit of Bregon

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%echni,ues for creating collaborative relationships and useful goals: $" Clarify where people are now vs" where they want to be in the future aC 2here are the now= @what is the problem=A Bf all these concerns on O' which one should we wor0 on first= 2hat does the problem loo0 li0e= 2here and when does it usuall happen= 2hat would I see if I watched this problem happening on a video= @having the client describe the problem in 9video.tal0:AH 2hat does the problem loo0 li0e= 2hat happens first= *e?t= Then what=H 2hereCwhen does it occur= 4ow does this problem affect ou and our lifeH O% 2hat have ou alread tried= 4ow did things wor0= 2hatKs most important to ou=

bC 2here do the want to be in the future= @2hat is the Goal=A E?plore how the goal will impact clientsK lives 2hat do ou want our life to stand for= 4ow will life be different when things start improving= 2hat would ou rather be doing instead of the problem= 2hat will ou be doing instead= @start basedA 2hat can ou do differentl = @self.manageableA 2hat would it e?actl loo0 li0e = If we watched a videotape of ou being 9less depressed': what would ou be doing= 2hat will be the first small sign of improvement=

and e?plore clientsK willingness and confidence Bn a scale or , to -,' how willing are ou to change something in order to reach our goal=H 4ow confident are ou in moving closer to our goal=% 2hat are ou willing to do this wee0 to move a little closer to that= 2hat are ou willing to do to ma0e this mar0 move up one or two centimeters on the line%

&" Invest in what is right aH search for e#ceptions : build on moments when the problem was not D or less 6 present TechniEues for building on e?ceptions: Identif one or more 9e?ceptions: to the problem @2hen is the problem absent or less noticeable=A' e?plore details of the e?ception @2hat was different about that time=A' and encourage 9more of: the e?ception @2hat would it ta0e to do more of this= "re ou willing to tr that =A Identif ing' E?ploring' and Encouraging 91ore of: the E?ception: Identif an e?ception 2hen is the problem absent or less noticeable= Tell me about the moments when ou were least aware of C suffer least from the problem= Tell me about a time this wee0 when ou and S got along a little better than usual%

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E?ploring details of the e?ception 2hat was different about that time= 4ow are ou different then compared to other moments=

Encouraging 9more of: the e?ception 2hat will it ta0e to do this again= 2hat will it ta0e to do more of that ne?t wee0= I wonder what would happen if ou tried this approach during other moments throughout the da = "re ou willing to tr it=

E?ample: Congratulations on changing our behavior last wee0% IKd li0e to learn more about what ou did to ma0e things better% Four ideas and advice will help me in m wor0 with other peoples who are struggling with similar challenges% I loo0 forward to learning more from ou%J bH Search for other >atural -esources: 1isten! loo for! as about resources you can build on" <isten' e?amine records' reports' and other information with an e e toward discovering resilience' cultural factors' special interests' and other potentiall useful resourcesH <isten' loo0 for' and as0 about 9natural resources: in the indivualKs life @cultural heritage' life e?periences' resilience' heroes and influential people' special interestsAH Incorporate their natural resources into interventions @inviting a respected grandparent to a meeting' building on their solution ideas or advice to others' incorporating their special interests and talents into counseling conversations and interventions% E?amples: The onl thing I care about are m friends and m music% I wouldnKt come to school at all if it wasnKt for art class and 1s% (a?ter%:AH 4ow have ou 0ept things from getting worse= Bf ever one who 0nows ou' who would be most surprised that ouKre having this problem= . 2h would the be surprised= 2ho do ou loo0 up to most in our life= 2ho are our biggest heroes= . 2hat would the do if the were in our shoes= 2ho do ou respect the most= . 2hat would he or she advise ou to do about this= 2ho else is on our 9support team: and how might the help ou with this problem= 4ow have ou managed to hang in there instead of giving up= 4ow have ou 0ept things from getting worse= If ou were a counselor' what advice would ou have for others who are dealing with this t pe of problem=

Incorporate the natural resources into interventions% "s0 how the individual has handled other tough challenges @resilienceA' and e?plore how one or more of the resources that helped them through a previous challenge might help them with the current problem% /eEuest the involvement C advice of influential people in the personKs life b calling them' as0ing them to spea0 with the individual' or inviting them to a counseling session or meetingH E?plore connections between the individualKs hobbies and special interests @s0ateboarding' musicA and solutions to the problem

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I wonder how the courage ou developed when ou learned how to ride a s0ateboard C pla the guitar O might help ou with this current problem% 2hat do ou thin0=

*" Empower desired changes by giving clients credit! preparing for setbac s! e#ploring their plans to continue positive changes! and using therapeutic letters and documents" E?amples of Giving Credit' &reparing for )etbac0s' and E?ploring &lans to Continue &ositive Changes: 4ow did ou manage to remain focused through the whole da = @giving credit for improvementAH 2hat will it ta0e to continue this= @e?ploring plans to continue positive changesAH " lot of times things donKt change in a straight line' but more li0e two steps up' one bac0' two up' three bac0' and so on% )o letKs tal0 about what ou can do to get bac0 on trac0 when ou hit rough spots along the wa @inviting to prepare for setbac0sA%

0" Invite something different by changing the viewing and doing" -% Changing the view: Invite people to consider a different et plausible view of the problem @Could it be thatO=AH Bffer a different motive or meaning for the behaviorH E?ternaliGe the problem from the person% ;or a person who views her aggressive behavior as a sign of strength and independence' invite her to consider the possibilit that the problem behavior reflects her desire for more attention from and connection with her peers% ;or a person who views another individualKs disruptive behavior as a personal attac0 or sign of disrespect' offer the possibilit that the individualKs behavior ma reflect an attempt to avoid public embarrassment about his personal difficulties% *BTE: In order to be most effective' the different view that is offered needs to: fit the facts at least as well as e?isting viewsH be different enough from e?isting views to ma0e a differenceH and ma0e sense and be acceptable to the client%

E?amples: Could it be that our boss C teacher gets on ou a lot because she cares enough to want ou to succeed= Can ou thin0 of an other reasons wh this person might be acting this wa =

2% Changing the doing: Invite people to alter their performance of or response to the problem @&attern interruption strategies including altering the seEuence' tone' time of da ' and other aspects of problem performanceH 9!o )omething !ifferent: e?periments% "re ou willing to tr something reall different= I wonder what ou could do to be less predictable% It might be interesting to do something reall different ne?t time this happens >ust to sha0e things up and see what happens% 1a be ou could thin0 of something reall different this wee0 and tr it out as an e?periment%

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Encourage clients to alter the problem pattern b doing something%%%an thingOdifferent ;or a person who argues a lot with her boss' invite her to be 9unpredictable: b sa ing something nice to the boss upon entering the wor0place for three consecutive da s and observing an differences in the relationshipH ;or a supervisor concerned about the behavior of a disruptive team member' encourage the supervisor to alter the problem pattern in the following wa : The ne?t time the problem starts' tell the individual that ou are going to start at the end and wor0 bac0wards b sa ing' 9IKm sorr I had to do this without ou' because itKs important to me that ou remain part of the team' but I canKt tal0 with ou all the time and organiGe things at the same time%: E?amples of 9!o )omething !ifferent: E?periments ;or parents who complain about 9dail arguments: with their daughter shortl after she arrives home from school' invite them to tr a 9!o )omething !ifferent: e?periment in which the @aA do something ver different when their daughter arrives home from school' and @bA ma0e careful observations' perhaps even notes' on her response to the e?periment% &ractice E?ercise: Invite )omething !ifferent b Changing the !oing Instructions: @aA The supervisorCteacherCparent describes a problem the are having with another personH @bA The service provider invite the supervisorCteacherCparent to consider being unpredictable b doing something different in order to change the problem% -% The service provider describes the problem in specific terms @2ho does what' when' to whom=A% 2% The service provider and the supervisorCteacherCparent wor0 through the following steps: 2hat do ou usuall do in response to this personKs problem behavior= 2hat is the usual result= 2hat could ou do that would be totall different and une?pected the ne?t time the person performs the problem behavior= @(rainstorm some possibilities before ruling an thing outA Bf all the options we >ust discussed' which one would ou be most li0el to tr = Bn a scale of , to -, where , _ 9not at all li0el : and -, _ 9ver li0el ': how li0el is it that ou will actuall do this when ou return to wor0= @circle oneA . , - 2 3 4 3 5 6 7 8 -,

3% E?ternaliGing the problem from the person% !iscuss the problem as a separate and distinct entit that is e?ternal to the client b giving it a name' e?ploring its power in the relationship' and e?ploring times in which the client has stood up to it instead of ielding to its influence E?amples: If ou were to name this problem' what would ou call it= 4ow long has 1s% *ast been part of our life= 4ow does she get ou to dance to her tune= Tell me about a time that ou stood up for ourself and did things our wa instead of giving in% 4ow will our life be different as things change between ou and 1s% 1ean = 2hat would happen if ou switched seats with 1r *ast @the problemA so that ou became the driver and he @the problemA became the passenger=

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I" Cuestions for ?oung (eople 3iewed as -eluctant or -esistant 5'.andated) Clients7 4ow can ou get out of coming here= 2hat would convince our teachersCparents that ou no longer need counseling= 2hat would our teacher @B/ parentC>udgeCprobation officerA sa needs to happen= 2hat will I need to sa or write to the court to convince them that ou no longer need counseling= 2hat are ou willing to do to ma0e that happen= 2ho suggested that ou tal0 to me= 2h do ou thin0 the suggested it= 2hat ma0es them thin0 ou need counseling= . !o ou agree with them= 2ould ou be interested in finding wa s to get our teachers and parents off our case= 2hat have ou found helpful to 0eep our others from hassling ou as much about this= [Insert the clientKs own words into Euestions when possibleYhassling' elling' being pic0ed on' etc%\ 4ow can I help= . 2hat can I do to help ou= 2hat are ou willing to do differentl to help our cause= 2hat would be the first small step ou could ta0e in that direction= 2hat would be the first small sign that would tell our teacherCparent that ou are ma0ing progress and improving things= Bf all the people in our life' who do ou loo0 up to and respect the most= 2hat would sChe advise ou to do about this= 2hat else would ou rather wor0 on here= [!iscuss something important to the client to engage their involvement and energ \ I canKt force ou do an thing ou donKt want to do' and I respect our choice to participate or not participate in counseling% If ou choose not to' I want ou to 0now that ou can come bac0 an time to ma0e sure ou have a sa in things%

JThe process b which the client reconstructs his e?perience is not one the wor0er createsH he simpl enters' and leaves%%% he is an incident in the life of his client% Thus the wor0er should as0 himself: 2hat 0ind of incident will I represent%%% 4ow do I enter the process' do what I have to do' and then leave=J
(Schwartz W. (1974): The Soc al Wor!er n the "ro#$, n: %len!, &.W.' &(an, &. ()d*.): The +ract ce o, Soc al Wor!, -el.ont /al., 2080228.)

The (est 2a To Empower )omeone Is To )how Them Their )trengths and praise them for who the are I come in contact with man people who are reall down on their luc0 or who >ust feel completel defeated b life% Fou hear it in their words and ou see it in their bod language% <istening to them and letting them vent is helpful' up to a point% (eing non.>udgmental and supportive is also helpful' up to a certain point% If itKs someone close to ou' being there for them is helpful% Fes' ou guessed it' up to a point% The best wa to empower people who feel down or at a low point' starts with listening reall carefull % 2hen ou listen carefull ' even if the stor is negative' sad or tough' ou can' from the words being spo0en' identif the personKs strengths and Eualities% 2hen ou then show the person what amaGing strengths the have' strengths that ou can bac0 up b e?amples of things the said' and praise them for what the are doing and who the reall are' it empowers them in a wa far be ond an other method I 0now about%

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Ta0e the case of a 24 ear old gu who wor0s in the hospital come into the E/% 4e was having bac0 pain and he had a painfull stiff nec0% It turns out that this gu was wor0ing in a >ob he hated% B0a ' nothing new there' man of us do that at one point or another% 4e told me about how he had no other option% @Bf course' I felt compelled to point out that there is alwa s more then one choice or option in an given situation% In the end' what we do is our choice based on the pluses and minuses to be gained or lost% (ut that is a completel different post%A 2hen I started digging deeper' he told me about the mortgage he has to pa as an e?ample of one of his man burdens in life% That intrigued me% " 24 ear old with a mortgage% The conversation went on for a while% To ma0e a long stor short he was supporting his mother' divorced sister and her child who all lived with him% I was blown awa % 2hat a hec0 of a burden for a 24 ear old gu to shoulder% I couldnKt leave him li0e that so I started telling him about his Eualities and strengths% Wualities and strengths that I heard during our conversation% I told him about his highl developed sense of responsibilit % I pointed out to him how committed he was to his famil % I pointed out his selflessness% 1an people his age put themselves and their needs before an thing else% I also pointed out to him how rare it was for someone his age to be able to plan ahead the wa he is% @4e had bought an apartment because the rent is >ust as high as his mortgage%A The more I pointed out his positive strengths' especiall ones that connected him with his sense of values' the more he per0ed up% The point of this stor is twofold% ;irst' even a few minutes can ma0e a big difference in someoneKs da and sometimes even their life% )econdl ' if ou reall want to encourage and empower someone' listen to them carefull % Even within their tales of despair ou can find a personKs strength% 2hen a person recogniGes' remembers and connects to their strengths' the are read to soar% 4as someone ever empowered ou through emphasiGing or pointing out our strengths= 9&raise is li0e sunlight to the human spirit% 2e cannot flower and grow without it%: `Vess lair I chose to share this stor with ou mostl because I found it so amaGing to see how things that ou learn . in this case things that I learned in m coaching training program . actuall come to life in our da to da interactions% I realiGe what a tremendous difference learning theor ' as well as certain techniEues' whether it be listening' re.framing or encouragement >ust to name a few' ma0e on the wa ou view and react to things% Fet' another e?ample of wh constant learning and self advancement is so important% Bn our >ourne through life' each of our inner circles is growing and encompassing more people: children' significant others' friends' colleagues' and random people we meet and donKt 0now as intimatel % "s the circle grows' so too does our influence% Ever nod' ever smile' ever interaction can completel change the course of someone elseKs da % 2e can either wield that influence in a positive or negative wa % The following I would li0e to dedicate to those special people who identif with their fellowmen' and use their influence to empower them% Empowering others is one of the most important acts of 0indness one can do for his fellow man% Empowering others means not criticiGing them% Empowering others means not >udging them% Empowering others means not being c nical toward them% Empowering others means praising the struggling student in the class on his or her progress Y an progress' no matter how small%

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Empowering others means curbing our ego% Empowering others means connecting to the best elements that lie within ou% Empowering others is contagious% Empowering others means giving them the feeling that the are loved% Empowering others is to understand that the cashier at the supermar0et' the waiter at the cafa' the gu who pumps our gas' the doorman' the street cleaner' and the >anitor are not transparent% The are people >ust li0e us% Empowering others means smiling at these people' inEuiring about their wellbeing' than0ing them for the services the provide' and wishing them a good da % Empowering others means being happ for them' and praising them on their accomplishments% &raising them in an wa possible% "lwa s% Empowering others means identif ing with them% Empowering others is eas % It does not reEuire an effort% Empowering others means smiling when someone else approaches% Empowering others also empowers us% Empowering others ma0es the world a better place% Empowering others means to be moved b the "merican poet and author 1a a "ngelou' one of the most important figures in the "merican Civil /ights 1ovement' who said' 9IKve learned that people will forget what ou said' people will forget what ou did' but people will never forget how ou made them feel%:

JEmpowerment suggests a sense of control over oneIs life in personalit ' cognition' and motivation% It e?presses itself at the level of feelings' at the level of ideas about self worth' at the level of being able to ma0e a difference in the world around us%%% 2e all have it as a potential%J @/appaport' V%: The power of empowerment language' )ocial &olic ' -3' -873% p% -3.2-A% GutierreG adapted this definition and tried to clarif it b adding four necessar changes which have to be seen in a person before heCshe can be described as Jsuccessfull empoweredJ . an increased self. sufficienc ' a developed group consciousness' a reduction of self.blame in the face of problems and the abilit to assume personal responsibilit for change% That is' not rel ing on other people to help out' but tr ing to ta0e matters in oneIs own hands and pursuing a change to the better% "nother definition has been given b )olomon who has developed a ver good definition of empowerment related to social wor0' adaptable to our focus on migrants and refugees% This is the definition that is used in this te?t for empowerment% Empowerment is defined as Ja process whereb the social wor0er engages in a set of activities with the client @%%%A that aim to reduce the powerlessness that has been created b negative valuations based on member.ship in a stigmatised group% It involves identification of the power bloc0s that contribute to the problem as well as the development and implementation of specific strategies aimed at either the reduction of the effects from indirect power bloc0s or the reduction of the operations of direct power bloc0s%J @)olomon' (%: (lac0 Empowerment: )ocial 2or0 in Bppressed Communities' *ew For0 -865%A In this conte?t' empowerment can be best described as a process which can be initiated and accompanied b advice' counsel and orientation programmes% Through this process' individuals' organisations or groups' who seem powerless or deprived of the means to reconstitute themselves in an alien societ ' can become IempoweredI% The can become aware of the power d namics at wor0' develop s0ills and the capacit to gain some control over their lives' e?ercise this control without infringing upon the rights of

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others and support the empowerment of others in their communit % In summary! therefore! empowerment can be described as having four goals: that the client sees himself as the agent of changeH that the client is able to use the 0nowledge and s0ills of others in furthering their own interestH that the client is able to wor0 in partnership with professionalsH that the client is open to developing the problem.solving s0ills to address their situation%

It is important to identify some basic principles of practice with regard to the relationship between the practitioner and client: interact with the person and not the JmigrantJ' 9patient:' OH respect the personIs right to self.determinationH accept the clientIs definition of the problemH focus on strengthsH respect the diversit of s0ills and 0nowledge that clients bring H share power and controlH respect the clientIs right to contribute and trust his or her motivation to learn and direct his or her lifeH be aware of cultural differences with regards to hierarch and superiorit % loo0 for groups: mutual help' consciousness raising' participation%

General .ethods %he empowerment process can be described as being made up of four elements" Attitudes! beliefs and values% This refers to the ps chological aspects of empowerment% It covers self.sufficienc and belief in self.worth% It is concentrated either on individuals or groups% 3alidation through collective e#perience% )haring common e?periences can avoid misinterpreting individual e?periences and help put these into perspective' alleviating loneliness and isolation% The collective e?perience can motivate a group to pursue changes' that go be ond the individual% =nowledge and s ills for critical thin ing" The abilit to access and acEuire information is an important element of empowerment% This can enable individuals to anal se their situation independentl and criticall ' reducing self.blame and feelings of helplessness% Action" Through empowerment individuals can develop plans for action to solve a problem% The can develop strategies and behavioural patterns that might help them in future challenges% "n increased abilit to co.operate with others is another possible outcome%

In addition! the empowerment process can be said to involve four stages: Establishing a relationship between the adviser and the client to meet immediate needs such as access to social services and benefits or to other sources of informationH Educating the client to improve his or her s0ills and thereb increasing the abilit for self.helpH Securing resources% This implies the development of s0ills to deal with other organisations and agencies' >oining self.help.programmes and groups' or establishing and using social networ0s% Enabling social and political action% 4elping the client to be able to articulate social and political needs at the appropriate time' enabling them to understand the basic principles of lobb ing' negotiation' campaigning and so forth%

The last stage is the most politicised stage in the empowerment process and might not be relevant to all advisers and organisations% (ut to ensure real change! the social and political conte#t of the individual has to be considered" 4ow far practitioners want to ta0e the four stages of empowerment depends on their ob>ectives%

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Empowering individuals The bloc0s to empowering an individual are often ps chological% ;irstl ' there is the phenomenon of alienation from the self% This is a phenomenon that has been identified as a ps chological and emotional response to oppression% It is manifested through the inabilit to identif and articulate oneIs needs and ta0e active steps to meet them% It can lead to low self.esteem and feelings of powerlessness' with the perception that one cannot influence and resolve issues in oneIs own life% )econdl is the use of stereot pes or stigmatisation% The migrants' who have repeatedl e?perienced re>ection' for whatever reason' will feel stigmatised or of being subsumed under a stereot pe% This will be e?acerbated b their e?periences of racism% The migrants might find themselves caught in a vicious circle of stigmatisation' re>ection and' subseEuent self.blame% This circle can be Euite destructive for the individual% %hree steps are important for the empowerment of individuals: %he first step is to define the problem" To define the problem' different factors have to be considered' such as the specific legal framewor0 of each countr ' particularl around their residenc status and emplo ment rights% "lso the attitude of each countr towards migrants and refugees is significant% In a societ with an assimilationist approach' there is an e?pectation of complete ad>ustment to all relevant features of the host societ % In countries where integration is the 0e .word' differences are accepted and even encouraged% %he second step addresses the issue of self6determination" It is important to define the criteria of success for ever individual% ;rom this perspective it is possible to set targets against which the goals can be said to be achieved% Establishing self.sufficienc and belief in oneIs own abilities starts from the moment contact with the client begins% "s soon as he or she is regarded as a valuable source of competence in dealing with the problem' an important step in the direction of empowerment has been ta0en% %his leads us to the third step which relates to consciousness raising" It is necessar to confirm to the clients that the are the e?perts of their particular situation and the best arbiters of their own treatment% The acceptance of the independence of the client is crucial' otherwise there can be no tal0 of empowerment% "n important precondition to an empowerment.process is access to information% " lot of problems arise because of a lac0 of information on both sides: Those see0ing for emplo ment and those able to give >obs% The availabilit of information on the labour.mar0et and its regulations ensures that the clients are not reliant on the advisor to assess their options%

6,

The E1&<BF1E*T wor0ing group on empowerment has assembled a number of JindicatorsJ for individual empowerment% These are: )0ills: <iterac and numerac ' mar0etable s0ills' having confidence and understanding of oneIs own strengths% "ctual or real potential: having secure and decent housing' being aware of the impact of good health and how to 0eep it' access to decision ma0ing processes' having choices for career development' being able to ma0e decent plan financiall ' being able to get a credit' interest in positive change in the host societ % Emplo ment: 4aving a >ob' better a >ob with a secure contract of emplo ment' establishment of own business' becoming an emplo er in own business%

The E1&<BF1E*T wor0ing group has formulated a number of indicators of success for group empowerment% These are: )upport and motivation: E?istence of peer support structures @self.help' voca.tional guidanceA' emergence of role models within the target group' availabilit of mentors from within the target group' s0illed trainers from within the target group' opportunities to collaborate with other to create common and effective pro>ects% /elationships with other organisations: &articipation in decision ma0ing process' provision of training to official agencies% Campaigning: !evelopment of an account of the groupIs previous e?clusion' of value attached to direct e?perience of that e?clusion' training and s0ill development for group members in the specific s0ills needed to engage with decision ma0ing processes% )ervices: &rovision of practical services for target group members' development of credit unions%

The E1&<BF1E*T wor0ing group in empowerment has identified some JindicatorsJ for empowerment within the conte?t of the wider communit % These are: policies respond to representatives of target groupH change in public attitudes . the rights of the target group are ac0nowledged' there is indignation when there are not supported' target group members are described as having rights' rather than needsH removal of obstacles to participation' e% g% greater availabilit of child.care' change in time of public meetings etc%H increase in numbers of target group being emplo ed in >obs concerned with maintenance of the state' e% g% police' armed forces' civil serviceH children of target group members born in the host societ do not e?perience e?clusion%

(roposed reading GutiarreG' <orraine et al% @eds%A: Empowerment in )ocial 2or0 &ractice% " )ourceboo0' &acific Grove et al% -887% <ee' Vudith "% (%: The Empowerment "pproach to )ocial 2or0 &ractice' *ew For0 -884% <ewis' V%" et al% @eds%A: Communit counselling% Empowerment strategies for a diverse societ ' &acific Grove et% al% -887%

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In life' li0e in business' ou never get ever thing ou wantH ou get what ou can negotiate% 2ere are five steps to empower people" -% Qnow their s0ills and Eualifications% <oo0 over their curriculum vitae' and find out what their strengths and abilities are% This will help ou decide where to ma?imiGe their potentials% 2% "s0 them what the are best capable of and find most en>o ment in doing' within the scope of their wor0 description% Encourage them to contribute in their areas of specialit and interests% 3% Give freEuent praises for good wor0 ever da % 1ost people @with possible e?ception of those with schiGoid personalit disorderA thrive in positive feedbac0% It helps them to 0now what the are doing is appreciated' and will encourage them to continue their good wor0% 4% "void criticisms if at all possible% Criticisms has the opposite effect of praises' and can discourage people greatl % "lwa s assume good faith' be understanding' thin0 in terms of good aspects' compare their mista0es to mista0es ou have made ourself' or could have made% If ou must give criticism' be constructive' and alwa s praise first' and provide clear suggestions on how to improve% 3% &rovide opportunities for further training and education% "llow them to e?pand their 0nowledge and s0ills so the can contribute in greater wa s% 9The beaut of empowering others is that our own power is not diminished in the process': said (arbara Coloroso% In fact' empowering other people puts out the positive vibes into the atmosphere that will be returned to ou' not in an sort of 0armic sense necessaril ' but in terms of improving our own sense of self.awareness and confidence% This can be achieved in a number of little wa s that can range from simpl boosting someone elseKs mood to helping them realiGe new aspects of their personalities% 2e are all in this life together' and helping others achieve their goals can get our own on trac0% The following are 3, little things ou can do to empower other people and get started down this path% -% Give out compliments that ou mean% 1ost people can see straight through a phon compliment' but if ou thin0 our friend loo0s especiall nice toda with that new hairst le' tell her so% Vust be open and direct in our interactions% 2% )pea0 and act with honest % If ou alwa s spea0 with integrit and believe in our own words and actions' others will also pic0 up on this and mimic it' fostering an atmosphere of trust% 3% <isten to others% "lwa s listen to what other people sa % I used to Gone out when others were spea0ing but now ma0e a point of loo0ing into their e es and listening to their words' which has made a world of difference in personal interactions% 4% 4elp illustrate our points with visual aids% 2hen leading a meeting or presentation' realiGe that man other people are visual learners% 1 girlfriend canKt understand a concept without a diagram to bac0 it up% 3% Teach a class% If ou have a s0ill or 0nowledge to share' wh not teach our own class that helps spread it to others=

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5% Get involved in communit art pro>ects% "rtistic pro>ects in the communit are a great wa to help get ever one involved in ma0ing the cit a more beautiful place to live' instilling a sense of pride in all residents% 6% 1entor a child or student% Getting involved in one childKs life' especiall if the are at.ris0' helps ou both ma0e connections throughout our lifetime% 7% Dolunteer with local organiGations% These can be communit discussion groups or of a more volunteer. oriented nature% 8% <ead a group on a travel e?pedition% 1 friend wor0s for the local art museum leading groups of the elderl on art.oriented field trips around town and abroad' which helps ever one connect and learn something new% -,% !onate mone to charit % If ou have e?tra mone ' helping organiGe a fund for a pet cause helps bring the communit together% --% 4elp the spread of communit health clinics% This can be done b volunteering ourself' or donating mone % Either wa ' it can be vital in helping those who have problems affording health care to realiGe that the are still valued individuals and that their health matters% -2% Ta0e the time to tal0 to strangers% That conversation that is simpl small tal0 to ou can mean a lot to someone else who is sh or feels that their opinion isnKt ta0en into consideration often enough% -3% )tart a non.profit% This is a pro>ect that can be difficult but ultimatel rewarding not onl for ou but for the others who become involved as well' helping ou all to wor0 together towards an ultimate goal% -4% Travel abroad and ma0e new friends% Getting out there as an ambassador of sorts in the world helps ou connect with others who ma want to learn more about our culture but otherwise wouldnKt have the opportunit % This ends up being a learning e?perience for both parties involved% -3% /each out to friends and relatives at a distance% If ou have lost touch with loved ones' give them a call and let them 0now that someone is thin0ing of them% -5% (e aware of bod language% Four bod language sends a strong message to others' so be aware if ou have our arms folded across our chest while ou tal0 that ou are shutting others out' for e?ample% -6% (e sincere% Four sincerit will help to ma0e people feel appreciated% -7% *urture talent in others% If ou notice someone has a talent that the arenKt putting to use' let them 0now% Gentl offer suggestions of where the ma go to learn more% If the child ou are mentoring is constantl doodling' for e?ample' get them signed up for an art class% -8% Go out and support local musicians% In ever cit there are unimaginable numbers of oung struggling musicians who could be the ne?t (eatles if given the chance% IKve seen some amaGing live acts recentl b pic0ing a name out of the listings and simpl turning up in support% 2,% Give thoughtful gifts% 2hen giving gifts during birthda s or the holida s' ta0e the time to thin0 about what the person might reall need or appreciate% 2-% Voin a communit farm or grocer coop% 2or0ing together to provide fresh' sustainable food for the communit is one of the hot trends in some communit organiGations% 22% Dolunteer in schools% Though it might sound clicha' oung people are our future indeed' and helping out in schools that are struggling financiall can ma0e a big difference in a oung personKs life% (e a positive role model%

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23% )ta in touch with local politics% 4elping others get empowered means also being 0ept up to date with the latest in what is going on in our own town% 24% Throw dinner parties with a mi?ed range of guests% Get together a group of people who donKt necessaril 0now each other et but ou feel that their personalities might mesh well together% This is how we learn from one another% 23% )mile more often% There is an anon mous Euote that states' 9" smile confuses an approaching frown%: 25% Nse public transportation% *ot onl is this better for the environment' but it gives ou a chance to interact more with the communit % 26% BrganiGe rec cling pro>ects% This helps give bac0 to the communit and teaches people about the need to respect our natural environment' which is empowering for all% 27% /un a benefit event% <eading a team of volunteersH set up a means for raising mone for a cause that ou all are interested in% This can be a chain reaction' with the volunteer team then feeling more empowered to go a step further with its own charit efforts% 28% &ro>ect positivit and eliminate negative thoughts% This positivit will then be returned b others% 3,% Voin a boo0 group or club% The e?change of ideas tends to be helpful for all people involved' and can spar0 new business or interpersonal ideas in between all of ou% 3-% )tart or >oin a language e?change program% This helps foster feelings of competenc in a foreign countr for someone who ma be feeling li0e an outsider' and also helps ou build our own language s0ills% 32% <ead team.building e?ercises at wor0% This can go be ond old.fashioned trust falls to more imaginative retreats% 1 friend recentl led his team out in a wild.mushroom foraging e?pedition' which was a uniEue wa for them to learn something new as well as get to 0now each other' in a beautiful outdoor setting% 33% Encourage social activities% Get new social activities planned within our group of friends' our famil ' or in a larger communit sense% 34% Initiate ph sical contact% In this societ in particular' there is a hesitance to touch one another% ( simpl placing a hand on someoneKs shoulder' ou are helping to reconnect with that person% 33% Tell our loved ones how ou feel about them% !onKt wait till itKs too late to let someone ou love 0now how ou feel about him or her% <ife is wonderful but short% 35% 1a0e sure the atmosphere at wor0 is a democratic one% <et ever oneKs opinion be heard' and be sure to give feedbac0 to their ideas% 36% *od our head when someone is ma0ing a point% " simple piece of non.verbal communication li0e this can help inspire someone to move forward in the discussion more% 37% 4elp foster creativit % If someone is talented' tell them so% "nd 2arhol was notoriousl sh as a child and perhaps would never have branched out to become the powerful artist he is now 0nown as if someone had not said a few words of encouragement to him in his earl art classes% 38% /un meetings with an open' discussion oriented atmosphere% 2hether at wor0 or in a larger communit sense' let ever one 0now their opinion is valued%

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4,% 4ave suggestions read for those who need advice% This means ta0ing the time to thin0 about our own behavior' past mista0es' and how ouKve moved forward% 2ith this information in hand' ou will be well eEuipped to advise others% 4-% Ta0e wal0s to new areas of town% IKve met some of m good friends b simpl wal0ing around in their neighborhood and having to as0 for directions% 42% )pend time planting trees in the communit % This helps improve the overall beaut and positive feelings in the cit ' instilling a sense of pride in other residents% 43% )et up a food or blan0et drive% This helps others in the communit and empowers the other volunteers b letting them see the can ma0e a difference% 44% <earn inspiring Euotes that can be doled out% "s (ill Gates once said' 9The vision is reall all about empowering wor0ers%: 43% <earn new listening techniEues% This can be a combination of proper responses and coc0ing our head at the right time to show someone else their opinion matters% 45% )tud ps cholog % " friend of mine went bac0 to school to be a ps chologist in order to reach out to people on a scientific level' but even a few basics of human behavior are both interesting and can help ou be more effective in interpersonal communications% 46% Give a helping hand% 2hether itKs helping someone who fell to get bac0 up' or pic0ing up something that spilled in the supermar0et' it shows ou care' which is empowering% 47% Give encouragement instead of criticism% !ale Carnegie said' 9"bilities wither under criticismH the blossom under encouragement%: Ever one of us has the magic power of empowering other people simpl b generousl giving praise and showing encouragement instead of criticism to help them realiGe their potential% 48% Ta0e time for ourself to help others% ( ta0ing the time to sit and reflect upon m own actions each da ' I find IKm better able to mentall be available for others when out in public or at home with m famil % Fou can do the same% 3,% <earn intervention techniEues% In the event that someone ou 0now is struggling with addiction' this is a wa to help them get over it and empower themselves to get bac0 on trac0%

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Empowering Crisis Interventions %AASA outlines nine steps for effective crisis intervention:

$" Establish -apport &" Active 1istening *" Define the (roblem 0" Assess the Situation I" E#plore 8ptions J" Discuss Acceptable Alternatives K" -eferral L" Closing M" 9ollow6up
The first step' establishing rapport' is intuitive% *o successful transaction occurs when there is a lac0 of comfort and trust% (oth librarians and crisis counselors should wor0 hard to ma0e that good first impression% The most stri0ing similarit is that regarding the concept of active listening% "ccording to (opp' 9"ctive listening involves reflecting bac0 to the user the librarianKs understanding of the Euestion to verif that it is being properl understood%: T"")" advises a crisis coach to 9chec0 out what ou understand them to be sa ing to see if ou are on the same wavelength%: "ctive listening can serve much the same purpose in both situations: clarif ing the problem or Euestion' ma0ing sure that it is being understood completel ' rephrasing it to cast it in a different light and using this broadened understanding to form an action plan% The third step recommended b T"")" is defining the problem% This is necessar in all reference interviews% 4os0isson stated that the first Euestion as0ed seldom addresses the true need% Eidson recommended that librarians should be able to ad>ust to a Euestion that changes as the conversation continues% In crisis coaching' defining the problem might involve isolating the survivorKs true emotions and needs% In a reference interview' the patronKs emotions might pla a lesser role' but the patronKs needs are still paramount% The fourth step' assessing the situation' is crucial to conducting a successful interview% The librarian should ta0e stoc0 of the patronKs appearance and behavior% Is she nervous or agitated= "re her Euestions clearl articulated or frantic= )uch an assessment might help the librarian learn the immediac of the patronKs needs% E?ploring options is an effective wa to help a survivor in her decision.ma0ing process% T"")" recommended avoiding advice and presenting all of the available options to the survivor% " survivor who has options from which to choose is ta0ing bac0 power over her own life from the assailant who too0 it awa % <ibrarians should be interested in giving complete information' including options for finding help' but a survivor might not be interested in all of the options% " librarian should understand that this does not mean that the interview has been unsuccessful% If a referral is necessar ' it is a good idea to give more than one% If a patron is given several different sources of assistance' this increases the options and gives bac0 a small part of that power over her life that an abuser too0 awa % *olan advised that an unsuccessful interview should be ended with a referral% In the case of a possible survivor' even a successful interview should be ended with a referral% It ma not be

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possible to recogniGe a survivor' so a referral to a rape crisis center 9for more information: might be ver useful for a survivor or even for a researcher% 1an larger hould be aware of all campus resources% The closing of a crisis coaching encounter is ideall initiated b the survivor% *olan pointed out that a reference interview ma be closed b either the reference librarian or the patron' or both simultaneousl % 4e recommended that a librarian encourage the patron to come bac0 for more help if necessar % It ma appear that in this situation the librarian is closing the interview' but in actualit he or she is leaving it open to continue at a time of the patronKs choosing% T"")" also recommends that the crisis coach let the survivor 0now that calling the hotline was the right thing to do and that it is the first step in the healing process% Eidson recommended a similar approach' but at the beginning of the reference interview% 4e suggested affirming that the patron has come to the right place and the librarian is open' available and read to help% This approach is well.placed at either end of the interview with a survivor% "t the beginning of the interview' it ma encourage the survivor to rela? and be more willing to as0 Euestions openl ' 0nowing that she will be heard and respected% "t the end of the interview' such an approach ma ma0e the survivor feel comfortable returning to the librar and wor0ing with its staff% It ma also ma0e her feel that if the librarian is 0ind' encouraging and affirming' there ma be others who are the same wa % This might encourage her to see0 the assistance of counseling professionals% ;ollow.up is defined as summariGing the encounter' encouraging the survivor to call the crisis center an time and sa ing goodb e% This leaves the decision of whether to have an more contact with the crisis couach in the survivorKs hands% *olan ta0es much the same position% In a crisis intervention situation' it might be helpful to offer to call the survivor a few da s later in order to offer additional help% " follow.up call' of course' should onl be made with the survivorKs permission% This is an e?cellent practice for librarians' too% " reference librarian ma need to contact a patron to offer additional information found after the patron has left or for related purposes% If the patron is currentl in an abusive relationship or does not want the people in her household to 0now that she has been assaulted' a call from a librarian ma raise suspicions% If a patron does not give permission' it is best to wait for the patron to come bac0 or call% Cualities for empowering family advocacy @"mended from 1arie )herrettA 2hich T pe of "dvocate "re Fou= !efender &rotector &romoter Enabler Investigator 1ediator )upporter 1onitor Teacher ;ights for the rights of individuals' children and families 2or0s to 0eep individuals' children and families from ph sical or ps chological harm 2or0s to cause something to happen &rovides individuals' children X families with the resources needed to achieve their goals )earches for facts and information <istens to and understands all points of view and remains ob>ective <istens to and gives ac0nowledgement to feelings' and needs without passing >udgment Chec0s in periodicall to see if things are going according to the plan "ssists in tr ing to decide the best possible approach to the situation%

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Caregivers are not empowering if the : ] (eat around the bush ] ;ail to describe problems ] ;eel guilt or are afraid to be vocal ] "gree with professionals to 0eep peace ] Ignore the right to services ] <eave ever thing to others ] "ccept e?cuses for inappropriate or inadeEuate services ] (eg for what the law sa s a child should have ] "bdicate to others the right to advocate for a child ] !epend on others to advocate ] Give up because of red tape ] "re too hast to act ] ;ail to act ] "ccept the status Euo ] Give in to defeat ] "re comfortable with accomplishments ] !iscourage our child from having hope for success% Caregivers are empowering if the : ] E?press themselves clearl ' directl and without guilt ] "re not intimidated ] &repare for meetings ] )ta together ] "re informed ] Qeep /ecords ] Collaborate ] Communicate effectivel ] !emonstrate self.confidence ] "dvocate effectivel ] "re self.reliant and independent ] &ersist ] "nal Ge problems ] BrganiGe to effect change ] "re positive and strong ] 4ave pride ] Encourage others and hold people accountable -esources 2hat is it that ou need to 0now if ou want to be an empowering advocate for our child = ;irst 0now that ou are the e?pert when it comes to our child% Fou 0now our child better that an one else% Fou 0now: ] 4ow our child responds to different situations ] Four childKs strengths and needs ] 2hat our child li0es and disli0es ] 2hat has wor0ed to help our child ] 2hat has not wor0ed

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Fou are the person who decides what services and supports our famil and child need% Include our child in decision ma0ing whenever possible% Fou child needs to be an active participant in the services ou receive% Ever child is different' et there are children similar to ours% Fou are not alone% Bther families have faced similar problems and shared the same e?periences% Getting connected to other families who are willing to help ou can ma0e all the difference% Fou need to begin as0ing the following Euestions: ] ] ] ] 2hat do I need to 0now and to do to help m child= 2hat agencies in the communit have programs or services that can help m child and other members of m famil = 4ow do I get services from them= 4ow will m childKs health' growth and development' social interaction' and abilit to learn be affected b the problem we face= 2hat has helped other children li0e mine=

In the conte?t of our interactions with children' alwa s: -% <oo0 through the childKs e es: Consider the world from the childKs point of view% 2hat >o s and challenges e?ist for this child each da = 2hat is their level of abilit and support to meet their challenges= 2ho are their friends= Is the childKs life basicall happ or full of considerable stress and loss= Too often as adults we view the child from the adult lens thin0ing about how the childKs behavior affects our wor0 or our da % Instead' remember what it was li0e to be ver oung and consider what dail life is li0e for this oung child% 2hen ou trul understand the needs of the child then ou have a much stronger abilit to assist this child with our professional s0ills% 2% <oo0 for the positive: !evelop an e?tensive list of the s0ills' interests' motivators' and personalit attributes of this child% This becomes essential information when ou develop positive action plans to help the child address challenges in their life% /egardless of age' we all are much more effective in responding to difficulties when personal strengths are identified and utiliGed to address needs% 3% 1eet at the childKs level: !evelop professional plans that start at the childKs level of comfortable functioning% If reEuired s0ills are above the childKs functional developmental level then the child will not be successful% )ince children are uniEue' it is normal for there to be variation in developmental levels across the developmental domains @cognitive' social' emotional' behavioral' and ph sicalA% "ssessment should include evaluation of each of these domains independentl and is critical for a thorough understanding of the childKs strengths as well as challenges% 4% &lan )uccess: Interventions and strategies should be designed with success in mind% !onKt create a plan if there is a Euestion about the child being able to accomplish the goal% (ehavior plans should include positive incentives which will encourage increased self.esteem and motivation for change and growth% 3% Child as e?pert: "t an earl age we all find wa s to communicate our li0es and disli0es in life% Gifted caregivers learn to recogniGe these communications and respond to them% (e sensitive to the childKs communication and find wa s to include the child in intervention planning% Even small children can choose their own rewards and ac0nowledge simple rules% "s the child grows' increase their participation in all decision processes about them%

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Empowerment Chec0list for &rofessionals Nse the following chec0list to help guide our professional approach with children and their families to be one that is empowering% The childKs needs are the guiding force for all decisions EvaluateCassess the child within our own s0ill base X training NtiliGe best practice approaches for the childKs developmental age and issue@sA that are the focus of care )ee0 0nowledge and e?pertise of adult famil members about the child "c0nowledge comple?it of issues &rovide an honest appraisal of available resources /efer to other professionals for additional supports X assessments that are indicated Bbtain authoriGation for releases of information for additional service providers so care can be coordinated X comprehensive Include adult famil members as full partners in action planning Include the child at developmentall appropriate levels in action planning E?planation is given to the child and famil about all initiatives and interventions &rovide regular feedbac0' including positive growth' to the child X famil /einforce positive social s0ills for the child Educate child X famil about educational X legal rights Encourage famil member advocac on behalf of the child )upport Eualities that lead to hope and resilience in the childCfamil ;acilitate a positive solution focused approach to issues%

Empowerment Chec0list for ;amilies Nse the following chec0list to help guide the approach of our famil with professionals to be one that is empowering for the child% Qnow the <aws and our ChildKs /ights Come to meetings prepared with written Euestions and thoughts *ever leave a meeting until ou are in full understanding of what too0 place and what is going to be the ne?t step 1a0e sure an verbal agreements are put in writing Ta0e along a peer or other support person when needed "dvocate for the best interest of our child (e willing to negotiate Ta0e notes and 0eep a list of people present at an meetings pertaining to our child Qnow our child and famil strengths !ocument phone calls and ma0e copies of letter correspondence )ta connected to the plan' as0ing for updates and feedbac0 &rovide information to professionals about how things are going at home and an changes whether positive or negative are occurring (e persistent and assertive Tell our childKs stor Qeep the focus on what will support our child in reaching hisCher goals

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;or a deeper understanding read: Empowering conversations: " /esource Guide for Team (uilding (etween ;amilies and &rofessionals to )upport "ction &lanning for Foung Children ( <aura (eard' <ead ;amil ContactH 1ichelle !ipbo e )ames' Earl Childhood Empowerment )pecialist' Qentuc0 Ks ) stem to Enhance Earl !evelopment' Qentuc0 &artnership for ;amilies and Children' Inc%

http:CCgucchdtacenter%georgetown%eduCresourcesCEC14CCEC)BCT2,Tool0itCQFT2,/esources T2,.T2,ConversationsT2,withT2,;amilies%pdf

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*" 9oundations of Empowering Interventions $" /rief Solution 9ocused Counseling /esearch )upport for the Tas0s and TechniEues of ();C: The 9Change &ie: The tas0s and techniEues of (rief )olution.;ocused Counseling are supported b a large bod of research on 9common factors of change: in helping relationships% These factors' and their percentage contributions to successful outcomes' are based on over -,,, studies involving a wide range of clients' problems' settings' and practitioners% Client ;actors @"ccounting for 4,T of changeH the ;illingA% The client is clearl the most potent factor in counseling @some research indicates an even stronger influence than 4,TA% Client factors include the clientKs life e?periences' values' opinions' interests' successes' resilience' and role models% Counseling outcomes depend largel on the e?tent to which the clientKs strengths' feedbac0' and other resources are integrated into therapeutic conversations and interventions @Gassman X Grawe' 2,,5A% (rief )olution.;ocused Counseling empowers client factors b helping people discover and appl their strengths and resources toward solutions% /elationship ;actors @"ccounting for 3,T of changeH the CrustA% /elationship factors' the second most powerful ingredient of effective counseling' include peopleKs perceptions of respect' validation' and encouragement from the practitioner% Client involvement is the centerpiece of a strong therapeutic relationship% The clientKs earl ratings of the helper and helping relationship @during first couple sessionsA are highl predictive of outcomes @*orcross' 2,-,A% (rief )olution.;ocused Counseling empowers relationship factors b involving people in ever aspect of their care' b obtaining their feedbac0' and b ad>usting services based on their feedbac0% 4ope ;actors @"ccounting for -3T of changeH the "nticipationA% 4ope factors refer to peopleKs belief that change is possible' and confidence in their abilit to change in positive wa s% 4ope pla s a 0e role in effective outcomes' though its influence is relativel smaller than client and relationship factors% (rief )olution.;ocused Counseling empowers hope factors b treating people as resourceful and capable of changing' and b focusing on future solutions rather than past problems% 1odelCTechniEue ;actors @"ccounting for -3T of changeH the ToppingA% 1odelCtechniEue factors refer to the practitionerKs theor and related techniEues% Given that no single counseling model or set of techniEues has proven superior to others in overall effectiveness @2ampold' 2,-,A' the most successful practitioners are fle?ible in their selection and application of therapeutic techniEues% (rief )olution.;ocused Counseling encourages practitioners to fit themselves and their techniEues to clients instead of the other wa around' and to tr something different when one idea or techniEue is not wor0ingYin other words' donKt marr the model or techniEuesP *ote: The factors above are applicable to an change.focused activit including group wor0' behavioral intervention' teacherCparent consultation' assessment' and s stems.level change%

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/rief Counselling 7e kind whenever possi le+ It is always possi le+ @ Dalai Lama /rief counselling is an approach to counselling characteriGed b a focus on resources and solutions rather than problems% The purpose of brief counselling is 9to provide people with a pleasant e?perience that turns problems into challenges' fosters optimism' enhances collaboration' inspires creativit ' and' above all' helps them to retain their dignit : @;urman X "hola' -884' p% 53A% 2ow /rief Counselling 2elps Bften counselling relationships are brief' sometimes limited to a few sessions' a single session' or even a brief encounter% 1ichael 4o t @-884A reviewed the literature and found that single.session therap is often the norm and that a significant number of clients and counsellors found it desirable and useful% In three s stematic studies of the effectiveness of single.session therap @))TA' more than 3, percent of clients showed improvement @4o t' -884' p% 4-A% 1oreover' man people solve ps chological problems without professional consultation% ;or others the 9light touch: of a single visit ma be enough' providing e?perience' s0ills' and encouragement to help them continue in their life >ourne @p% -33A% ;urthermore' a change in some part of a clientKs life can affect other aspects of his or her life' including relationships with significant others% Thus' brief counselling that helps a client achieve some success @e%g%' insight' reduction of painful feelings' new s0illsA' however small' can have a dramatic long.term impact if it switches the client from a point of despair to a position of optimism and a ripple effect occurs% 92hen clients alter their behaviors ever so slightl ' it causes a chain reaction in response to the initial change% Those affected b the change find themselves ad>usting their responses' which in turn elicits further changes in clients: @)0lare' -886' p% --A% !e )haGer @-873A argues that it is not necessar to spend time searching for the root causes of a problem' nor is it necessar to have elaborate 0nowledge about the problem% In brief counselling the goal is to help clients do something different to improve their situation rather than repeat the same ineffectual solutions% (rief counselling ma help in man wa s% (ecause of its emphasis on action and change' brief counselling helps clients to become 9unstuc0: from ineffectual wa s of thin0ing' feeling' and acting% Clients can be encouraged to reframe b focusing their attention on whatKs wor0ing' thus interrupting their preoccupation with problems and failure% This focus ma generate or renew the clientsK optimism that change is possible% In addition' brief counselling' even a single session' can be therapeutic for clients if the are able to unload pent.up feelings% " caring and empathic counsellor can encourage such ventilation and reassure clients that their reactions and feelings are normal% This can significantl reduce feelings of isolation b disputing the belief that man clients hold: 9IKm the onl one who feels this wa %: (rief counselling can also provide important information to clients% ;or e?ample' the can be referred to appropriate alternative services% Br the can be given information that might help them deal with their situation% ;inall ' brief counselling can be used to dem stif the counselling process and to help clients understand what the might reasonabl accomplish in counselling% In this wa brief counselling ma be useful for motivating reluctant clients to engage with or to continue with counselling% (rief or single.session therap is not appropriate for all clients% It is less li0el to be effective with these client groups: clients who need inpatient ps chiatric care' including those who are suicidalH clients with

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schiGophrenia' bipolar disorder' or drug addictionH clients who need help in dealing with the effects of childhood abuseH and clients with chronic eating disorders @4o t' -884A% Selected /rief Counselling %echni,ues (recounselling Change 1omentum for change is often established at the moment that clients see0 counselling% Carpetto @2,,7A notes that studies have shown that changes freEuentl occur in the interval between the time clients ma0e an appointment to see a counsellor and the first meeting% Thus' counsellors can ma0e use of the fact that some clients realiGe progress while waiting for their first scheduled appointment% %he .iracle Cuestion " t pical miracle Euestion might be formulated as follows: 9)uppose that tonight while ouKre sleeping a miracle happens and our problem is solved% 2hen ou wa0e up' what will be different about our life=: Dariations of this Euestion ma need to be developed to accommodate different clients% ;or e?ample' some clients ma ob>ect to the religious overtones in the Euestion and a more neutral term' such as something remarka le' could be used% The e?ample below illustrates the process: Counsellor: )uppose when ou wo0e up tomorrow something remar0able has happened and problem is gone% 4ow would ou 0now that our problem is solved= Client: 2ell' for one thing' IKd be worr ing less% Counsellor: 2hat might our famil see as different= Client: IKd be more willing to get involved in famil activities% Counsellor: "ctivities= Client: Things li0e sports' famil outingsYmovies and so forth% Counsellor: 2hat else would the find different= @*ote: It is important for the counsellor to use probes such as this to elicit detail% If a change can be imagined' the more possible it will seem and the more the behavioural changes to ma0e it possible will become apparent%A Client: I thin0 that weKd be happier% *ot >ust because weKre doing fun things together' but weKd be arguing less about mone and our other problems% Counsellor: 4ow much of this is alread happening= The above e?cerpt shows how Euic0l the counsellor can move the interview to focus on solution possibilities% 2hen clients engage with the miracle Euestion the begin to identif potential changes that might occur' and the often become more hopeful about their situation% "s Carpetto @2,,7A concludes' 9the are alread on their wa to finding solutions to their problems: @p% -7-A% )ince the client has imagined and described some of what needs to happen to solve the problem' the counsellorKs ne?t tas0 is to get clients moving in the direction of the 9miracle: with Euestions such as 92hat would ou need to do now to begin to move toward the miracle=: or 92hat would it ta0e to ma0e the first step=: Success %ip CapitaliGe on the possibilit of precounselling change b as0ing Euestions such as' 9)ince ma0ing our appointment' have ou noticed that things have improved in an wa ' however small=: If the response is positive' sustain this change movement b helping the client identif the feelings' thoughts' and behaviour associated with it% our

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2elping Clients Get on %rac Counsellors need to shift their own thin0ing awa from believing that the have to sta with clients until the clientsK problems are solved and their lives are in order% ;or e?ample' counsellors might assist clients to organiGe their thin0ing about grieving' but the process of grieving is normal and might last a long time' and counsellors do not have to be present for the entire grieving process @2alter X &eller' -884A% Counselling ends with the client still grieving but with a much greater sense of control and of being on trac0% If clients have a plan in mind for dealing with their problems' the have the capacit to put that plan into action% 1oreover' if the are alread implementing that process' counsellors should consider getting out of their wa % 1oo ing for E#ceptions 4uber and (ac0lund @-88-A propose wor0ing with the e?ceptions to the times when clients are having difficult % The contend that regardless of the severit of their clientsK problems' there are moments when clients are managing their troubles% 1oments when an?ious persons feel calm' acting.out children listen to their parents' and angr people are peaceful can all be studied to discover potentiall successful answers to chronic problems% 4uber and (ac0lund believe that clients become fi?ated on their problems and on what doesnKt wor0% ( doing so' the often fail to notice those times when their problems have abated% In fact' the often continue to repeat or e?aggerate 9solutions: that have alread proved unwor0able% Nsing this e?ceptions approach' counsellors as0 clients to focus on those moments' however rare' when the are coping successfull % )o when clients are as0ed' 92hat is different about those occasions when our child obe s ou or at least responds more receptivel to our reEuests=: or 92hat is different about those times that ouKre not angr or onl minimall upset=: the counsellor is reEuesting that clients report on e?periences to which the have paid almost no attention% ConseEuentl ' the have given little or no credence to the more successful manner in which the were resolving what at other times the e?perienced as a persistent difficult @4uber and (ac0lund' -88-' p% 55A% 2or0ing with e?ceptions provides a dramatic and Euic0 wa to motivate and energiGe clients to thin0 about solutions rather than problems% In the following brief e?cerpt' the counsellor uses the techniEue to assist a client who is having trouble dealing with her teenage son% Counsellor: ;rom what ouKve been sa ing' itKs a rare moment when ou and our son can sit together and tal0 calml % Client: 1a be once or twice in the last ear% Counsellor: <etKs loo0 at those two times% IKm reall curious about what was different about them that enabled ou to tal0 without fighting% &ic0 one time that wor0ed best% Client: ThatKs eas % 1 son was e?cited because he was going to a roc0 concert' and he was in a reall good mood% I felt more rela?ed too% 4e >ust seemed more approachable that da % Counsellor: 4ave ou considered that part of our success might have to do with our mood= &erhaps our son was more approachable because ou were more rela?ed% Client: Interesting point% Counsellor: <etKs e?plore that a bit further% (ecause ou were more rela?ed' what else was different about the wa ou handled this encounter= Client: I didnKt feel stressed' so I thin0 I was more open to listening to him% Counsellor: 2hat were ou doing differentl =

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Client: I let him tal0 without >umping in to argue% The counsellorKs goal in the above interview is to find what wor0s and then to encourage the client to appl successful solutions more freEuentl % The process is as follows: $" Identif e?ceptions to those times when the client is having difficult % &" E?plore what was different about those times' including what @specificall A the client was doing differentl % *" Identif elements @e%g%' behaviour' setting' and timingA that contributed to a successful solution% 0" 4elp the client increase the freEuenc of the success.related elements when dealing with the problem situation% Clients are often more e?perienced in using ineffectual strategies to deal with their problems% !espite the fact that these strategies do not wor0' clients ma compulsivel repeat them to the point where the give up and conclude that their problems are hopeless% ConseEuentl ' counsellors need to encourage clients to appl the elements of success% ;or e?ample' a behavioural rehearsal @role pla A that focuses on s stematic e?ploration of the elements of success can be used% Counsellors also need to encourage clients to pa attention to what the are doing when the are managing their problem' as in the following case: /odne came to counselling as0ing for help to Euit what he described as 9compulsive mari>uana use%: 4e was concerned that he might slip into heav drug use% The counsellor as0ed him to observe what he was doing when he was not using mari>uana and what he did to overcome his urge to use% This techniEue empowered /odne b helping him become aware of successful strategies he was alread using% )ubseEuentl ' he was encouraged to increase the freEuenc of these successful behaviours% Success %ip 2hen using the miracle Euestion' it is important that the client' not the counsellor' generates the vision of the situation where the problem has been removed @response to the miracle EuestionA% )imilarl ' it is the client who must describe what changes or solutions need to happen for the miracle to occur% The role of the counsellor is to manage the e?ploration and solution.finding process% 9inding Strengths in Adversity 4ardships and difficulties often have positive spin.offs in that people develop s0ills to deal with their misfortunes or discover capacities that the did not 0now the had% (elow are some sample probes: Z 4ow have ou managed to 0eep going in conditions that would have defeated a lot of people= Z Fou have dealt with this problem for a long time% 1an people would not have survived% 4ow did ou manage to 0eep going= 2hat strengths were ou able to draw on= Z 2hat have ou learned from lifeKs trials and tests= Z 4ave hardships helped to shape our values and character in positive wa s= Z &eople often develop talents or discover strengths from facing challenges% 4ow has this been true for ou=

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@sing Solution %al ;urman and "hola @-884A introduced the idea of 9solution tal0: as a wa to evo0e a solution.oriented focus to the counselling interview% The goal is to create a climate of discover and action% ;or e?ample' to get clients to notice their s0ills and capacities' counsellors can use statements and Euestions such as' 92hen ouKve successfull coped' how did ou do it=: In addition' counsellors need to be alert for opportunities to reinforce clientsK strengths% &ersonal Eualities' actions that underscore their determination' attitudes' positive decisions' accomplishments' effort toward change' and courage in the face of adversit can all be used to bolster clientsK sense of capacit and self. esteem% Clients ma alread have a rich understanding of their problems and the wa s in which the might be solved% )o counsellors need to tap their clientsK e?pertise about possible answers to their problems% The central assumption here is that clients have the capacit to resolve their distress% Z 2hat solutions have ou alread tried= Z 2hat would our best friend advise ou to do= Z )uppose one da ou received an invitation to give a lecture to professionals about the 0ind of problem ou have had to live with% 2hat would ou tell them= @;urman X "hola' -884' p% 3-A Z To solve our problem' what will ou have to do= Creative solution finding can be stimulated with statements and Euestions such as these: Z <etKs tr to identif something different for ou to do to solve our problem% Z <etKs brainstorm ideas% !onKt censor an thing% The wilder the idea' the better% -eframing is another a wa to help clients modif their thin0ing% /eframing suggests another wa of loo0ing at problems' which in turn generates new wa s of loo0ing at solutions% /eframing is elaborated more in depth at another part of this guide% %he miracle ,uestion @)0lare' -886H 4o t' -884A can also be used to direct clients to thin0 about solutions: Z If a miracle occurred and our problem was solved' what would be different in our life= Z 4ow could ou ma0e that miracle happen= 2hat would ou have to do differentl = " variation is to use the miracle Euestion to probe for e?amples of success and e?ceptions to clientsK problems: Z Tell me about the times when part of this miracle has alread happened' even >ust a little bit @)0lare' -886' p% 57A% Success %ip Nse a Euestion such as' 92hat do ou want to change about ourself toda =: as a Euic0 wa to set a goal. directed sessional contract%

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%he Change Continuum Bften clients are overwhelmed with the number and depth of their problems% Their despair can easil infect counsellors% The continuum is a tool to assist clients to become motivated in the direction of positive change% 2hen clients can gain some control over their situation through small successes' this promotes further optimism and change% Counsellors do not have to be involved for the whole change process% )ometimes helping clients head in the right direction is the e?tent of their involvement% Qim' a oung woman of -8 who is heavil involved in drugs' see0s counselling for help 9to get her life in order%: Counsellor: ABses a flip chart to draw the continuum depicted elow+* Qim' thin0 about an area of our life where ou would li0e to ma0e a change% The continuum represents things as bad as the could be if things got worse at one end' and our ultimate goal at the other end% =im: I need to change m whole life% Counsellor: 2here are ou on the continuum= =im: ADraws a circle+* IKm about here' prett near the bottom% Counsellor: 2hat direction are ou heading= =im: ADraws an arrow+* 91 life is a mess' and itKs getting worse%: Counsellor: 1a be ouKd agree that the direction ouKre heading in is ultimatel more important that where ou are on the continuum% =im: "bsolutel ' I can see that% Counsellor: )o whatKs one thing that would need to happen for ou to change directions= =im: ThatKs eas % I need a place of m own' and I need to get out of this area% Counsellor: <etKs start there and ma0e that the focus of our wor0% Comments: The continuum has a number of useful features% It is visual' which ma0es it easier for some clients to understand% It is a Euic0 wa to prioritiGe comple? problems and goals% This helps clients generate a sense of control and direction% Bnce completed' it provides shorthand communication for counsellors and clients% The two basic Euestions of the continuum can be used at the beginning of subseEuent interviews to assess progress and to identif emergent issues: 92here are ou on the continuum=: and 92hat direction are ou headed=:

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&" Cognitive /ehavioural Counselling

#atch your thoughtsC they ecome words+ #atch your wordsC they ecome actions+ #atch your actionsC they ecome ha its+ #atch your ha itsC they ecome character+ #atch your characterC it ecomes your destiny+ @Drank 3utlaw

Cognitive behavioural counselling @therap A' or C(T' has been empiricall tested in hundreds of studies% The results have demonstrated its usefulness for a wide range of social' emotional' and mental health problems such as mood disorders @depression' bipolar disorderA' an?iet disorders @obsessive.compulsive disorder' post.traumatic stress disorderA' substance use problems' eating disorders' gambling problems' anger' personalit disorders' stress' and unresolved grief @(utler' Chapman' ;orman X (ec0' 2,,5H Chamless X Bllendic0' 2,,-A% "merican ps chiatrist "aron Tem0in (ec0 @-82-A is considered the founder of C(T% The central assumptions behind (ec0Ks approach are these: Z &roblemsCdistress is caused b fault thin0ing @cognitive distortionsA and negative interpretationH thus' our thoughts and beliefs affect our behaviour and emotions% Z &eople ma pa too much attention to an?iet .provo0ing stimuli rather than to neutral or positive stimuli% Z (ehaviour is learnedH it can be unlearned% The 0e to changing problematic behaviour or emotions is to e?plore and modif distorted thin0ing' and then to learn and practise new responses% C(T focuses on understanding current thin0ing @the presentA and problem solving to develop new behaviours% 1arie and "iesha are passengers on the same airline flight% 1arie is consumed b her fear that the plane will crash' thin0ing' 9This is a dangerous situation% 2hat if the engines fail= "nd air turbulence will surel tear the plane apart%: "iesha boards the plane and Euic0l immerses herself in a boo0 with no intrusive thoughts of d ing% Ellis @2,,4A developed the famous "(C model @;igure 6%2A as a tool for understanding wh 1arie and "iesha e?perience the flight so differentl % In the model: Z " represents an activating event @in this case the airplane flightA% Z ( refers to the beliefs that are triggered b the activating event' "% Z C is the conseEuent emotion or behavioural reaction% Clearl ' 1arieKs beliefs about fl ing are mar0edl different from "ieshaKs% Cognitive behavioural counselling would concentrate on how 1arie can modif her thin0ing about fl ing' which is based on erroneous and distorted beliefs about its dangers%

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A "ctivating Event / (eliefs C ConseEuent (ehaviour or Emotion Cognitive behavioural counselling uses a combination of methods to help clients learn more effective coping strategies' including: Z helping clients recogniGe and modif thin0ing patterns Z a wide range of techniEues to help clients understand and modif behavioural patterns% This includes such tactics as 9autopsies: @a detailed review of actions to see what went wrongA' contingenc planning' goal setting' relationship problem solving' an?iet management' and the use of homewor0% "s well' e?posure can be used in real or imagined situations to assist clients to s stematicall overcome an?iet % Drama CycleHDrama /uster %he Drama Cycle is ] a repetitive' automatic pattern of behavior that is 9thought.driven: followed b feeling' followed b action ] pattern happens in a 4.part c cle thats complete within 3, seconds or less ] words' issues' dishonored values' situations' XCor personalities trigger our 9drama c cles%: ] when our drama c cles are triggered' our communication becomes distorted X ineffective it prevents effective listening ] we tune out' pre>udge' criticiGe' X condemn spea0er' situation X self% %he Drama /uster is a 4.step process to assist ou to recogniGe and bust our drama c cle: )et -: Thought############### ;eeling################ "ction################# )et 2: Thought############### ;eeling################ "ction################# )et 3: Thought############### ;eeling################ "ction################# )et 4: Thought############### ;eeling################ "ction#################

8,

-ecogni<ing and .odifying %hin ing and Core /eliefs ;reEuentl ' clients have difficult brea0ing out of established patterns because of the wa the thin0 about issues or problems @!e (ono' -873A% In addition' d sfunctional thin0ing patterns that affect reactions are freEuentl outside a clientKs awareness% Success %ip If oneKs thin0ing changes' behaviour and emotions also change% If oneKs behaviour changes' thin0ing and emotions also change% If oneKs emotions changes' thin0ing and behaviour also change% Nnderstanding how one thin0s is crucial to the change process because thoughts precede and influence feelings and behaviours% 1omentar thoughts are heavil influenced b core beliefs or schema' so it is important to recogniGe that how one thin0s is not necessaril driven b fact% )chema or core beliefs are defined as the 9basic beliefs individuals use to organiGe their view of the self' the world' and the future: @)perr ' 2,,5' p% 22A% 1aladaptive beliefs can lead to distress' inaction' low self.esteem' depression' and reluctance to engage in health ris0.ta0ing such as initiating social relationships% Cognitive behavioural counselling helps clients to recogniGe automatic thoughts' identif 9errors in thin0ing': and e?plore how thoughts hinder them from reaching goals% Bnce clients become aware that an automatic thought is about to happen' the can practise replacing that thought with an alternative% This interrupts the repetitive c cle of problematic behaviour% Bn a broader level' clients learn to understand and modif schemas that drive d sfunctional behaviour and painful emotions% E?ample: " new social setting triggers Tro Ks automatic thoughts: 9I donKt belong% I wonKt fit in%: These thoughts originate from his core belief' 9I am unlovable%: 4is automatic thoughts and his core beliefs create an?iet and fear% 4is strateg is to use drugs to curb his an?iet ' which in turn lead to the new belief that he wonKt be able to cope unless he uses drugs% .aladaptive 5unhealthy7 and Adaptive 5healthy7 beliefs ] I am unlovable% ] To see0 help is a sign of wea0ness% ] 2ithout a relationship partner' I am nothing ] I will fail% I am helpless% ] I have to be loved b ever one% ] I must be perfect in ever thing that I do ] I must be seen b others as the best% ] I am specialH I can ta0e advantage of others ] 1 rights as well as the rights of other people need to be respected% ] I am a person worth of love and respect% ] I can as0 for and offer assistance% ] I am responsible for m own happiness ] I will do m best' savour m success' and learn from m mista0es% ] I accept that not ever one will love me% ] I accept m limitationsH the do not diminish me%

Common %hin ing Errors )ince ma>or errors in thin0ing ma be outside oneKs awareness and can easil lead to fault interpretations and maladaptive behaviour' it is important to understand the ma>or t pes of thin0ing errors' such as distortion' selective attention' magnificationCminimiGation' perfectionism' and self.defeating thought%

8-

Distortion !istortion results from misinterpretations' fault assumptions' or cultural biases% 4ere are some common e?amples: Z 1isreading another personKs silence as lac0 of interest @mind readingA% Z "ssuming that others should 0now what we want' need' or feel without being told% Z Interpreting lac0 of e e contact as a sign of disrespect or l ing when' in fact' the other person is from a culture where direct e e contact is discouraged% Selective Attention )elective attention errors arise from a failure to loo0 at all aspects of a problem or situation% ;or e?ample: Bnl listening to information and facts that support our point of view% !e (ono @-873A made this important observation: 9Nnfortunatel ' 2estern thin0ing' with its argument habits' prefers to give a conclusion first and then to bring in the facts to support that conclusion: @p% 33A% /igid thin0ers act as if to sa ' 92eKll 0eep tal0ing until ou agree with me%: Z Selective memory: This behaviour involves recalling onl selected aspects of the past% 2e might overloo0 events or facts that threaten our self.image% Conversel ' people with low self.esteem ma overloo0 evidence to the contrar ' remembering onl their failures and mista0es% Z 1osing focus on what a person is saying: This happens because of factors such as lac0 of interest' preoccupation with other thoughts' or distracting noise% Z 9ocusing only on the present: ;or e?ample' prison inmates ma overestimate their abilit to cope with life outside >ail% The ma become clouded b unrealistic optimism that the will be able to avoid getting caught again or beat an charges if the are caught% In addition' the ma neglect to consider the long. term conseEuences of their criminal behaviour' a pattern of thin0ing that is characteristic of lifest le or habitual criminals% 2alters @-88-A reached this conclusion: 9Nntil high rate offenders realiGe the self. destructive nature of their super.optimism' the will continue to resist change because the are operating on the mista0en belief that the can get awa with >ust about an crime: @p% 35A% 2alters sees laG thin0ing as the root of the offendersK problems% Even those with the best of intentions ma find themselves in trouble because the fail to thin0 about long.term outcomes% Z Egocentric thin ing: Errors of this 0ind come from a failure or inabilit to consider other peopleKs ideas or to loo0 at how oneKs behaviour affects others% &eople ma adopt an arrogant position of self. righteousness' confident that their ideas and conclusions are sound% Egocentric thin0ers are li0el to be seen b others as aggressive and insensitive' interested in meeting onl their own needs% Egocentric thin0ers are not onl poor thin0ers but also poor listeners% T picall ' the believe that the purpose of thin0ing' listening' and responding is to prove themselves right% !e (ono @-873A contends that self. protection is a ma>or impediment to their thin0ing: 9The main restriction on thin0ing is ego defence' which is responsible for most of the practical faults of thin0ing: @p% 28A% .agnificationH.inimi<ation These t pes of thin0ing errors distort facts b e?treme and e?aggerated thin0ing% )ome e?amples: Z )plittingYthe tendenc to interpret people' things' and e?periences as either totall good or totall bad' with no shades of gre %

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Z BvergeneraliGationYdrawing conclusions from a single fact or event% ;or e?ample' after being turned down for a >ob' a man concludes that he is worthless and no one will ever hire him% Z !iscountingYre>ecting compliments b refusing to believe that the other person is telling the truth% Z 9CatastrophiGing:Ymagnif ing small mista0es into disasters or total failures% (erfectionism 4ealth individuals set realistic' challenging' and achievable goals% The are motivated to do their best and the maintain high standards for themselves% Conversel ' people who are perfectionist set unrealistic standards of achievement with an e?pectation of constant success% &erfectionist individuals are under constant stress caused b the an?iet to perform' or the realiGation that the have failed to reach or sustain their unrealistic e?pectations of self% Irrational beliefs that arise from perfectionism include: Z I canKt ma0e a mista0e% Z I am a failure if I am less than perfect% Z I have no value unless I achieve the ver best% Z If I canKt be perfect' then I might as well give up% Z I have to be the best% To win is the onl option% Z IKm probabl going to fail an wa ' so wh tr = The personal cost of perfectionism can include chronic pessimism' low self.esteem' lac0 of confidence' depression' an?iet ' and obsessive concern with order and routine% &erfectionists freEuentl use the words must' only' always' never' and should @the 1B"*) acron mA% Self6Defeating %houghts )elf.defeating thoughts are irrational ideas about oneKs own wea0nesses% "lbert Ellis has written a great deal about what he defined as irrational thin0ing and its impact on emotions and behaviour @2,,4' -883aH -883bH -874H -852A% Ellis argues that peopleKs belief s stems influence how the respond to and understand problems and events% 2hen their beliefs are irrational and characteriGed b an unrealistic should' the are li0el to e?perience emotional an?iet or disturbance% This thin0ing is often accompanied b self.depreciating internal dialogue: 9IKm no good': 9Ever one must thin0 IKm an idiot': and 9*o one li0es me%: Ellis concludes that irrational beliefs fall into three general categories with associated rigid demands or shoulds: $" 9I @egoA absolutel must perform well and win significant othersK approval' or else I am an inadeEuate' worthless person%: &" 9Fou @other peopleA must under all conditions and at all times be nice and fair to me' or else ou are a rotten' horrible personP: *" 9Conditions under which I live absolutel must be comfortable' safe' and advantageous' or else the world is a rotten place' I canKt stand it' and life is hardl worth living: 2ic0s and &arsons @-874A offer a similar perspective when the suggest that man clients are discouraged because the set unattainable goals: 9These goals are often based on irrational' simplistic views: @-A if a person acts properl ' ever one will li0e himH and @2A either a person is totall competent or he is completel inadeEuate: @p% -6,A%

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2elping Clients Change %hin ing (atterns 2hen people learn to pa attention to their thoughts' the are more apt to test the realit of the truth of their beliefs% 2hen people learn to recogniGe those thoughts that are d sfunctional' perhaps because the impede action and goal attainment or the cause distress' the can ta0e steps to change their thin0ing% "mong the strategies that counsellors can use to assist clients to change maladaptive thin0ing are the following: Z reframing Z encouraging clients to see0 out information and data Z suggesting to clients that the tal0 with others about their assumptions Z )ocratic Euestioning targeting overloo0ed areas Z direct challenge of the validit of beliefs Z teaching empathic s0ills as a wa to help clients learn about other perspectives Z brainstorming to generate new ideas and e?planations Z thought.stopping techniEues to overcome self.defeating inner dialogue 4ere are some e?amples of Euestions that can be used to help clients shift perspective: Z 4ow are our thoughts consistent with the evidence= Z 4ow do ou 0now this to be true= !o ou have facts or are ou assuming= Z 2hat are some other wa s of thin0ing about our situation= Z If a friend thought this wa about his situation' what would ou sa to him= -eframing /eframing is a counselling s0ill that helps clients shift or modif their thin0ing b suggesting alternative interpretations or new meanings% It empowers clients b focusing on solutions and redefining negatives as opportunities or challenges% Client stubbornness might be reframed as independence' or greediness as ambitiousness% E?ample: Carl' age --' is pla ing baseball b himself% 4e throws the ball into the air and e?claims' 9IKm the greatest batter in the world%: 4e swings and misses% Bnce again' he tosses the ball into the air and sa s' 9IKm the greatest batter in the world%: 4e swings and misses% " third time he throws the ball into the air proclaiming emphaticall ' 9IKm the greatest pitcher in the world%: Success %ip 4elp clients practise thought stopping to brea0 the pattern of repetitive self.defeating thought patterns% TechniEues include thought replacement @immediatel substituting rational ideas or pleasant thoughts for unwanted onesA' elling 9stop: in oneKs mind until the undesired thought disappears' snapping an elastic band on the wrist to shift thin0ing' and activit diversion% (efore presenting reframed ideas' counsellors should use active listening s0ills to full understand the clientKs current perspective% "s well' empath is crucialH otherwise' clients ma conclude that their feelings are being discounted or trivialiGed% 1oreover' reframing should not be confused with platitudes' such as 9ItKs alwa s dar0est >ust before dawn': which are t picall not ver supportive or helpful% "n e?ample of a well.meaning but misguided reframe that people give in times of grief over the loss of a child is 9FouKre oungY ou can have more children%: 9(ecause strong emotions of sadness and loss are present' most people cannot accept a

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reframing that does not ta0e into account the most salient feature of their e?perienceYthe grief itself : @Foung' -887' p% 272A% /eframing should not trivialiGe comple? problems with pat answersH rather' it should offer a reasonable and usable alternative frame of reference% ClientGs (erspective or Statement This counselling is a waste of time% CounsellorGs Initiative to -eframe )ounds as if ouKve done some thin0ing about how our wor0 could be more relevant to ou% Bf course% )ome people have not had much e?perience with our culture' and the ma be frightened% &erhaps ou could loo0 at this in a different wa % Four e?periences might also be fascinating for people who have not lived outside the countr % The might welcome our fresh ideas% Fou li0e to be patient until ou have a sense of whatKs happening% Fou also seem to want to develop alternatives' such as being more e?pressive in the beginning% Bbviousl ' this is devastating% "t the same time I wonder if this might also be an opportunit for ou to tr something different% IKm curious about wh she might do this% &erhaps she has trouble telling ou how scared she is that something ma have happened to ou% It might seem strange' but her anger could be her wa of sa ing how much she loves ou% )ounds li0e ouKve had to survive under conditions that might have defeated most people% 4ow did ou do that=

I donKt fit in% I come from a different culture and m ideas and values must seem strange%

IKm ver sh % 2hen I first >oin a group' I usuall donKt sa an thing% &eople who are impulsive are wor0ing to develop this s0ill% ;or the first time in 2, ears' IKm without a >ob

2henever IKm late for curfew' mother waits up for me and immediatel starts screaming at me%

1 life is a mess% IKve lived on the streets for the last si? months%

Success %ip The fact that a client firml defends a lifest le that he 0nows is unwor0able is proof that he is in need of great assistance and support% @2ic0s X &arsons' -874' p% -6-A Clar0 @-887A offers guidelines for using reframing: $" Nse reframing to help clients brea0 out of thin0ing that is self.defeating' constricted' or at an impasse% &" 1a0e sure that clients are not so emotionall distracted that the are unable to hear or process the reframed idea% *" Bffer a reframed idea in a tentative wa that invites consideration% 0" Ensure that reframed ideas are plausible% I" "llow clients sufficient time to consider a reframed idea% Clients with firml entrenched perspectives ma not immediatel accept logical and sound reframes' but with gentle persuasion and patience the ma

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begin to accept new ideas% Even though it ma be obvious that a clientKs thin0ing is distorted' it ma be wise to hold bac0 on reframing until the clientKs problem is full e?plored% 1oreover' as suggested above' it is important that the clientKs feelings be ac0nowledged through empath % E?ploration and empath ensure that the counsellor understands the clientKs feelings and situation' and the provide a basis for the client to consider reframed ideas as reasonable or worth of consideration% If counsellors push clients too Euic0l ' clients ma feel devalued and misunderstood' and in response the ma resist new ideas% Empath helps counsellors to establish and maintain credibilit with their clients% In addition' counsellors can use directives to invite clients to use different language to describe the distorted idea @Foung' -887A% ;or e?ample' when clients avoid responsibilit for their actions with statements such as 9I canKt get organiGed': counsellors can challenge them b proposing that the rephrase with statements such as 9I wonKt let m self get organiGed%: " client might sa ' 9)he ma0es me feel hopeless%: In response' the counsellor can propose that the client rephrase the statement b stating' 9I have decided to feel hopeless%: The latter response underscores the clientKs control over personal feelings% "s part of this wor0' counsellors can empower their clients b e?plaining that clients have ownership over their feelings and that no one can ma0e them feel a certain wa % "fter offering a reframe' counsellors should chec0 for the clientKs Euestions and reactions to it% Then' if the reframed idea is accepted' the can encourage further e?ploration and problem solving based on the new perspective% /eframing can energiGe clients% 2hen clients are loc0ed into one wa of thin0ing about their problems' their solutions are limited% (ut when the consider new perspectives' problems that seemed insurmountable can ield new solutions% 1oreover' reframing can serve to redirect client an?iet awa from self.blame and onto other rational e?planations that are less self.punishing% In these wa s effective reframing empowers clients to action' problem resolution' and management of debilitating feelings% 2hen counsellors 9consider the Euestion' U2hatKs good about it=K the give clients new perspectives on positive things that are alread happening: @1ile ' BK1elia' X !u(ois' 2,,4' p% 326A% Cognitive /ehavioural %echni,ues The following interview e?cerpt illustrates some of the essential strategies of cognitive behavioural counselling% The client' a 4,. ear.old first. ear universit ps cholog student' has sought help to deal with the fact that she has been 9overwhelmed and depressed: since returning to school% Dialogue Counsellor: "s we discussed' one of the things we will do during our sessions is to e?plore how our thin0ing affects our feelings and our behaviour% Analysis Cognitive behavioural counselling reEuires a collaborative relationship% "n important component of this is educating the client on how the process wor0s% This will also help the client to ma0e her own interventions when she recogniGes problematic thin0ing% Client: IKm at the point where' if I donKt do something fast' IKm going to lose the whole term% I might as well drop out% Counsellor: FouKre feeling desperate% Analysis

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In all phases of counselling' empath is an important response% 1ore than an other s0ill' it tells clients that the have been heard and that their feelings have been understood% Counsellor: Can ou remember a time in the last few da s when these feelings were particularl strong= 2hat was going through our mind at the time >ust before class= Analysis Eliciting and e?ploring e?amples such as this provides a database for helping this client understand how her thoughts contribute to her feelings% )ignificantl ' probes to discover thin0ing patterns ma reveal 9inner dialogue: @self.defeating thought patternsA or images% Client: Festerda ' I was scheduled to ma0e m first class presentation% I was thin0ing that I was going to ma0e a fool of m self in front of the whole class% Ever one else seems so confident when the tal0' but I havenKt been in school for 2, ears% Counsellor: "nd that made ou feel % % % Client: )tupid and terrified% I finall phoned in sic0% Counsellor: )o' here we have an e?ample of how what ou were thin0ingY9IKm going to ma0e a fool of m self:Yinfluenced how ou were feeling and what ou did% !oes this ma0e sense to ou= <etKs use the "(C model to illustrate it% A,he counsellor uses a flip chartE A Factivating situationG@thinking of making the presentationC 7 F eliefG@I$m going to look like a fool!C " Fconse-uent emotionG@fear, feeling overwhelmed+ Counsellor: If ou agree' IKd li0e to as0 ou to ma0e notes during the ne?t wee0 when ou find ourself feeling worse% 2hen this happens' I want ou to pa attention to whatKs going through our mind% Analysis Earlier the counsellor and the client discussed the essential elements of cognitive behavioural counselling% *ow the clientKs e?ample can be used to reinforce the principles% Nsing a flip chart or drawing is ver helpful for man clients' particularl for those who are less comfortable in the verbal modalit % 4omewor0 is essential to effective cognitive behavioural counselling% 4ere' the homewor0 creates an opportunit for the client to become more familiar with how her feelings and behaviour are intimatel connected to her thin0ing% In the ne?t session @e?cerpted belowA the counsellor uses reframing and thought stopping as tools to help the client change her thin0ing% Counsellor: Four >ournal is great% FouKve identified lots of great e?amples% <etKs tr something different for a minute% 2hat if it were possible to loo0 at our fears differentl = A"lient nods approval+* Analysis The counsellor introduces the possibilit of reframing% Counsellor: I thin0 itKs natural when we have a problem to dwell on all its unpleasant aspects% I 0now that I tend to do that unless I discipline m self not to% ;or e?ample' when ou thin0 of how nervous ou are' ou thin0 of all the negatives' such as ou might ma0e a fool of ourself' or our mind might go blan0 while ouKre tal0ing%

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Client: ALaughs+* Br that I might throw up in front of ever one% Counsellor: B0a ' those are real fears% (ut b considering onl our fears' ou become fi?ated on the negatives and ou ma be overloo0ing some important positives% If ou can loo0 at it differentl ' ou might discover a whole new wa of dealing with our class presentation% Counsellor: 2ant to tr it= A,he client nods+* B0a ' tr to identif some positive aspects of our fear% Client: 2ell' I guess IKm not the onl one who is scared of public spea0ing% Counsellor: )o ou 0now that there will be other people in the class who understand and will be cheering for ou to succeed% Client: I never thought of that before% 4ereKs another idea: (ecause IKm so nervous' IKm going to ma0e sure that IKm reall prepared% Counsellor: GreatP !o ou thin0 it might be possible to loo0 at our fears differentl = Consider that itKs normal to be nervous% Br go a step further and loo0 at it positivel % 1a be thereKs a part of it thatKs e?citing Y 0ind of li0e going to a scar movie% Analysis The counsellorKs short self.disclosure communicates understanding and a non>udgmental attitude% Bne tenet of cognitive behavioural counselling is that people tend to pa too much attention to the negative aspects of their situations while ignoring positives or other e?planations% "s a rule' itKs more empowering for clients to generate their own suggestions before counsellors introduce their ideas and suggestions% In this wa clients become self.confronting and are more li0el to come up with ideas that the will accept as credible% In this e?ample the client is able to generate a reframe' which the counsellor embellishes% In other situations' counsellors might introduce reframes of their own% The counsellor offers the client a reframed wa of loo0ing at nervousness% Client: I did come bac0 to school because I hated m boring >ob% Bne thing is for sure' IKm not bored% Counsellor: )o the more ou scare ourself' the more ou get our mone Ks worth% @The counsellor and the client laugh%A Counsellor: 4ereKs an idea that wor0s% If ou agree' IKd li0e ou to tr it over the ne?t wee0% Ever time ou notice ourself starting to get overwhelmed or feeling distressed' imagine a stop sign in our mind and immediatel substitute a healthier thought% Analysis The clientKs response suggests that this notion is plausible% )pontaneous humour helps the client see her problems in a lighter wa @ et another reframeA% "nother e?ample of counselling homewor0% The counsellor introduces thought stoppingY a techniEue to help clients control self.defeating thin0ing @Gilliland X Vames' -887H Cormier X

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Cormier' -873A% The basic assumption is that if self.defeating thoughts are interrupted' the will eventuall be replaced b more empowering' positive perspectives% "t this point the counsellor could also help the client develop different choice strategies for dealing with d sfunctional thin0ing' such as an activit diversion to shift attention' use of a prepared cue card with a positive thought recorded' imagining success' or substituting a different image% .a ing behavioural changes Goal Setting 3 stacles are those frightful things you see when you take your eyes off your goals+ AAnonymous* Goal setting is a counselling process that helps clients define in precise' measurable terms what the hope to achieve from the wor0 of counselling% Two t pes of goals are outcome goals and process or tas0 goals @)hebib' -886H Vacobs' 1asson X 4arvill' -887A% 8utcome goals relate to what the client hopes to achieve from counselling% These goals have to do with changes in the clientKs life' such as getting a >ob' improving communication with a spouse' dealing with painful feelings' or managing self.defeating thoughts% (rocess goals concern the procedures of counselling' including such variables as the freEuenc of meetings and the nature of the counselling relationship% &rocess goals are strategies for reaching outcome goals% In practice there ma be some overlap between process and outcome goals% ;or e?ample' a process goal might be to develop trust in the counselling relationship% )uccess in achieving this process goal might assist the client in achieving an outcome goal targeted at improving communication with famil and friends% There is wide support in the counselling literature for the importance of setting goals @Egan' -887H Foung' -887A% Goal setting serves man important purposes' including giving direction' defining roles' motivating' and measuring progress% Giving Direction Goals help to give direction' purpose' and structure to the wor0 of counselling% 1oreover' goals help counsellors and clients decide which topics and activities are relevant% In addition' when clients are clear about their goals' the can begin to structure their thin0ing and action toward their attainment% ;inall ' setting goals helps clients ma0e reasoned choices about what the want to do with their lives% Goal setting helps clients prioritiGe these choices% Defining -oles Goals provide a basis for defining roles% 2hen goals are clear' counsellors 0now which s0ills and techniEues are appropriate' and clients 0now what is e?pected of them% 1oreover' when counsellors 0now the goal of the wor0 the can ma0e intelligent decisions regarding whether the have the s0ills' capacit ' and time to wor0 with the client% If not' the ma ma0e a referral% .otivating Goals motivate clients% )etting and reaching goals is also therapeutic% It energiGes clients and helps them develop optimism and self.confidence about change% Goal achievement confirms personal capacit and further promotes action% 2riting down goals ma add an e?tra measure of motivation%

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.easuring (rogress Goals help provide benchmar0s of progress' including defining when the counselling relationship should endYthat is' when the goals have been reached or their pursuit is no longer viable% Developing Effective Goal Statements )ometimes clients are able to clearl articulate what the hope to achieve as a result of counselling% "t other times the have difficult identif ing their goalsH however' through s stematic interviewing counsellors can help these clients define and target their goals% In addition' counsellors can use their 0nowledge base to develop simple chec0lists of potential goals' customiGed to the common needs and problems of particular client groups% 4owever' these goals should alwa s be concrete' measurable' challenging but realistic' and 9owned: b the client% Effective Goals Are Concrete Bne defining feature of a counselling relationship is its goal.directed nature% (ut some clients begin counselling with vague and undefined goals: Z 9I want to feel better%: Z 91 husband and I need to get along better%: Z 9I need to ma0e something of m life%: These goals are starting points' but the are useless until the are described as clear and concrete targets% (eginning phase wor0 that e?plores problems and feelings should lead to the development of goals that define and structure subseEuent wor0% Then in the action phase clients can develop these goals as specific and measurable targets% This step is a prereEuisite for action planningYthe development of strategies and programs to achieve goals% Dague goals result in vague and ill.defined action plans' whereas e?plicit goals lead to precise action plans% Concreteness is the remed for vagueness% Concreteness can add precision to unclear and ambiguous goals% ;or e?ample' when clients are describing their goals' counsellors can use simple encouragers' such as 9Tell me more: and 9Fes' go on: to get a general overview of what clients hope to achieve% This is the first step in shaping wor0able goals% The ne?t step is to use Euestions to identif goals' define terms' probe for detail' and develop e?amples% This step helps to cast the emerging goals in precise language and move from good intentions and broad aims to specific goals @Egan' -887A% <isted below are some e?amples of probes and directives that might be used to start the process: 2hat is our goal= 2hen ou sa ouKd li0e to feel better' what e?actl do ou mean= !escribe how our life would be different if ou were able to reach our goal% Tr to be as detailed as possible% If our problem were to be solved' what would need to be different in our life= 2hat do ou thin0 would be the best resolution to our problem= 2hat are some e?amples of what ou would li0e to achieve= "s a result of counselling' what feelings do ou want to increase or decrease= 2hat do ou want to be able to do that ou canKt do now= If I could watch ou being successful' what would I see=

)ome clients are reluctant or unable to identif goals' and the ma respond with a dead.end statement such as 9I donKt 0now: when the are as0ed for their goals% To brea0 this impasse' counsellors can use

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some of these responses: 9Guess%: 92hat might our best friend @mother' father' teacher' etc%A suggest as our goal=: 92hat would ou li0e to achieve but donKt thin0 is possible=: " good general techniEue is to encourage clients to visualiGe themselves reaching their goals% Success %ip 2hen clients sa ' 9I donKt 0now': donKt rush in too Euic0l with another Euestion or comment% Bften' after a short silence' clients will generate new ideas' feelings' or thoughts% *ote also that when clients sa ' 9I donKt 0now': their responses ma indicate friction in the counselling relationship and this answer is a wa of sabotaging the wor0% In such cases goal setting might be premature' and the focus of the interview ma need to shift to relationship problem solving @immediac A% 1oreover' when clients sa ' 9I donKt 0now: the might also be sa ing' 9I canKt do it: or 9IKm afraid%: In such situations suggesting a ver small goal ma be a starting point @e%g%' 9If ou could ma0e >ust one tin change in our life' what would it be=:A% The miracle ,uestion @de )haGer' -873H Carpetto' 2,,7A is widel used in brief and single.session counselling as a wa to help clients shift their thin0ing awa from problems to goals and possibilities for change @more on the miracle Euestion belowA% Effective Goals Can /e .easured 2hen goals are measurable' clients are able to evaluate progress and the 0now precisel when the have reached their goals% 1oreover' clear goals sustain client enthusiasm and motivation% Dague and unmeasurable goals' on the other hand' can result in apath and vague action plans% Thus' goals need to be defined in terms of changes @increases or decreasesA in behaviours' thoughts' or feelings% E?ample @s0illA: 91 goal is to e?press m opinion or as0 a Euestion once per class%: E?ample @thoughtsA: 91 goal is to manage self.depreciating thought patterns b substituting positive affirmations%: E?ample @feelingsA: 91 goal is to reduce an?iet %:

4elp clients frame goals in Euantifiable language with Euestions such as 94ow often=:' 94ow man times=: and 94ow much=: Goals should also have a realistic schedule @a target date to start wor0ing on them and a target date to reach themA% ;or e?ample' 9Target weight reduction of 8 0ilograms in ten wee0s: or 91a0e five calls per da to potential emplo ers%: Effective Goals Are Challenging but -ealistic " goal has to be something that clients can reasonabl e?pect to achieve' even though it ma reEuire effort and commitment% )o counsellors need to consider variables such as interest in achieving the goals' s0ills and abilities' and resources @including the counsellorA available to help in reaching the goals% In addition' the goals need to be significant enough to contribute to managing or changing the core problem situation% (ut some clients ma be reluctant to set challenging goals or even to set goals at all%

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This situation can occur for a number of reasons: Z poor self.esteem Z fear of failure Z lac0 of awareness of capacit for change Z fear of change and reluctance to give up established patterns Z lac0 of resources to support pursuit of the goal @)hebib' -886' p% 2-,A )o addressing these reluctance issues is a prereEuisite for goal setting% 2hen problems are comple? and the clientKs capacit or self.esteem is low' setting short.term goals or subgoals is particularl useful% )hort.term goals represent small' attainable steps toward long.term goals% "chieving them helps build optimism and helps clients overcome a sense of inadeEuac @&incus X 1inahan' -863A% Effective Goals Are '8wned) by Clients Clients need to see goals as relevant to their needs and consistent with their values% Thus' when clients are involved in the process of deciding what their goals are' the are more li0el to be motivated to wor0 toward achieving them% Counsellors can suggest goals' as in the following e?ample: Evel n was referred to the counsellor for help in coping with Trevor' her -7. ear.old stepson' who was involved in pett crime% Evel nKs immediate goal was to encourage Trevor to move out of the house' and she hoped that the counsellor might help her do this% !uring the interview it became apparent to the counsellor that Evel n needed help developing parenting s0ills for dealing with Trevor and her two other teenage stepsons% 2ithout dismissing Evel nKs ob>ective' the counsellor suggested that this be part of their agenda% 2hen clients are forced to come to counselling b a third part ' the ma not feel committed to an of the goals of counselling% Thus' the chances of success are diminished greatl unless some mutuall acceptable wor0ing agreement can be reached% Nnderstanding a clientKs values is an important part of goal setting% )ome clients are motivated b spiritual values' some b material gain' and others b famil values% Bther clients focus on immediate gratification' while still others have ob>ectives that are long.term% 1ing left his famil in China to come to *orth "merica% 4e has seen his wife onl once in the last five ears' when he returned to China for a short visit% 4e maintains regular contact with her and their si?. ear. old son% 4e sends much of his monthl pa home to support his wife and e?tended famil % "lthough he hopes that one da his famil will be able to >oin him' he has accepted that his purpose is to position future generations of his famil for a better life% )ometimes clients set goals that reEuire others to change' such as 9I want m husband to stop treating me so badl %: Counsellors need to encourage clients to form goals based on what is under their control' namel their own feelings' behaviour' and thoughts% Client complaints and problem statements can usuall be reframed as positivel worded goal statements%

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4ere are some e?amples: E#ample $ : Client: Ever one alwa s ta0es advantage of me% Counsellor: )ounds as though ouKd li0e to learn to stand up for ourself% E#ample & : Client: IKm tired of not wor0ing% Counsellor: &ut simpl ' our goal is to get a >ob% E#ample * : Client: 1 life is a mess% Counsellor: Fou would li0e to find a wa to get our life in order% The above responses change the focus of the interview from problems to goals% Bf course' the counsellor and client will have to wor0 together to shape these vague goals into more e?plicit terms% The overall goal of an counselling relationship is change% (ut' depending on the needs of individual clients' the targets for change might focus on behaviour' feelings' thoughts' s0ills' relationship enhancement' or other areas of the clientKs life% %arget Area (ehaviour 3ague Goal To do better in m courses Specific Goal Statements To improve m grade.point average from C to ( b the end of the semester To overcome depression so I am able to en>o <ife% That would include mi?ing sociall with people and having a sense that life is worth living% IKll be more able to accept m problems without withdrawing or drowning in self.pit % To regard mista0es as normal and as learning opportunities% 2hen IKm successful' IKll ta0e credit% Bverall' IKll be able to sa to m self that IKm capable% To develop s0ill at organiGing m time and setting priorities% I need to set up a schedule so I can plan at least a month in advance% To reduce the number of fights that we have b not being so e?plosive% Instead of elling' I need to remain calm% Instead of husband not listening' I need to chec0 with him to ma0e sure I understand what he wants' too% To lose 3 0g over the ne?t two monthsH to increase m wee0l running from 3 to -, 0m To ma0e meditation a dail part of m life% To read something spiritual at least once a wee0% To wal0 in the forest three times a wee0

;eelings

To feel better

Thoughts

To stop putting m self down

)0ills

To get organiGed

/elationship

To be able to communicate better

4ealth and fitness )piritual

To get in shape

To be closer to God and nature

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Action (lanning Counselling is a developmental process% In the beginning phase' the focus is on the development of a strong wor0ing relationship based on a contract that describes the wor0 to be done and the respective roles of both the counsellor and the client% The beginning phase is also concerned with problem identification and e?ploration% This wor0 provides the foundation for clients and counsellors to define goals% )o attention to detail in the beginning phase helps prevent problems from premature action% &roblem e?ploration leads to goal setting' which in turn forms the foundation for action planning% (roblem E#ploration 6N Goals 6N Action (lanning )ome clients will need additional coaching and support to develop and implement s stematic action plans to avoid the *ew FearKs resolution s ndrome% "ction planning and implementation consists of a series of steps leading to the clientKs goal @or subgoalA% &ut simpl ' action planning involves developing strategies to help clients get where the want to go% This involves four steps: @-A identif alternatives for action' @2A choose an action strateg ' @3A develop and implement plans' and @4A evaluate outcomes% Step $: Identify Alternatives The first tas0 in selecting a plan is to list alternative ideas for achieving the goals% This step serves two purposes% ;irst' it holds clients bac0 from impulsive action based on the first alternative available' which ma simpl be a repeat of previous unsuccessful attempts at change% )econd' it helps ensure that clients have choices based on a full range of possibilities% 2hen there is choice' clients can ma0e more rational decisions% (rainstorming is one wa to Euic0l generate a list of possibilities% To encourage clients to generate ideas' counsellors can use leads such as these: 9<et our imagination run wild and see how man different ideas ou can come up with that will help ou achieve our goals%: 9!onKt worr for now about whether itKs a good idea or a bad one%: )ometimes counsellors can prompt clients to be creative b generating a few 9wild: ideas of their own% The following interview e?cerpt illustrates goal.setting techniEues% &rior to this dialogue' e?ploration and active listening enabled the counsellor to develop a solid base of understanding% 2ith this wor0 apparentl finished' it seems timel to move on to goal setting% Dialogue Counsellor: FouKve tal0ed about how ouKre determined to changeYas ou put it' 9now or never%: That suggests to me that ouKre read to set a change goal% Client: Feah' I canKt go on living li0e this% )omething has to happen' and soon% Counsellor: I thin0 it might be helpful at this point to figure out what ou want to achieve' what ouKd li0e to change% This would give ou something to wor0 toward% 2hat do ou thin0= Client: )ounds good% I thin0 itKs time to do something% ;or one thing I reall havenKt invested too much in m marriage% I have to change m priorities% Counsellor: 2hat do ou mean b 9change our priorities:=

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Client: If possible' IKve got to stop spending so much time at wor0% ( the time I get home IKm so tired that I have no energ or motivation to be involved with m famil % Counsellor: B0a ' I thin0 I get a sense that what ouKd li0e is to be more committed to our famil % To do that' ouKd have to cut bac0 on wor0% Client: E?actl % Counsellor: Vust so we can be clear' can ou tr to be more specific= )uppose ouKre successful% 2hat will be different from the wa things are now= Client: I donKt understand% 2hat do ou mean= Counsellor: 2ell' ma be ou canKt plan it out e?actl ' but what do ou see happening in terms of the amount of time ouKd li0e to spend with our famil = Tr to be specific' so ouKll have something to aim for% Client: ALaughs+* Bh' I see% Fou want to nail me down and close the deal% Fou should be a salesperson% 2ell' I thin0 itKs important that I free up the wee0ends and at least two nights a wee0% )unda should be strictl famil time' a time to do something with the 0ids% Counsellor: ;rom our e?cited tone I get the sense that ouKd feel reall good if ou could do that% Client: In m heart itKs what IKve alwa s wanted% Counsellor: " while bac0 ou used the words 9if possible: when ou tal0ed about cutting bac0 on wor0% 2hat problems do ou anticipate= Client: IKd li0e to tr for a management position at the compan ' but ever oneKs so competitive% IKve got to put in the hours if IKm going to 0eep m sales above the others% "nd high sales is the first thing the loo0 for when itKs time for promotion% Counsellor: FouKre torn% To compete' ouKve got to put in the hours% (ut if ou do that' it ta0es awa from our time and energ with the famil % ThatKs a lot of stress% Client: *ow that ou point it out' it seems obvious% IKve been under stress for so long I donKt even thin0 about it an more% ItKs clear to me now that the price of success is >ust too much% Acontinued* Analysis The counsellor recogniGes the clientKs positive motivation for change and uses it to ma0e a transition to goal setting% &roblem statements can often be reframed to ma0e goal statements% The client ma0es a general statement confirming motivation for change% This undeveloped goal is a useful starting point' but it is not et an operational goal% The counsellor see0s to contract with the client to wor0 on goal setting% The counsellor uses the criteria for effective goals as a reference point% "s the interview progresses' other Euestions will be as0ed that help frame the goal% There is no secret agenda to this' and the counsellor might decide to review the process with the client% The final open Euestion reaches for client input and agreement% The client begins to identif an area for change% The counsellor reEuests more definition @goal specificit A% This ensures that no assumptions are made% Bften' as here' client goals are stated in the negative Y that is' in terms of what the client would li0e to stop doing% The counsellor attempts to help the client put an emerging goal statement in behavioural terms b reframing the idea% This reEuest for more specificit encourages the client to reframe the goals in positive terms b stating what will be done differentl % The client is confused' but the relationship is strong enough that the client is able to as0 for help%

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The counsellor clarifies the Euestion% This helps to educate the client regarding some of the criteria for goal setting% " clear goal statement has emerged' but the wor0 is not et finished% Empath lets the client 0now that the counsellor has recogniGed the clientKs feelings and their importance% The client confirms acceptance of the counsellorKs empath % "n important part of goal setting is to assist the client to loo0 at potential problems' including the relative advantages and disadvantages of goal attainment% 4aving identified this potential barrier' the client can address it Y for e?ample' b considering wa s to overcome it Y or ma0e a decision about whether the costs involved are too high% The counsellor recogniGes the clientKs ambivalence% )olutions to problems' however obvious' are often not acted upon because of such ambivalence% Acontinued* Dialogue Acontinued* Counsellor: 1eaning that if ou have to sacrifice time with our famil to get ahead' ouKre not interested% A"lient nods+* )ounds as if ouKve made a decision' but let me pla devilKs advocate% )uppose ou cut bac0 on our >ob and lost a promotion% 4ow would ou feel about that= Client: It would be hard on me' but I thin0 not nearl so hard as whatKs happening now% "t heart IKm reall a famil man% IKm certain of it% ;amil has to be number one% 1 career is important to me' but itKs m second priorit % Counsellor: <etKs go bac0 to our goal% 2hat other problems do ou anticipate= A)8 seconds of silence+* Client: 4ereKs one% 1 famil is so used to getting along without me' the Kve developed lives of their own% I guess I canKt e?pect them to drop ever thing for me% Counsellor: )o how can ou deal with that realit = Client: ThatKs eas % I guess IKll >ust have to negotiate with the famil on how much time weKll spend together% Counsellor: Bne thought occurs to me% 4ow will our boss react if ou suddenl start spending less time on the >ob= !o ou thin0 thatKs something to consider= Analysis Acontinued* The counsellorKs empath provides a basis for insight% )uch responses ensure that the client will not gloss over or minimiGe difficulties% The counsellor also prevents the client from acting impulsivel % ( anticipating ris0s' the client is challenged to decide whether the costs are acceptable% The client confirms a decision% If the counsellor is satisfied that the client has ta0en a serious loo0 at all reasonable ris0s' itKs time to move on% The counsellor challenges the client to loo0 ahead to see if there are other ris0s% )imilar responses are called for until all difficulties are e?plored% The counsellor must be patient and give the client enough time to complete the thought process%

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This t pe of response ensures that the client sets goals and embar0s on action plans with a clear sense of direction and planning% &roblems ma be prevented or anticipated' and the client is far less li0el to face a crisis that leads to abandonment of otherwise health ob>ectives% It is appropriate for the counsellor to tentativel introduce some of her own ideas' leaving a lot of room for the client to respond% 4owever' as a rule' counsellors should let the client have the first opportunit % "dapted from )hebib' -886% Step &: Choose an Action Strategy Bnce a creative list of alternative action strategies is identified' the ne?t tas0 is to assist clients in evaluating alternatives and ma0ing choices% This involves helping clients intelligentl consider each alternative against a number of criteria% "n obvious first criterion is that the alternative is potentiall effective for meeting the clientKs goal% It must be sufficient to ma0e a difference and relevant to the problem being addressed% " second criterion is that the alternative is within the capacit of the client% Btherwise' failure is inevitable% " third criterion is that the alternative is consistent with the values and beliefs of the client% " fourth is that the alternative is reviewed in terms of potential cost% Cost might be measured b time' mone ' and energ e?pended in finding resources to e?ecute the alternative% "s well' alternatives might result in other losses for the client% ;or e?ample' suppose a client wishes to end a pattern of alcohol abuse' but the personKs friends are drin0ing buddies% If Euitting drin0ing involves developing new activities' the potential loss of friends and social structure must be considered as a negative conseEuence that will have an impact on the client% Nnderstanding and e?ploring this loss is important' for unless clients are aware of and prepared for these contingencies' the ma be unable to sustain an efforts at changing% Success %ip 4elp clients conduct autopsies @also 0nown as post.mortemsA on past e?periences as a tool to help them identif errors in thin0ing' triggers' problematic responses' and successes% 4elp them answer the Euestions 92hat went wrong=: 92hat could I have done differentl =: and 92hat wor0ed well=: Step *: Develop and Implement (lans !eveloping and implementing plans involves four substeps: @-A seEuencing plans' @2A developing contingency plans' @3A putting plans into action' and @4A evaluating plans% Effective plans are maps that detail the seEuence of events leading to the final goal% Counsellors should avoid tailor.made plans in favour of customiGed strategies that are designed in collaboration with individual clients% )ome of the important Euestions that need to be answered include the following: Z 2hat specific strategies will be used= Z In what order will the strategies be used= Z 2hat resources or support will be needed at each step= Z 2hat are the ris0s and potential obstacles= Contingency (lanning Effective plans anticipate the potential obstacles that clients might encounter along the route% Bnce clients 0now and accept the possible barriers that could interfere with their plans' the can develop contingenc plans to deal with these barriers% This preventive wor0 helps 0eep clients from giving up when things

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donKt go smoothl % " variet of different strateg choices can be used to support contingenc planning' including the following: Z anticipator Euestions such as 92hat will ou do if % % % @detail possible obstaclesA=: Z role pla ing @including counsellor modellingA to e?plore and practise strategies Z use of contractingY(efore problems occur' counsellors can as0 clients for advice on how the can respond when the time comes% ;or e?ample @to a client who has >ust begun a >ob searchA: 92hat would ou want me to do if a few wee0s from now I notice that ouKre becoming frustrated with our >ob search=: 2ith flight simulators airline pilots learn to fl aircraft in emergencies% )hould a real.life emergenc happen' the are able to respond with confidence 0nowing that their training has prepared them% )imilarl ' contingenc planning helps clients prepare for personal challenges that might arise as the implement their action plans% Success %ip 2A1% @hungr ' angr ' lonel ' tiredA is an acron m for common feelings that can trigger relapses% 4elp clients e?plore what the tend to do' and what the might do differentl ' when the are hungr ' angr ' lonel ' or tired% Counsellors need to support and encourage clients as the deal with the stress of change% Bne wa the can help is to remind clients that an?iet ' aw0wardness' and periodic slumps are normal when change is occurring% 1eanwhile' counsellors can loo0 for wa s to reframe failure or setbac0s as learning opportunities% 2ilsonKs @-884A comments might be offered to clients: 9"lthough ou ma fail to reach the goal' there are benefits of having wor0ed toward it% Bne benefit is the practical education of ma0ing the effort% "nother is the opportunit to practice specific s0ills% " third is the recognition that meeting some goals and failing to meet others is part of the ebb and flow of life% /ecogniGe that ou probabl will not achieve significant goals without some failures% ;ailing provides uniEue learning opportunities that ultimatel contribute to our personal growth%: 1oreover' empath is particularl important at this time to support clients dealing with feelings that accompan change% !uring implementation' counsellors should also encourage clients to use famil ' friends' and support groups to assist them% Step 0: Evaluate 8utcomes Effective plans include continual evaluation during the implementation phase% Evaluation recogniGes and confirms success and is a powerful motivator% 4owever' evaluation ma also uncover problems that need to be addressed% ;or e?ample' it ma become apparent that the goals are too unrealistic% If the are too challenging and unreachable' counsellors can help clients define smaller goals% )imilarl ' if goals prove to be too eas ' the can be modified to provide more challenge% Thus' regular review of progress ensures that goals and action strategies remain relevant and realistic% 2hen evaluation reveals that the plan is unli0el to be successful' efforts can be redirected toward redesigning the plan or selecting a different strateg for action% In some cases the client ma need help that is be ond the capacit of the counsellorH in this case' referral to another counsellor or service is appropriate%

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Dialogue 'IGve %ried Everything) S%@DE>%: I get stuc0 when a client sa s' 9IKve tried ever thing and nothing seems to wor0%: %EAC2E-: Fou feel stuc0' which is precisel how the client feels% Clients often bring out in counsellors the same feelings that the are e?periencing% This realit can be a useful tool for empath % 2hen clients sa the Kve tried ever thing' itKs important not to get into a 9 es' but: game' whereb counsellors generate ideas and clients dismiss them with a 9 es' but: response% S%@DE>%: )o what are m choices= %EAC2E-: IKd be interested in e?ploring what the client did% !id he or she tr long enough= "t the right time= In the right wa = )ometimes problems get worse before the get better' and clients ma give up too soon% " mother might tr ignoring her child when he has a tantrum and then tell ou ignoring doesnKt wor0' but she ma have abandoned this tactic after a few minutes when it appeared that the intensit of her childKs tantrum was increasing% In this situation ou could help her anticipate this obstacle so that she would not be demoraliGed if it recurred% Br ma be she has been giving her child lots of nonverbal attention' not realiGing how this has been reinforcing the tantrum% S%@DE>%: I can thin0 of another e?ample% Bne of the members of m wor0 group was having trouble with her supervisor% )he told us that there was no point in tal0ing to him because he didnKt listen an wa % (ut from the wa she described how she tal0ed to him' I wouldnKt listen either% )he was vicious and cruel% %EAC2E-: )o' if she were our client' she would need some help developing awareness about how she affects others%

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*" Empowering 1anguage /eplacing disempowering language with empowering language can transform our perspective% 2e can shift how we hold things' even if circumstances remain the same% That shift can move us to a place of empowerment% ItIs part of recogniGing that we are alwa s at choice% 4ow often can ou replaceO I shouldH I ought to I need to I have to I canIt IIll tr to I should have [done\ but I am >ustH I am onl Fou 0nowH li0e 0ind ofH sort of I would li0e to sa Cac0nowledgeCdo Owith empowering language= I willH I choose to ItIs important to me to I choose toH I want to I am not willing to I willH I intend toH I aim toH I commit to *e?t time I canH *e?t time I will and I am [nothing needed\ [nothing needed\ [>ust ma0e the statementH these prefaces diminish it\

3alue In -eplacing Disempowering With Empowering 1anguage <anguage' as our e?pression of thoughts and feelings' has the power to transform% ItIs ine?tricabl lin0ed to our view of realit % ( changing our language' we can affect our view of realit ' which is' in effect' our realit % IIve observed significant energ shifts as clients replace disempowering language with empowering language% This means that' >ust b changing our language' we can move from pla ing the victim to having choices' from feeling powerless to being in control of our life' from fear to love% "nd we can move into action: JI reall want toOJ b JI willOJ JI have toOJ b JI choose toOJ (utO b &ersonall ' I have replaced most uses of JbutJ with JandJ% I pic0ed this because' when I read the empowering language table above' it was the entr most charged for meP 1 initial reaction was' JI(utI is a perfectl good and useful word% 2h should I replace itP=PJ 2olding Space 9or /oth The word JbutJ separates two clauses representing things that are in some wa in opposition% The implication is often that one or the other must be chosen' or one or the other is true% The word JandJ >ust con>oins two things in a list' with a sense of inclusivit % Technicall ' the word JbutJ e?presses more information about the relationship of the things being described' "*! using an inclusive con>unction @JandJA serves better to hold space for both' e?panding the possibilities as IIm considering the issue%

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OIO Statements "nother important piece of using empowering language is using JIJ statements% These are claims a person ma0es about themselves using the pronoun JIJ rather than J ouJ% ;or e?ample' imagine I said' JFou 0now how ou sometimes donIt want to get up in the morning= 4aving the aroma of freshl brewed coffee reach our nose can reall helpPJ Clean CommunicationI am' in fact' telling ou something about m self: J)ometimes I >ust donIt want to get up in the morning% 4aving the aroma of freshl brewed coffee reach m nose can reall helpPJ E?pressed using J ouJ and J ourJ' IIm impl ing that ou should agree% 4owever' ou ma never have trouble getting up in the morning' or ou ma not even li0e the aroma of coffee% /ather than assuming these things and telling ou what will help ou' itIs much cleaner if I >ust claim what is true for me% Then' if ou notice that resonates with ou' ou can offer our agreement% The value in using JIJ statements is ownership% 2hen I use JIJ statements I am owning what I sa as m view or realit % I am not pro>ecting it onto J ouJ% This facilitates m separating m issues from our issues so that I can deal with mine and donIt have to ta0e responsibilit for dealing with or responding to ours% ThatIs a win for me% 4ow about for ou=

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0" Sample 9ormats for Sessions Sample 9ormat for 9irst Session -% Brient Client: )mall tal0H )tate our desire to be helpful and the importance of client feedbac0% 2% Identif the &roblemH !etermine the clientKs main concern and clarif details @2hoCwhatCwhenCwhere=H 2hatKs alread been tried and how well has it wor0ed=H 4ow can I help ou with this=A% 3% Create Nseful Goals: Nse rating scales or other methods to create useful goals @2hat will ou do different when this mar0 moves a little higher= 2hat will a 3%3 loo0 li0e=A% 4% Identif E?ceptions and Bther /esources: E?ceptions @2hen is the problem absent or less noticeable=H 2hat is different about those times=AH Bther /esources @E?plore the clientKs special talents and interests' resilience' heroes' influential people' solution ideas' and other resourcesA% 3% Can Interventions (e (uilt from E?ceptions or Bther /esources= If es' collaborate to develop interventions based on e?ceptions or other resources% If no' move to the ne?t step% 5% Change the Diewing or !oing of the &roblem: Diewing @Invite client to consider a different viewCe?planationCinterpretationAH !oing @Invite client to 9do something different:A 6% Compliment' /eview' )ession /ating )cale' 2rap.Np: Compliment the client on positive attributes' coping' persistence' and other assetsH /eviewCrefine intervention plans and responsibilitiesH "ddress closing Euestions or comments from the clientH "dministerCdiscuss rating scalesH 7% Than0 client for cooperation and inputH 8% )chedule ne?t meeting%

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Sample 9ormat for Second 5and 1ater7 Sessions -% "ssess &rogress: Nse rating scales or other client feedbac0Cscaling techniEue to assess progress from the clientKs perspective% 2% 2hen improvements are reported: a% b% c% d% "s0 for the clientKs theor @4ow do ou e?plain this=A' compliment and credit the client @4ow did ou ma0e it happen=AH E?plore e?ceptions @2hat was different this wee0=AH Empower progress @4ow is life different for ou now=A%

3% 2hen no change or slips are reported: a% "s0 for the clientKs theor @2hat do ou ma0e of that= )hould we tr something different or hang in there and see what happens ne?t wee0=AH b% *ormaliGe and validate @)ometimes it ta0es a while to get some tractionH )ometimes things get worse before the get betterAH c% "s0 coping Euestions @2here do ou find the strength to 0eep tr ing=AH d% E?plore e?ceptions and other resources @"s bad as it was' was there an small thing that went well this wee0= 4ow did ou 0eep things from getting worse=A% 4% Can Interventions (e (uilt from E?ceptions or Bther /esources= If es' collaborate to develop interventions based on e?ceptions or other resources% If no' move to the ne?t step% 3% Change the Diewing or !oing of the &roblem: Diewing @Invite client to consider a different viewCe?planationCinterpretationAH !oing @Invite client to 9do something different:A 5% Compliment' /eview' )ession /ating )cale' 2rap.Np: Compliment the client on positive attributes' coping' persistence' and other assetsH /eviewCrefine intervention plans and responsibilitiesH "ddress closing Euestions or comments from the clientH "dministerCdiscuss rating scalesH 6% Than0 client for cooperation and inputH 7% )chedule ne?t meeting or terminate services based on client progress and input @4ow will we 0now when to Euit=A%

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Summary The foundation for empowerment in counselling is the belief that clients are capable and have a right to manage their own lives% To empower clients' counsellors need to forgo controlling them' dem stif the counselling process' promote client self.determination' advocate for progressive changes in the s stem' and assist clients to change established patterns of thin0ing and acting that are interfering with their lives% Counsellors can help clients change established patterns with strategies such as motivational interviewing' cognitive behavioural counselling' and brief counselling% 1otivating involves engaging clients in a change process as well as supporting and energiGing them as the deal with the rigours of change% Counsellors ma face a range of motivational challenges' and the can emplo different strategies to address each of them% The stages of change model @precontemplative' contemplative' preparation' action' and maintenanceA provides a useful framewor0 for understanding where clients are at in the process of change% 1otivational interviewing is a practice approach that uses the stages of change model to help clients overcome ambivalence to changes% Its central features include active listening' especiall empath ' developing discrepancies' and rolling with resistance% Cognitive behavioural counselling helps clients understand how to brea0 out of established patterns of thin0ing and behaviour% Bne central feature includes helping clients understand and modif d sfunctional thin0ing through strategies li0e reframing' a tool for helping clients e?amine problems from another perspective% " variet of strategies help clients modif behaviour' including the use of 9autopsies': contingenc planning' an?iet management' relationship problem solving' and goal setting% Goal setting serves man important purposes' including giving direction' defining' roles' motivating' and measuring progress% Effective goals need to be concrete' measureable' challenging but realistic' and owned b clients% Effective goals can be developed from problem statements% "ction planning consists of a series of steps leading to the clientKs goal or subgoal% )electing a plan involves s stematic identification and evaluation of the possibilities for action' then choosing one or more alternative action plans% "ction planning involves four substeps: identif ing alternatives' choosing an action strateg ' developing and implementing plans' and evaluating outcomes% Bften counselling relationships are limited to a few sessions or even a single session% *evertheless' these brief encounters have the potential to be helpful for clients% (rief counselling wor0s on the assumption that a change in some part of a clientKs life will affect other aspects of his or her life' including relationships with significant others% (rief counselling techniEues include the use of the miracle Euestion' loo0ing for e?ceptions' finding strengths in adversit ' using solution tal0' and the change continuum%

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E#ercises $" Consider areas in our life where change is possible' is necessar ' or has alread occurred% Classif our stage of change with each issue' based on the stages of change model: precontemplative' contemplative' preparation' action' maintenance% 2hat could potentiall 9move: ou from one stage to another= &" )uggest Euestions ou might as0 clients to assess their stage of change% *" Identif which stage of change best describes each of the following clients: a" 9I hardl 0now an one who smo0es an more% IKll get there too one da %: b" 92hatKs the point of loo0ing for wor0= )ince the big stoc0 mar0et crash there arenKt an >obs out there an wa %: c" 9ItKs been almost si? months since m last drin0% I donKt even crave it li0e I used to%: 0" 2or0ing with a colleague' ta0e turns e?ploring a time in our life when ou were unmotivated% 2hat feelings were associated with this period= 2hat helped ou get unstuc0= I" )tart a log that chronicles our automatic thin0ing' for e?ample' when ou meet someone new' before as0ing a Euestion in class' when ou want to as0 for help' etc% J" Identif errors in thin0ing for each of the following client statements% a" 9IKll never get a >ob%: b" 9)he didnKt even sa hello when she saw me at the store% I guess she doesnKt li0e me%: c" 9I have to be number one%: K" )uggest reframed responses for each of the following client statements% a" I canKt do it% b" AA student counsellor+* I feel so unnatural and phon e?pressing empath all the time% c" I reall want m 0ids to avoid ma0ing the same mista0es I did% I donKt 0now wh the donKt listen to me% d" If he reall loved me' heKd send me flowers% e" 1 life is a mess% f" IKm tired of being depressed all the time% L" *ame at least ten different wa s to motivate clients% M" Evaluate how effectivel the following statements meet the criteria for effective goals: a" to be a better person b" to get m boss to stop hassling me c" to drin0 less d" to be able to disagree with someone without dismissing them or their ideas e" to improve m fitness b ne?t ear to the point where I can run - 0ilometre in -3 minutes $P" &ractise brainstorming techniEues% Identif different action strategies for a client who wishes to Euit drin0ing% $$" Nse the concepts from this chapter to practise goal setting and action planning for ourself% &ic0 one or more target areas @behaviour' feelings' thoughts' s0ills' or relationshipA%

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Chapter 0 %he Intervention (rocess What is involved in the crisis intervention process+ "lan "% /oberts' in his boo0 Crisis Intervention and Time <imited Cognitive Treatment' identifies seven stages of wor0ing through a crisis situation with someone% These stages include the following: 1. "ssessing lethalit @potential for harm to self or othersA and safet needsH 2. Establishing rapport and communicationH 3. Identif ing the ma>or problemsH 4. !ealing with feelings and providing supportH 1. E?ploring possible alternativesH 2. ;ormulating an action planH and 7. ;ollow up measures " brief assessment of lethalit and safet needs should be done in an telephone screening or face to face assessment and should hold an important place in an intervention% @Is the person safe= Is the person alone= !oes the person intend harm to self or others= !oes the person have means to carr out his or her intentions=A These screenings must be done with sensitivit % )ome callers are offended if as0ed Euestions about suicidal or homicidal intent before the are allowed to identif the issues that the are calling about% "ssessment of danger to self or others should continue throughout an crisis assessment' crisis intervention' and crisis stabiliGation process% <ethalit and safet needs are however not the onl elements of a telephone screening or face to face assessment% What is the first step in interviewing in a personal crisis+ JIn the midst of a crisis' or most other times for that matter' people want to be heard' understood' validated and valued as a human being% Instead' we are li0el to get advice' JI told ou so'J or J ou thin0 ou have it bad%J " person in crisis needs to be empowered' given choices' options' resources' encouragement' and hope% " responder needs to establish rapport and communication with the person% Bne of the best tools in building rapport and communicating clearl is active listening% Active 1istening Active Listening provides empowerment+ As a listener, you donHt have to Ido anything, Ifi( anything, or Ichange anything+ #hen people are Iheard, they will Ido, Ifi(, and%or Ichange things for themselves+! <istening is an art% " lot of people stop tal0ing and in their mind the Ire alread tr ing to thin0 of what the Ire going to sa ne?t% That is not reall listening% If ou are @preAoccupied with our own thoughts' then there is no room for the other an more% *ot reall % "nd even if ou are listening and not bus with our own thoughts on the matter' listening is so much more than >ust hearing the words and being able to repeat them% To get the essence of whatIs being said .the words behind the words' is >ust as important' if not more so% 2hile the other person is telling his stor ' tr to also listen for things li0e a slip of the tongue' >o0es' omissions' recurring themes' metaphors and contradictions% The can spea0 volumes%

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"part from the intonations ou can pic0 out the different emotions in the individualIs voice% (od language and other signals can strengthen or wea0en the stor % Contradictions are called incongruence and ou can either 0eep these in mind or as0 about them% 1a0e sure ou do this carefull ' so the other wonIt feel caught out% In active listening' the personal crisis intervention provider has an open and alert attitude' heIs completel there for the other and is peeling his ears' so to spea0% To listen empathicall means that the service provider shows a lot of understanding for what the other is e?periencing and in a wa he manages to conve this warm understanding to them' who can appreciate it% (efore as0ing Euestions' we must learn to listen attentivel and effectivel % "ctive listening is a ma>or part of communicating well% It is e?tremel important and necessar % ( activel listening to a personIs stor ' the responder will hopefull accomplish the following with the individual: ;ind out what their real needs are Nnderstand their realit and emotions Qnow what is motivating them and what is 0eeping them bac0 4elp them ma0e sense of what happenedH

Dalidate their concerns' emotions' and reactionsH Bffer perspective from our ob>ective viewpointH &rovide hope and a sense of directionH &oint out resources the ma have forgottenH Give them power to ma0e choices' and ta0e action% )et correct and smart goals Concentrate on one goal at the time &lan good action steps &roceed towards their goal with enhanced commitment and accountabilit !eal with setbac0s and celebrate successes

To the individual' the personal crisis intervention services provider listening activel to them proves that the are ta0en seriousl as a person and that the other is ma0ing efforts to understand their situation% "ctive listening sounds eas ' but it reEuires s0ill and practice% "ctive listening s0ills are essential for a crisis services provider% Good communication is a solid foundation for an relationship% Communicating well sounds eas ' but it is reall Euite comple? in practice% T pical e?pressions related to active listening are: . If I understand correctl ' ou thin0 that O . )o' what ou are sa ing is O . If ou thin0 O' then I can see wh this situation ma0es ou upset . I understand wh ou are so O% . 2ow' I want to ac0nowledge the courage C maturit C persistence C O ou have shown in spea0ing up to O C in ta0ing this initiative O C in wor0ing so long O

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. In repl to a statement . In repl to 9I must:: . In repl to 9I cannot:: . In repl to 9nothing' all' alwa s' never O:: . If ou donKt 0now what to answer' as0: Active 1istening S ills

as0 : how do ou 0now= what would happen if ou donKt= what is stopping ou= as0 to thin0 of e?ceptions 2h do ou sa that=

Contrar to what some thin0' active listening does not stop at listening and creating rapport b nodding and humming' but involves a wide range of different s0ills% Each s0ill is used concurrentl with the others while attempting to remain ob>ective' empathic' and human% &a ing attention to bod language 1inimal encouragementsH "s0ing Euestions /epeating and summariGing the messageH "c0nowledging the feelings e?pressed and the reasons for these feelings "c0nowledging the Eualities shown' that is: who the have to be to accomplish O &robing for bac0ground information Chec0ing the Eualit of the communication &araphrasingH /eflectingH )ummariGing Emotional labelingH DalidatingH /eassurance EncouragingH and 2aiting%

(aying attengion to /ody language (od language is important% E?cessive e e.contact ma be felt as threatening% *ot maintaining enough e e. contact on the other hand might be interpreted as a lac0 of interest @e%g% when listener is repeatedl loo0ing at their watch or documents on their des0PA' or as an indication that the listener is hiding information or is not sufficientl open or honest% (od language includes @affirmativeA head nodding and the use of silence' which are powerful tools in an conversation% Gerard Egan describes the correct position for listening as follows : )B<E/ ) : )it sEuarel ' face interlocutor B: 0eep an Bpen posture <: <ean forward when appropriate E: maintain regular E e contact @donKt stareA /: /ela?ed bod language

)how individuals that ou are interested in the situations' e?periences and feelings that the are communicating and that ou care not onl about what the are sa ing' but also about how this affects them%

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@sing .inimal Encouragements *on verbal encouragement such as ma0ing e e contact' nodding' orienting our bod toward the person and leaning slightl forward' humming' and short e?pressions li0e 9Fes:' :I seeJ' 9go on:' 9what happened ne?t=: O are used to confirm the other person that ou are listening to him 0eenl % These e?pressions also help them to understand which part of their message is being appreciated and to elaborate on that particular topic% As ing ,uestions "s0ing Euestions is another wa of showing our interest and ma0ing people feel understood' valued' respected and listened to% 2ell chosen' powerful Euestions facilitate a person in finding his own answers% @<ife.coaching for dummies Veni 1umfordA Clarif ing and reflective Euestions often are a ver good idea: Clarif ing brings unclear or vague sub>ects into sharper focus% It is useful to confirm what was said' to get supplementar information' to present fresh points of view or add details' or to shed light on new elements% -% /estate what ou heard the trainee sa 2% <isten for confirmation that what ou are sa ing is correct 3% Encourage trainees to tell ou if ou are right or wrong E?amples of clarif ing Euestions: . . . . . . . . Tell me more about O Go on O I am interested to hear more about O 2hat did ou do then= Fou sa O' wh is this so = Is this alwa s the case= <et me see if IKve got it all O <et me tr to state what I thin0 ou said O

E?amples of reflective Euestions: . . . . . . 4ow was this different from O= 2hat would it loo0 li0e if O= 2hat would happen if O= 2hat do ou wish O= 2hat did ou want him to do instead= 4ow would this impact C change O =

-epeating words! content! meaning and feelings Bften enough' it is also ver useful to repeat in some wa what the have said% This forces people to concentrate on what ou are sa ing' thus helping them to ta0e some distance from their own stor and obtain an improved general view of the whole situation% ( repeating their messages' ou also stimulate their thought process' without introducing new sub>ects%

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!ifferent options to repeat a message are available: -% &arroting : literall echo their e?act words% Bften' onl the last words are repeated @mirror.EuestionsA in an invitation to amplif on them% The use of parroting should however be limited' since hearing our own words echoed repeatedl soon becomes ver anno ing% /epeating Content: This techniEue goes be ond parroting: The individualKs e?act words are repeated' inviting them to elaborate on their stor or to continue it% /epeating Conflict: /epeat both sides of a conflict situation' opposing pros and cons stimulate them to ma0e a considered choice% &araphrasing or /eflecting 1eaning: /epeating the individualKs message in our own words' that is: reflecting the facts or ideas' but not the emotions and without getting emotionall involved' ma open new perspectives% Bften an element of ac0nowledgement or positive feedbac0 will be part of the paraphrasing' thus motivating the other to continue sharing%

2%

3%

4%

(araphrasing &araphrasing e?presses interest and focuses on the individual and hisCher problem% ( activel see0ing clarit ' ou achieve a shared meaning' avoid misunderstanding' and gain the trust of the person with whom ou are spea0ing% &araphrasing includes several elements% /epeating the intent or content of what the person has stated is ver helpful in ma0ing sure that the responder understands the meaning of the words the person is using% 1ost people do this when communicating on a regular basis% Ta0e this brief e?ample: - " woman wal0s into her house after being at wor0 all da % J(o ' what a rough onePJ she sa s% - 4er daughter as0s' JFou had a bad da =J - The woman responds b sa ing J*o' not the whole da ' >ust the drive home% The traffic was horrible%J In this e?ample' the daughter stated what she thought her mother meant' and the mother clarified% The daughter' however' does not use the same words to JparaphraseJ her mothersI statement% Crisis service providers must be ver careful about parroting phrases that the person uses% Nnless done thoughtfull ' this can come across as not hearing or mimic0ing the person% Clarif ing can be done in a number of wa s% The crisis service provider can simpl sa ' JI am not clear about what ou mean when ou sa %%%J or JTell me more about that%J )imple paraphrasing also opens the door for the person to restate his or her intent in a different wa % In order to ensure a shared understanding of the situation' the crisis service provider ma want to summariGe the information to be sure that he or she has understood correctl and has the whole picture% )imultaneousl ' paraphrasing is . either a reEuest for verification of our perceptions @feedbac0A . or a confirmation that ou have correctl understood the message% Good openings for paraphrasing are: . )o ou thin0' O% . Fou donKt believe that O . Fou donKt understand wh O

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. )o' what ou are sa ing is O . )ounds to me li0e ou O% . The wa ou see things O . To ou' this means O . )o' ou are sa ing that O . I guess it is our opinion that O . If I understand correctl O . FouKve alwa s thought O' but now ou found out that O )ome manuals use the term 9reflecting: to indicate reflection of meaning @thoughtsA onl 9paraphrasing: for referring to reflecting thoughts "*! emotions -eflecting 9eelings /eflecting ;eelings . or /epeating ;eelings . is ver similar to paraphrasing' but instead of reflecting the meaning' the service provider now reflects the emotions that are the basis of other personKs words% /eflecting feelings resorts a much stronger effect' because the individual will e?perience that the service provider is not onl understanding him' but is also empathiGing with his feelings% /eflecting feelings is the basis of emphatic listening and creates rapport% *aming the feeling that ou recogniGe in their stor ' helps people to define and e?plore their own feelings and become more aware of their seriousness% /eflecting is ver useful also when ou feel people are rattling information without feeling involved% /eflecting gives the person an idea of what is being interpreted from their information% It can help himCher identif what he or she is feeling and pro>ecting% Tone of voice and pointing out what is being heard or sensing helps ma0e sense of the confusion and adds to rapport% /eflecting means telling the person how the are being seen such as JFou loo0 reall worried @scared' etc%AJ or heard such as JFou sound ver an?ious' @angr ' etc%AJ% /eflecting is giving feedbac0 on the situation such as JFou seem so tense right now' what would help ou rela? while we tal0=J "n ob>ective part is an ideal person to provide this sort of feedbac0% ;eedbac0 is a wa to communicate thoughts and reactions to another person% E?ample of a specific method to present feedbac0: Identif what ou are thin0ing' feeling' etc% Identif the behavior that ou thin0 provo0ed our response% Indicate how this might impact the individual% @;or e?ampleA' JIt concerns me when ou tal0 about committing suicide' even though ouIve said that ou are not seriousH it ma scare others enough that the donIt want to tal0 to ou about it or about our situation%J The person has a lot to gain b hearing honest' direct feedbac0 in a sensitive wa % &eople who are too closel related to the problem ma hesitate for fear of hurting someone' fear of a reprisal or the ma >ust feel inadeEuate in handling a sensitive situation% Nnfortunatel ' if the person is not aware of how his or her behaviour affects others' he or she canIt change% This t pe of feedbac0 should alwa s be given in a ver thoughtful wa or else the person ma shut down and not discuss their thoughts or feelings with an one% and use

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Good introductions for reflecting are: . Fou feel doubl hurt' because O . The situation is worr ing ou' O . Fou are disappointed' O . Fou feel itKs a shame' O . Fou are feeling sad' O . Fou were angr ' because O . Fou donKt dare to' O . Fou are afraid' O . Fou must be ver fond of him% . Fou feel ou have failed O . Fou are worried that ou O . Fou had the strong feeling that O . Fet' I notice some doubt in our voice . Fou donKt sound ver convinced though . "nd et' ou sound sad% 1a be ou can tell me what happened= . I sense ou are still angr ' troubled' mi?ed up' confused O ma be thatKs wh O Summative -eflection )ummative /eflection involves summariGing the message in order to provide a structured' complete and comprehensive feedbac0% "side from organiGing and integrating the ma>or aspects of the dialogue' summariGing also establishes a basis for further discussion and offers a sense of progress in the conversation% It is reEuired to also plan regular summaries and evaluations during which ou . repeat the essence of what has been said or done . provide a clear image of the situation . locate where the other is with respect to the total >ourne <ogical moments for summariGing and evaluating are: . "t the start and end of each session . "t transiting to a new phase . "t an moment that ou feel a summar might be helpful to 0eep trac0 of the situation or to stimulate the individual% "lternativel ' it is a good idea to as0 individuals ever now and then to summariGe and evaluate things themselves% This will help ou to ta0e notice of . Their point of view . 2hich elements have stuc0 . 2hat is most important to them now . 2hat the are 9forgetting:

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The most important elements in a summar are: . . . . . "ccurate summar of core material Clarit and structure /eflection of content /eflection of feelings !eeper empath

&ossible opening lines for summariGing: "% S' letKs see how far ou got until now: . Fou came to me S wee0s ago' because O and because O% . 2e determined that O' because O% . Is there something ou would li0e to add at this point= (% )o' to summariGe' ou sa that O' is that correct= C% "t that moment' ou set ourself the target of O% (ecause O% . To this end' we composed an action plan . *ow' the Euestion is when to start with the e?ecution of this plan% !% )ummariGing our stor ' ou reported that O ' but O' and O . Can ou agree with this presentation= E% This seems a good moment to summariGe what we have done during this session% . Is there something ou want to add= . 4ow did ou e?perience the conversation= . ( the ne?t session' I would li0e ou to consider C go through toda Ks points again C to start the actions we agreed upon . 2hich would allow us to proceed ne?t time with O% ;% Is there an thing ou want to add= E?amples: I donIt understand wh m wife is getting wor0ed up' I for instance never get madPP )till I hear a bit of anger in our voice% Four wife might perceive this as ou being angr % If ou thin0 it helps' IIm Euite willing to do it' ou 0now= Fou donIt sound convinced' what might be holding ou bac0= I actuall wanted to stop coming here as I thin0 IIm doing much better now% IIm glad ouIre feeling a lot better and of course ouIre free to stop whenever ou want% 4owever IIve noticed there are still some things that seem to trouble ou%%% I havenIt touched a drin0 in wee0s' itIs clear IIm not an alcoholic%%% @hiccupA (eing an alcoholic might be too strong a word' but something tells me ou still do have a drin0 regularl % I donIt 0now whatIs wrong with me or where to start% 2e can ta0e our time% Fou sound ver sad' ma be ou could tell me what has happened=

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Emotional 1abeling !uring a crisis situation' feelings are often confusing and hard to define% 4elping the person label the emotions that he or she is feeling helps him or her to ma0e sense and gain some control of these emotions% <abeling the emotions also gives the person a chance to clarif and correct the perceptions of the crisis service provider% Crises happen as a result of some loss' real or perceived' in a personIs life% The pain felt in a crisis is grief over that loss% The loss ma be something ou can put our hands on li0e an automobile' mone ' or a home% It ma also be less tangible' li0e loss of self.Iesteem' power' freedom' or prestige% The resulting grief is the same% There ma be a number of losses present in a single event% ;or instance' it is not unusual for a widow to lose financial well.being because of her husbandIs deathH thereb she loses securit ' power' prestige' and Euite possibl friends and social contact% Two 0e elements in an crisis are griefCloss and an?iet " *o one can predict e?actl what a grieving person will feel li0e% 4owever' there are stages identified b EliGabeth Qubler./oss' which are seen in most people e?periencing grief% %he five stages of grief are: 1) !enialH 2) "ngerH 3) )adnessCdepressionH 4) (argainingH and 1) "cceptance These stages provide a road map of sorts that point out where someone ma be in the process of his or her grief% Grief doesnIt progress through the stages and end there% /ather' it seems li0e a series of loops' traversing the same ground over and over% 2e ma be at different stages with each aspect of our grief at an given time% The following responses ma or ma not occur as a grief reaction% This is not meant to be a complete listH other reactions ma occur that are Euite normal% Emotional reactions and their somatic' or ph sical' counterparts often occur in JwavesJ' lasting a varied period of time% Emotional responses )adnessC"bandonmentC!espair "ngerC/ageC/esentment . Irritabilit CDengefulness /elief ;earC&anicC"n?iet C2orr Guilt ;eeling <ostC*umbness 4opelessnessC4elplessnessC Somatic 5physical7 responses Cognitive responses Tightness in the throat )hortness of breath Empt feeling in the stomach *ausea C 4eadaches C !r mouth 2ea0ness' overall lac0 of ph sical strength !elusionsC4allucinations *ightmares &oor attention spanCIndecisionC)lowed thin0ing !isorientationC1emor problemsC(lan0ing out /ehavioral responses Cr ing at une?pected times 4ostile reactions to those offering help or solace /estlessness <ac0 of initiative or desire to engage in activities !ifficult sleeping Constantl tal0ing about the loved one and his death Isolation or withdrawal Increased smo0ingCalcohol use

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An#iety is an emotional response that can be e?pected to manifest in an crisis situation' because there are no answers' and seemingl no resolution% &eople ma become afraid of the un0nown or what the fear might happen% This pro>ecting into an unsure future is a normal' natural response to crisis situation% "n?iet also acts as a motivator to find options' solace' and resolution to problems% )ometimes an?iet can be e?perienced as free.floating fear or panic% /ereaved by Suicide <osing someone close to ou brings about intense grief and mourning% The loss of someone through suicide often results in different responses and emotions% (ereavement b suicide is prolonged% )hoc0' social isolation and guilt are often greater and the element of choice raises painful Euestions% Fou ma e?perience some or all of the following: Intense )hoc0 The sense of shoc0 and disbelief following a death of this 0ind ma be ver intense% " common aspect of grief is recurring images of the death' even if this was not witnessed% ;inding the bod ma be another traumatic and indelible event% It is a natural need to go over and over the ver frightening and painful images of the death and the feelings these create% Wuestioning . 2h = (ereavement through suicide often involves a prolonged search for an e?planation of the traged % 1an people eventuall come to accept that will never reall 0now wh % !uring the search for e?planations' different members of the same famil ma have ver different ideas as to wh a death happened% This can be a strain on famil relationships' particularl where an element of blame is involved% Wuestioning . Could it have been prevented= It is common to go over and over how the death might have been prevented and how the loved one could have been saved% Ever thing can seem painfull obvious in retrospect% The Iwhat.ifsI ma seem endless% /ewinding events is a natural and necessar wa of coping with what has happened% /esearch suggests that some people bereaved b suicide feel more guilt' self.blame and self.Euestioning than those bereaved in some other wa % "bandonment C re>ection Fou ma e?perience a sense of re>ection% It is common to feel abandoned b someone who IchoosesI to die% JI was upset that he hadnIt come to tal0 to us% I thin0 we all went through anger at some point% Fou thin0: I4ow could ou do this to us=I J% @" sister whose brother too0 his life%A )uicidal fears and feelings !espair is a natural part of the grieving process' but after the suicide of a loved one hopelessness ma be combined with fear for oneIs own safet % Identification with someone who has ta0en their life can be deepl threatening to oneIs own sense of securit % Fou ma suffer more an?iet than those bereaved in other wa s and be more vulnerable to suicidal feelings%

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1edia "ttention 2hen someone dies b suicide or other une?pected causes' it ma attract public interest% The inEuest that ma be demanded b law draws attention to the person who has died and to close relatives and friends% "ttention from the media can be ver stressful for bereaved relatives and friends' particularl where a death is reported in an insensitive or inaccurate manner% )tigma and Isolation )ocial attitudes to suicide are changing' but the ma still limit the support that is available% The silence of others ma reinforce feelings of stigma' shame and Ibeing differentI% If others are embarrassed' uneas or evasive about suicide' ou ma be left feeling intensel isolated% Bpportunities to tal0' remember and celebrate all aspects of a loved oneIs life and personalit ma be denied% " strong need to protect a loved one' and oneself' from the >udgement of others ma also be felt% " mother writing about her sonIs death pointed out that we have never been told what to sa to someone who has had a suicide in the famil % )he needed to hear the same thing that might be said to an one else who had e?perienced the death of someone close: JIIm trul sorr for our pain and is there an thing I can do= If ou need to tal0 about it' I am a good listener% IIve got a shoulder to cr on%J *eeds: " group of Canadians bereaved b suicide were consulted and felt that the needed help and support to: get the suicide in perspective deal with famil problems caused b the suicide feel better about themselves tal0 about the suicide obtain factual information about suicide and its effects have a safe place to e?press their feelings understand and deal with other peoplesI reactions to suicide get advice on practicalCsocial concerns

2ow to give support to a grieving person+ (e available% /emember that the individual is in a ver different place emotionall % If ouIre not sure what to sa or do' >ust as0% )a ' J!o ou feel li0e tal0ing about this right now=J If the do' be there for them% !onIt tell them ou 0now how the feel' unless ouIve reall been there% Fou donIt have to 0now e?actl what the are going through to offer support% If the donIt want to discuss their heartache' donIt press the issue% <et them 0now that ou are there for them regardless% !onIt treat the individual li0e an invalid% Encourage him or her to get out and get bus doing da .to. da activities% (e supportive but not smothering% /ecogniGe that ou ma need our own support s stem% )ometimes ou can give support' and other times ouIll need to receive it% !onIt e?pect ourself to alwa s be the leader% 2atch out for a shift into depression% If ou see the individual withdrawing into an emotion fetal position' itIs time to intervene%

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3alidation &erhaps the most important support to give to a person in crisis is validation% Dalidation is conve ing that it is o0a to feel whatever it is the client is feeling and that he or she is not alone' in that given the same circumstances' others might feel the same wa % "ffirm their worth and their efforts to cope with the situation% Crises spawn feelings of inadeEuac % /eassure them that the can get through this crisis' and that the deserve help when things seem intolerable% The most important thing is to somehow conve the idea that the feelings the person is having are normal% )ome e?amples of validation are listed below: - JFou donIt sound craG to me%J - JIId be angr too if that happened to me%J - J2ith so man things going on' of course ou feel overwhelmedH I thin0 an one would in our situation%J Affirmations "ffirmations are simple' direct statements that go a long wa toward instilling confidence' hope' and reassurance% ;or e?ample: JIIm glad ou decided to tal0 to me%J JFou sound li0e a ver @strong' caring' sensitiveA person%J JIIm glad ouIve decided to get help' ou deserve it%J JFou have a good sense of humor' thatIs a great wa to cope sometimes%J

It is ver important not to ma0e a statement that is not true% If ou sa that the person sounds li0e a sensitive person but do not believe that' the person ma sense that ou are being less than truthful% ;alse statements ruin rapport and trust% Identifying a ma:or problem " number of Euestions need to be answered to identif the nature of the crisis situation: 1) 2hat happened to prompt the call= 2) 2hat led up to the precipitating event= 3) 2ho is involved in the situation= 4) 2hat does the person feel= 1) 2hat do the fear= 1an of these Euestions will be answered as the person tells hisCher stor and rapport is built% The basic information needed is the answer to J2here does it hurt=J and J4ow can I help=J -esponding to specific symptoms of behavior 4ow can a person who is e?periencing specific s mptoms or behaviors be assisted= /eview the s mptom behavior below with suggested actions%

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Symptom /ehavior6 An#iety or Agitation !ecrease stimuli that might increase agitation Identif the agitating stimulus and remove it if possible /emain calm "s0 the person to slow down /eassure the person that there is plent of time to sort the situation out Give the person enough personal space% @Fou ma wish to as0 about what is JenoughJ as personal space varies% &eople who e?perience paranoia generall need more personal space%A - !onIt demand answers - 4elp the person find a safe' Euiet space as needed

Symptom /ehavior6 1ow self6esteem - "ssist person in pointing out his or her own strengths' but if he or she is unable' then the crisis services provider can point out strengths - !o not discuss past failure or wea0nesses unless brought up b the person - !iscuss an wea0nesses or past failure the person brings up in a tactful manner - 4elp the person problem.solve wa s to deal with these perceived wea0nesses Symptom /ehavior6 8ppression! frustration! loneliness! feelings of guilt "llow the person to vent hisCher feelings <isten and accept hisCher feelings as stated "llow the person to cr (eware of tr ing to cheer someone up because the person ma perceive this as minimiGing the pain 4elp in problem solving and ma0ing changes in behavior that will have an impact on the feelings

Symptom /ehavior6 2allucinations andH or delusions or disorgani<ed or illogical thin ing !o *BT dispute the personIs realit of e?periencing delusions or hallucinations "ccept that this is what the person trul believes or perceives !o not encourage the person to e?press accelerated or illogical thoughts Encourage the use of a Euiet place )ta calm 2ord sentences in simple terms "s0 one Euestion at a time (e clear' practical' and concrete "llow time for the person to decode our communication and form an answerCresponse "ct as a buffer between the person and outside stimuli or other people if needed

Symptom /ehavior6 Slow response time - (e patient - "llow the person time to formulate a response Symptom /ehavior 1oss of contact with reality6based personal boundaries - )upport realit .Ibased statements - !o not encourage out of touch with realit statements - (e careful with the use of touch

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Symptom /ehavior Difficulty with establishing self6initiated goal directed activity - 1a0e e?pectations clear and realistic - 4elp the person identif meaningful tas0s and brea0 these down into JdoableJ pieces Symptom /ehavior Difficulty ma ing decisions - !ecrease stimuli - <imit number of decisions to be made if possible - Ta0e a directive stance about issues that relate to the personIs safet Symptom /ehavior /i<arre behaviour - )et firm limits - Identif biGarre or inappropriate behavior specificall % @It is better to sa J2rapping our fingers with aluminum foil to bloc0 thought transmissions might seem strange to man people'J rather than JFou have some habits that other people would find strange%JA Symptom /ehavior6 Withdrawn behaviour &eople with schiGophrenia need a Euiet place to withdraw and ma wish to be alone more often than others "llow the person some Euiet time as a wa to cope with chaos !o not ta0e withdrawal as re>ection (e available at the personIs reEuest

Symptom /ehavior6 E#aggerated response to stimuli - /educe e?citing stimuli - "ssist the person to find a Euiet space - Nse clear' concise Euestions or statements Symptom /ehavior6 Aggressive behaviour - )et limits on behaviour - (e aware of threatening statements and ta0e them seriousl Symptom /ehavior 1ethargy! loss of interest - 4elp the person set realistic' doable goals Symptom /ehavior6 Sleep disturbances Encourage adeEuate ph sical activities during the da Encourage reduction of caffeine and other stimulants Encourage a regular bedtime and wa0e.up time 4elp the person identif a calming pre.sleep routine

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E#ploring possible alternative solutions 4ow does a crisis services provider help the person go about e?ploring possible alternative solutions= )everal Euestions are pertinent to e?ploring alternatives: -% 2% 3% 4% 3% 5% 2hat does the person believe is the most important issue that heCshe is dealing with= 2hat is the person hoping for= 2hat does the person thin0 heCshe needs= 2hat has heCshe alread tried= 2hat has wor0ed in the past= 2hat personal and communit resources does this person have to draw on=

1an people in crisis tend to see their world in blac0 and white% The feel that the have limited options% Bffer alternatives that the person ma not have thought of% Evaluating In a supportive conversation' ou will not want to stop at listening% Towards the end of the conversation' ou will want the other to ta0e a ne?t step' start changing things' commit to action% E?amples: . )o' where does this leave us= . 2hat will ou do ne?t= . 4ow will this help ou to proceed towards our goal= . 2hat will be our first step now= 9ormulating an action or crisis plan If someone has an active mental health provider' it is possible the ma have an e?isting crisis plan the have developed with their mental health provider% If this is the case' it is necessar to tr to access the personIs current crisis plan% If a plan has not been developed then the person ma find it useful to develop a plan% The plan that is developed should be short.term' clear' doable and developed as much as possible b the person e?periencing the crisis situation% )pecific activities that will give the person the feeling of control over hisCher life should be included% "lternatives to harmful or unproductive behavior should be included% ;or instance' instead of going for a drive when feeling upset' the person might decide to call a friend or pla with the dog% Including resources identified b the individual is also useful% The person ma be able to thin0 of these resources when heCshe is wor0ing with the crisis services provider but ma not be able to identif them when alone or in the midst of an escalating situation% 2riting the plan down and ma0ing a cop for both the person and the crisis services provider is important% The crisis services provider ma also find it appropriate to ma0e referrals to other services in the communit % The ma serve an Jintroductor roleJ to ensure that a person who has e?perienced a crisis ma0es connections with services that heCshe needs to prevent further crises% Agreeing on 9ollow6up measures The follow up service is a ver important part of the crisis intervention services% These services can range from a telephone call or a face.to.face contact the ne?t da ' depending on the need of the person% ;ollow.up measures should be written into the crisis plan and agreed to b both the person and the crisis service provider%

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Contractual time frames andCor standards for follow.up must be followed% D8Gs and D8>G%s in De6Escalating Crisis Situations !B approach clients in a calm non.threatening manner% !B be assertive' not aggressive% !B allow clients to resolve a situation themselves' if possible% !B remove an b standers from the area% !B remove an dangerous articles from the area% !B encourage clients to use more appropriate behavior to get what the want% !B wor0 with other staff or significant others available as appropriate in defusing a crisis% !B give an agitated client time and space to calm down% !B ma0e use of &/* medication when appropriate based on a consultation with a ph sician' nurse practitioner' or ph sician assistant% !B negotiate temporar solutions to bu time% !B be respectful toward the client% !B leave a ph sical escape route for both ourself and the client% !B*T get into an argument or power struggle with the client% !B*T be authoritarian or demanding% !B*T tell clients ou are frightened even if ou are% !B*T argue with clients over the realit of hallucinations or delusions% !B*T JhumorJ clients regarding hallucinations or delusions% !B*T overreact to the situation% !B*T insist that a client discuss a situation if he or she doesnIt want to% !B*T confront a client under the influence of substances%

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Chapter I Critical Incident Stress .anagement 5CIS.7 The Critical Incident )tress 1anagement process includes education and awareness% CI)1 is a comprehensive range of integrated services' procedures' and intervention strategies designed to mitigate the effects of e?posure to a critical incident% The core components of CI)1 are: -% &re.Crisis &reparation 2% 1obiliGationC!emobiliGation and Crisis 1anagement (riefing @C1(A 3% !efusing 4% Critical Incident )tress !ebriefing @CI)!A 3% Individual @Bne.Bn.BneA Crisis Intervention 5% ;amil Crisis Intervention 6% ;ollow.up )ervices% .obili<ationHDemobili<ation 1obiliGation and !emobiliGation are group processes that are generall reserved for crisis interventions b trained crisis intervention staff operating in the wa0e of deepl distressing events that have the potential for widespread effect on a particular group of people% This includes events that are prolonged or have high media visibilit % )upport is provided b wa of factual information about the incident' stress education information and restCrefreshment as necessar % This is often delivered in con>unction with start of shift or end of shift staff meetings provided b management% )peciall trained emplo ee peers usuall conduct 1obiliGation C !emobiliGation on a rotating basis for the first few da s post.incident% Crisis .anagement /riefing 5C./7 C1( is a large group crisis intervention ideall suited to business and industrial applications for up to 3,, persons% It is used after large.scale events @disasters' ma>or crisis' etc%A% " C1( ma be thought of as a form of 9town meeting: for the e?pressed purpose of crisis intervention and is led b CI)1 Team members it should *BT be considered an 9operational debriefing:% " C1( ma include a panel of CI)1 peer support personnel' mental health professionals' management and union representatives' and operational e?perts from within the organiGation or suitable outside agencies' as reEuired% " C1( consists of four distinct phases @"ssembl H InformationH /eactionsH and Coping )trategiesC/esourcesA and ma be used to triage individuals for more intense and appropriate intervention at a later time% It is primaril used to assist tertiar groups who ma be less directl affected b a crisis% This is sometimes used when emergenc operations impact a communit % " C1( assists communit members copeCcooperate with an increased operational presence%

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Defusing !efusing is the front.line response to a critical incident or potential critical incident% It is provided within a few hours of a crisis event to minimiGe the effect of acute critical incident stress% Its goal is to reduce intense reactions to the eventH to normaliGe the e?perienceH to provide practicalCuseful information @stress educationAH to develop e?pectancies about recover ' and to assess the need for follow up with a Critical Incident )tress !ebriefing @CI)!A% This process is used primaril to assist small groups of individuals who were directl e?posed to and most seriousl affected b a critical event% " !efusing is led b a trained peer team member without the aid of a mental health professional% It is less structured and less time consuming @appro?imatel 3, to 5, minutesA than a !ebriefing% " !efusing ma eliminate the need for' but should *BT substitute for a formal !ebriefing if one is obviousl reEuired% "fter a !efusing' follow up is essential% !efusings are highl fle?ible in how the are delivered and are of low visibilit % This combines to ma0e them one of the most effective CI)1 tools% Critical Incident Stress Debriefing 5CISD7 CI)! is a structured seven.phase group process utiliGed in the normaliGation of critical incident stress or traumatic stress and integrates crisis intervention strategies with educational techniEues% It is best conducted in the short.term aftermath of a critical incident' appro?imatel 24 hours post.incident' but usuall within the first 62 hours @later if circumstances reEuireA% " CI)! is called for after obvious' deepl disturbing events that ma overwhelm the coping s0ills of those involved% T picall a 2.3 hour confidential group intervention led b a speciall trained mental health professional and assisted b trained emplo ee peers' after deliver ' follow up is essential% Two main goals of a Critical Incident )tress !ebriefing -% 1itigate the impact of the Critical Incident on those who were victims of the event% Dictims are defined as: aA &rimar victims i%e% those directl traumatiGed b the event% bA )econdar victims i%e% those individuals who are in some wa observers of the immediate traumatic effects that have been e?perienced b the primar victims% Co.wor0ers peripheral to the scene would be an e?ample% cA Tertiar victims i%e% those affected indirectl b the trauma via later e?posure to the scene of the disasterCtrauma or b a later e?posure to primar or secondar victims% T picall tertiar victims are those not e?posed to the immediate 9first.hand: aspects of the traumatiGation' thus not impacted b the 9shoc0ing immediac :% )taff from other departments' famil members X co.wor0er friends of victims or rescuers might be e?amples of tertiar victims% 2% "ccelerate recover process in people who are e?periencing stress reactions to abnormal traumatic events% Individual Intervention 58ne68n68ne7 This is an individual intervention provided b a &eer Team 1ember after a critical incident or potential critical incident% Individual Intervention is used to support' stabiliGe and provide stress education and to help assess the need for a formal !ebriefing' in a group setting' if other individuals were involved% It is best provided within 24 to 62 hours of an incident @later if circumstances reEuireA and ma be conducted b speciall trained peers' in person or b telephone% "n Individual Intervention should *BT substitute for a formal !ebriefing if one is obviousl reEuired for a group of individuals% "fter deliver ' follow up is essential and a referral@sA ma be reEuired%

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9amily Crisis Intervention )upport is not complete unless it also includes special support services for spouses and significant others who ma be indirectl and negativel impacted b the same traumatic events% )upport for the families ma include providing educational information' !ebriefings' Bne.on.Bne interventions and Crisis 1anagement (riefings @C1(A% 9ollow6up Services Ever time a CI)1 intervention is provided @!efusing' !ebriefing' 1obiliGationC !emobiliGation' Crisis 1anagement (riefing' Bne.on.BneA it is necessar to ensure that follow up services are provided% ;ollow Np )ervices are generall provided b &eer team volunteers' and ma include telephone callsH chaplain contactsH small group meetingsH peer visitsH one.on.one servicesH famil contactsH referrals for professional contact or an other helpful outreach programs% CIS. Assessment Criteria D Emergency %riage ] *ature of incident and complications ] <ocation' date' time of incident ] &resent location of person@sA affected ] "n in>uries or fatalities= ] *umber of people involved ] &ersonal information of people involvement in incident ;ull *ame Gender "ge "ddress Gsm or cell phone number <andline telephone number ; sical situation: general health C in>uries 1ental condition Contact !ata of spouse C relatives ] "re individuals as0ing for CI)1 intervention= ] "n stress reactionsC s mptoms noticed in an of the individuals= ] )ource of incident report@sA Assessing the >eed for a Critical Incident Stress Debriefing 5CISD7 !ebriefings are to be conducted onl when it is necessar % The following Euestions and comments should be helpful in determining if a !ebriefing is necessar :

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"dditional Information: 4ow long ago did the incident occur= Is the event ongoing= Is it getting worse C more complicated= !oes the event fit within the definition of a Critical Incident= Is the event of sufficient magnitude to cause significant emotional distress among those involved= @9!efusing: within initial few hours ma allow for assessment of involved personnel%A 4ow man individuals are involved in the incident= @If more than three' thin0 CI)!P If less' perhaps individual intervention would be more appropriate%A "re there several distinct groups of people involved or is there onl one= "re there witnesses= !oes ever one belong to the same communit = Brganisation= Team or wor0 group= "re the staff or management= "re the related @married' partners' etc%A= !o the have the same incident perspective= EtcO !epending on criteria' more than one CI)! ma be reEuired% 2hat is the status of the involved individuals= 2here are the and how are the reacting= 2hat signs and s mptoms of distress are being displa ed= "re an of the following 0e indicators present: (ehavioural change /egression Continued s mptoms Intensif ing s mptoms *ew s mptoms arising Group s mptoms 4ow long have the reactions or signs and s mptoms of distress been going on= )ignificant s mptoms that continue past a few da s indicate a !ebriefing ma be necessar % If s mptoms of distress continue longer than one wee0 after the incident' a !ebriefing is definitel necessar % "re the s mptoms growing worse as time passes= 2orsening s mptoms ma !ebriefing% indicate a need for

"re individuals simpl reEuesting information on stress' stress management' operational details' etc= @" formal !ebriefing ma be unnecessar if these reEuests are not accompanied b significant stress reactions%A "re the willing to come to a !ebriefing= 2hat other stressors or influences are complicating= "re there an other issues that might inhibit or otherwise derail a successful !ebriefing=

Automatic CIS. Debriefings The incidents listed below will mandate that a Critical Incident )tress !ebriefing be automaticall offered to affected individuals% In the interim' whenever possible a !efusing should be conducted within -2 hours of the incident and prior to the individuals return to home% If a !efusing is not possible andCor a formal !ebriefing is not practical then a &eer Team member can provide individual interventions @in.person or b telephoneA to those involved%

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Incidents that will result in automatic CI)1 !ebriefing: ] line of dut death ] suicide or homicide ] armed C violent assault ] hostage.ta0ing ] disaster ] client C traveler fatalit (otential CIS. Debriefings The incidents listed below have a potential to result in a Critical Incident )tress !ebriefing and will depend on !efusing held within a number of hours of the incident prior to the affected peopleKs return to home% This provides an opportunit to assess the impact of the incident on them% If a !efusing is not possible then a &eer Team member can provide individual intervention @in.person or b telephoneA to those involved% Incidents that have the potential to result in a CI)1 !ebriefing: ] serious in>ur or death of a relative' friend or co.wor0er' especiall when under unusual circumstances ] perceived threat to personal safet ] medical emergenc

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Critical Incident Stress Signs and Symptoms: Critical Incident )tress is a normal reaction b normal people to an abnormal situation% It ma affect individuals at var ing degrees and for different lengths of time% It is significantl more intense than ever da stress and is tied to a specific event% CI) reactions ma include emotional' ph sical' and cognitive reactions that are be ond a personIs control @listed belowA% "fter a Critical Incident' individuals are li0el to e?perience one or more of the following%%% (hysical reactions -% E?haustion 2% *auseaCvomiting 3% 2ea0ness 4% !ifficult breathingc 3% Chest painsc 5% /apid heart rate 6% 4eadaches 7% !r mouthCalwa s thirst 8% Elevated blood pressure -,% ;aintingCdiGGiness --% E?acerbation of allerg problems -2% ) mptoms of shoc0c Emotional reactions -% ;rustration 2% )trong need for recognition of what the e?perienced 3% "n?iet 4% GuiltCfeeling strongl for victims 3% )ense of loss 5% "nger 6% !enial 7% ;ear of loss of control 8% Irritabilit Cagitation -,% !epression --% ;eeling overwhelmed -2% ;eeling isolated -3% <oss of emotional control Cognitive reactions -% (laming attitude 2% Confusion 3% /educed attention span 4% ;lashbac0s 3% &oor concentrationCloss of confidence 5% *egative self.tal0Closs of confidence 6% !ecreased awareness 7% Troubled thoughts 8% *ightmares -,% Easil distracted --% )hort.term memor disturbance -2% TimeCplaceCperson distortionc /ehavioural reactions -% Emotional outbursts 2% Change in activit level 3% !isturbed sleep 4% Increase in smo0ing 3% Easil startledC h per.vigilance 5% "ntisocial behaviour 6% 2ithdrawal 7% Change in eating habits @increase or decrease in food consumptionA 8% !ifficult rela?ing -,% ;idget Crestless --% Increased use of alcohol and other drugs -2% Change in se? drive

* definite indication of the need for medical evaluation Individuals e?periencing cumulative stress or dela ed stress reactions should see0 out help from an E"& practitioner%

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.oving (ast a .oment of Crisis If ou have recentl had a traumatic e?perience' ou ma be having feelings that are new to ou% !r% &hil e?plains that some of these emotions and fears are normal under the circumstances' and offers suggestions on how to move past the moment of crisis: If ou fear that something traumatic might happen again' ou are e?periencing rational regression% Nnderstand that this is a natural reaction to a traumatic event% (e patient with ourself and realiGe there is rational fear and irrational fear% 2ith rational fear' we react to a real threat and protect ourselves% 2hen we have irrational fear' we are scared even though there is no threat to us% If ou were in>ured during our traumatic event' itIs normal to have fears @that ma seem irrationalA until our bod heals% Nnderstand that it will not be li0e this for the rest of our life% Fou will heal% )top as0ing J2hat if something happens again=J /emember that something traumatic happened and ou got through it% If something else happens' ou will get through that too% 2hen ou do survive a moment of crisis' 0now that there is a reason% !onIt have survivorIs guilt% !ecide that thereIs a purpose' find it' and live it% !onIt be afraid to reach out and as0 for help from friends' famil or a mental health professional% The "merican Counseling "ssociation recommends ;ive 2a s to help with coping ";TE/ a crisis situation% -% /ecogniGe our own feelings about the situation and tal0 to others about our fears% Qnow that these feelings are a normal response to an abnormal situation% 2% (e willing to listen to famil and friends who have been affected and encourage them to see0 counseling if necessar % 3% (e patient with peopleH fuses are short when dealing with crises and others ma be feeling as much stress as ou% 4% /ecogniGe normal crises reactions' such as sleep disturbances and nightmares' withdrawal' reverting to childhood behaviors and trouble focusing on wor0 or school% 3% Ta0e time with our children' spouse' life partner' friends and co.wor0ers to do something ou en>o % (ost6%raumatic Stress Disorder: %he Symptoms &ost.Traumatic )tress !isorder @&T)!A is a comple? an?iet disorder that ma develop after e?posure to an e?tremel stressful or life.threatening event Y involving death' the threat of death or serious in>ur Y with resulting intense fear' helplessness or horror% If ou e?perience these s mptoms for a duration of more than a month' ou could be suffering from &T)!% JThis is not meant to be used to diagnose ourself' but rather raise our awareness of when ou might need to reach out'J !r% &hil sa s% &ersistentl /e.E?periencing the Event 4aving recurring dreams about the event or having persistent and distressing recollections of the event% ;eeling and acting as if the trauma was reoccurring Y hallucinations or flashbac0s Y and e?periencing distress when e?posed to cues% ;or e?ample' !r% &hilIs guest' )helita' was attac0ed at gunpoint in her house' so when she is at home' she often repla s the event in her mind%

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"voiding )timuli "ssociated with the Trauma 1a0ing efforts to avoid thoughts' conversations' people' places and activities associated with the trauma' and avoiding activities' places or people that arouse recollections of the trauma% )helita ma0es ever effort to avoid being inside her house% )he often spends long periods of time at the mall and sits in her car outside her home so she doesnIt have to go inside% *umbing of General /esponsiveness &ulling bac0 and having a diminished interest in activities that are significant' and suffering low energ % ;eeling detached or estranged from others% !ispla ing a restricted range of affect Y unable to have loving feelings' or donIt want to become e?cited and happ or let scared emotions out% Increased "rousal ) mptoms *ot &resent before the Trauma (eing easil startled' having difficult sleeping or concentrating% !eveloping a heightened irritabilit andCor having angr outbursts% (ecoming h pervigilant Y behaviors ou did not e?perience before the event% !isturbance Impairs other "reas of ;unctioning E?periencing significant impairment in social or occupational activities or an other important areas of functioning% )helita has a difficult time wor0ing' because loud noises easil startle her% 8ther (ossible Symptoms Inabilit to recall important aspects of the trauma )leep difficult Irritabilit or anger ;eeling hopeless )ense of foreshortened future E?cessive drug andCor alcohol use

If ou find ourself e?periencing these s mptoms' donIt let it drain our life energ % )ee0 help from a medical professional% &ost Traumatic )tress !isorder ma come on silentl % It is a ver progressive illness that becomes more severe ear after ear if left untreated% It will eventuall consume those victims who have e?perienced trauma be ond what their minds are able to comprehend or deal with at one time%

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Common Signs and symptoms of (ost %raumatic Stress Disorder (hysical ;atigue Domiting or *ausea Chest &ain Twitches Thirst 2ea0ness Insomnia or *ightmares (reathing !ifficult 1uscle Tremors Grinding of Teeth &rofuse )weating &ounding 4eart !iarrhea or Intestinal Npsets 4eadaches Apprehension Am I Stressed 8ut"""+ If ou e?perience the s mptoms below' &ost Traumatic )tress !isorder ma be starting to show its earl signs% &lease see a doctor' as well as a Eualified &olice )tress Therapist' to discourage the disorder from getting worse% 4eadaches ;atigue . &ounding 4eart . !igestive Npsets . Teeth Grinding . <ight 4eadedness . <owered )e? !rive . Irritabilit . )hort.temper . (ac0aches . 1uscle "ches . <oss or Gain in 2eight . Insomnia . /estlessness . 1uscle Tics . !rin0ing too 1uch . 2ow to Cope With Emotional (ain -% !onIt tr to cure what is normal% Temporar emotional pain is caused b an number of events: death of a loved one' a brea0up' thoughtlessness or cruelt on the part of others% 2hen ouIre hurting because of an of the above' accept that itIs normal to feel hurt or angr for a short time% <etIs face it: if a loved one dies' onl a ver cold person would be unaffected b it% If ou love someone and that person dumps ou' itIs natural to feel hurt% These things are normal% Tr ing to cure what is normal is pointless% E?pect to feel pain for a while . itIs normal% 2% ThereIs a statement that goes something li0e' IIf ou get @enter mad' hurt' insulted' offended' etc%' hereA itIs our fault%I ThatIs >ust not true% That suggests that people donIt love' or bond' or trust' or invest emotions% If ou have emotional pain' thereIs a reason for it% 3% !onIt pretend ou donIt feel it% The pain is real% Fou have to address it' or ou will never get be ond it% !onIt tr to rush through this season of pain% Even though all ou can reall thin0 about is ending the pain' the truth is that >ust allowing ourself the feelings is important% 1as0ing our pain when ouIre tr ing to wor0 or >ust get through each da ma be necessar to a point' but ma0e sure to allow ourself some Jme.timeJ . some time to allow ourself to reall feel all of the feelings ou are having' rather than >ust suppressing and den ing them% /ehavioral 2ithdrawal &acing and restlessness "nti social acts )uspicion and &aranoia Inabilit to rest <oss of interest in hobbies Increased "lcohol Consumption Bther substance abuse Emotional "n?iet or &anic ;ear !enial Irritabilit !epression Intense "nger "gitation

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4% Identif all of our feelings% "re ou >ust heartbro0en= Br are ou angr ' too= 1a be >ust the tiniest bit relieved . which is also ma0ing ou feel guilt = !o ou feel betra ed= Insecure= "fraid= Giving some thought to e?actl how ou are feeling can be ver helpful in processing all of our emotions in the wa0e of a traumatic or life.changing event% 3% Endure it% Things that cannot be cured must be endured% It sounds obvious' but sometimes' thin0ing of emotional pain as if it were ph sical pain can be ver helpful% Thin0 of our bro0en heart >ust as if it were our arm that is bro0en instead% " bro0en arm ta0es time to heal' and it hurts li0e craG >ust after itIs bro0en' even after itIs been set and casted% " few da s later' it doesnIt hurt so much% (ut wee0s or even months later' if ou bump or >ar it' that pain can come roaring bac0 to life with a vengeance% Fou bab it a little' ta0e care not to aggravate it' and eventuall ' itIs stronger where it was bro0en than it was before% Fou have no choice . ou canIt cut off the arm% That wonIt ma0e it hurt an less% Fou >ust have to endure it while it heals% 5% Tal0 to someone% There are times when it seems that the hurt ou feel inside is >ust too deep to tal0 about% Fou feel li0e no one could understand% Br ma be ou worr because our loved ones didnIt share our feelings about whatever it is thatIs hurting ou% 1a be the didnIt care for our bo friend' whom ou >ust bro0e up with' or the didnIt 0now our friend' who passed awa % Fou ma be right . the ma not totall understand% (ut right now' it isnIt being understood that ou need% ItIs compassion% Four famil and friends love ou% The see ou hurting and want to help% )ometimes' if ou will >ust tr to tal0 out our feelings' sa something about what hurts' it can help start our healing% <etting someone put his or her arm around ou and hearing them sa ' JItIs going to be o0a J ma not seem that helpful' but it reall is' because it helps ou feel ouIre not totall alone% /ealiGing that someone wants to be there for ou will help% 6% !onIt let an one tell ou that our feelings arenIt real% The are real' significant' and important% "nd' the Ire our feelings% ;eeling alone doesnIt mean there is no one around% ;eeling sad doesnIt mean ouIll never be happ % ;eel our feelings' thin0 our thoughts' but realiGe the Ire >ust feelings and thoughts% 7% Get our mind off ourself and how bad ou feel% Fou have the right to feel sorr for ourself . for -, minutes% Then move on% *o e?ceptions% Go out with friends% Tell ourself that ou will not tal0 about our pain for more than a few minutes . ou will not bring down the activit b wallowing in it% !onIt let our friends wal0 on egg shells around ou >ust because ouIve been traumatiGed% Fou still need to live% !istract ourself b >ust forgetting it for a little while% If ouIre grieving a death' or heartbro0en over a brea0up' especiall ' giving ourself a little time to >ust be without obsessing on the event that hurts will help ou to heal and move past it% ThatIs not to sa that ou >ust forget about it and move on . no% ItIs onl to sa that even grief needs to ta0e a breather% Give our wear heart a little respite' and let it mend with the love and lightness of heart that comes from being with friends' or doing something that brings ou pleasure% There will be time to cr again' but not >ust now% 8% "llow time to heal% This is part of >ust enduring% Fou will need to muster up the patience to allow healing to commence% There isnIt an substitute for >ust %%% waiting% Time reEuires one thing: that ou allow it to pass% Getting past emotional pain reEuires a grieving process' which ta0es time% -,% !onIt let our pain define ou% /emember ou are greater than this hard time' ou have a past and a future% Fou have awareness and creativit % This was a single episode which will soon pass%

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--% 2rite a letter% 2riting down our feelings can help ou to sort them out% It can help more if ou use positive JI messagesJ instead of negative ones% If ou donIt write' tal0 about our feelings with someone close or a therapist% !onIt >ustif them' >ust tal0 about them' get them out' and listen to what ou sa % -2% )ta awa from statements that blame ou or others% Ta0e responsibilit for our actions' and our part of whatever went wrong' but do not indulge in blaming% The Euestion of J"nd whose fault isCwas that=J does not appl % -3% !evelop a learning orientation% <ife hands ou difficulties so ou can learn from them% &eople who have reall eas lives fall apart when bad things happen because the have never learned how to cope or let things roll off their bac0s% Ever thing' even ver painful times' can be used to learn better coping s0ills and to develop wisdom and perspective about life that will help ou deal with man difficulties in the future% 2hatever doesnIt destro ou can serve to ma0e ou stronger% -4% 1a0e a IThan0fulness <istI% 2rite down what ou are than0ful for' even basic things li0e having clothes and a warm place to sleep' then moving to people who care for ou' and good things in our life% (eing than0ful is naturall healing and will balance out an trauma over time% -3% If the pain is lasting more than a wee0 or so' or ouIve lost hope or ouIre thin0ing of suicide' ouIre either suppressing our pain or ou have deeper unresolved issues that ou need to complete% The strategies above are health wa s to deal with emotional pain% Bften as 0ids' we didnIt use these strategies and instead incorporate the pain into our character' our subconscious% )aid another wa ' when weIre oung' itIs eas to let emotional pain define ou% Bften this needs to be undone' teased apart and handled in a health manner for us to be free% If a current incident upsets ou too much or for too long' or our whole life is colored b a negative outloo0' consider getting some help to unearth' re.e?amine and complete a prior incident%

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CIS. 9ollow @p (rotocol CIS. Debriefing 9ollow @p "ll participants in formal CI)1 !ebriefing sessions will receive at least T2B follow up telephone calls or visits no later than: ] 47 hours after conclusion of !ebriefing session' and ] Three wee0s after conclusion of !ebriefing session " second !ebriefing session ma be held for the same participants if: ] There is an e?pressed need from the participants' andCor ] Two or more groups wish to be debriefed together' andCor ] 1ultiple events necessitate "nniversar follow up should be planned for one ear later% *ote: The same &eer Team 1embers who participated in !ebriefing should provide follow up services whenever practicable% CIS. Defusing 9ollow @p "ll participants in CI)1 !efusing will receive a follow up telephone call no later than 47 hours after conclusion of defusing session' or within 24 hours if circumstances warrant priorit attention% CIS. Individual Intervention 58ne68n68ne7 9ollow @p "ll participants in Bne.Bn.Bne Intervention will receive a follow.up telephone call no later than 47 hours after conclusion of Intervention' or within 24 hours if circumstances warrant priorit attention% *ote: The same &eer Team 1embers who provided Bne.Bn.Bne should provide follow up services whenever practicable% CIS. .obili<ationHDemobili<ation 9ollow @p ;ollow up telephone calls should be made within 24 hours to an staff member who ma be assessed to reEuire additional andCor priorit attention% CIS. Crisis .anagement /riefing 5C./7 9ollow @p ;ollow up ma be provided immediatel after conclusion of C1(% &eers Team 1embers in attendance ma provide this service as informal 9wal0 and tal0: conversations with audience members who reEuest it or who ma e?hibit stress reactions% -efreshments The provision of refreshments is strongl advised to help facilitate certain CI)1 intervention techniEues' specificall !ebriefing and 1obiliGationC!emobiliGation% Care must be ta0en to ensure that the refreshments are appropriate for the intervention% !B *BT over.cater the refreshments are intended as an incentive toward the goal of stress.reduction through health eating' and as an encouragement to participate in a particular CI)1 activit %

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Nse the following as a guide: /efreshments situated opposite entrance to room @across room if possibleA% 4ealth snac0s' sandwiches @simple fillingsA' fruit' >uice' bottled water' decaffeinated coffee @do not indicateA' mil0Csugar% *o red food' no grilled food' no bone.in food @rare beef' Italian' barbeEue' fried chic0en' etc%A% "void strongl .spiced' mess or 9ethnic: foods whenever possible%

Critical Incident Stress .anagement 5CIS.7 : '2ow do I now when IGm in over my head+) &repared b : Gregor Vanelle' Vanelle X "ssociates Consulting <td%' -886% /evised 2,,&eer support training does not full eEuip the average la person for the occasionall overwhelming circumstances that ma be encountered after a critical incident% This is especiall true during !efusing and Bne.Bn.Bne intervention' when the &eer is often the first to respond and assessment of a survivorKs emotional state is difficult at best% *o matter how e?perienced and confident one ma feel going into a situation' there ma inevitabl come a point when it would be harmful' even dangerous' to tr to handle a survivor without professional mental health intervention% " responsible &eer will alwa s enter a dialogue cautiousl and follow established guidelines with due care% It is ver important that the &eer remain constantl vigilant to 9danger signals: that ma alert them to the moment when the feel the are be ond their limits as a caregiver and no longer capable of providing proper support to the traumatiGed individual% To err on the side of caution is alwa s the best route to ta0e% As a helpful guide! consider the following /E98-E spea ing to a person in crisis: @E?cerpt with permission' from 9Coping 2ith )urvival: b 1argaret "% Qilpatric0' -87-A Alertness and Awareness Fou can probabl handle' if the survivor: is aware of who heCshe is' and what happened is onl slightl confused or daGed' or shows slight difficult in thin0ing clearl or concentrating on a sub>ect

Consider referral' if the survivor: Actions Fou can probabl handle' if the survivor: wrings hisCher handsH appears still and rigidH clenches hisCher fists is restless' mildl agitated and e?cited has sleep difficult has rapid or halting speech is unable to give own name or names of people heCshe is living with cannot give dateH state where heCshe isH tell what heCshe does cannot recall events of past 24 hours complains of memor gaps

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Consider referral' if the survivor: is depressed' and shows agitation' restlessness and pacing is apathetic' immobile' unable to rouse self to movement is incontinent mutilates self e?cessivel uses alcohol or drugs is unable to care for self' eg% doesnKt eat' drin0' bathe or change clothes repeats ritualistic acts

Speech H .ental 9unctioning Fou can probabl handle' if the survivor: has appropriate feelings of depression' despair' discouragement has doubts of hisCher abilit to recover is overl concerned with small things' neglecting more pressing problems denies problemsH states heCshe can ta0e care of ever thing himCherself blames problems on othersH is vague in planningH bitter in feelings of anger that heCshe is a victim

Consider referral' if the survivor: hallucinates hears voices' sees visions' or has unverified bodil sensations states hisCher bod feels unreal and fears losing hisCher mind is e?cessivel preoccupied with one idea or thought has delusion that someone or something is out to get himCher and famil members is afraid of 0illing self or another is unable to ma0e simple decisions or carr out ever da functions shows e?treme pressure of speechH tal0 overflows

Emotions Fou can probabl handle' if the survivor: is cr ing' weeping' with continuous retelling of the disaster has blunted emotions' little reaction to what is going on around himCher shows e?cessive laughter' high spirits is easil irritated and angered over trifles

Consider referral' if the survivor: is e?cessivel flat' unable to be aroused' completel withdrawn is e?cessivel emotional' shows inappropriate emotional reactions

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Critical Incident Stress: %ips on 2ow to -ecover from a Critical Incident Critical Incident )tress @traumatic stressA tests our coping mechanisms to the limit% (ecause of the impact on our ps chological s stem' a variet of coping mechanisms appear some health ' some not so health % /esearch has shown that the wa in which a person ta0es care of him or herself during the first few da s following a traumatic event will help to minimiGe the development of future ps chological reactions to the event% 4ere are some tips on how to cope in the aftermath of an incident: $"7 Do not use alcohol or other drugs to cope" !rugs' in particular alcohol' are powerful s mptom suppressors% Ethanol' the active ingredient in alcohol' saturates the brain' creating an artificial feeling of euphoria% "s more ethanol is absorbed into the s stem' more and more areas of the brain are numbed or shut down' creating a distance from emotional issues% *o ps chic healing ta0es place because of the alcohol in the s stem% ConseEuentl ' once the alcohol leaves the bod ' not onl is the original problem still there' but our bod is now struggling with the depression and nausea from the alcohol% )imilarl ' drugs also prevent an ps chological resolution at the subconscious level% &"7 Do not isolate yourself from family! friends and co6wor ers" &eople react to ps chological trauma b 0eeping it inside% Bften the trauma ma seem so great that life seems meaningless% ( withdrawing' ou isolate ourself running the ris0 of allowing the incident to become larger than life% ( remaining involved with others: ] Fou prevent ourself from becoming obsessed with the incidentH ] Fou are more li0el to appreciate that' though this incident was traumatic' life goes onH ] Fou ma end up tal0ing out the incident' contributing to our wor0ing it through% *"7 Eat well and maintain a physical outlet" !iet is an important factor in reducing the negative effects of stress% Even though ou ma not feel hungr ' eat something and ma0e sure itKs health food% E?ercise is critical to cleansing the bod of the negative conseEuences of stress% It is recommended to get good e?ercise within 24 hours of the incident% (ut donKt stop with that% Qeep up regular activit whether itKs a tennis game' a run or a swift wal0% 0"7 Assess your situation carefully" If ou are ver traumatiGed b an incident' it ma be necessar to ta0e time off wor0% 2or0ing while being emotionall vulnerable puts us more at a ris0 for an acute stress reaction% Bn the other hand' ou ma be someone who finds that being bac0 on the >ob is >ust what ou need% "ssess our situation carefull % If ou feel vulnerable' reEuest time off or arrange to have a reduced wor0load% I"7 Watch your fi#ation on the incident" )ome individuals become obsessed with finding reasons for the event% )hoc0ed b what has happened' the feel a need to regain meaning or a sense of fair pla in life% 2hether the are loo0ing for simple or comple? answers' the solution doesnKt come immediatel % "llow time to pass% Bnl over time will the real meaning of what has happened become apparent%

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J"7 Give yourself time to heal" Traumatic stress can seriousl affect ou% "ccept that it ta0es time to heal% (eware of having unrealistic e?pectations for hast recover % K"7 E#pect the incident to bother you" Ta0e comfort in 0nowing that the incident wonKt bother ou forever% Though ou ma never completel forget the incident' recalling it doesnKt have to cause emotional distress% Four goal shouldnKt be to totall forget the incident' rather' it should be to heal% Fou 0now ou are healed when ou thin0 ou are able to thin0 of or tal0 about the incident without profound emotion% L"7 1earn or review your facts about critical incident stress 5C"I"S"7 Fou need facts about what ou are going through% ( reading up on C%I%)% and itKs associated reactions' ou will see that' however unusual the ma seem' our reactions are normal% M"7 %a e time for fun" Fou must ta0e care of ourself that includes doing what ou en>o % Ta0e time for leisure activities% $P"7 Get help if necessary" If ou find the incident is sta ing with ou longer than it should' see0 individual counselling% Through tal0ing with a trained professional' an unresolved issues can be faced and resolved% If ou donKt get help' ou run the ris0 of remaining distressed or of seeing this incident affect ou more intensel in the future' when facing other events%

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Critical Incident Stress D %ips to Colleagues and 9amily If a friend or mate has e?perienced a traumatic event' our behaviour ma help the recover process% 4ere are some suggestions: 1earn about Critical Incident Stress 5C"I"S"7 so e?periencing% ou can begin to understand what the person is

Encourage the individuals to tal about the incident' but donKt be overl demanding% The ma feel that others donKt want to hear about their feelings or that ou e?pect them to be able to 9handle: the situation% Fou need to challenge these beliefs b indicating our willingness to listen% As '2ow are you doing+) or '2ow are you feeling+) If people want to tal0 the willH if not' the wonKt% ( our Euestions' ou have at least sent the message that a listening ear is available% !onKt be afraid of deep emotion% 1an of us have not e?perienced profound grief or anguish% )eeing someone cr uncontrollabl can be somewhat distressing% TraumatiGed individuals need to vent their emotions and if the are in our presenceH the need our support% )impl be there to listen and let them tal0% "fterwards' suggest a wal0 to help them further reduce their level of stress% Share your feelings about the situation" !onKt sa 9I 0now how ou feel': because ou donKt% Fou ma have gone through a similar e?perience' but no two e?periences are the same or perceived as being the same% Fou can' however' sa things li0e 9I can imagine this must hurt a lot: or 9I feel sorr for what has happened%: DonGt ma e false promises such as 'everything will be o ay" *o one 0nows the future% Four role is that of a support person' not a miracle wor0er% If ou donKt 0now what to sa ' sa nothing% In most cases' all people need is someone to 9hear them out': not necessaril to solve their problems% Say 'itGs o ay for you to feel the way you do": "ffirm that there has been a terrible traged and that it is normal to feel pain' confusion' etc% )uch a statement is particularl reassuring if ou are a peer% It is helpful to have co.wor0ers legitimiGe our feelings% Do not e#plain away anything" "t this stage' our e?planation is not neededH emotional release is% Four e?planation ma be interpreted as minimiGing rather than supporting the individualKs feelings% Encourage a subse,uent debriefing or counselling session if the pain persists" Guidelines are difficult to provide% 4owever' the situation should improve one wee0 to ne?t% Indications of progress include hearing comments such as 9Feah' IKm feeling better toda ': seeing less stress and strain on the individual or seeing the individual become more li0e hisCher former self% %a e care of yourselfQ you are a co6survivor" Though not involved in the incident' ou are a victim of the b .product of the incident% 1a0e sure there is someone with whom ou can tal0 things out%

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Chapter J 2arm Assessment 5Suicide! 2omicide! In:ury to self or others7 What should a responder new about suicide+ &eople become suicidal because of a crisis or series of crises in their lives% )ometimes people see suicide as a resolution to the pain the are e?periencing in the midst of a crisis% 2hat the ma not see is that there are alwa s other options% )uicide is rare' but devastating when it does occur% The information below shows a few relevant statistics: In 2,,-' suicide too0 the lives of 3,'522 people in the N)% In 2,,-' there were twice as man deaths due to suicide than due to 4IDC"I!) @-4'-63A In 2,,4' suicide too0 the lives of 32'438 people in the Nnited )tates% 23'355 were males' 5'763 were females : 28'23- were white ' 3'-77 were non.Iwhite 4'3-5 were -3.24 ears' 3'-87 were 53d ears : 7,T male vs 2,T femaleP : *on.whites _ more than 23T of the population' account for onl -,T of the suicides : ;rom -888 to 2,-,' the suicide rate for men in their fifties rose 48'4T

"verage suicide rate is -2C-,,',,, but for white men over 73 it is 53%3C-,,%,,, 1ales are four times more li0el to die of suicide than are females% 4owever' females are more li0el to attempt suicide than are males

In 2,,4' suicide was the --th leading cause of death in the N)% In 2,-,' 37%354 "mericans 0illed themselves *o official data was compiled on the number of attempts' but it is estimated to be 23 attempts for ever death b suicide% )uicide attempts are e?pressions of e?treme distress that need to be addressed' and not >ust a harmless bid for attention% " suicidal person should not be left alone and needs immediate mental health treatment% )uicide is a comple? behavior usuall caused b a combination of factors% /esearch shows that almost all people who 0ill themselves have a diagnosable mental or substance abuse disorder or both' and that the ma>orit has a depressive illness% )tudies indicate that the most promising wa to prevent suicide and suicidal behavior is through the earl recognition and treatment of depression and other ps chiatric illnesses% 2ow should a crisis service provider deal with someone who may be considering suicide+ The statistics are nice as guidelines' but offer little help when dealing with an individual% Each individual has hisCher own histor and reasons for thin0ing of suicide% If someone is suspected to be thin0ing of suicide' the best thing to do is as0 directl ' J"re ou thin0ing of 0illing ourself=J ( as0ing directl ou are actuall giving the person permission to tal0 about it% Tal0ing it through is the best wa to prevent a suicide% Fou will not be putting the idea into someoneIs head% "s0 open.Iended Euestions% <et the person tal0 about what happened' who else is involved' how long has heCshe been thin0ing of suicide' what would happen if heCshe went on living' how others would react' etc%

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What do people who feel suicidal want+ )omeone to listen% )omeone who will ta0e time to reall listen to them% )omeone who wonIt >udge' or give advice or opinions' but will give their undivided attention% )omeone to trust% )omeone who will respect them and wonIt tr to ta0e charge% )omeone who will treat ever thing in complete confidence% )omeone to care% )omeone who will ma0e themselves available' put the person at ease and spea0 calml % )omeone who will reassure' accept and believe% )omeone who will sa ' JI care%J What do people who feel suicidal not want+ To be alone% /e>ection can ma0e the problem seem ten times worse% 4aving someone to turn to ma0es all the difference% Vust listen% To be advised% <ectures donIt help% *or does a suggestion to Jcheer upJ' or an eas assurance that Jever thing will be o0a %J !onIt anal Ge' compare' categoriGe or criticiGe% Vust listen% To be interrogated% !onIt change the sub>ect' donIt pit or patroniGe% Tal0ing about feelings is difficult% &eople who feel suicidal donIt want to be rushed or put on the defensive% Vust listen in a caring and non.>udgmental wa and ou will be an invaluable resource to people who feel the have nowhere else to turn% 2ho 0nows= . Tal0ing to ou ma help someone save their life% /eing listened to If someone is feeling depressed or suicidal' our first response is to tr to help% 2e offer advice' share our own e?periences' tr to find solutions% 2eId do better to be Euiet and listen% &eople who feel suicidal donIt want answers or solutions% The want a safe place to e?press their fears and an?ieties' to be themselves% <istening . reall listening . is not eas % 2e must control the urge to sa something . to ma0e a comment' add to a stor or offer advice% 2e need to listen not >ust to the facts that the person is telling us but to the feelings that lie behind them% 2e need to understand things from their perspective' not ours% It is important for people to have the opportunit to e?plore difficult feelings% (eing listened to in confidence' and accepted without pre>udice' can alleviate general distress' despair and suicidal feelings% Bften being listened to is enough to help someone through a time of distress% Even >ust showing that ou are there for them' and that ou 0now the are going through a distressing time' can in itself be a comfort% Important elements of active listening when listening to a person who is feeling depressed or suicidal: "lwa s tr to give people our undivided attention <et them sit in silence and collect their thoughts if the need to Wuestion them gentl ' tactfull and without intruding Encourage them to tell their stor in their own words and in their own time /efrain from offering advice based on our own e?perience "lwa s tr and see their point of view even though ou ma not agree with it

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&eople who feel suicidal should not tr to cope alone% The should see0 help *B2% ;or people who are lonel ' despairing and considering suicide' the most important step is to tal0 to someone the can tal0 to in complete confidence about their deepest fears and dar0est secrets% Tal0 to famil or friends% Vust tal0ing to a famil member or a friend or a colleague can bring huge relief% Call a hotline' search a support group on the internet' call a befriender% )ome people cannot tal0 to famil or friends% )ome find it easier to tal0 to a stranger% There are befriending centers all over the world' with volunteers who have been trained to listen% If calling is too difficult' the person can send an email% Tal0 to a doctor% If someone is going through a longer period of feeling low or suicidal' he or she ma be suffering from clinical depression% This is a medical condition caused b a chemical imbalance' and can usuall be treated b a doctor through the prescription of drugs andCor a referral to therap %

Time is an important factor in Umoving onI' but what happens in that time also matters% 2hen someone is feeling suicidal' the should tal0 about their feelings immediatel % What other things might a crisis service provider need to eep in mind+ )uicide is rarel a spur of the moment decision% In the da s and hours before people 0ill themselves' there are usuall clues and warning signs% The strongest and most disturbing signs are verbal . JI canIt go on'J J*othing matters an moreJ or even JIIm thin0ing of ending it all%J )uch remar0s should alwa s be ta0en seriousl % 8ther common warning signs include: /ehaviors Cr ing ;ighting (rea0ing the law Impulsiveness )elf.mutilation 2riting about death and suicide &revious suicidal behavior E?tremes of behavior Changes in behaviour (ecoming depressed or withdrawn (ehaving rec0lessl Getting affairs in order and giving awa valued possessions )howing a mar0ed change in behavior' attitudes or appearance "busing drugs or alcohol

" personIs histor ma actuall ma0e him or her more susceptible to completing a suicide% (redisposing 9actors Chaotic or dis>ointed life st le 1ental illness' especiall depression "doption Isolation &h sical healthCweight concerns

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;amil histor of suicide or violence )e?ual or ph sical abuse )uffering a ma>or loss or life change !eath of a close friend or famil member !ivorce or separation' ending a relationship ;ailing academic performance' impending e?ams' e?am results Vob loss' problems at wor0 Impending legal action /ecent imprisonment or upcoming release

There are also certain perpetuating factors to ta0e into account% If a person is in the midst of a crisis' these things ma prevent him or her from getting assistance% (erpetuating 9actors *egative coping patterns' i%e% hostile' no sense of humor' thin0ing ever thing is meant negativel toward them Bverl controlled' rigid personalit Bverachiever &oor communication s0ills overl sensitive <ow self.esteem "nti.social behaviour !rugCalcohol abuse or addiction or gambling addiction !epression: <ow mood that persists Change in eating or sleeping habits "n inabilit to en>o an thing Irritabilit " hopeless' helpless outloo0 ;eeling guilt for no apparent reason Cr ing or weeping with little or no provocation

(hysical Changes <ac0 of energ !isturbed sleep patterns . sleeping too much or too little <oss of appetite )udden weight gain or loss Increase in minor illnesses Change of se?ual interest )udden change in appearance <ac0 of interest in appearance

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%houghts and Emotions Thoughts of suicide <oneliness . lac0 of support from famil and friends /e>ection' feeling marginaliGed !eep sadness or guilt Nnable to see be ond a narrow focus !a dreaming "n?iet and stress 4elplessness <oss of self.worth

Additionally! the Surgeon General4s Call to Action on Suicide identifies the following ris factors: &revious suicide attempt 1ental disorders . particularl mood disorders such as depression and bipolar disorder Co.occurring mental and alcohol and substance abuse disorders ;amil histor of suicide &ersonal histor of abuse.ph sical' se?ual' emotional' victimiGation 4opelessness Impulsive andCor aggressive tendencies (arriers to accessing mental health treatment /elational' social' wor0' or financial loss &h sical illness Eas access to lethal methods' especiall guns Nnwillingness to see0 help because of stigma attached to mental and substance abuse disorders andCor suicidal thoughts Influence of significant people . famil members' celebrities' peers who have died b suicide . both through direct personal contact or media representations Cultural and religious beliefs . for instance' the belief that suicide is a noble resolution of a personal dilemma <ocal epidemics of suicide that have a contagious influence Isolation' a felling of being cut off from other people

Bf course' in most cases these situations do not lead to suicide% (ut' generall ' the more signs a person displa s' the higher the ris0 of suicide% -is 9actors for Aail Setting Individuals who are ps chotic in a >ail setting are also at increased ris0 for self in>urious behaviors and suicide attempts% The ps chotic individual is also at increased ris0 of being harmed b other inmates due to the perception of the individual with mental illness as vulnerable or biGarre%

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Vust as there are factors that create a higher ris0 for suicide' there are factors that lessen the probabilit of suicide% (rotective 9actors Effective and appropriate clinical care for mental' ph sical' and substance abuse disorders Eas access to a variet of clinical interventions and support for help see0ing /estricted access to highl lethal methods of suicide ;amil and communit support )upport from ongoing medical and mental health care relationships <earned s0ills in problem solving' conflict resolution' and nonviolent handling of disputes "ffective coping techniEues Cultural and religious beliefs that discourage suicide and support self.preservation instincts

"ll of the perpetuating' ris0' and protective factors listed are important considerations in assessing a personIs abilit to cope and gain assistance during periods of crisis% %here are two! however! that deserve special consideration: Depression and alcoholH drug use" What ma es depression and alcoholHdrug abuse important+ )tudies have shown that roughl 8,T of those who complete suicide have a diagnosable behavioral health disorder' commonl a depressive disorder or a substance abuse disorder%-7 1ost of us can relate to depression because we have felt a bit of the low mood' listlessness' restlessness' helplessness' and hopelessness that accompanies depression% 4owever' true depression is far more intense than a blue mood% The !iagnostic and )tatistical 1anual of 1ental !isorder' 4th Edition' Te?t /evCsad @!)1.ID.T/A identifies criteria for a 1a>or !epressive Episode% " condensed version of these criteria follows% ;ive or more of the following s mptoms have been present nearl ever da during the same 2.wee0 period and represent a change from previous functioning: !epressed mood most of the da 1ar0edl diminished interest in all or almost all activities most of the da )ignificant weight loss or significant weight gain without attempting to either lose or gain weight' or a decrease or increase in appetite Insomnia @inabilit to sleep or sta asleepA or h persomnia @need for more sleep than usualA &s chomotor agitation or retardation @as noted b observation b othersA ;atigue or loss of energ ;eelings of worthlessness or e?cessive or inappropriate guilt !iminished abilit to thin0 or concentrate or indecisiveness /ecurrent thoughts of death' suicidal ideation or a suicide attempt

These s mptoms must cause significant distress or impairment in functioning% @Bne depression sufferer described the effects of depression as having so little energ that lifting a pencil became an overwhelming tas0%A ;or man people' alcohol and other drug abuse is both a ris0 factor and a s mptom% "lcoholism is a primar diagnosis in 23T of people who complete suicide% )elf.medication to relieve s mptoms of depression or other mental illnesses is not uncommon% It is estimated that appro?imatel 3,T of people who have a serious and persistent mental illness @)&1IA also abuse substances%

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2hen providing crisis services' it important to remember that the use of alcohol and drugs ma increase impulsiveness and reduce >udgment% "dditionall ' drug into?ication or withdrawal from drugs @both licit and illicit drugsA ma cause s mptoms that are similar to s mptoms of a mental illness% /esponders should as0 about ps chotropic medications as well as illicit drug use% "ntidepressants ma allow the reason to regain ph sical energ before mood improves% &ersons ma be at higher ris0 of suicide at this point% "t the time someone completes suicide' there is often some identifiable event that precedes the act' a conflict or loss that pushes a person to believe that the pain is no longer tolerable and even death is preferable to living through this miser % The event is what most people thin0 of as the wh of suicide% )uicide is almost alwa s much more complicated than simpl being the result of one event in a personIs life% 4istor ' concurrent stressors' and coping abilit are all part of the eEuation% There are man facts of the circumstances that add up to the whole stor % 2hen in the depths of despair' people are most li0el to focus onl on the negative' leaving out an positive aspects of their situation% The positives usuall become obvious to an one listening' and it is important to point them out% &ointing out positive aspects' Jthere are people who care' ou do have value'J will create ambivalence% The goal of course is to create enough ambivalence to tip the scale in favor of living rather than d ing% "lwa s start with the precipitatorH what happened toda or in the recent past that made the difference% (recipitating 9actors Nsuall an accumulation of life stressors' conflict' or loss " conflict with famil member or love relationship ;ailure to get a >ob' get a promotion' achieve something <oss of mone ' income' material goods <egal problems' !NI' etc% In>ur or illness &regnanc The number and seriousness of previous attempts The level of stress and number of concurrent stressors The intensit and duration of depression The normal abilit to cope with lifeIs ups and downs The personIs ph sical health "ctive s mptoms of ps chosis' especiall command hallucinations The level of e?ternal support available to the individual Impulsivit Cabsence of protective factors "lcohol andCor drugs and "n prescribed or over the counter medication

Command hallucinations: 4allucinations that tell the hearer to act or behave in a particular wa % In a true command hallucination' the hearer feels that heCshe 1N)T behave in the wa indicated b the hallucinator voice%

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Intuition or Jgut senseJ of the seriousness of this particular personIs presentation is a ver valuable tool in assessing suicide ris0% 9rom the beginning of the interaction with the person! begin to as for contracts or little agreements" ;or e?ample: JI 0now ou feel lous right now' but would ou agree to sit and tal0 with me >ust for half an hour=J Ta0e ever threat of suicide seriousl % Consult others as necessar and never promise an thing that ou cannot do% !o not sa that ou care if ou do not reall care% 9It is ver hard to ma0e decisions when ou are feeling this bad% Can ou let us help ou with decisions until ou are feeling better=J Develop a strategy 4elp the person ma0e a decision on a specific' short.term plan% Fou wonIt resolve all the problemsH stic0 to one issue that is doable% %here are three wishes identifiable prior to a person attempting suicide: 1. %he wish to die or be dead 2. %he wish to be illed 3. %he wish to commit murder "n one of these wishes ma create ambivalence% The wor0 of the crisis services provider is to identif the ambivalence' point it out' and create more time% The more time between the impulse to commit suicide and the act' the more li0el it is the person will choose life% Certain steps should be followed when intervening with someone who feels suicidal% Suggested guidelines for assessment and prevention CA@%I8>R >8 8>E CA> (-EDIC% A S@ICIDER Assess lethality The following factors are important in determining if the person is li0el to actuall attempt suicide and how lethal the attempt ma be: 2hat resources does heCshe have= 2hat resources can ou offer= 2hat has this person alread tried= The level of detail to which the person has planned the act The dangerousness and availabilit of the method The level of isolation

899E- 8(%I8>S 66 >8% S81@%I8>S Choices empower a person to ma0e decisions and create a plan that is specific' doable' and short.term%

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What is the difference between para6suicide and suicide+ (arasuicide is a word used to describe behavior in which a person hurts himself or herself b cutting' burning' etc% but does not intend to carr out the suicide% These behaviors are also referred to as )I) @self.in>uriesA' )I(s @self.in>urious behaviorA or self.Imutilation% &eople who engage in parasuicidal behavior often indicate that their self.in>ur is a mechanism to cope with overwhelming emotion that the do not 0now how to regulate or e?press effectivel % These individuals are sometimes diagnosed as having borderline personalit disorder% What if a suicide occurs despite your best efforts+ In the event that a suicide occurs' even after ou have tried to help' get some support for ourself% )uicide is a ver personal decision and no one else can ever ta0e responsibilit for anotherIs suicide% In a li0e manner' each staff person will respond differentl due to his or her individual histor and relationship with the person who completes suicide% Ta0e some time to support ourself and our colleagues% J!ebriefingJ' Jcase reviewJ or Jps chological first aidJ are terms used b mental health professionals to describe interventions that should be available when a crisis service provider e?periences a completed suicide or traumatic event that involves a service recipient% The goal of these interventions is to allow a crisis service provider to e?press their personal reactions to the event and to identif steps that might relieve stress s mptoms related to their e?posure to the event% In some cases' emergenc mental health interventions ma include staff members outside of the crisis service provider% "n of these interventions should be conducted b ' or in consultation with' a trained mental health professional in the area of emergenc mental health services% Assessing dangerousness to others 2ow does a crisis service provider wor with a person who may become violent+ "ssessing for dangerousness to others is similar in man wa s to assessing for suicidal intent% 1an of the items considered and the process of developing a plan is similar% /is0 assessment for dangerousness is a ver in.e?act science% )tudies have shown that even trained professionals can accuratel predict onl one out of three episodes of violent behaviour% %he following are some basic guidelines for interacting with a person who is potentially violent: Get as much information from records on file or other sources before going into an crisis situation% Triage staff should as0 about presence of weapons before dispatching crisis service provider' when applicable% If ou believe that a person ma have a potential for violence do not intervene alone% &artner with another crisis responder or involve law enforcement personnel% !o not conduct an interview in a room with weapons present% o If the person is armed' ou ma wish to as0 the person wh he or she feels a need to carr a weapon% The personIs response to this Euestion ma help the responder to formulate a wa to reEuest the weapon be put aside with which the person ma be willing to cooperate% If a potentiall dangerous person refuses to give up the weapon' the crisis services provider should e?cuse him or herself and see0 assistance from law enforcement officials%

!o not interview potentiall violent people in cramped rooms' especiall if the are agitated and need to pace% Qitchen' bedrooms' and bathrooms are usuall poor intervention sites due to the potential presence of items that ma be used as weapons%

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(e aware of e?it routes for ourself and for the person in crisis% " paranoid or agitated person must not feel that the are trapped' and a crisis service provider must have an avenue of escape if the person does become violent% &a attention to the personIs speech and behavior%

Clues to impending violence include:

speech that is loud' threatening or profaneH increased muscle tension' such as sitting on the edge of the chair or gripping the armsH o h peractivit @pacing' etc%AH slamming doors' 0noc0ing over furniture or other propert destruction%

Do not stay in a dangerous situationR What factors should be considered when assessing a person for potential of harm to others+ The following factors are important in determining if the person is li0el to actuall attempt to harm someone else: &revious episodes of violent or assaultive behavior @This is perhaps the best indicator of potential for violent behavior%A Nnder what circumstances was the person violent in the past= 2hat is the freEuenc of violence= 4ow does the person behave in between episodes= 2hat is the most violent thing that the person has ever done= 2hat was the intent= Clarit of the plan for violence% 4as the person identified a victim= !o the have means or access to a means to harm the potential victim= !oes the person have or could he or she gain access to the potential victim= The level of isolation' agitation' paranoia' or belief that another is planning to or is hurting or harming them in some wa % Command hallucinations ordering violence% Into?ication from alcohol or other drug use' especiall cocaine' amphetamines or other stimulants or withdrawal from alcohol' drugs or medications% &s chotic s mptomsClac0 of contact with realit The level of stress and number of concurrent stressors% The intensit and duration of homicidal or assaultive ideation% The normal abilit to cope with lifeIs ups and downs . coping s0ills and mechanisms% The personIs ph sical health "n histor of mental illness' especiall command hallucinations%

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The level of internal abilit to control impulses% !oes the person wish to control him or herself= "nd if so can she or he= Is the person overl controlled= !oes the person have a brain in>ur or other cognitive impairment that ma0es control difficult= The level of e?ternal support or e?ternal constraints available to the individual% If a personIs mental state is so agitated that a full evaluation or assessment cannot be completed' the crisis responder should consider the person as potentiall violent% Collateral information from famil ' friends' and medical records is ver appropriatel with potentiall violent individuals% important in intervening

?our own intuition or Ogut senseO of the seriousness of this particular person4s presentation is a very valuable tool in assessing ris " Establishing -apport and Communication: 2ow can a crisis services provider best intervene with a potentially violent person+ -% )how concern for the person% (e respectful and offer some choices' even if the are small% @2here to sit' whether to have a snac0 or beverageA% 2% "ttempt to spea0 with the person at e e level% 3% )it in a manner with feet solidl on the floor with heels and toes touching the floorH hands unfolded in our lap and our bod leaning slightl forward toward the person% This position gives the person the feeling that ou are attentive to what he or she is sa ing and it permits ou to respond immediatel if threatened 4% )tand in a manner with feet placed shoulder width apartH one foot slightl behind the otherH weight on the rear leg' 0nees slightl bentH hands folded' but not interloc0ed' on the upper abdomen or lower chestH arms unfolded% This stance allows instant response to ph sical threat% !o not place hands in poc0ets% This slows response and ma add to paranoia of the person% ;olded arms also slow response and can be interpreted as threatening% 1aintaining weight on rear leg with 0nees slightl bent also allows Euic0 movement and response to an threat% &ractice this stance to become comfortable in it before using it in a crisis situation% If the stance is unfamiliar to ou' our discomfort will onl add to the stress of the situation%

%A=E E3E-? %2-EA% SE-I8@S1?! C8>S@1% 8%2E-S AS >EEDED" D8 >8% S%A? I> A DA>GE-8@S SI%@A%I8>" !evelop some rapport with the person before as0ing Euestions about histor or intent of violence% "ssure the person that ou will do what ou can to help them sta in control of violent impulses% )et firm limits but do not threaten or displa anger% 6% a person is e?periencing paranoia' it is best to conduct the intervention as if the person and the intervener are facing the problem together% " crisis situation is not the time to tell the person that he or she is e?periencing delusional thin0ing% 7% Give the person adeEuate ph sical space% 8% !evelop a strateg % 4elp the person ma0e a decision on a specific! short6term plan" Fou wonIt resolve all the problemsH stic0 to one issue that is doable% 3% 5%

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What are some of the legal implications of wor ing with suicidal people+ If a person completes suicide after a crisis services provider intervenes' it is possible that the famil or friends of the individual ma hold the crisis services provider responsible for the suicide% Three sorts of suicides are most prone to this sort of blaming andCor legal suits: 1) Butpatient suicides @should the clinician have hospitaliGed the individual=A' 2) Inpatient suicides @!id the institution provide a safe environment=A' and 3) )uicide following discharge or escape% In determining malpracticeHliability! four elements must be present: 1." therapist.patient relationship must e?ist which creates a dut of care to be present% 2." deviation from the standard of care must have occurred% 3.!amage to the patient must have occurred% 4.The damage must have occurred directl as a result of deviation from that standard of Care% -is management guidelines: !ocumentation . alwa s document' what is not documented' did not happen per most entitiesI opinion% Information on previous treatment Involvement of famil and significant others Consultation on present clinical circumstances )ensitivit to medical issues Qnowledge of communit resources Consideration of the effect on self and others &reventive preparation%

D84S and D8>G%S in suicide prevention /emove opportunities /eceive and accept suicidal communication !o intrude &revent isolation and involve significant others Transfer rather than refer ;ollow.up "lwa s obtain consultation when unsure !o 0now our own value s stem about suicide Get precipitant @Identif those issues' concerns' andCor events that led up to the current crisis%A Nse self as instrument of prevention !o not worr about sa ing the wrong thing !o not consider suicidal persons as special !o not assume abilit to solve problem@sA !o not tr to tal0 the person out of committing suicide !o not engage in abstract discussion about suicide' death' !o not be too accepting of suicide !o not delegitimatiGe !o not give cheap general reassurance !o not lose confidence @ma need more limited goalsA

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%he following are e#amples of forms that can be utili<e for crisis evaluations: 1aureen 1allo ' /%*% (ehavioral Emergenc Butreach &rogram% 1E%2A1I%? ASSESS.E>% W8-= S2EE%

18W 1E%2A1I%? (1A> .E%28D A3AI1A/I1I%? %I.E (-E3I8@S A%%E.(% DE(-ESSI8> -ECE>% 18SSES
Dague' indeterminate plan 1ethod undecided 1ethod unavailable *o time specified *o &revious attempts ;eeling low or blue *o specific stress Clear thoughts' philosophical 1ethod: pills' cutting Can acEuire easil )pecified vaguel ' within wee0s - or 2 gestures 1ild depression - minor conflict or loss )ome specifics 1ethod: CB' oven gas' car )ome effort reEuired to !a and time chosen' within a wee0 4? of man threats' attempts Chronic depression )everal concurrent stressors !isabilit or chronic health problems Bthers close b

2IG2 1E%2A1I%?"
*ote X or will thought out' written 1ethod: 4anging' Vumping &lan Complete toda &lan to complete toda 4? of highl lethal attempt 1a>or depression 1a>or loss or conflict *ote written' time' place method chosen 1ethod: Gun &lan in progress &lan in progress Bver 2 serious attempts 1a>or depression' hopeless )everal significant lossesCchanges Terminal illness' /ecent !? "lone' rented room or car ' isolated )uicidal careers

2EA1%2 IS81A%I8>

&h sicall health Bthers present and supportive *o presence >f , predictors listed below

Transitor illness /oommatesC)B there

)evere illness or in>ur ' /ecent !? "lone' at home' no help nearb <ong term e?istence of several factors

C8.8-/IDI%?

- predictor present

1ore than factor present'

Common single predictors of suicide listed in order 2 3 4 3 5 6 !epressive illness' mental disorder "lcoholism' drug abuse )uicide ideation' tal0' religion &rior suicide attempts <ethal means Isolation' living alone' loss of support 4opelessness' cognitive rigidit 7 8 -, --2 -3 -4 Blder white males 1odeling' suicide in famil ' genetics 2or0 problems' occupation' economics 1arital problems' famil patholog )tress' life events "nger' aggression' irritabilit ' &h sical illness

-5-

Critical Item Suicide (otential Assessment This tool should be used in assessing the ris0 of suicide for clients% I% &/I1"/F /I)Q ;"CTB/): If an one of the following is present' the client should be considered a high ris0 for potential suicide' which should be given serious consideration in placement decisions% A. Attempt: -% )uicide attempt with lethal method @firearm' hangingCstrangulation' >umping from heights' etc%A% 2% )uicide attempt resulting in moderate to severe lesionsCto?icit % 3% )uicide attempt with low rescuabilit @no communication prior to attempt' discover unli0el because of chosen location or time' no one nearb ' active prevention of discover ' etc%A% 0" )uicide attempt with subseEuent e?pressed regret that it was not successful and continued e?pression of intent or unwilling to accept treatment% -. Intent: @as e?pressed directl b client or b another based on their observationsA -% Intent to commit suicide immediately" 2% Intent with lethal method selected and readil available% 3% Intent with post.mortem preparations @disposal of personal propert ' writing a will' writing a suicide note' ma0ing business and insurance arrangements' etc%A% 4% Intent with planned time' place and opportunit % 3% Intent without ambivalence or inabilit to see alternatives% 5% Command hallucinations to 0ill self regardless of e?pressed suicidal intent% 6% Intent with active ps chotic s mptoms' especiall affective disorder or schiGophrenia% 7% Intent or behavior indicates intent' but client unwilling to cooperate in adeEuate assessment% II% )ECB*!"/F /I)Q ;"CTB/): "n individualIs ris0 increases with the presence of the following factors% If over half of the following factors are present' consider the person a high ris0 for potential suicide in ma0ing placement decisions% -% 2% 3% 4% 3% 5% 6% 7% 8% -,% --% E?pressed hopelessness% /ecent death of significant other% /ecent loss of >ob or severe financial setbac0% )ignificant lossCstressCchange event @victimiGation' threat of prosecution' pregnanc ' illness' etc%A% )ocial isolation% Current or past ma>or mental illness% Current or past chemical dependenceCabuse% 4istor of suicide attempt@sA% 4istor of famil suicide @including recent suicide b close friendA% Current or past difficulties with impulse control or antisocial behavior% )ignificant depression @clinical or notA especiall with feelings of guilt' worthlessness or helplessness% -2% /ecent separation or divorce% -3% /igidit in adapting to change Crisis Intervention Center'

@"dapted from the CI)&" form used at the 4ennepin Count 1inneapolis' 1*%A

-52

What professional crisis services are currently available in S"+ Ever crisis service provider should at all times have an updated database of available crisis services centers at hand% Crisis services include 24 hour' seven da s a wee0 @24C6A toll free telephone lines answered in real time b a trained crisis specialist with face.to.face crisis service capabilities including' but not limited to: triage' intervention' evaluation' referral' tele.health capabilities' wal0.in services' crisis respite services andCor crisis stabiliGation units for additional servicesCtreatment and follow.up services% 1an individuals and families access crisis services directl ' but several of the high volume crisis calls are from emergenc departments' law enforcement agencies' communit providers' advocates' etc%

-53

Anne# $: Screening Screening %ools %he most important domains to screen include:
-% 2% 3% 4% 3% 5% 6%

)ubstance abuse Immediate ris0s for self.harm' suicide' and violence &regnanc considerations Immediate ris0s related to serious into?ication or withdrawal &ast and present mental disorders' including posttraumatic stress disorder @&T)!A and other an?iet disorders' mood disorders' and eating disorders &ast and present histor of violence and trauma' including se?ual victimiGation and interpersonal violence 4ealth screenings' including 4IDC"I!)' hepatitis' tuberculosis' and )T!s

$" Substance Abuse Screening The goal of substance abuse screening is to identif individuals who have or are developing alcohol. or drug.related problems% /outinel ' women are less li0el than men to be identified as having substance abuse problems @(uchsbaum et al% -883AH et' the are more li0el to e?hibit significant health problems after consuming fewer substances in a shorter period of time% )ubstance abuse screening and assessment tools' in general' are not as sensitive in identif ing women as having substance abuse problems% )creening for substance use disorders is conducted b an interview or b giving a short written Euestionnaire% 2hile selection of the instrument ma be based on various factors' including cost and administration time @Thornberr et al% 2,,2A' the decision to use an interview versus a self.administered screening tool should also be based upon the comfort level of the counselor or healthcare professional @"rborelius and Tha00er -883H !usG ns0i et al% -883H Gale et al% -887H Thornberr et al% 2,,2A% If the healthcare staff communicates discomfort' individuals ma become war of disclosing their full use of substances @"Euilino -884H see also Center for )ubstance "buse &revention [C)"&\ -883A%

How Much Is Too Much

3en .a( be at r *! ,or alcohol0related $roble.* , the r alcohol con*#.$t on e4ceed* 14 *tandard dr n!*5 $er wee! or 4 dr n!* $er da(, and wo.en .a( be at r *! , the( ha6e .ore than 7 *tandard dr n!* $er wee! or 3 dr n!* $er da(. S78&/): 9at onal :n*t t#te on ;lcohol ;b#*e and ;lcohol *.. Helping Patients Who Drink Too Much: A Clinicians Guide. 9:< +#b 9o. 01=3729. -ethe*da, 3>: the :n*t t#te, 2001. 5; *tandard dr n! * de, ned a* one 120o#nce bottle o, beer, one 10o#nce ?la** o, w ne, or 1.1 o#nce* o, d *t lled *$ r t*.

-54

General Alcohol and Drug Screening

A@DI% The "lcohol Nse !isorder Identification Test @"N!ITH (abor and Grant -878A is a widel used screening tool that is reproduced with guidelines and scoring instructions in TI& 25 Su stance A use Among 3lder Adults @C)"T -887dA% The "N!IT is effective in identif ing heav drin0ing among nonpregnant women @(radle et al% -887cA% It consists of -, Euestions that were highl correlated with haGardous or harmful alcohol consumption% This instrument can be given as a self.administered test' or the Euestions can be read aloud% The "N!IT ta0es about 2 minutes to administer% %he Alcohol @se Disorders Identification %est: Interview 3ersion
/ead Euestions as written% /ecord answers carefull % (egin the "N!IT b sa ing 9*ow I am going to as0 ou some Euestions about our use of alcoholic beverages during this past ear%: E?plain what is meant b 9alcoholic beverages: b using local e?amples of beer' wine' vod0a' etc% Code answers in terms of 9standard drin0s:% &lace the correct answer number in the bo? at the right% -% 4ow often do ou have a drin0 containing alcohol= @,A *ever [)0ip to Ws 8.-,\ @-A 1onthl or less @2A 2 to 4 times a month @3A 2 to 3 times a wee0 @4A 4 or more times a wee0 2% 4ow man drin0s containing alcohol do ou have on a t pical da when ou are drin0ing= @,A - or 2 @-A 3 or 4 @2A 3 or 5 @3A 6' 7' or 8 @4A -, or more 3% 4ow often do ou have four @womenA C si? @menA or more drin0s on one occasion= @,A *ever @-A <ess than monthl @2A 1onthl @3A 2ee0l @4A !ail or almost dail Skip to Juestions K and 48 if ,otal Score for Juestions ) and & L 8 4% 4ow often during the last ear have ou found that ou were not able to stop drin0ing once ou had started= @,A *ever @-A <ess than monthl @2A 1onthl @3A 2ee0l @4A !ail or almost dail 3% 4ow often during the last ear have ou failed to do what was normall e?pected from ou because of drin0ing= @,A *ever @-A <ess than monthl @2A 1onthl @3A 2ee0l @4A !ail or almost dail 5% 4ow often during the last ear have ou needed a first drin0 in the morning to get ourself going after a heav drin0ing session= @,A *ever @-A <ess than monthl @2A 1onthl @3A 2ee0l @4A !ail or almost dail 6% 4ow often during the last ear have ou had a feeling of guilt or remorse after drin0ing= @,A *ever @-A <ess than monthl @2A 1onthl @3A 2ee0l @4A !ail or almost dail 7% 4ow often during the last ear have ou been unable to remember what happened the night before because ou had been drin0ing= @,A *ever @-A <ess than monthl @2A 1onthl @3A 2ee0l @4A !ail or almost dail 8% 4ave ou or someone else been in>ured as a result of our drin0ing= @,A *o @2A Fes' but not in the last ear @4A Fes' during the last ear -,% 4as a relative or friend or a doctor or another health wor0er been concerned about our drin0ing or suggested ou cut down= @,A *o @2A Fes' but not in the last ear @4A Fes' during the last ear

/ecord total of specific items here . If total is greater than recommended cut.off' consult NserKs 1anual

-53

%he Alcohol @se Disorders Identification %est: Self6-eport 3ersion &"TIE*T: (ecause alcohol use can affect our health and can interfere with certain medications and treatments' it is important that we as0 some Euestions about our use of alcohol% Four answers will remain confidential so please be honest% &lace an S in one bo? that best describes our answer to each Euestion% Cuestions -% 4ow often do ou have a drin0 containing alcohol= 2% 4ow man drin0s containing alcohol do ou have on a t pical da when ou are drin0ing= 3% 4ow often do ou have si? or more drin0s on one occasion= @for women: four or moreA 4% 4ow often during the last ear have ou found that ou were not able to stop drin0ing once ou had started= 3% 4ow often during the last ear have ou failed to do monthl what was normall e?pected of ou because of drin0ing= 5% 4ow often during the last ear have ou needed a first drin0 in the morning to get ourself going after a heav drin0ing session= 6% 4ow often during the last ear have ou had a feeling of guilt or remorse after drin0ing= 7% 4ow often during the last ear have ou been unable to remem. ber what happened the night before because of our drin0ing= 8% 4ave ou or someone else been in>ured because of our drin0ing= -,%4as a relative' friend' doctor' or other health care wor0er been concerned about our drin0ing or suggested ou cut down= %otal @cA )0ip to Euestions 8 and -, if total for Euestion -' or total for Euestions 2d3 _ , P *ever @cA - or 2 $ 1onthl or less 3 or 4 & 2.4 times a month 3 or 5 * 2.3 times a wee0 6 to 8 0 4 or d t% a wee0 -, or more !ail or almost dail !ail or almost dail !ail or almost dail !ail or almost dail

*ever @cA *ever

<ess than monthl <ess than monthl

1onthl

2ee0l

1onthl

2ee0l

*ever

<ess than

1onthl

2ee0l

*ever

<ess than monthl

1onthl

2ee0l

*ever

<ess than monthl <ess than monthl

1onthl

2ee0l

!ail or almost dail !ail or almost dail Fes' during the last ear Fes' during the last ear

*ever

1onthl

2ee0l

*o

Fes' but not in the last ear Fes' but not in the last ear

*o

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-is 1evel Intervention A@DI% score 5E7 Rone I "lcohol Education Rone II )imple "dvice Rone III )imple "dvice plus (rief Counseling and Continued 1onitoring Rone ID /eferral to )pecialist for !iagnostic Evaluation and %reatment The "N!IT cut.off score ma var slightl depending on the countr Ks drin0ing patterns' the alcohol content of standard drin0s' and the nature of the screening program% Clinical >udgment should be e?ercised in cases where the patientKs score is not consistent with other evidence' or if the patient has a prior histor of alcohol dependence% It ma also be instructive to review the patientKs responses to individual Euestions dealing with dependence s mptoms @Wuestions 4' 3 and 5A and alcohol.related problems @Wuestions 8 and -,A% &rovide the ne?t highest level of intervention to patients who score 2 or more on Wuestions 4' 3 and 5' or 4 on Wuestions 8 or -,% Total scores of 7 or more are recommended as indicators of haGardous and harmful alcohol use' as well as possible alcohol dependence% @" cut.off score of -, will provide greater specificit but at the e?pense of sensitivit %A )ince the effects of alcohol var with average bod weight and differences in metabolism' establishing the cut off point for all women and men over age 53 one point lower at a score of 6 will increase sensitivit for these population groups% )election of the cut.off point should be influenced b national and cultural standards and b clinician >udgment' which also determine recommended ma?imum consumption allowances% Technicall spea0ing' higher scores simpl indicate greater li0elihood of haGardous and harmful drin0ing% 4owever' such scores ma also reflect greater severit of alcohol problems and dependence' as well as a greater need for more intensive treatment% ,.6 7.-3 -5.-8 2,.4,

%he A@DI% ,uestionnaire: choosing a cut6off score"

Conigrave Q1' 4all 2!' )aunders V(. Source
/entre ,or >r#? and ;lcohol St#d e*, &o(al +r nce ;l,red <o*$ tal, 9ew So#th Wale*, ;#*tral a.

Abstract Three hundred and thirt ambulator care patients were interviewed using a detailed assessment schedule which included the "N!IT Euestions% "fter 2.3 ears' sub>ects were reviewed and their e?perience of alcohol.related medical and social harm assessed b interview and perusal of medical records% "N!IT was a good predictor of both alcohol.related social and medical problems% Cut.off points of 6.7 ma?imiGed discrimination in the prediction of trauma and h pertension% 4igher cut.offs @-2 and 22A provided better discrimination in the prediction of alcohol.related social problems and of liver disease or gastrointestinal bleeding' but high specificit was offset b reduced sensitivit % 2e conclude that the recommended cut.off score of eight is a reasonable appro?imation to the optimal for a variet of endpoints% @&1I!: 75-5453 . [&ub1ed . inde?ed for 1E!<I*E\

-56

1ore detailed interpretation of a patientKs total score ma be obtained b determining on which Euestions points were scored% In general' a score of - or more on Wuestion 2 or Wuestion 3 indicates consumption at a haGardous level% &oints scored above , on Euestions 4.5 @especiall wee0l or dail s mptomsA impl the presence or incipience of alcohol dependence% &oints scored on Euestions 6.-, indicate that alcohol.related harm is alread being e?perienced% The total score' consumption level' signs of dependence' and present harm all should pla a role in determining how to manage a patient% The final two Euestions should also be reviewed to determine whether patients give evidence of a past problem @i%e%' 9 es' but not in the past ear:A% Even in the absence of current haGardous drin0ing' positive responses on these items should be used to discuss the need for vigilance b the patient% In most cases the total "N!IT score will reflect the patientKs level of ris0 related to alcohol% In general health care settings and in communit surve s' most patients will score under the cut.offs and ma be considered to have low ris0 of alcohol related problems% " smaller' but still significant' portion of the population is li0el to score above the cut.offs but record most of their points on the first three Euestions% " much smaller proportion can be e?pected to score ver high' with points recorded on the dependence. related Euestions as well as e?hibiting alcohol.related problems% "s et there has been insufficient research to establish precisel a cut.off point to distinguish haGardous and harmful drin0ers @who would benefit from a brief interventionA from alcohol dependent drin0ers @who should be referred for diagnostic evaluation and more intensive treatmentA% This is an important Euestion because screening programmes designed to identif cases of alcohol dependence are li0el to find a large number of haGardous and harmful drin0ers if the cut.off of 7 is used% These patients need to be managed with less intensive interventions% In general' the higher the total score on the "N!IT' the greater the sensitivit in finding persons with alcohol dependence% (ased on e?perience gained in a stud of treatment matching with persons who had a wide range of alcohol problem severit ' "N!IT scores were compared with diagnostic data reflecting low' medium and high degrees of alcohol dependence% It was found that "N!IT scores in the range of 7.-3 represented a medium level of alcohol problems whereas scores of -5 and above represented a high level of alcohol problems% Bn the basis of e?perience gained from the use of the "N!IT in this and other research' it is suggested that the following interpretation be given to "N!IT scores: )cores between 7 and -3 are most appropriate for simple advice focused on the reduction of haGardous drin0ing% )cores between -5 and -8 suggest brief counseling and continued monitoring% )cores of 2, or above clearl warrant further diagnostic evaluation for alcohol dependence% In the absence of better research these guidelines should be considered tentative' sub>ect to clinical >udgment that ta0es into account the patientKs medical condition' famil histor of alcohol problems and perceived honest in responding to the "N!IT Euestions% 2hile use of the -,.Euestion "N!IT Euestionnaire will be sufficient for the vast ma>orit of patients' special circumstances ma reEuire a clinical screening procedure% ;or e?ample' a patient ma be resistant' uncooperative' or unable to respond to the "N!IT Euestions% If further confirmation of possible dependence is warranted' a ph sical e?amination procedure and laborator tests ma be used%

-57

8ther Screening tools: %C@DS II The Te?as Christian Nniversit !rug )creen II @TCN!) IIA is a -3.item' self.administered substance abuse screening tool that reEuires 3-, minutes to complete% It is based in part on !iagnostic Interview )chedule and refers toDiagnostic and Statistical 2anual of 2ental Disorders, M th Ndition, ,e(t Oevision @!)1.ID.T/H "merican &s chiatric "ssociation ["&"\ 2,,,aA criteria for substance abuse and dependence% TCN!) II is used widel in criminal >ustice settings% It has good reliabilit % @Qnight 2,,2H Qnight et al% 2,,2A% This screen' along with related instruments' is available at www%ibr%tcu%edu% CAGE C"GE @Ewing -874A as0s about lifetime alcohol or drug consumption% Each 9 es: response receives point' and the cutoff point @the score that ma0es the test results positiveA is either - or 2% Two 9 es: answers results in a ver small false.positive rate and the clinician will be less li0el to identif clients as potentiall having a substance use disorder when the do not% 4owever' the higher cutoff of 2 points decreases the sensitivit of C"GE for womenYthat is' increases the li0elihood that some women who are at ris0 for a substance problem will receive a negative screening score @i%e%' it increases the false.negative rateA% >ote: It is recommended that a cutoff score of - be emplo ed in screening for women% This measure has also been translated and tested for 4ispanicC<atina populations% " common criticism of the C"GE is that it is not gender.sensitiveYthat is' women who have problems associated with alcohol use are less li0el than male counterparts to screen positive when this instrument is used% Bne stud of more than -',,, women found that as0ing simple Euestions about freEuenc and Euantit of drin0ing' coupled with a Euestion about binge drin0ing' was better than the C"GE in detecting alcohol problems among women @2aterson and 1urra .< on -877A% The C"GE is 9relativel insensitive: with Caucasian females' et (radle and colleagues report that it 9has performed adeEuatel in predominantl blac0 populations of women: @-887c' p% -6,A% Vohnson and 4ughes @2,,3A conclude that C"GE has similar reliabilit and concurrent validit among women of different se?ual orientations% The C"GE."I! @C"GE "dapted to Include !rugsA modifies the C"GE Euestions for use in screening for drugs other than alcohol% This version of the C"GE shows promise in identif ing pregnant' low.income women at ris0 for heavier drug use @1idani0 et al% -887A%

Substance Abuse Screening and Assessment Among Women

4ow screenings and assessments are conducted is as important as the information gathered% )creening and assessment are often the initial contact between a woman and the treatment s stem% The can either help build a trusting relationship or create a deterrent to engaging in further services%

-58

)elf.administered tools ma be more li0el to elicit honest answersH this is especiall regarding Euestions related to drug and alcohol use%

true

;ace.to.face screening interviews have not alwa s been successful in detecting alcohol and drug use in women' especiall if the counselor is uncomfortable with the Euestions% )ubstance abuse screening and assessment tools' in general' are not as sensitive in identif ing women as having substance abuse problems%

&" Screening Instruments for (regnant Women Considering the devastating impact of substances on the developing foetus' routine screening for drug' alcohol' and tobacco use among pregnant women is imperative% ;ace.to.face screening interviews are not alwa s successful in detecting alcohol and drug use' especiall in pregnant women% 4owever' self. administered screening tools have been found to be more li0el to elicit honest answers @<essler and BK/eill -886H /ussell et al% -885H Tourangeau and )mith -885A% Three screening instruments for use with pregnant women are T2E"Q' T."CE' and 3&s &lus @C)"& -883H 1orse et al% -886A% 2omen who smo0ed in the month before pregnanc are nine times more li0el to be currentl using either drugs or alcohol or both while pregnant @Chasnoff et al% 2,,-A% %WEA= T2E"Q @/ussell et al% -88-A identifies pregnant women who are at ris0 for alcohol use% It consists of five items and uses a 6.point scoring s stem% Two points are given for positive responses to either of the first two Euestions @tolerance and worr A' and positive responses to the other three Euestions score - point% " cutoff score of 2 indicates the li0elihood of ris0 drin0ing% In a stud of more than 3',,, women at a prenatal clinic' the T2E"Q was found to be more sensitive than the C"GE and 1ichigan "lcohol )creening Test @1")TA' and more specific than the T."CE @/ussell et al% -885A% The tolerance Euestion scores 2 points for an answer of three or more drin0s% 4owever' if the criterion for the tolerance Euestion is reduced to two drin0s for women' the sensitivit of T2E"Q increases' and the specificit and predictive abilit decrease somewhat @Chang et al% -888A% In comparison with T."CE' T2E"Q had higher sensitivit and slightl lower specificit @/ussell et al% -884' -885A% It can also be used to screen for harmful drin0ing in the general population @Chan et al% -883A%

-6,

%6ACE The T."CE is a 4.item instrument appropriate for detecting heav alcohol use in pregnant women @)o0ol et al% -878A% T."CE uses the "' C' and E Euestions from C"GE and adds one on tolerance for alcohol% The first Euestion assesses tolerance b as0ing if it ta0es more than it used to to get high% " response of two or more drin0s is scored as 2 points' and the remaining Euestions are assigned - point for a 9 es: response% )cores range from , to 3 points% " total of 2 or more points indicates ris0 drin0ing @Chang et al% -888A% T."CE has sensitivit eEual to the longer 1")T and greater than C"GE @(radle et al% -887cA% It has been validated onl for screening pregnant women with ris0 drin0ing @/ussell et al% -884A%

In a stud with a culturall diverse population of pregnant women' Chang and colleagues @-887A compared T."CE with the 1")T @short versionA and the "N!IT% The stud found T."CE to be the most sensitive of the three tools in identif ing current alcohol consumption' ris0 drin0ing' or lifetime alcohol diagnoses @Chang et al% -887A% "lthough T."CE had the lowest specificit of the three tests' it is argued that false positives are of less concern than false negatives among pregnant women%% (renatal substance abuse screen 5I(s7 This screening approach has been used to identif women who are at ris0 for substance abuse in prenatal health settings% " 9 es: response to an item indicates that the woman should be referred for assessment @1orse et al% -886A% Briginall ' four Euestions regarding present and past use' partner with problem' and parent histor of alcohol or drug problems were used @Ewing -88,A% 4owever' several adaptations have been made' and recentl a Euestion about tobacco use in the month before the client 0new she was pregnant was added @Chasnoff 2,,-A% Chasnoff and colleagues @2,,-A reported that women who smo0ed in the month before pregnanc were -- times more li0el to be currentl using drugs and 8 times more li0el to be currentl using either drugs or alcohol or both while pregnant%

In a stud evaluating prevalence of substance use among pregnant women utiliGing this screening tool' the authors suggest that it not onl identified pregnant women with high levels of alcohol and drug use but also a larger group of women whose pregnancies were at ris0 from smaller amounts of substance use

-6-

@Chasnoff et al% 2,,3A% ;or a review on how to improve screening for pregnant women and motivate healthcare professions to screen for ris0' refer to the "lcohol Nse !uring &regnanc &ro>ect% At6-is Screening for Drug and Alcohol @se During (regnancy

In screening women who are pregnant' face.to.face screening interviews have not alwa s been successful in detecting alcohol and drug use% )elf.administered tools ma be more li0el to elicit honest answersH this is especiall regarding Euestions related to drug and alcohol use during pregnanc % true

2hile Euestions regarding past alcohol and drug use or problems associated with self' partner' and parents will help to identif pregnant women who need further assessment' counselors should not underestimate the importance of inEuiring about previous nicotine use in order to identif women who are at ris0 for substance abuse during pregnanc % There are other factors that are associated with at.ris0 substance abuse among women who are pregnant' including moderate to severe depression' living alone or with oung children' and living with someone who uses alcohol or drugs @for review' see Chasnoff et al% 2,,-A%

*ot all drugs produce ph siological withdrawalH counselors should not assume that withdrawal from an drug of abuse reEuires medical intervention% Bnl in the case of opioids' sedative.h pnotics' or benGodiaGepines @and in some cases of alcoholA' is medical intervention li0el to be reEuired% *onetheless' specific populations ma warrant further assessment and assistance in deto?ification' including pregnant women' women of color' women with disabilities or co.occurring disorders' and older women% @/eview TI& 43 Deto(ification and Su stance A use ,reatment, [C)"T 2,,5a\' pp% -,3--3%A )pecific to women who are pregnant and dependent on opioids' withdrawal during pregnanc poses specific medical ris0s including premature labor and mortalit to the foetus% >ote: 2omen who are dependent on opioids ma misinterpret earl signs of pregnanc as opioid withdrawal s mptoms @review TI& 43 2edication5Assisted ,reatment for 3pioid Addiction in 3pioid ,reatment Programs [C)"T 2,,3a\' pp% 2--224A% *" Acute Safety -is -elated to Serious Into#ication or Withdrawal )creening for safet related to into?ication and withdrawal at inta0e involves Euestioning the individual and their famil or friends @with clientKs permissionA about current substance use or recent discontinuation of use' along with past and present e?periences of withdrawal% If the individual is obviousl severel into?icated' he needs to be treated with empath and firmness' and provision needs to be made for his or her ph sical safet % If a client has s mptoms of withdrawal' formal withdrawal scales can be used b trained personnel to gather information to determine whether medical intervention is reEuired% )uch tools include the Clinical Institute 2ithdrawal "ssessment for "lcohol 2ithdrawal @)ullivan et al% -878H and the Clinical Institute *arcotic "ssessment for Bpioid 2ithdrawal @Rilm and )ellers -867A% 2hile specific normative data are unavailable' it is important to screen for withdrawal to assess ris0 and to implement appropriate medical and clinical interventions%

-62

Clinical Institute Withdrawal Assessment of Alcohol Scale! -evised 5CIWA6Ar7

&atient:########################## !ate: ################ Time: ############### &ulse or heart rate' ta0en for one minute:######################### (lood pressure:###### >A@SEA A>D 38.I%I>G As ODo you feel sic to your stomach+ 2ave you vomited+O Bbservation% , no nausea and no vomiting - mild nausea with no vomiting 2 3 4 intermittent nausea with dr heaves 3 5 6 constant nausea' freEuent dr heaves and vomiting %AC%I1E DIS%@-/A>CES As O2ave you any itching! pins and needles sensations! any burning! any numbness! or do you feel bugs crawling on or under your s in+O Bbservation% , none - ver mild itching' pins and needles' burning or numbness 2 mild itching' pins and needles' burning or numbness 3 moderate itching' pins and needles' burning or numbness 4 moderatel severe hallucinations 3 severe hallucinations 5 e?tremel severe hallucinations 6 continuous hallucinations %-E.8Arms e#tended and fingers spread apart" Bbservation% , no tremor - not visible' but can be felt fingertip to fingertip 2 3 4 moderate' with patientIs arms e?tended 3 5 6 severe' even with arms not e?tended

-63

A@DI%8-? DIS%@-/A>CES As OAre you more aware of sounds around you+ Are they harsh+ Do they frighten you+ Are you hearing anything that is disturbing to you+ Are you hearing things you now are not there+O Bbservation% , not present - ver mild harshness or abilit to frighten 2 mild harshness or abilit to frighten 3 moderate harshness or abilit to frighten 4 moderatel severe hallucinations 3 severe hallucinations 5 e?tremel severe hallucinations 6 continuous hallucinations (A-8B?S.A1 SWEA%S Bbservation% , no sweat visible - barel perceptible sweating' palms moist 2 3 4 beads of sweat obvious on forehead 3 5 6 drenching sweats 3IS@A1 DIS%@-/A>CES As ODoes the light appear to be too bright+ Is its color different+ Does it hurt your eyes+ Are you seeing anything that is disturbing to you+ Are you seeing things you now are not there+O Bbservation% , not present - ver mild sensitivit 2 mild sensitivit 3 moderate sensitivit 4 moderatel severe hallucinations 3 severe hallucinations 5 e?tremel severe hallucinations

6 continuous hallucinations
A>BIE%? As ODo you feel nervous+O Bbservation% , no an?iet ' at ease - mild an?ious 2 3 4 moderatel an?ious' or guarded' so an?iet is inferred 3 5 6 eEuivalent to acute panic states as seen in severe delirium or acute schiGophrenic reactions

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2EADAC2E! 9@11>ESS I> 2EAD As ODoes your head feel different+ Does it feel li e there is a band around your head+O !o not rate for diGGiness or lightheadedness% Btherwise' rate severit % , not present - ver mild 2 mild 3 moderate 4 moderatel severe 3 severe 5 ver severe 6 e?tremel severe AGI%A%I8> Bbservation% , normal activit - somewhat more than normal activit 2 3 4 moderatel fidget and restless 3 5 6 paces bac0 and forth during most of the interview' or constantl thrashes about 8-IE>%A%I8> A>D C18@DI>G 89 SE>S8-I@. As : OWhat day is this+ Where are you+ Who am I+O , oriented and can do serial additions - cannot do serial additions or is uncertain about date 2 disoriented for date b no more than 2 calendar da s 3 disoriented for date b more than 2 calendar da s 4 disoriented for placeCor person

Total CI2"."r )core ######

/aterIs Initials ######

1a?imum &ossible )core 56 . The CI2"."r is not cop righted and ma be reproduced freel % This assessment for monitoring withdrawal s mptoms reEuires appro?imatel 3 minutes to administer% &atients scoring less than -, do not usuall need additional medication for withdrawal% )ullivan' V%T%H ) 0ora' Q%H )chneiderman' V%H *aran>o' C%"%H and )ellers' E%1% "ssessment of alcohol withdrawal: The revised Clinical Institute 2ithdrawal "ssessment for "lcohol scale @CI2"."rA% (ritish Vournal of "ddiction 74:-333.-336' -878%

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4% "ssessing /is0 of 4arm to )elf or Bthers "bout 7,T of all suicides are committed b men% Fet suicidal attempts and parasuicidal behavior @nonfatal self.in>urious behavior with clear intent to cause bodil harm or deathH 2elch 2,,-A are more prevalent among women% The greatest predictor of eventual suicide is prior suicidal attempts and deliberate self.harm inflicted with no intent to die @Voe et al% 2,,5A% 2hile substance dependence and &T)! are associated with self.harm and suicidal behavior @4arned et al% 2,,5A' the most freEuent diagnoses associated with suicide are mood disorders' specificall depressive episodes @Qessler et al% -888A% Considering the prevalence of suicides' suicidal attempts' self.in>urious behavior' and depression' emplo ing safet screenings should be a standard practice% ;rom the outset' clinicians should specificall as0 the client and an one else who is providing information whether the client is in immediate danger and whether the have an immediate intention to engage in violent or self.in>urious behavior% If the answer is 9 es': the clinician should obtain more information about the nature and severit of the thoughts' plan' and intent' and then arrange for an in.depth ris0 assessment b a trained mental health clinician% The client should not be left alone% *o tool is definitive for safet screening% Clinicians should use safet screening tools onl as an initial guide and proceed to detailed Euestions to obtain relevant information% In addition' care is needed to avoid underestimating ris0 because clients that are using substances ma also engage in self.in>urious behavior% ;or e?ample' a woman who is into?icated might seem to be ma0ing empt threats of self.harm' but all statements about harming herself or others must be ta0en seriousl % Bverall' individuals who have suicidal or aggressive impulses when into?icated are more li0el to act on those impulsesH therefore' determination of the seriousness of threats reEuires a s0illed mental health assessment' plus information from others who 0now the client ver well% )creening tools and procedures in evaluating ris0 are discussed in depth in TI& 3, Addressing Suicidal ,houghts and 7ehaviors in Su stance A use ,reatment @C)"T 2,,8aA% )ubstance abuse treatment programs need clear mental health referral and follow.up procedures so that clients receive appropriate ps chiatric evaluations and mental health care% The "merican "ssociation of Communit &s chiatrists @""C&A developed the <evel of Care NtiliGation ) stem for &s chiatric and "ddiction )ervices @<BCN)A that evaluates clients along si? dimensions and defines si? levels of resource intensit % It includes an e?cellent tool for helping the counselor determine the ris0 of harm @""C& 2,,,A% The potential ris0 of harm most freEuentl ta0es the form of suicidal intentions' and less often the form of homicidal intentions% The scale has five categories' from minimal ris0 of harm to e?treme ris0 of harm% It is available at www%comm%ps ch%pitt%eduCfindsC<BCN)2,,,%pdf and can be easil adapted for use in treatment facilities%

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-is indicators for life6threatening self6harm

Preparation for self5harm: someone who has ta0en time to plan' considered the conseEuences of their actions' said goodb e to people or ta0en precautions to avoid being discovered b others represents a much higher ris0 than a person who self.harms without much thin0ing about it @i%e% self. harm as an UimpulsiveK actA% Seriousness of the method used to self5harm: violent methods such as hanging' stabbing or throwing oneself into deep water are considered serious and indicate higher ris0% "urrent mental illness: at least 5,T of people who self.harm have some form of mental illness% Dactors that reduce self5control: the use of alcohol or other drugs' or having an impulsive personalit ' reduce self.control and increase the ris0 of serious self.harm% Presence of ongoing :real life$ difficulties: marital problems' financial problems' difficulties at wor0' or other problems in dail life increase the ris0 of self.harm%

Screening %ools $" 1evel of Care @tili<ation System 518C@S7 (urpose: To assess immediate service needs @e%g%' for clients in crisisAH to plan resource needs over time' as in assessing service reEuirements for defined populationsH to monitor changes in status or placement at different points in time% Clinical utility: <BCN) is divided into three sections% The first defines si? evaluation parameters or dimensions: @-A /is0 of 4arm' @2A ;unctional )tatus' @3A 1edical' "ddictive' and &s chiatric Co. 1orbidit ' @4A /ecover Environment' @3A Treatment and /ecover 4istor ' and @5A Engagement% " five. point scale is constructed for each dimension' and the criteria for assigning a given rating or score in that dimension are elaborated% In dimension ID' two subscales are defined' whereas all other dimensions contain onl one scale% Groups with whom this instrument has been used: "dults Administration time: -3 to 3, minutes . Scoring time: 2, minutes Available from: "merican "ssociation of Communit &s chiatrists www%wpic%pitt%eduCaacpCfind%html

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&" @niversity of 8#ford -is assessment for clients with depression

-is factors specific to depression

;amil histor of mental disorder% 4istor of previous suicide attempts @this includes self.harmA% )evere depression% "n?iet % ;eelings of hopelessness% &ersonalit disorder% "lcohol abuse andCor drug abuse% 1ale gender%

8ther ris factors for consideration

;amil histor of suicide or self.harm% &h sical illness @especiall when this is recentl diagnosed' chronic andCor painfulA% E?posure to suicidal behaviour of others' either directl or via the media% /ecent discharge from ps chiatric inpatient care% "ccess to potentiall lethal means of self. harmCsuicide%

(ossible protective factors

)ocial support% /eligious belief% (eing responsible for children @especiall

oung childrenA%

In assessing patientsG current suicide potential! the following ,uestions can be e#plored:

"re the feeling hopeless' or that life is not worth living= 4ave the made plans to end their life= 4ave the told an one about it= 4ave the carried out an acts in anticipation of death @e%g% putting their affairs in orderA= !o the have the means for a suicidal act @do the have access to pills' insecticide' firearms%%%A= Is there an available support @famil ' friends' carers%%%A= 2here practical' and with consent' it is generall a good idea to inform and involve famil members and close friends or carers% This is particularl important where ris0 is thought to be high% 2hen a patient is at ris0 of suicide this information should be recorded in the patientKs notes% 2here applicable' it is important to share awareness of ris0 with other team members% /egular and pro.active follow.up is highl recommended%

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*" %he (syChec Suicide H Self62arm -is Assessment Chec0 ris0 for harm to others following a similar process% " histor of violence or aggression towards others indicates a ris0 for future harm" Bther factors associated with harm to others are: ] being male ] being under 33 ears of age ] having a criminal histor ] having a histor of using weapons ] having a histor of child abuse or mistreatment b others Current factors to assess include: ] verbal intent to harm others ] paranoid thoughts about others ] preoccupation with violent images and thoughts ] access to lethal means ] high levels of anger' frustration or agitation ] a lac0 of problem.solving s0ills ] current role instabilit @for e?ample changes in wor0' relationship or accommodation circumstancesA " client poses a high ris0 of harm to others if some of the following are true: male under 33 ears of age previous histor of violence or aggression previous use of weapons role instabilit paranoid thoughts about others increasing anger' frustration or agitation

0" -esponding to potential self6harm or harm to others .anaging ris s If there is no ris : 1onitor the client as reEuired% Chec0 at regular intervals' especiall if there are potential triggers in the future' or there is as histor of self.harm% If the ris0 is considered to be low: 1onitor the client closel % "gree on a verbal or written contract to maintain safet and develop a contingenc plan that includes support numbers for out.of.hours counseling services% "s0 for a commitment from the client to follow a contingenc plan in the event that their suicidal thoughts become more prominent"

If the ris is considered moderate: /efer the client for further assessment with a mental health service or other service that offers inpatient facilities in the event of a suicide or self.harm attempt% "gree on a written contract to maintain safet ' and a written contingenc plan with the client' listing supports to be contacted if feelings escalate% /eEuest the clientKs permission to contact their famil andCor an emergenc mental health service if necessar % Consult a supervisor for a second opinion"

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If the client is considered to pose a high ris of harm to self or others: 1a0e an immediate referral to a place of safet such as a hospital mental health service or emergenc mental health team% Call an ambulance or police if necessar % Contact the appropriate person in our service who has designated authorit or powers under the 1ental 4ealth "ct or relevant legislation for advice and support% Inform a supervisor or a senior colleague"

It is a clinicianKs dut to warn and protect others if credible threats are made against them% This dut overrides the clientKs right to confidentialit % 4owever' in man instances it is reasonable to inform the client that ou need to brea confidentiality because of concerns about them" I" .ental Illness Symptoms and .ental Disorders Considering that women are twice as li0el as men to e?perience mood disorders' e?cluding bipolar and an?iet disorders @(urt and )tein 2,,2A' all women entering substance abuse treatment should be screened for co.occurring mental disorders% If the screening indicates the possible presence of a disorder' a woman should be referred for a comprehensive mental health assessment and receive treatment for the co. occurring disorder' as warranted% !epression' an?iet ' eating disorders' and &T)! are common among women who abuse substances @1cCrad and /a te0 -883A% (ecause certain drugs as well as withdrawal s mptoms can mimic s mptoms of mental disorders' the continual reassessment of mental illness s mptoms is essential to ensure accurate diagnosis and treatment planning% TI& 42Su stance A use ,reatment for Persons #ith "o53ccurring Disorders @C)"T 2,,3eA contains information on screening and treatment of persons with co.occurring substance use and mental disorders% General mental disorder screening instruments ) mptom screening involves Euestions about past or present mental disorder s mptoms that ma indicate the need for a full mental health assessment% Circumstances surrounding the resolution of s mptoms should be e?plored% ;or e?ample' if the client is ta0ing ps chotropic medication and is no longer s mptomatic' this ma be an indication that the medication is effective and should be continued% Bften' s mptom chec0lists are used when the counselor needs information about how the client is feeling% The are not used to screen for specific disorders' and responses are e?pected to change from one administration to the ne?t% ) mptom screening should be performed routinel and facilitated b the use of formal screening tools% (asic mental health screening tools are available to assist the substance abuse treatment team% The -7 Euestions in the 1ental 4ealth )creening ;orm.III @14);.IIIA screen for present or past s mptoms of most mental disorders @Carroll and 1cGinle 2,,-A% It is available at no charge from the &ro>ect /eturn ;oundation' Inc%' and is reproduced in TI& 42 Su stance A use ,reatment for Persons #ith "o53ccurring Disorders @C)"T 2,,3eA' along with instructions and contact information @a )panish.language form and instructions can be downloaded fromwww%asapn s%orgCresources%htmlA% 14);.III was developed in a substance abuse treatment setting and is referred to as a 9rough screening device: @Carroll and 1cGinle 2,,-' p% 33A% The 1ini.International *europs chiatric Interview @1%I%*%I%A is a brief' structured interview for more than 2, ma>or ps chiatric and substance use disorders @)heehan et al% 2,,2A% "dministration time is -33, minutes% )coring is simple and immediate% 1%I%*%I% can be administered b clinicians after brief training

-7,

and b la personnel with more e?tensive training% 1%I%*%I% can be downloaded from www%medical. outcomes%com and used for no cost in nonprofit or publicl owned settings% The (rief ) mptom Inventor is a research tool that can be adapted for use as a screening chec0list% This toolKs 33 items measure 8 primar s mptom dimensions as well as 3 global indices of distress% /espondents rate the severit of s mptoms on a 3.point scale ranging from 9*ot at all: @, pointsA to 9E?tremel : @4 pointsA @!erogatis and 1elisaratos -873A% Depression and an#iety disorders 1an formal tools screen for depression' including the (ec0 !epression Inventor .II @(ec0 et al% -885a' H )mith and Erford 2,,-H )teer et al% -878A' the Center for Epidemiologic )tud !epression )cale @/adloff -866A' and the General 4ealth WuestionnaireYa self.administered screening test to identif short.term changes in mental health @depression' an?iet ' social d sfunction' and somatic s mptomsAYare available% The N%)% &reventive )ervices Tas0 ;orce @2,,2A recommends two simple Euestions that are effective in screening adults for depression: $" &" 8ver the past & wee s have you felt down! depressed! or hopeless+ 8ver the past & wee s have you felt little interest or pleasure in doing things+

&rograms that screen for depression should ensure that 9 es: answers to these Euestions are followed b a comprehensive assessment' accurate diagnosis' effective treatment' and careful followup% "s0ing these two Euestions ma be as effective as using longer instruments @N%)% &reventive )ervices Tas0 ;orce 2,,2A% <ittle evidence e?ists to recommend one screening method over another' so clinicians can choose the method that best fits their preference' the specific population of women' and the setting% /efer to TI& 47 2anaging Depressive Symptoms in Su stance A use "lients During Narly Oecovery @C)"T 2,,7A for more guidance in wor0ing with clients who have depressive s mptoms% >ote: 2omen who are depressed are more li0el to report bodil s mptoms' including fatigue' appetite and sleep disturbance' and an?iet @(ars0 et al% 2,,-H Qornstein et al% 2,,,H )ilverstein 2,,2A% "n e?ample of an instrument that can detect s mptoms of an?iet is the 2-.item (ec0 "n?iet Inventor @("IH (ec0 -883H 4ewitt and *orton -883A% "mong a group of ps chiatric patients with a variet of diagnoses' womenKs ("I scores indicated higher levels of an?iet than menKs ("I scores% 4owever' the nature of the an?iet reported appears similar for women and men @4ewitt and *orton -883A% J" %rauma and (osttraumatic Stress Disorder &T)! can follow a traumatic episode that involves witnessing' being threatened' or e?periencing an actual event involving death or serious ph sical harm' such as auto accidents' natural disasters' se?ual or ph sical assault' war' and childhood se?ual and ph sical abuse @"&" 2,,,aA% !uring the trauma' the individual e?periences intense fear' helplessness' or horror% &T)! has s mptoms that last longer than month and result in a decline in functioning in several life areas' such as wor0 and relationships% " diagnosis of &T)! cannot be made without a clear histor of a traumatic event @;igure 4.3 presents sample screening Euestions for identif ing a womanKs histor of traumaA% General s mptoms of &T)! include persistentl re.e?periencing the traumatic event' numbness or avoidance of cues associated with the trauma' and a pattern of increased arousal @"&" 2,,,aA%

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4istoricall ' women have not been routinel screened for a histor of trauma or assessed to determine a diagnosis of &T)! across treatment settings @*a>avits 2,,4A% "mong women in substance abuse treatment' it has been estimated that 3388 percent have e?perienced traumaYcommonl childhood ph sical or se?ual abuse' domestic violence' or rape @*a>avits et al% -886H Triffleman 2,,3A% )tudies have reported that current &T)! rates among women who abuse substances range between -4 to 5, percent @(rad 2,,-H *a>avits et al% -887H Triffleman 2,,3A% In comparison to men' women who use substances are still more than twice as li0el to have &T)! @*a>avits et al% -886A% (rief screening is paramount in not onl establishing past or present traumatic events but in identif ing &T)! s mptoms% Npon identification of traumatic stress s mptoms' counselors need to refer the women for a mental health evaluation in order to further assess the presenting s mptoms' to determine the appropriateness of a &T)! diagnosis' and to assist in establishing an appropriate treatment plan and approach% (rief screenings are used to identif clients who are more li0el to have were not normal and were abusive% )ome women do not remember the abuse% Therefore' a negative finding on abuse at an inta0e screening should not be ta0en as a final answer% The )ubstance "buse and 1ental 4ealth )ervices "dministration @)"14)"A.funded 2omen' Co. Bccurring !isorders and Diolence )tud includes Euestions about se?ual abuse in its baseline interview protocol' presented in ;igure 4.5% In addition' )"14)"Ks C)"T has developed a brochure for women that defines childhood abuse and informs the reader of how to begin to address childhood abuse issues while in treatment @C)"T 2,,3aA% TI& 35 Su stance A use ,reatment for Persons #ith "hild A use and 0eglect Issues @C)"T 2,,, A includes detailed information on this topic%

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Interpersonal violence )tudies estimate that between 3, to 88 percent of women with substance use disorders have a histor of interpersonal violence @1iller et al% -883H /ice et al% 2,,-A% In one stud focused on sensitivit and specificit of screening Euestions for intimate partner violence' &aran>ape and <iebschutG @2,,3A concluded that when three simple screening Euestions were used together' identification of lifetime interpersonal violence was effectivel identified for women% This screening tool' referred as the )TaT' is presented in ;igure 4.6 @p% 62A% "long with a sample personaliGed safet plan' additional screening tools' including the "buse "ssessment )creen @English and )panish versionA' !anger "ssessment' The &s chological 1altreatment of 2omen Inventor ' and The /evised Conflict Tactics )cale @CT)2A' are available in TI& 23 Su stance A use ,reatment and Domestic Qiolence @C)"T -886 A% >ote: It is important to assess for interpersonal violence in heterose?ual and homose?ual relationships%

)TaT: Intimate &artner Diolence )creening Tool SourceE &aran>ape and <iebschutG 2,,3%

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Interpersonal violence and disabilities 2omen with disabilities are at a significantl greater ris0 for severe interpersonal violence and neglect @(rownridge 2,,5A% "s a counselor' additional screening Euestions tailored to address uniEue vulnerabilities associated with the specific ph sical disabilit ma be warranted% ;or e?ample'

4as an one ever withheld food or medication from ou that ou as0ed for or needed= 4as an one ever refused to let ou use our wheelchair or other assistive devices at home or in the communit = 4as an one ever refused to assist ou with self.care that ou needed' such as getting out of bed' using the toilet' or other personal care tas0s= 4as an one used restraints on ou to 0eep ou from getting out of bed or out of our wheelchair=

Initial Euestions about trauma should be general and gradual% 2hile ideall ou want the client to control the level of disclosure' it is important as a counselor to mediate the level of disclosure% "t times' clients with &T)! >ust want to gain reliefH the disclose too much' too soon without having established trust' an adeEuate support s stem' or effective coping strategies% &reparing a woman to respond to trauma.related Euestions is important% ( ta0ing the time with the client to prepare and e?plain how the screening is done and the potential need to pace the material' the woman has more control over the situation% Bverall' she should understand the screening process' wh the specific Euestions are important' and that she can choose not to answer or to dela her response% ;rom the outset' counselors need to provide initial trauma.informed education and guidance with the client% K" 2ealth screenings! including 2I3HAIDS! hepatitis! tuberculosis! and S%Ds Eating Disorders Eating disorders have one of the highest mortalit rates of all ps chological disorders @*eumar0er -886H )teinhausen 2,,2A% "ppro?imatel -3 percent of women in substance abuse treatment have had an eating disorder diagnosis in their lifetimes @4udson -882A% Three eating disorders are currentl included in the !)1.ID.T/: anore?ia nervosa' bulimia nervosa' and eating disorder not otherwise specified @ "&" 2,,,aA% Compulsive eating' referred to as binge.eating disorder' is not included as a diagnosis in the !)1% Currentl ' it is theoriGed that substance use disorders and compulsive overeating are competing disorders' in that compulsive overeating @binge.eatingA is not as li0el to appear at the same time as substance use disorders% ConseEuentl ' disordered eating in the form of compulsive overeating is more li0el to appear after a period of abstinence' thus enhancing the ris0 of relapse to drugs and alcohol to manage weight gain% (e aware that weight gain during recover can be a ma>or concern and a relapse ris0 factor for women% (ulimia nervosa' characteriGed b recurrent episodes of binge and purge eating behaviors' has the highest incidence rates in the general population for eating disorders @4oe0 and van 4oe0en 2,,3A' and it is the most common eating disorder among women in substance abuse treatment @Corcos et al% 2,,-H )pec0er et al% 2,,,H "&" 2,,,aA% ;or specific information regarding the co.occurring disorders of eating and substance use disorders' counselors should refer to TI& 42 Su stance A use ,reatment for Persons #ith "o53ccurring Disorders @C)"T 2,,3eA%

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)creening for eating disorders in substance abuse treatment is based on the assumption that identification of an eating disorder can lead to earlier intervention and treatment' thereb reducing serious ph sical and ps chological complications and decreasing the potential ris0 for relapse to manage weight% Eating disorder screenings are not designed to establish an eating disorder diagnosis but instead to identif the need for additional ps chological and medical assessments b a trained mental health clinician and medical personnel% The E"T.25 @Garner et al% -872A' or Eating "ttitudes Test' is a widel used screening tool that can help identif behaviors and s mptoms associated with eating disorder ris0 @Garner et al% -887A% It is recommended that a two.stage process be emplo ed using the E"T.25: screening followed b a clinical interview% )pecificall ' if the woman scores at or above a cutoff score of 2, on the E"T.25' she should be referred for a diagnostic interview% ;or a cop of the screening tool and scoring instructions' refer to "ppendi? C% ;igure 4.7 lists Euestions that probe for an eating disorder% " woman with an eating disorder often feels shame about her behavior' so the general Euestions help ease into the topic as the counselor e?plores the clientKs attitude toward her shape' weight' and dieting%

Screening by 2ealthcare (roviders in 8ther Settings 4ealthcare providers such as nurse practitioners' ph sicians' ph siciansK assistants' and social service professionals have opportunities to screen women to determine whether the use or abuse alcohol' drugs' or tobacco% The most freEuent points of entr from other s stems of care are obstetric and primar careH hospital emergenc roomsH probation officer visitsH and social service agencies in connection with housing' child care' and domestic violence% Bur own preconceived images of women who are addicted' coupled with a m th that women are less li0el to become addicted' can undermine clinical >udgment to conduct routine screenings for substance use% (etween 3 and 4, percent of people seeing ph sicians andCor reporting to hospital emergenc rooms for care have an alcohol use disorder @Chang -886A' but ph sicians often do not identif ' refer' or intervene with these patients @Quehn 2,,7A% Even clinicians who often use the C"GE or other screening tools for certain patients are less li0el to as0 women these Euestions because womenYparticularl older women' women of "sian descent' and those from middle and upper socioeconomic levelsYare not e?pected to abuse substances @Chang -886A% Dol0 and colleagues @-885A found that' among primar care patients who were identified as 9at ris0: for alcohol abuse or dependence b a screening Euestionnaire' men were -%3 times as li0el as women to be warned about alcohol use and three times as li0el to be advised to stop or

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modif their consumption% 2omen ma be less li0el to have problems with alcohol or drugs than men @Qessler et al% -884' -883AH however' when women have substance use disorders' the e?perience greater health and social conseEuences% )creening must lead to appropriate referrals for further evaluation and treatment in order to be worthwhile% 1issed opportunities can be especiall unfortunate during prenatal care% In one stud of ethnicall diverse women reporting to a universit .based obstetrics clinic' 37 percent screened positive for ps chiatric disorders andCor substance abuse% 4owever' onl 43 percent of those who screened positive had s mptoms recorded in their chart' and onl 23 percent of those screening positive were given treatment% This low rate of treatment is of great concern' given the untoward conseEuences of substance use for maternal and infant health @Qell et al% 2,,-A% To address the disconnection that often happens @beginning with the lac0 of identification of substance. related problems of the patient and e?tending to the failure of appropriate referrals and brief interventionsA' )"14)" has invested in the )creening' (rief Intervention' and /eferral to Treatment Initiative @)(I/TAY research' resources development' training' and program implementation across healthcare settings% "lthough studies have not focused on gender comparisons' )(I/T programs have ielded short.term improvements in individual health @for review' see(abor et al% 2,,6A% )pecificall ' some )(I/T programs on the )tate level have tailored )(I/T to provide assistance to pregnant women @<ouisiana !epartment of 4ealth and 4ospitals 2,,6A%

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Anne# & : Assessment tools Choosing an Instrument )ome instruments are clearl for screening' and others are clearl for assessment% )till others are sometimes used for either purpose% (efore choosing an instrument' read its stated purpose' statistical properties @norming and standardiGation populations' reliabilit ' validit A and 0now our population of focus and purpose @eligibilit determination' screening or assessmentA% IndividualiGe our choices based upon our population' purposes' and circumstances% Bn the T" &artnershipKs 1ental 4ealth 2eb page' there is a list of .ental 2ealth and Substance Abuse Screening Instruments % The page lists screening instruments' the developerCpublisher' purpose' age of the covered population' and where to obtain further information% .ental 2ealth Screening and Women 2omen need to be routinel screened for depressive' eating' and an?iet disorders including &T)!%

2omen tend to report higher levels of an?iet and somatic s mptoms associated with depression% E?plicit details' especiall related to traumatic sub>ect matter that ma uncomfortable' are not necessar earl in the process% ma0e a woman

;or some women' drugs have had a secondar effect and purpose' i%e%' weight management% (e aware that weight gain during recover can be a concern and a relapse ris0 factor for women and that clinical and medical issues surrounding bod image' weight management' nutrition' and health lifest le habits are essential ingredients in treatment for women% (ulimia nervosa is the most common eating disorder among women in substance abuse treatment' and counselors should become 0nowledgeable about the specific behavioral patterns associated with this disorder' e%g%' compensator and e?cessive e?ercise for overeating' routine pattern of leaving after meals' persistent smell of vomit on the womanKs breath or in a particular bathroom' ta0ing e?tra food @from dining roomA' or hoarding food' etc% (e aware that women with bulimia nervosa are usuall of normal weight%

The following section reviews core assessment processes tailored for women' including gender.specific content for biops chosocial histories and assessment tools that are either appropriate or possess normative data for women in evaluating substance use disorders and conseEuences% It is be ond the scope of this chapter to provide specific assessment guidelines or tools for other disorders outside of substance.related disorders% General Guidelines for Selecting and @sing Screening and Assessment %ools

2hat are the goals of the screening and assessment= Is the screening and assessment process appropriate for the particular setting= 2hat costs are associated with the screening processH e%g%' training' bu ing the screeningCassessment instruments or eEuipment @computerA' wages associated with giving and scoring the instrument' and time spent providing feedbac0 to the client and establishing appropriate referrals=

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2hat other staff resources are needed to administer and score the instrument' interpret the results' review the findings with the client' arrange referrals' or establish appropriate services to address concerns highlighted in the screening and assessment process= 2hile screening measures can be completed in >ust a few minutes' positive screenings involve more wor0% !oes staff see a need for and value of the additional wor0= !id ou prepare and train staff= 2hat strategies did ou emplo to obtain staff or administrative bu .in= 2hat other obstacles have ou identified if the screening is implemented= 4ave ou developed strategies to target their specific obstacles= !o ou have a s stem in place to manage the results of the screening and assessment process=

*ote: 2hile formal assessment tools are consistentl used in research associated with substance use disorders' treatment providers and counselors are less li0el to use formaliGed tools and more li0el to onl use clinical interviews @"llen -88-A% The standardiGation of formal assessment measures offers consistenc and uniformit in administration and scoring% If the implementation of these tools is not cost prohibitive and staff maintain adherence to administration guidelines' formal assessment tools can be easil adopted regardless of diverse e?perience' training' and treatment philosoph among clinicians% Nsing ps chometricall sound instruments can offset clinical bias and provide more credibilit with clients% The focus of the assessment ma var depending on the program and the specific issues of an individual client% " structured biops chosocial histor interview can be obtained b using The &s chosocial 4istor @&)4A assessment tool @Comfort et al% -885A' a comprehensive multidisciplinar interview incorporating modifications of the "ddiction )everit Inde? @")IA designed to assess the histor and needs of women in substance abuse treatment% Investigators have sought to retain the fundamental structure of ")I while e?panding it to include famil histor and relationships' relationships with partners' responsibilities for children' pregnanc histor ' histor of violence and victimiGation' legal issues' and housing arrangements @Comfort and Qaltenbach -885A% &)4 has been found to have satisfactor test.retest reliabilit @i%e%' the e?tent to which the scores are the same on two administrations of the instrument with the same peopleA and concurrent validit with the ")I @Comfort et al% -888A% (sychosocial and Cultural 2istory Treatment programs have their own prescribed format for obtaining a ps chosocial histor that coincides with )tate regulations as well as other standards set b Voint Commission on "ccreditation of 4ealthcare BrganiGations @VC"4BA and Commission on "ccreditation of /ehabilitation ;acilities @C"/;A% 2hile man )tates reEuire screening and assessment for women' specific guidelines and specificit in incorporating women.specific areas var in degree @C)"T 2,,6A% >ote: 2hen using information across )tate standards' the following ps chosocial and cultural subheadings should be included in the initial assessment for women' and these areas need to be addressed in more depth as treatment continues% =eep in mind that the content within each subheading does not represent an entire psychosocial and cultural history" 8nly biopsychosocial and cultural issues that are pertinent to women were included in the list below" 2edical 'istory and Physical 'ealth: /eview 4IDC"I!) status' histor of hepatitis or other infectious diseases' and 4IDC"I!) ris0 behaviorH e?plore histor of g necological problems' use of birth control and hormone replacement therap ' and the relationship between g necological problems and substance abuseH obtain histor of pregnancies' miscarriages' abortions' and histor of substance abuse during pregnanc H assess need for prenatal care%

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Su stance A use 'istory: Identif people who initiall introduced alcohol and drugsH e?plore reasons for initiation of use and continued useH discuss famil of origin histor of substance abuse' histor of use in previous and present significant relationships' and histor of use with famil members or significant others% 2ental 'ealth and ,reatment 'istory: E?plore prior treatment histor and relationships with prior treatment providers and conseEuences' if an ' for engaging in prior treatmentH review histor of prior traumatic events' mood or an?iet disorders @including &T)!A' as well as eating disordersH evaluate safet issues including parasuicidal behaviors' previous or current threats' histor of interpersonal violence or se?ual abuse' and overall feeling of safet H review famil histor of mental illnessH and discuss evidence and histor of personal strengths and coping strategies and st les% Interpersonal and Damily 'istory: Bbtain histor of substance abuse in current relationship' e?plore acceptance of clientKs substance abuse problem among famil and significant relationships' discuss concerns regarding child care needs' and discuss the t pes of support that she has received from her famil andCor significant other for entering treatment and abstaining from substances% Damily, Parenting, and "aregiver 'istory: !iscuss the various caregiver roles she ma pla ' review parenting histor and current living circumstances% "hildren$s Developmental and Nducational 'istory @applicable to women and children programsA: "ssess child safet issuesH e?plore developmental' emotional' and medical needs of children% Sociocultural 'istory: Evaluate clientKs social support s stem' including the level of acceptance of her recover H discuss level of social isolation prior to treatmentH discuss the role of her cultural beliefs pertaining to her substance use and recover processH e?plore the specific cultural attitudes toward women and substance abuseH review current spiritual practices @if an AH discuss current acculturation conflicts and stressorsH and e?plore need or preference for bilingual or monolingual non.English services% Qocational, Nducational, and 2ilitary 'istory: If emplo ed' discuss the level of support that the client is receiving from her emplo erH review militar histor ' then e?pand Euestions to include histor of traumatic events and violence during emplo ment and histor of substance abuse in the militar H assess financial self.reliance% Legal 'istory: !iscuss histor of custod and current involvement with child protective services' if an H obtain a histor of restraining orders' arrests' or periods of incarceration' if an H determine histor of child placement with women who ac0nowledge past or current incarceration% 7arriers to ,reatment and Oelated Services: E?plore financial' housing' health insurance' child care' case management' and transportation needsH discuss other potential obstacles the client foresees% Strengths and "oping Strategies: !iscuss the challenges that the client has faced throughout her life and how she has managed them' review prior attempts to Euit substance use and identif strategies that did wor0 at the time' identif other successes in ma0ing changes in other areas of her life% Assessment %ools for Substance @se Disorders Addiction Severity Inde( AASI*: The ")I @1c<ellan et al% -87,A is the most widel used substance abuse assessment instrument in both research and clinical settings% It is administered as a semi.structured interview and gathers information in seven domains @i%e%' drug use' alcohol use' famil Csocial' emplo mentCfinances' medical' ps chiatric' and legalA% The ")I has demonstrated high levels of reliabilit

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and validit across genders' racesCethnicities' t pes of substance addiction' and treatment settings @1cCus0er et al% -884H 1c<ellan et al% -873H Ranis et al% -884H )ee"ppendi? C for specific information on the ")IA% ASI5D @C)"T -886cA: The ")I.; is an e?panded version of ")IH several items were added relevant to the famil ' social relationships' and ps chiatric sections% "dditional items refer to homelessnessH se?ual harassmentH emotional' ph sical' and se?ual abuseH and eating disorders% The supplemental Euestions are as0ed after the administration of ")I% &s chometric data for ")I.; are limited% ,e(as "hristian Bniversity 7rief Intake, the "omprehensive Intake, and Intake for #omen and "hildren: These instruments are available electronicall and are administered b a counselor% The seven problem areas in the (rief Inta0e Interview were derived from the ")I: drug' alcohol' medical' ps chological' emplo ment' legal' and famil Csocial% )coring is immediate' and the program generates a one.page summar of the clientKs functioning in -4 domains @Voe et al% 2,,,A% The Comprehensive Inta0e has an online version for women @)impson and Qnight -886H ;or review' visit: http:CCwww%ute?as%eduCresearchCcswrCnidaCinstrument<isting%htmlA% )ince women are more li0el to e?perience greater conseEuences earlier than men' using an instrument that highlights specific conseEuences of use is crucial% Drinker Inventory of "onse-uences ADrin"*: This measurement is a self.administered 3,.item' true.false Euestionnaire that elicits information about negative conseEuences of drin0ing in five domains: ph sical' interpersonal' intrapersonal' impulse control' and social responsibilit @1iller et al% -883A% This instrument has normative data for women' men' inpatient and outpatient' and has good ps chometric properties% )ince women are more li0el to e?perience greater conseEuences earlier than men' using an instrument that highlights specific conseEuences of use is crucial% " version that assesses drug use conseEuences is also available @Tonigan and 1iller 2,,2A% ;or a cop of the assessment tool' scoring' and gender profile in interpreting severit of lifetime conseEuences' see "ppendi? C% .easurements of spirituality and religiousness )piritualit and religion pla an important role in culture' identit ' and health practices @1usgrave et al% 2,,2A% In addition' people are li0el to embrace different coping strategies @including emotional outlets and religionA to assist in managing life stressors @!ennerstein 2,,-A% &ractices such as consulting religious leaders or spiritual healers @curanderas' medicine menA and attending to spiritual activities @including sweats and pra er ceremonies' pra ing to specific saints or ancestorsA are common% The consensus panel believes it is important that programs assess the spiritual and religious beliefs and practices of the individual and incorporate this component into their treatment with sensitivit and respect% " challenge in determining the effect of spiritualit on treatment outcomes is how to assess the e?tent and nature of a personKs spiritualit or religiousness% )everal assessment tools are availableH however' the are more often used for research% The include' but are not limited to' the /eligious &ractice and (eliefs measurement @C")"" 2,,4A' a -8.item self.assessment tool that reviews specific activities associated with religious practicesH the 1ultidimensional 1easure of /eligiousnessC)piritualit ' an assessment device that e?amines domains of religious or spiritual activit such as dail spiritual e?periences' values and beliefs' and religious and spiritual means of coping @;etGer Institute -888AH and the )piritual 2ell. (eing )cale' a 2,.item scale that e?amines the benefits of spiritualit for "frican."merican women in recover from substance abuse @(rome et al% 2,,,A%

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2ealth Assessment and .edical E#amination with women (ecause women develop serious medical problems earlier in the course of alcohol use disorders than men' the should be encouraged to see0 medical treatment earl to enhance their chances of recover and to prevent serious medical complications% 4ealth screenings and medical e?aminations are essential in womenKs treatment% In particular' women entering substance abuse treatment programs should be referred for mental health' medical' and dental e?aminations% In man cases' the ma not have had adeEuate health care because of lac0 of insurance coverage or transportation' absence of child care' lac0 of time for self.care' chaotic lifest le related to a substance abuse' or fear of legal repercussions or losing custod of children% The acute and chronic effects of alcohol and drug abuse' the potential for violence' and other ph sical hardships @e%g%' homelessnessA greatl increase the ris0 for illness and in>ur % 2omen ma practice behaviors that put them at high ris0 for contracting se?uall transmitted diseases @)T!sA and other infectious diseases @Greenfield -885A% Testing for 4IDC"I!)' hepatitis' and tuberculosis is importantH however' it is as essential to have adeEuate support services to help women process test results in earl recover % "nticipation of the test results is stressful and ma place the client at ris0 for relapse% /esidential centers ma offer medical e?ams onsite' but outpatient service providers ma need to refer patients to their primar care provider or other affordable health care to ensure that each client has a thorough medical e?am% 4ealthcare professionals ma benefit in using the 2omen.)pecific 4ealth "ssessment @)tevens and 1urph -887A' which assesses health and wellness and addresses g necological e?ams' 4IDC"I!)' drug use' )T!s' pregnanc Cchild deliver histor ' famil planning' mammograph ' menstruation' disease prevention' and protection behaviors%

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Anne#* : 2ow to deal with an e#istential crisis

2ow to Deal with an E#istential Crisis

2IQI4B2 "/TIC<E Edited b (ill Foung' Qr stle C%' Imperatri?' (en /ubenstein and 44 others "n e?istential crisis can occur when the answers to the Euestions about the meaning and purpose of life @as well as our place in itA no longer provide satisfaction' direction or peace of mind% 2hen ou find ourself contemplating life' not 0nowing what illusor fulfilment ouIre see0ing' it can get prett mentall hectic% (ut with a little purpose and determination' itIs eas to become all the better for itP

Steps

$" -ecogni<e that you4re having an e#istential crisis" If ouIre Euestioning the meaning or purpose of our e?istence' or if the foundations of our life seem sha0 and transient' ou might be e?periencing a crisis @usuall called Je?istentialJ because it relates to ideas e?plored b the philosophical school of e?istentialismA' which ma result from: . The sense of being alone and isolated in the world . " new.found grasp or appreciation of oneIs mortalit . (elieving that oneIs life has no purpose or e?ternal meaning

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. "wareness of oneIs freedom and the conseEuences of accepting or re>ecting that freedom . "n e?tremel pleasurable or hurtful e?perience that leaves one see0ing meaning% &" Choose the meaning of your life" E?istentialism posits that each individual is empowered to choose the parameters of his or her e?istence% Choosing to add meaning to our life yourself' without the help of an one else' can ultimatel help ou resolve an e?istential crisis% (elow are some methods that can help% .ethod $ of &: %he 1ast .essiah .ethod *orwegian philosopher &eter 2essel Rapffe contends that the human self.conscious is activel engaged in the Jrepression of its damaging surplus of consciousness'J and offers four wa s of doing so% The are: -% Isolation: !ismiss all upsetting or negative thoughts and feelings from our consciousness and activel den them% 2% Anchoring: Combat feelings of isolation b JanchoringJ our consciousness to fi?ed values or ideals' such as JGod' the Church' the )tate' moralit ' fate' the laws of life' the people' the future%J ;ocusing our attention on these things @whether ou support or contradict themA can help ou feel li0e our consciousness is not adrift' or as Rapffe said' build Jwalls around the liEuid fra of consciousness%J 3% Distraction: Qeep our thoughts from turning to distressing ideas b filling our life with distractions% ;ocus all our energ on a hobb ' pro>ect' >ob' or other outlet that can consume our thoughts 4% Sublimation: /efocus our energ toward positive creative outlets' such as music' art' literature' or an other activit that ou find allows ou to e?press ourself% .ethod & of &: 8ther .ethods $" @nderstand what caused the problem" The issue is not our thoughts Y it is our attachment to the thoughts% Four thoughts @and the language in which ou e?perience themA come from our conditioning' our societ ' our reaction to e?periences% &" %ry to see life and your place in it as it really is" Wuestion ever thing and attempt to see past all social' political' spiritual and personal conditioning and falsehoods% *" Ac nowledge that this is a common problem" Qnow that we humans often feel that we are stuc0 in a game designed and controlled b others who do not have our or humanit Is best interests in mind% 2hen ouIre in crisis' it loo0s li0e others succeed through ignorance' fear and the abilit to lead ou around b the nose% /esearch the histor of civiliGation and how this rat race began' and how it is perpetuated' then begin to formulate our own understanding as to where it ma be heading% 0" Consider how well orchestrated life seems to be" )ome t pe of consistenc does appear to e?ist' at least on a micro level% I" Stop comparing yourself to others" Four abilit to e?perience >o will grow dramaticall when ou stop comparing ourself to other people and onl compare ourself to ourself' if to an one at all% In an ironic twist of fate' this can be achieved incrementall b holding a more stoic sub>ectivit % J" Don4t be afraid to ma e up your own rules" /emember to let go of JshouldJ Y ou are in charge% @This message is a JshouldJ' so ta0e it with a grain of salt%A Fou are the lightning of our values' and donIt forget that' ultimatel ' value is geneticall grounded in the bod ' even if it appears to be emotion% If ou feel an?iet about Jwhat to doJ' now that nobod else is telling ou what to do' thatIs the most e?citing

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part of the >ourne %%% remember childhood= 1 ster = "dventure= )melling new smells and feeling new fabrics= *ew foods= !o something to improve our e?perience of >o % K" %ry to voice what your problem is" )ome people write full.length sentences to help determine what their issues are% Bthers start b writing a poem in order to get their thoughts and feelings flowing% <ater' ou can elaborate in prose% L" Imagine several different people you li e or respect giving you advice"!onIt pic0 an one abusive% Tr 1r% /ogers' our first grade teacher' or that person ou had a crush on in 8th grade% The donIt help ver much' do the = (ut itIs fun tal0ing to them% M" Imagine giving advice to someone else in your situation" 2ould ou still thin0 this was as big a problem= $P " (roblem solve" If ou canIt figure out our problem' that means itIs legitimate% If our solution involves ma0ing big changes' ta0e a few da s to thin0 about it% If ou canIt do an thing about our problem right now' accept it% If itIs late' go to sleepH if ou canIt sleep' find something to do that does not involve a television or computer screen @blue light causes insomniaA% FouIll want to go to sleep later% If itIs da time' get some e?ercise or finish our >ob% (e professional% " few successes never hurt an one% $$" %a e what you4ve learned" If after e?hausting research ou still feel unsatisfied' ou still have gained a lot of insight into the philosoph of the situation% Fou must 0now b now that a will to truth is absurd @to use the terminolog A% )ince we trul donIt 0now whether there is meaning to e?istence or not' we can alwa s fall bac0 on ris0 assessment% If ou put life and death in two columns' and meaningfulCmeaningless e?istence into two rows' ou will find that living out the rest of our life is the best option @no matter what horror e?istence ma beA% $&" Aim to create peace and :oy" In whatever situation ou find ourself' do no harm to ourself or othersH even though sometimes it hurts' it will pass% ;ind meaning in the simple pleasures of life through our senses% )top to smell the roses' feel the sunlight' taste the food' see the beaut and listen to our heart calling% Fou can create our own meaning for ourself and our own life% "fter all' it is our life' our game' our e?periment% &la our game with respect for others' and deal with our circumstances to the best of our abilit % To reall succeed' respectfull enlist the help of others% $*" Clean whatever room you4re in" This will help ou clarif our power over the world and give ou a few minutes to do some basic problem.solving% !onIt >ust straighten things up' clean% Nse a cleaning product% $0" -emember that tomorrow is a new day" ItIs another opportunit for ou to ma0e changes in our life to see0 happiness and self.fulfillment% This power is ours Y claim it%

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%ips
(reathe deepl through our nose and out through our mouthH shallow breaths through the mouth are a signal of panic% "uthors that have dealt with such sub>ects include *ietGsche and Camus% !epending on who ou are' reading these people ma ma0e ou feel worse or better% !onIt be afraid to laugh and ma0e fun of ourself% ItIs a good wa to find out who ou reall are% This practice gives ou a true sense of personal freedom% This is also a good wa to clarif whatIs reall important% If ou find it difficult to laugh at something' our problem is much bigger than ou originall imagined% "ccept the things @and peopleA ou cannot change or control% Choose to live' forgive' learn' love and prosper% In fact' donIt be afraid at allP *o matter how tempting it ma be' donIt ta0e our insecurit out on others% If ou thin0 ou suc0' thatIs for ou to handle% Tearing other people down isnIt going to change how ou feel about ourself' no matter how often ou tr % Ta0e care of our bod % !rin0ing more water can combat headaches and changes in mood and improve brain function% Ta0ing a wal0 can provide ou with a new perspective and a boost of endorphins% Eat real food' and drin0 plain filtered water% 1editate%

Warnings
!onIt resort to alcohol or drug abuse to cope with our crisis% "lthough the might seem to provide momentar relief' these compulsive behaviors will onl add to our suffering in the long run and ma0e it considerabl more difficult to grow and to improve our life% 2hatever ou do' donIt 0ill' cut' or maim ourself% !onIt ma0e an permanent changes because of temporar problems: destro ing the onl cop of our novel or getting a facial tattoo is unacceptable% If ou want to get in a fight with our parents' d e our hair blue% /espect the e?istence of others% If there is someone or something stopping ou from achieving our goal' it is best to determine a mutuall beneficial course of action% In other words' 0illing' maiming' or otherwise harming people is an unacceptable practice that ma lead to our own undoing% <ive and let live' bab % (esides' if ou thin0 that life stin0s' now' ouIve not been to prison% If ou reall feel that life is more meaningful through suffering' then simpl ignore this tip and get on with it% FouIll find some ver heav dut meaning on the inside' certainl % !onIt hesitate to call hotlines% The are there for the benefit of people who have similar difficulties% <ife is hard% 4elp others' and as0 for help when ou need it%

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Anne#0: 2ow to help a friend with depression

2ow to 2elp a 9riend with Depression

2IQI4B2 "/TIC<E Edited b !avid V' Dersagee0' 4alf&int8-33' TheQnowerBf)tuff and 35 others !epression% 2eIve all heard of it% 1ost of us will come into contact with it at some point in our lives% !epression is a ver difficult serious disorder and miserable e?perience for someone to go through' and itIs something that either ou or someone ou care about will have to deal with% 4owever' it isnIt >ust the victims who are impacted% 2hat about their friends= Dictims of depression need stead ' supportive friends to rel on in their times of need% If ouIre the friend of a depression victim and are confused and donIt 0now what to do or how to help them best' then worr no longer% This article is for ou%

Steps
-% "c0nowledge% Tell the person suffering from depression that ouIve noticed that the seem down or depressed latel % @Nnless the have alread told ou that the are suffering from depression%A If so' tell them that since ou now 0now that the Ire sad that ou want to help% This will be ver re. assuring to them% )ometimes the depressed donIt even feel li0e telling an one because of the stigma associated with depression% "lso' ma0e them feel li0e the are needed% Tal0 to them when ou are upset about something or when ou want to vent% Trust them with things that ou wouldnIt tell >ust an one else% This ma0es them feel ver important to ou% !epression lies to them and ma0es them feel li0e the arenIt needed b an one% This ac0nowledgment that ou 0now how bad the feel ma be the little JpushJ the need to start tal0ing about it' and ma be even see0 help% 2% 2hat not to do: &retend li0e it is not there or that this is not a serious condition% This is debilitating for a person% The canIt help it% This will ma0e them feel li0e the are insignificant and that ou donIt even ta0e their problem seriousl % 3% ;ind out wh our friend is depressed% !id the >ust have a bad brea0.up or did their parents get divorced= Br are the >ust simpl mad or disappointed with life and the world= "s0 them what ou can do to help% "s0 carefull and gentl ' and donIt get upset if the Ire slow to tell ou% )ome people ta0e longer than others to tal0% If the do tell ou a list of things ou can do' then do them% Nsuall if the answer a Euestion li0e this in full the absolutel genuinel need those things from ou% 2hat not to do is to as0 that and the answer and not carr those things out% This will >ust send them bac0 into a deeper state of their depression because once again' the have been let down% Especiall since it would be b someone so close as their best friend' it could be ver damaging% 4% 2hat not to do: If the tell ou wh the are depressed' or wh the thin0 the are% @sometimes people donIt even 0now what causes their s mptoms%A (e sure to ta0e those reasons seriousl % !onIt >o0e around with them% !o not bring them up in a light hearted conversation' because this can cause a wave of emotions associated with that topic' altering their mood for the worst% !o not bring up what the have told ou in trust' in front of other people% This is ver ver damaging to the friendship and to the person%

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3% <isten% "lthough ou ma thin0 that the last thing our friend wants to do is tal0 to ou about depression' ou could be wrong% )ometimes a friend >ust needs someone to tal0 to% "ctivel listen to them without >udging or giving advice% !epression is an issue that people sometimes feel the must hide' in order to maintain their usual life% (ecause people see it as a wea0ness or a cr for attention the feel li0e not telling an one% This is wrong though' the depressed person would li0e nothing better than to feel happ again and be themselves% Either that or the are onl >ust coming to terms with it' let alone the idea of letting other people in on it% 4owever' from time to time' our friend ma open up' or e?press the desire to tal0 to ou% )ometimes the >ust want to vent% !onIt start spitting out possible solutions until ou 0now the full e?tent of the problem% " good listener can sometimes be vastl more helpful than someone who tries to offer solutions% 2hen this happens' be understanding and 0ind and willing to listen% This means a lot to them% This also should mean a lot to ou because the are trusting ou with something so personal thatIs affecting them% !onIt interrupt' donIt tr to convince them the Ire wrong' donIt give advice and tr not to react in horror% It can be difficult to hear about how terrible our friend feels' but remember that the Ire trusting ou% Dalue this trust' donIt brea0 it and 0eep it close% Vust be there to listen% ThatIs the number - thing the need right now% 5% 2hat not to do: !onIt ma0e >o0es when the are tal0ing to ou% This ma0es them feel li0e ou donIt see their feelings as legitimate or serious% Fou ma be tr ing to help b lightening the mood but it is not good for the depressed person% !o not tell them >ust to J(e happ %J Br J2h canIt ou >ust be happ for once=J or J<ighten up%J J2ill ou ever stop being li0e this=J JItIs getting anno ing%J This will not encourage them at all% Bnce again this ma0es them feel li0e ou arenIt even listening and it ma0es them feel li0e their issues donIt matter which could lead to them feeling li0e their whole self doesnIt matter to ou% !onIt tell our friend to stop being depressed or be happier% This is out of their control% !epression is a sic0ness' not a choice% " depressed mind is the most sensitive mind% /emember that% 6% Tr to understand% Ever personIs stor is different' and so it is impossible to completel understand% !epression is a ver comple? and complicated disease% )o it is o0 for ou not to understand where the are coming from% 4owever' 0eeping an open mind and putting ourself in our friendIs shoes can help ou come closer to them% Bnce ouIve done our research on depression' ou should 0now a lot more about the disorder% "ppl the s mptoms and emotions to ourself' and contemplate how ou would feel if this was happening to ou% Call upon things our friend has done or told ou' and tr to understand wh and what the mean% In times of need' having someone understand or tr too' can be all the relief in the world% 7% 2hat not to do% !onIt tell our friend that life is still worth living and that this situation will improve and the sadness will get better% This trivialiGes their pain and will not help% !o not tr to ma0e them feel better b reminding them how much better their lives are than other peopleIs% The 0now that and it ma0es them feel guilt about their condition because the feel li0e the should >ust be able to be grateful for life because the have it better than a lot of people et the canIt seem to do it% !onIt as0 them to Jcheer upJ or Jsnap out of itJ% &eople with depression arenIt capable of >ust doing it so simpl ' so be sensitive to that% ItIll onl ma0e them feel more guilt about their condition% *EDE/ tell them that their problems are stupid or that there is nothing to worr about% The Ill stop tal0ing% This can lead them to more suicidal tendencies%

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8% (e There% 1ost importantl is to >ust be there for our friend% (e ver genuine and donIt lie to them% !onIt tell them things and not trul mean it% )ometimes the can tell and this will hurt them greatl % This a time when the are their lowest point in life% Especiall if the are a teen battling with depression% (ecause the are wasting awa their most precious ears' and this also ma0es them sad and guilt because the feel li0e the canIt >ust en>o their life% Things ou can do to ma0e them 0now that ou are there is to obviousl tell them that% Fou could sa something li0e JI am here for ou and whenever ou feel li0e tal0ing IIll alwa s be willing to listen and to tr X understand%J )ometimes' the thing the need most is >ust a simple hug and a JI am here for ou% Ever thing is going to be o0%J "lso let them 0now that ou value their friendship and that ou care about their life% The depression can cause them to feel worthless and not needed% The need to be re.assured that the matter to ou and that ou want to help them through this% <et them 0now that the arenIt wea0 or worthless because the ma feel li0e this because of societ and itIs view on this serious disorder% If ou honestl mean it and can do so with an open heart' offer to be there 24C6% Tell them that ou welcome their phone calls at all hours% Fou will rarel ' if ever' receive a middle of the night call% (ut a sincere offer sends a message of support that will be heard% If ou see them in public places' ma0e sure to sa hi and notice them% !onIt pretend li0e ever thing is o0 though' alwa s remember that% "s0 them how the feel toda and be sure to pa attention to them from time to time because the feel alienated from people when out in the world% !o these things because the feel completel alone and isolated% This is a ma>or side effect of depression and causes lots of suicidal thoughts and tendencies' especiall in teenagers% 4ug them' hold their hand' ph sical contact is good for people that are suffering from depression% It ma0es them feel better and comforted' and safe' so do those things as often as ou can% Tell them that ou love them and care for them% Give them a shoulder to cr on% (e there% -,% 2hat not to do: !onIt sa ou will be there for them and then not be there% This will be ver damaging to them% (ecause the have been let down once again% "lso' do not ignore them% If the want to tal0 >ust to chat or want to tal0 heart.to.heart' respondP The feel li0e ou donIt care in the least when the get nothing from ou% If ou canIt tal0 or are tired' sa that% !onIt ever leave them in the dar0% This causes them to worr even more than the alread are% "nd ta0es a toll on their insecurit % !onIt do things half.heartedl % Bne of the main reasons people get depressed is because the seem to feel li0e the care too much or the love people too hard% "nd the get sad because the feel li0e the are the onl ones being genuine% )o do not do things in vain with them% It will damage them greatl % --% (e patient% (ecause depression is heav ' slow moving and unpredictable' it can frustrate and even anger those who are tr ing to help% /emember that depression is a comple? disorder' and tr to understand that the depressed person is not herself or himself right now% If our friend doesnIt seem to appreciate our efforts' or is pushing ou awa ' donIt wal0 off in a temper% Give them space or give them comfort if the need it' and be there for them' no matter how much the believe ou donIt need to be% -2% !onIt push too hard% If it ma0es our friend feel worse to face up to their problems' do not force them to continue% )ometimes anal Ging a personIs past can ma0e them feel worse about themselves and dredge up past traumas% In this case' focus on how the feel now and how the want to be in future' and forget whatever caused them to feel depressed% <eave it in the past until the are read to either deal with it or let it go% (e gentle% !epression can be dar0' confusing and

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angr ' but it can also be tender' hurtful and full of sensitive tears% !onIt ell or be rough.0eep our voice and bod language soft and donIt force our friend into an thing% -3% )ta in contact% Chec0 in% Call them >ust to call them% Chec0 up on them occasionall ' esp% at night when the depression is at its worst% Te?t them occasionall >ust to sa ou are thin0ing about them and as0 how the feel toda % This means the world to them and ma0es them feel li0e the matter and re.assures them that ou care and causes them to feel more at ease% )upport them and as0 what ou can do to help' of course% 2hen the have severe depression' often times the will confess to ou that the sometimes want to >ust die% (ut the actuall donIt% 1ost of these happen while driving% )o as0ing them a Euic0 J"re ou home and o0=J 2ill ma0e them feel ver cared for% Fou donIt want to be that person finding out something terrible >ust because ou arenIt worr ing about them% 1a be even give them a card or bring them lunch or ta0e them to a movie% This means so much to someone who is depressed% Fou wonIt believe how it will uplift their mood% It ma0es them feel significant% -4% 2hat not to do: Is ignore them or blow them off% If ou canIt do something tell them% "nd donIt sa ou will do things and not do it% ;or e?ample: JI will call ou later tonight%J and then not% or JI am going to get ou somethingPJ and then not% This ma0es them feel li0e ou are >ust sa ing that in the moment and donIt even bother to do it later% -3% Ta0e care of ourself% Fou have to be mindful of ourself and our mind to in helping this friend% It can ta0e a toll especiall if the are ver need % If ou need to ta0e brea0s then tell them that% /emember though' do not ignore them% Go have fun with other friends' and en>o our life too% (ut ou have to remember that depression is not them% Four friend will eventuall come out of this' and become the person ouIve grown to love and have fun with% Vust give them time and have patience% -5% It is o0 to have funP *ot ever thing has to be so serious all the time' even with depression% Especiall if the are alread on medication% )ometimes the feel completel up to >ust doing an thing and having mindless fun% Vust be aware that their mood can alter for no reason' and do not get mad at them for it% The canIt help it% Vust be there for them if that happens% -6% Encourage our friend not to abuse drugs% &eople with depression can be much more vulnerable to the negative effects that occur when recreational drugs wear off% If our friend is ta0ing antidepressant or anti.an?iet medication' encourage them not to ma0e an changes without tal0ing to their doctor or ps chiatrist% Ta0ing more than the were prescribed can be dangerous' and going off the medication suddenl ma ma0e them feel much worse% "void alcohol as well . nobod is going to conEuer depression with a hangover% -7% "dvise them to see0 professional help% The ma den that the need it' or tell ou that JitIs o0a J or the Ill be JfineJ% If the react this wa ' stop pestering them about it for a while% Bver time' the idea might grow on them% !epression is not something that goes awa b itself after a while% This is probabl the most difficult step% (e sensible% If ou friend is sounding li0e the are harming themselves or are thin0ing of suicide' ou need to alert somebod % <isten out for suicidal li0e comments when the are tal0ing to ou% )uch as J I wish I were dead%J or JI donIt want to live an more% I feel useless%J IIm not good enough% These should be ta0en seriousl %

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-8% !epression is complicated% This is a lot to ta0e in% (ut if ou use this as a tool to help our best friend in need' ou will be surprised at how much little steps and things ou can do for them will greatl affect their disorder% 2hen the ma0e it out of their depression' the will be so grateful that ou pla ed a part in help guiding them out of it%

%ips
!o not tr to ma0e them feel better b reminding them how much better their lives are than other peopleIs% 2hen our friend is confiding in ou with their feelings' donIt start bringing up our own problems% This might ma0e them feel li0e their depression isnIt as important as our own problems and ma0e things worse% Qeep them tal0ing' tal0ing helps but give them wa s to wor0 out their problems privatel too' donIt force them to be dependent on ou% &eople can and do recover from depression% *ever lose sight of that' and without pushing it in the depressed personIs face' ma0e sure the remember it too% )ometimes venting to them might not be wise' as the Ire alread in a dar0 place and might not be able to handle someone elseIs troubles on top of their own% ;ollow the advice presented under *o%- with caution% Tr not to give them advice' tr to >ust guide them% If ou honestl mean it and can do so with an open heart' offer to be there 24C6% Tell them that ou welcome their phone calls at all hours% Fou will rarel ' if ever' receive a middle of the night call% (ut a sincere offer sends a message of support that will be heard% (e patient% !onIt involve other peers unless the person is happ with ou involving other people% "nd above all remind them that ou will alwa s be there for them% "nd if ou sa it' mean it% !onIt as0 them to Jcheer upJ or Jsnap out of itJ% &eople with depression arenIt capable of >ust doing it so simpl ' so be sensitive to that% ItIll onl ma0e them feel guilt about their condition% " lot of times depressed people >ust want to be alone' so donIt push% If ou can' tr to get them interested in going out with friends and doing things again% Even getting them to be happ again for a couple hours means there is still hopeP

Warnings
!onIt tell ou friend to stop being depressed or be happier% This is out of their control% 1an people with depression will turn down our offer of assistance% !onIt ta0e it personall % *ever tell them that their problems are stupid or that there is nothing to worr about% The Ill stop tal0ing% 1an suicide attempts happen when people begin to feel slightl better' rather than in their ver deepest depression% 2hen someone is at roc0 bottom the ma not have enough energ to do an thingH when their energ starts to return' that is when the ma ta0e action% )elf.harm could be the precursor to thoughts of suicide' so watch them closel and continue to provide gentle encouragement and reassurance% 4owever' self.harming does not definitel mean

2,,

that a person will become suicidal' it usuall indicates that a person has significant personal problems and ma simpl be a cr for help% If our friend does an of the following things' ou should call the *ational )uicide &revention <ifeline for referrals [-.7,,.263.T"<Q@7233A\ or see0 immediate help% Tal0s about Jwanting to die'J or Jwishing it was all over%J (egins stoc0piling medication' bu s guns or gets them out of safet loc0ers' or does an thing else to ma0e a suicide attempt easier% (egins giving awa possessions% 2rites notes to tr to Jtie things up'J even if the are not e?plicitl tal0ing about a potential attempt% (egins abusing drugs or alcohol' or eating dramaticall less% !epression is ver serious% It often ta0es a professional to ta0e care of it%

If ou believe our friend ma be at ris0 of harming themselves or others' ta0e them to their doctor or a drop.in accident and emergenc center%

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Sources: Crisis Training 1anual Tennessee !epartment of 1ental 4ealth and )ubstance "buse )ervices @T!14)")A' 6-, Vames /obertson &ar0wa *ashville' T* 36243 ( The T!14)") Crisis 2or0group: Trish 2ilson' &hillip Earhart' <iG <edbetter' 1ar )helton' T!14)") )taff 1elissa )par0s' !irector of Crisis )ervices' !ivision of 1ental 4ealth )ervices' 1ar !illon' "ssistant !irector of Crisis )ervices' !ivision of 1ental 4ealth )ervices' (ob Dander)pe0' Bffice of Consumer "ffairs @/etiredA' (ec0i &oling' !irector' Bffice of 4ospital )ervices' 1arthagem 2hitloc0' "ssistant Commissioner' !ivision of &lanning' /esearch' and ;orensics' < gia 2illiams' !ivision of 1ental 4ealth )ervices and Cind )need' former &resident of Crisis 1anagement Group' Inc% The Crisis Curriculum' a 1ental 4ealth 1anual' ( <arraine &ierce' 1innesota !epartment of 4uman )ervices http:CCcebmh%warne%o?%ac%u0CcsrCclinicalguideCris0assessment%html Centre ;or )uicide /esearch . Nniversit of B?ford 2orld 4ealth BrganiGation . The "lcohol Nse !isorders Identification Test . Guidelines for Nse in &rimar Care "udit ( Thomas ;% (abor' Vohn C% 4iggins.(iddle' Vohn (% )aunders and 1aristela G% 1onteiro http:CCwww%wi0ihow%comCDolunteer.at.a.Crisis.4otline http:CCwww%reddit%comCrC"s0/edditCcommentsC-s2>?7Cserious#suicide#hotline#operators#of#reddit#whatC http:CCwww%reddit%comCrCI"m"CcommentsCl4di7Ciama#phone#operator#at#a#suicide#hotline#amaaC http:CCwww%ma oclinic%comChealthCsupport.groupsC14,,,,2 http:CCwww%mindtools%comCstressC(rnCIntro&age%htm http:CCwww%ncbi%nlm%nih%govCboo0sC*(Q73233C *ational Center for (iotechnolog Information' N%)% *ational <ibrar of 1edicine 75,, /oc0ville &i0e' (ethesda 1!' 2,784 N)" http:CCwww%tapartnership%orgCcontentCmental4ealthCfaEC,-screening%php www%cisresponse%com www%icisf%org . Critical Incident )tress 1anagement @CI)1A &rogram Canada (order )ervices "genc . &acific /egion ( 1itchell' V%T% &h!' and Everl ' G%)% &h!' Critical Incident )tress !ebriefing: CI)! "n Bperations 1anual for the &revention of Traumatic )tress "mong Emergenc )ervice and !isaster 2or0ers% Ellicot Cit ' 1ar land: Chevron &ublishing Corporation 2nd Edition /evised . ICI); Internet )ite . " &rimer on Critical Incident )tress ( Vanelle X "ssociates . Canada Customs CI)1 Training and !evelopment Consultant www%dr>ohnmurph %com +2,-3 Vohn 1urph NC" (o? 48-3 Conwa ' "/ 62,33.,,,&h: 3,-.43,.343, email: >murph $uca%edu ( Vohn 1urph http:CCwww%drphil%comCarticlesCarticleC-3 . grieving

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http:CCwww%drphil%comCarticlesCarticleC2,3 . moving past a moment of crisis http:CCwww%drphil%comCarticlesCarticleC2,4 . Common signs and s mptoms of &T)! @( Glor A http:CCwww%md>unction%comCbipolarCarticlesCcommon.signs.and.s mptoms.of.ptsd TB"C 2eb )ite . powered b bravenet%com http:CCwww%newda newlesson%comCthe.best.wa .to.empower.someone.is.to.show.them.their.strengthsC ( )usie http:CCwww%wi0ihow%comCEmpower.&eople ( !ifu2u' !aniel (auwens http:CCtin buddha%comCblogCempower.others.and.ma0e.a.positive.difference.in.their.da C Empower Bthers and 1a0e a &ositive !ifference in Their !a ( "snat Greenberg . 4elping 4and http:CCwww%lifeoptimiGer%orgC2,-,C,3C-,Cempower.peopleC ( 1ar0 ;oo of 66 )uccess Traits &osted b !onald <atumahina http:CCwww%lifecoachingstudio%comCacom-3%htm The Coaching Clinic: Verome )hore . tel 4-5.676.3333 or coach$coachingclinic%com . @www%coachingclinic%com A% http:CCbetterlifecoaching%wordpress%comC2,--C,5C-6C3.tips.for.building.rapportC dand0po0e$bigpond%com%au http:CCwww%ehow%comChow#2,5,3-8#develop.collaboration.s0ills%html^i?GG-EbT24e>* 4ow to !evelop Collaboration )0ills e e4ow%com http:CCwww%reliableplant%comC/eadC-73,,Ca.to.G.strategies.for.building.collaboration ( Carol Qinse Goman% Carol Qinse Goman' &h%!%' is a 0e note spea0er and author of -, business boo0s% 4er latest is 9The *onverbal "dvantage: )ecrets and )cience of (od <anguage at 2or0:% Contact: editorial$tro media%com http:CCwww%collaboration%me%u0C4B22#(NI<!#CB<<"(B/"TIB*%php www%befrienders%org + The /o al College of &s chiatrists -886 (ereavement Information &ac0 ( Qate 4ill' Qeith 4awton' "slog 1almberg and )ue )im0in 4ow to Cope 2ith Emotional &ain ( !oris "nn @!EEA -2 Canadian Vournal of Connselling C /evue canadienne de counseling C -887' Dol% 32:"n Empowerment 1odel of Counsellor Education ( Ellen 4awle 1c2hirter . Nniversit of Bregon

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Ellen 4awle 1c2hirter' &h%!%' is an assistant professor in the counselling ps cholog program at the Nniversit of Bregon in Eugene% 4er research and scholarl interests include the career development of adolescents of color and applications of the construct of empowerment in counselling% "ddress correspondence to: Ellen 4awle 1c2hirter' &h%!%' Counseling &s cholog &rogram' !"(C)' College of Education' 323- Nniversit of Bregon' Eugene' B/ 864,3 323-% )erving se?ual assault survivors in the academic librar : Nsing the tools of crisis intervention and empowerment counseling in the reference interview b 2end )% 2ilmoth Georgia <ibrar Wuarterl spring 2,,7 . Georgia <ibrar "ssociation Empowering conversations: " /esource Guide for Team (uilding (etween ;amilies and &rofessionals to )upport "ction &lanning for Foung Children ( <aura (eard' <ead ;amil ContactH 1ichelle !ipbo e )ames' Earl Childhood Empowerment )pecialist' Qentuc0 Ks ) stem to Enhance Earl !evelopment' Qentuc0 &artnership for ;amilies and Children' Inc% Empowering <anguage http:CCseiGetruth%comCEmpowering<anguage%html Comm 2388: )pecial Topics in Communication: <istening *ine Tools of Empowered <istening http:CCfacult %stedwards%eduCterivCCB11T2,2388T2,<isteningC1cCalls#8#Tools#of#<istening%pdf ( Teri <% Darner' &h%!% "ssistant &rofessor of Communication and !r% Carol 1cCall )obell and )obell' +2,,7 1otivational Interviewing )trategies and TechniEues: /ationales and E?amples <a Counselling: " TrainerKs 1anual' developed b the !anish Cancer )ociet ' the 2ar Trauma ;oundation in the *etherlands' the Nniversit of Innsbruc0' "ustria and the /eference Centre for &s chosocial )upport of the International ;ederation of /ed Cross and /ed Crescent )ocieties' based in Copenhagen' is based on evidence.informed practice over man decades in la counselling and ps chosocial wor0' and has been researched and field.tested before publication% It is available online at http:CCwww%pscentre%org ' where ou will find lots of other interesting materials to e?tend 0nowledge about best practice in la counselling and which will be useful to ou and our organisation% The recover coach manual . The 1c)hin ;oundation . " /ecover /esource ;oundation V% !aniel &a ne E?ecutive !irector . Vohn )hinholser &resident 23,, !umbarton /oad /ichmond' D" 23227 @7,4A 248.-743 info$mcshin%org . www%mcshin%org http:CCmcshinfoundation%orgCsitesCdefaultCfilesCpdfsC/ecover T2,CoachT2,1anualT2,.T2,6.22. 2,-,%pdf

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