As we turn the Rubik's Cube of addiction counseling once again, we see the fourth side is as important as the first three, as it deals with managing risk when dealing with a client. The first three sides provided color and structure for getting the client ready for counseling, intake, assessment, designing and developing a treatment plan, and implementing a recovery contract.

Traditionally, once the recovery contract is in place the client has defined the first step in his or her journey to recovery. However, like any journey there can be bumps and sharp turns along the way. This side of the Rubik's cube discusses the aspect of risk management, whose goal it is to prepare for events that may put the client's journey at risk.

This article introduces six core questions that build a framework for managing the kinds of risks that could disrupt a client's journey. A client's resiliency develops each day he or she is able to achieve milestones set out in his or her treatment plan and recovery contract.

In the early stages of recovery, a client's resiliency may not have developed or is fragile; events and perceptions may put them at risk. Addiction counselors need to learn to anticipate the kinds of events and perceptions that can negatively impact a client. The five questions discussed here are intended to get the addiction counselor thinking about some of the kinds of risks that may impact a client. At the end of this article, ask yourself what other questions you could ask and prepare for.

Six risk management considerations

The first risk management consideration - Do I have a crisis intervention model ready?

Crisis often comes without notice, thus having a crisis intervention model ready and in place to support a client who perceives that he or she is in a crisis is critical for his or her safety. One of the first rules for managing a crisis is to be aware that what may be a crisis for one person may not be a crisis for another.

The person who is experiencing the crisis defines crisis. The role of an addiction counselor, when they have a client in crisis, is to support him or her in getting past it. The treatment plan is not the priority when a person is in crisis; the crisis is. Once the crisis is resolved, the person will have the capacity and opportunity to continue with his or her treatment plan and recovery contract.

A few common examples of the kinds of crises clients may need to deal with are: personal safety issues (e.g., an abusive husband); financial challenges (e.g., lost job); no safe shelter; no means to feed themselves; coping with anger management issues (e.g., in trouble with employer); or stopped psychiatric medications on their own and are now suffering the consequences. One common factor in all these examples is that these events can become all-consuming and paralyze a client. They can flood the client's ability to cope and disrupt his or her journey, and each will need a crisis intervention.

The Six-Step Intervention developed by James and Gilliland (2005) is a proven and effective crisis intervention model that can be added to the addiction counselor's toolbox. The number one consideration in crisis is the preservation of life and to prevent the crisis from escalating out of control. The model below provides a structured process for managing general crisis situations:

Step One - Define the problem. The client's functioning ability determines how directive the counselor will need to be. It is important to be mindful of the intensity, duration, and degree of the crisis. This will help the addiction counselor calibrate the potential extent and damage to the person(s) involved in the crisis. The lower the client's functioning, the more directive the counselor will be, especially if safety is an issue. One of the telling signs a person is recovering is when they are able to make decisions that are cognitively sound and are able to be part of the collaborative process. This is a sign that the counselor can be more non-directive.

Step Two - Ensure personal safety. Safety is a major concern and the first goal. The outcome is to get the client to a safe place. However, the counselor must be careful not to put themselves within arm's length of danger.

Step Three - Provide support. Rapport, trust, empathy, and compassion are all-important to a person in crisis. The person's body may not be injured, but crisis can injure their mind and soul. Clients need this security band-aid to help them gain control of emotional bleeding that may be occurring.

Step Four - Explore options and alternatives. What are the options, and what needs to be done? This needs to involve the person as much as possible. The counselor has a role in crisis situations to offer suggestions when the client is lost for direction or is not making safe and healthy decisions.

Step Five - Make a plan. Develop a plan that is realistic and action oriented that gets the client on track to solve the crisis, keeping in mind the importance of his or her recovery and how the plan can be aligned with the journey as much as possible.

Step Six - Get a commitment. Be mindful of the client's motivation and commitment to the plan. The goal is to get a commitment to take action and move forward in a set time with follow up and support.

The second risk management consideration - Do I have a strategy for reducing the risk of suicide & homicide?

In addition to using the six-step model, having a framework to prevent suicide and homicide is important. James and Gilliland (2005) suggest professionals be aware and monitor the following points:

Risk factors: Has this person attempted suicide before? What kind of stressful or traumatic events have recently been going on in his/her life? Does he/she have a plan and a means for suicide?

Suicidal/homicidal clues: Does the person say he/she wants to die, or is going to kill himself/herself? Does he/she make comments like, "There's no point in going on any more?"

Verbal clues: Spoken or written statements that can be direct ("I'm gonna do it this time.") or indirect ("I'm of no use to anyone anymore.").

Behavioral clues: Purchasing a grave marker for oneself, or slashing one's wrist as a practice run.

Situational clues: May include concerns over a wide variety of conditions, (e.g., death of a spouse, divorce, a painful physical injury or terminal illness, sudden bankruptcy, preoccupation with a loved one's death, anniversary).

Syndromatic clues: Include symptoms such as severe depression, loneliness, hopelessness, dependence, and dissatisfaction with life.

Cries for help: The fact that he/she is even talking to someone about it is a sign that he/she is feeling ambivalent.

When dealing with a potential threat of suicide or homicide, it is important to ask direct questions, such as:

• Are you thinking about killing yourself?
• Are you thinking about killing someone else?
• Have you tried before to kill yourself?
• Do you have a plan as to how you will kill yourself?
• Do you have the means to kill yourself today?

In the above five questions, the more the person responds with a yes, the greater the risk. However, even answering the first one as a yes and the rest no, indicates the person may still be at risk. It is important to use the six-step crisis intervention model to assist them to feel they are in control again and safe. Finally, legal and ethical questions of action are defined by professional codes of ethics and legislation. It is the counselor's responsibility to be aware of reporting procedures whenever suicide or homicide have been threatened, regardless of how effective the intervention.

The third risk management consideration - Do I have a relapse prevention strategy in place?

There are many triggers, such as person, place, thing, smell, thought, or taste that may spark a person to return to an old behavior. We know in treating clients with addictive disorders that relapse is going to happen and this may become a major event that gets the client off their journey. Effective crisis prevention is the implementation of a well thought out relapse prevention plan.

There are two widely used models today.

The first is Allan Marlatt and Judith Gordon's RP relapse model that is rooted in social learning theory and cognitive psychology. This model operates from a biopsychosocial perspective. Visit http://www.niaaa.nih.gov/publications/arh23-2/151-160.pdf  for a full overview of this model.

The second is Terrance Gorski's CENAPS (Center for Applied Sciences) relapse prevention model that is grounded in cognitive-behavioral psychology. For more information, visit http://www.cenaps.com.

Two mnemonics developed by Gorski teach clients a strategy for how to stay aware and avoid relapse. ESCAPE points out the kinds of behaviors and triggers that may lead to relapse and RADAR is an action plan when faced with ESCAPE situations.

Gorski's Mnemonics

RADAR

R = Recognize

A = Accept

D = Detach

A = Ask for Help

R = Response

ESCAPE

E = Evade + Denies

S = Stress

C = ‑Crisis building and/or compulsive behavior

A = Avoid

P = Problems

E = Evade + Denies

The fourth risk management consideration - Do I monitor the client's self-esteem?

Self-esteem is critical for developing the resiliency that is needed for recovery. The amount of self-esteem a client has defines the perception of his or her value and belief in one's current and potential abilities. Self-esteem can be defined as one's internal belief and abilities for coping with the challenges of life. One core life task for each client is learning how to develop happiness from within.

There are two components of self-esteem that are important for recovery.

The first is Self-efficacy - confidence in the ability to think, understand, learn, choose, and make decisions. The experience of self-efficacy generates the sense of control over one's life.

The second is Self-respect - belief in one's value, right to live and to be happy, comfort in appropriately asserting thoughts, wants, and needs. The experience of self-respect makes it possible for a person to become aware of the importance of taking care of oneself and of making healthy choices.

Strategies for increasing self-esteem are important to have in the counselor's toolbox. Some examples include:

Working with the client to define the kinds of events and perceptions that impact his/her self-esteem, then developing an action plan for coping with these challenging situations. Role playing can help the client develop his/her competency.

Defining with the client where he/she has healthy and safe emotional support and social approval. Clients benefit in their recovery from having healthy relationships to feel valued and accepted. Peer groups are potential sources for this kind of support.

Daily recording of personal achievements and success. Journaling is a powerful tool for helping clients process and cope with events of the day, but it is also a great strategy for creating a living document that defines a person's success and self-esteem levels (e.g., track perceived highs and lows then explore the root causes of the lows and what alternatives the client has).

The client's primary problem may not be reported as low self-esteem, however, it is recommended to monitor their self-efficacy and self-respect as a risk management strategy.

The fifth risk management consideration - Do I have a process to deal with a grieving client?

One challenge for many clients in the early and middle stages of recovery is to process losses that have occurred because of the addictive disorder. These might include a gambler's loss of his house, or a drug addict's loss of her husband and children. Grief comes at different intensities and at different times for clients. Some may appear to be fine, but three months into their recovery they become overwhelmed with grief. This grief may lead to depression, anger, self-hate, anxiety, or loss of hope, the kinds of emotions that can damage the client's resiliency. Addiction counselors need to be aware of the grieving process and how to support their clients.

Schneider model

Stage 1: Initial Awareness of Loss. The client feels out of balance because of emotions such as feelings of shock, detachment, disbelief, disorientation, numbness, and confusion.

Stage 2: Attempts at Limiting Awareness by Holding On. The client tries to hold on to an experience as a way to cope and deal with the current situation, with the hope that it will go away. This kind of avoidance is normal.

Stage 3: Attempts at Limiting Awareness by Letting Go. This is when the client gives up on holding on, and accepts the situation has occurred and is real. Powerful emotions such as guilt, anger, and shame are likely to come up.

Stage 4: Awareness of Extent of Loss. This is traditionally called the mourning phase, and it is normal for a client to be flooded with conscious thinking about meaning and future direction.

Stage 5: Gaining Perspective on the Loss. The person is gaining his or her perspective, and organizing the loss in a way that is less draining both mentally and emotionally.

Stage 6: Resolving Loss. This is the time to say good-bye, do unfinished business, and move forward.

Stage 7: Reformulating Loss in a Context of Growth. Out of the grief comes the will to want to grow, and move on with motivation for personal growth and discovery.

Stage 8: Transforming Loss into New Levels of Attachment. This is the stage where the person has transformed, and is now releasing the pain of the past fully as they are on a new plan of acceptance, awareness of the structure of life, and what it is to be a human being.

The sixth risk management consideration - Do I have a strategy to help a client manage stress?

Stress is real and can immobilize a client. Not taking action when stressed will increase a person's risk of being negatively impacted. For example, the client's physical response to stress will lead to the release of the neurotransmitter epinephrine (adrenaline). Adrenaline is mainly responsible for the flight or fight response that was originally designed to keep humans alive and survive in the wild kingdom. It mobilizes sugars providing the body with increased strength, stamina, and energy to respond to a physical or emotional threat. Today this defense mechanism continues at the same levels as it did to help humans have fear and learn how to get to the top of the food chain. This response is often counter productive to our survival. For example, having a full chemical dump because someone left a door open in the house is an overreaction and puts hormones in the body that are not needed and which weaken the immune system. Many clients with addictive disorders have weakened systems because of the abuse they put their body through. It is important that they learn how to manage stress so it does not manage them.

Inside the counselor's toolbox

Counselors need to have a toolbox of strategies ready to assist in reducing and preventing stress. Below are five examples:

1. Continue to review how the client is dealing with his or her recovery contract commitments to ensure he or she is coping with and managing the demands. Sometimes a client's recovery plan can be over-programmed and become a major stressor.

2. Teach the person normal signs and symptoms of stress overload, such as:

• Irritability - becoming overly critical and annoyed by little things.
• Insomnia - trouble falling or staying asleep.
• Fatigue - feeling weary for no apparent reason, having odd aches and pains, especially in the head, neck, or back.
• Weight changes - significant gain or loss.
• Respiration problems - shortness of breath or hyperventilation without much physical exertion.
• Psychological upsets - feeling of depression and anxiety.

Most important, coach the client that when he or she feels stress it is a normal response; he or she has some control over what can be done to manage it; and if it becomes unmanageable to report it to you and his or her doctor.

3. Promote the value and benefits of exercise - 20 to 30 minutes, several times a week - once he or she has medical permission to exercise.

4. Promote the importance of a healthy and balanced diet. Include high-octane nutrients, such as fruits and vegetables. Limit sugar, salt, and caffeine intake.

5. Promote the value of life balance: how to manage work and home. Teach strategies to prevent and manage stress (e.g., meditation, music therapy, healthy activities, walking, guided imagery, and progressive muscle relaxation).

Some or all of the above elements may end up in the client's treatment plan and recovery contract. It is important to monitor the ones that do not end up as primary or secondary issues as a part of client management. In addition, it is important to anticipate other kinds of risks you may need to prepare for.

The next article in this series will introduce the fifth side of the Rubik's cube of addiction counseling and provide the framework for a problem solving approach to working with a client one-on-one.

References

James, R. K., & Gilliland, B. E. (2005). Crisis Intervention Strategies (5th edition). Belmont, CA: Thomson Brooks/Cole.

Schneider J. M. (1994). Finding My Way: Healing and Transformation Through Loss and Grief. Old Mission, MI: Seasons Press.

This article is published in Counselor,The Magazine for Addiction Professionals, December 2006, v.7, n.6, pp.38-43.

Comments

Add New Search RSS

Write comment
Name:
Email:	do not notifynotify
Title:
	Please input the anti-spam code that you can read in the image.

Powered by !JoomlaComment 3.26

3.26 Copyright (C) 2008 Compojoom.com / Copyright (C) 2007 Alain Georgette / Copyright (C) 2006 Frantisek Hliva. All rights reserved."

---