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Developing genuine relationships with clients is a cornerstone to improving communication. There are also some universal strategies you can use, and with a number of clients you can help by using strategies to improve their memory and attention.

• Genuine, hopeful and empathetic relationships
• Universal communication strategies
• Strategies to support memory and attention
• Find out more

Genuine, Hopeful and Empathetic Relationships

Having a genuine, hopeful and empathetic client/worker relationship makes a difference to the lives of clients. When you're working with people with complex needs, this relationship is particularly important as it's likely the person will have experienced 'service system fatigue' and feel that services they've been involved with in the past have given up on them. Developing solid engagement and rapport and developing and maintaining boundaries are key components of developing this relationship.

Rapport and Engagement

Establishing solid engagement and rapport with your client cuts across all theoretical approaches and is one of the most important tools in successfully supporting someone to participate in a drug and alcohol program. When supporting a person with complex needs, use the following engagement strategies:

• Get to know them. Learning information about a person, such as what they like or what they're interested in, can help you develop engagement and rapport. The better you know the person, the easier you'll find it to identify when they need additional support and how to help them work through particular impulses or challenging behaviours.
• Time and patience. It may take more time and perseverance than usual to develop a solid level of engagement with a person with complex needs. Don't give up!
• Be present. Focusing on being emotionally present is particularly powerful and effective and is essential to a genuine, empathetic and hopeful worker/client relationship. Minimising the possibility of distraction and staying completely present with the person will show your commitment to supporting them.
• Focus on the positive. Use a strengths-based approach, focusing on achievements and acknowledging that setbacks are part of the change process. People with complex needs may take longer to achieve their goals. It's likely they'll have more setbacks on their path to change than other clients. Celebrate all the effort and small achievements and allow the person time to learn from their mistakes.

Boundaries

Developing and maintaining professional boundaries is an important part of a genuine, hopeful and empathetic relationship between worker and client. Consider the following points when working with people with complex needs:

• Understanding boundaries. People with complex needs are likely to have difficulty understanding, setting and maintaining personal boundaries. This may be because of a cognitive impairment or may be in response to having personal boundaries damaged or violated during their life.
• Time to learn. Knowing what boundaries are appropriate and acting accordingly is something we learn over time. Some people with complex needs may need support and time to learn what is appropriate in your service, in the community and in their personal relationships. This may mean resetting the boundaries every day, sometimes more than once a day, and being consistent with what the boundaries are.
• Modelling boundary-setting. Modelling effective boundary-setting is a useful tool in helping people see how they can respectfully deal with situations where their personal boundaries are being threatened. This can mean showing a person how to set limits, demonstrating that you're able to say, for example, "No thanks. I don't feel like doing that now", or "Would you mind stepping back a little bit - you're standing a little bit close", or "I'm not sure about that - I'll think about it and get back to you".
• Communication. Showing people that you can communicate in a respectful way what you're thinking and feeling, even if this is different from what they want and is difficult for them to hear, demonstrates that it's okay to tell them what you need, and provides a model of how to achieve this.
• Feedback. Give the person clear and straightforward feedback on inappropriate behaviour and you and your service's future behavioural expectations. Help the client to identify the consequences of their actions for themselves and for other people.

Universal Communication Strategies

Universal communication strategies are beneficial to all service users and are particularly valuable when working with people with complex needs. They support service access and participation for all people using your service, and many of these strategies cost little or nothing to implement.

Strategies include modifying language, establishing rapport and involving clients in their care and service planning. Having universal communication strategies in place helps you and your service comply with legislation and accreditation standards relating to access and equity.

Communication

Face-to-face communication is the most effective way of communicating with someone. If it's not possible to communicate face to face and you have to rely on phone or email communication, be aware of the communication challenges that present when cues like body language and facial expressions are not available.

For example, if you know or suspect someone has specific cognitive functioning difficulties related to communication and comprehension and you have to speak to them over the phone, use strategies to make sure they've understood what you've said. This may include having a support person or advocate for the client involved in the phone conversation. Also, be aware of how you're communicating, including your use of complex words, or long sentences in which multiple pieces of information are included.

Verbal Communication Tips

• Keep your language simple by using short sentences and avoiding jargon. This will increase the likelihood that the person will understand directions or questions.
• Raise only one topic at a time. Clearly signpost changes in topic to avoid confusion.
• When explaining tasks, make sure you break the task into a step-by-step process, as these are easier to both understand and remember.
• Ask the person to explain in their own words the information you're giving them - don't just ask 'Do you understand?' (If you do this, they may automatically say 'yes' because they think this is the 'right' response and/or what you want to hear.)
• Allow more time than usual for a response.
• Encourage the person to ask for information to be repeated if they haven't understood fully.
• Minimise distractions in the immediate environment.
• When language is a barrier, use action-based strategies to help the person understand, such as demonstrating what needs to be done or asking them to demonstrate their understanding of a direction or question.
• Support verbal communication with audiovisual, written and pictorial resources where possible.

The Intellectual Disability Rights Services has developed a guide called Introduction to Intellectual Disability (IDRS 2009) that contains a summary of communication tips to use when working with people with intellectual disability and people with cognitive impairment. It was developed by Robert Strike, a leading advocate for people with intellectual disability in NSW and gives the following advice:

• "Talk to us, not at us or through others."
• "Hearing is not enough. Listen to us and respect what we say."
• "Do things with us, not for us."
• "Explain things slowly and get straight to the point."
• "Talk to us face to face."

See also Maximise People's Ability to Make Their Own Decisions (IDRS 2004)

Written and Visual Materials

Many people find it difficult to understand complex text, so it's essential to consider the literacy needs of your client group.

The Australian Bureau of Statistics (ABS) has identified that almost half of Australian adults have literacy skills considered inadequate to meet the demands of common daily activities. This includes understanding narrative texts and completing forms. See the figure below for the results of the 2006 Adult Literacy and Life Skills Survey conducted by the ABS (ABS 2006, reissued 2008).

Literacy levels are affected by a range of factors, including school leaving age, quality of education, having English as a second language, and learning disabilities or cognitive impairments. People with a disadvantaged background are more likely to have literacy problems.

Preparing written materials that are easy to understand will ensure they're accessible to a wider audience and will lessen disputes or difficulties that can occur through misunderstandings. 'Plain English' and 'Easy English' (see below) can both be used to make written material more accessible.

Figure 4.1: Adult literacy in Australia

To obtain a pdf of Figure 4.1, visit page 27 of the document:

• Complex Needs Capable (pdf).

Knowledge and skills needed to understand and use various kinds of information from text, including editorials. news stories, brochures, and instructional manuals.

Knowledge and skills required to locate and use information contained in various formats, including job applications, payroll forms, transportation schedules, maps, tables, and charts.

Understanding the problem situation and it’s step-by-step transformation, based on planning and reasoning, constitute the process of problem solving.

Note: Level 3 is considered the equivalent of High School years 8-10 which the survey developers regard as the minimum required for individuals to meet the complex demands of everyday life and work in the emerging knowledge base.

Level 4/5 includes those education post High School Year 10.

Source: Australian Bureau of Statistics (2006, reissue 2008), Adult Literacy and Life Skills Survey, Summary Results, Australia

What Is Plain English and When Should I Use It?

Plain English is a flexible and efficient writing style that readers can understand in one reading. It combines clear, concise expression, an effective structure and good document design (Plain English Campaign).

Plain English should be used for any information that's in the public domain and that the public uses to make decisions.

What Is Easy English and When Should I Use It?

Easy English (also known as 'easy read' or 'easy to read') is a simple and controlled writing style developed for people who have difficulty reading and understanding information. Easy English identifies the key points a person needs to know and the most direct and concise way to say it, and includes the use of relevant images.

Easy English documents are usually developed for a specific target audience. Documents that provide essential information that helps a person make an informed decision or where action is required should be developed using Easy English.

There are a number of resources available to help people develop documents that use plain English and Easy English. The types of written materials that may need to be modified in a drug and alcohol service are:

• Forms
• Information sheets
• Brochures
• Booklets
• Reports
• Policies and procedures
• Signage
• Websites.

Services often already use signage that incorporates plain or Easy English, usually for health and safety. For examples of signs and posters to promote cough etiquette and hand washing refer to the pdfs and images below.

Easy English signage examples

• Cover Your Cough (pdf)
• How to Handwash Poster (pdf)

You should make sure all materials meet plain English requirements at a minimum, and consider when Easy English should be used. All clients will benefit from the use of both plain and Easy English, whether or not they have literacy problems.

Staff may feel uncomfortable using Easy English, thinking they are being condescending or patronising. But anecdotal evidence shows this is not the case, and people are happy to receive materials in this format. By developing materials in consultation with the target audience, and being sensitive and responsive to their needs, you will ensure this doesn't happen.

The NSW Council of Intellectual Disability (NSW CID) partners with Scope Victoria to facilitate Easy English writing courses in NSW. These courses cover the essential skills to develop written information for people with limited literacy. For more information contact NSW CID.

Written Materials Tips

• Use plain English
• Consult with the target audience when developing materials to ensure appropriate content and design
• Consider people's literacy levels when distributing written materials in your service
• Supplement written materials with a face-to-face explanation to ensure key messages are easily understood
• Use images or audiovisual materials to support written materials
• Get ongoing feedback from the target audience when using written materials, and adapt as needed.

Using Visual Aids to Support Written Materials

The use of visual aids (images, symbols, illustrations) and audiovisual materials can help the reader understand and remember key information. Incorporating images into text can be done for minimal or no cost and commercial software is available to assist you develop visual aids, including:

• CHANGE Picture Bank^©
• Valuing People ClipArt, from Inspired Services Publishing Pty Ltd^©
• Bonnington Symbols

A wide range of stock images can be sourced from a number of websites such as Shutterstock. Microsoft Office software also includes a searchable range of ClipArt images. You can also use images relevant to your service by creating photos or drawings.

When using visual aids

• Consider how relevant the image is to what you're trying to represent and whether it could be confused with something else.
• Make sure images are not overused, or used inconsistently, in a document (e.g. the same image being used to refer to multiple concepts).
• Consider the acceptability of the image for the target audience (e.g. in terms of culture, age and life experience).
• Consider getting staff and clients involved and using real images from your service to complement stock and ClipArt images.

Strategies to Support Memory and Attention

A person who has difficulty remembering, concentrating or paying attention may use specific compensatory strategies to improve their functioning. You should support the use of these positive compensatory strategies and, if the person hasn't developed their own strategies, work with them to test a range of strategies they could use.

Compensatory strategies include (Synapse 2011a, 2011b):

• Using external memory aids, including writing lists, keeping a diary or wall calendar, using a mobile phone alarm or alarm clock for reminders, using a dictaphone or an electronic organiser
• Using specific memory techniques such as repeating and rehearsing key information and using visual or verbal associations to help recall information and categorise information into groups
• Organising the environment to reduce the demand on the person's memory; this may include having noticeboards with tasks and reminders, labelling or colour- coding cupboards and tying objects to things (e.g. tying a pen to the phone)
• Developing a structured daily routine.

Find Out More

• The Intellectual Disability Rights Services (IDRS) has developed a guide called Introduction to Intellectual Disability (IDRS 2009) that contains a summary of points to consider when working with people with intellectual disability and people with cognitive impairment.
• See also the fact sheet Maximise People's Ability to Make Their Own Decisions (IDRS 2004)
• For further information on what written materials and information may suit your service see Making Your Service Complex Needs Capable.
• See also scopevic.org.au for a range of resources on easy English.

As a case manager in a drug and alcohol setting you are not expected to provide all the necessary services to support a person's needs, but you are expected to work with staff from appropriate agencies to provide holistic care.

• Care planning and case management
• Case management for people with FASD
• Counselling
• Cognitive behaviour therapy and cognitive impairment

Care Planning and Case Management

Many drug and alcohol and community services use a variation of case management or care planning approaches. These approaches allow for "a process that coordinates the acquisition and delivery of services to meet individual client needs" (Marsh et al 2007a:55).

Care planning and case management is an effective approach to working with clients with complex needs. Case management may at times require a high level of coordination with external services depending on the individual's needs. Having close partnerships with relevant serviceproviders will assist you in facilitating this process.

Your case management approach when working with clients with complex needs may require a more proactive or assertive approach to maintain client engagement. Both approaches draw significantly from the strength-based model of care and have been shown to be highly beneficial in mental health service provision.

A proactive style of case management promotes strong client engagement and close follow-up of new or fragile clients (Mental Health Services 2008). This includes people who have complex needs and people who shift between the stages of change in alcohol or drug treatment.

An assertive approach to case management focuses on ensuring the person doesn't 'fall through the cracks' by providing service support but knowing when to stand back and give support when invited. The assertive approach supports not intervening so as to abuse a person's human rights, but not passively neglecting them either. This approach requires a good and often long-term relationship with the client that fosters engagement and collaboration (Mental Health Services 2008).

There are advantages and disadvantages to these approaches in terms of accountability, coordination of services and funding models for providing services. Whatever the approach your organisation uses, the following considerations, developed to inform case management for working with people with FASD (Gelb & Rutman 2011), are a useful guide for working with all clients:

• Establish a trusting relationship with the person.
• Establish close and frequent communication with them (e.g. check-ins and regularly scheduled meetings).
• Develop a care plan based on their goals, strengths and needs.
• Facilitate transportation for important appointments.
• Liaise with other service providers.
• Assist the development of life skills and/or the person's participation in healthy, safe activities.
• Establish close communication with supportive significant others in the person's life.
• Advocate for improved communication among service providers, continuity of care and access to care/services.

For further guidance on case management and case planning see:

• Marsh, A., Dale, A. & Willis, L. (2007a) A Counsellor's Guide to Working with Alcohol and Drug Users, Drug and Alcohol Office Western Australia: Perth
• Victoria Department of Human Services, The Multiple and Complex Needs Initiative
• Mental Health Services (2008) Resource Manual: Assertive Case Management: A Proactive Approach, Department of Health and Human Services, Tasmania.

Case Management for People With FASD

People with FASD learn and behave differently. They are usually expected to change and adapt to the world, when in fact they can't change. Changes to the environment (both physical and social) should be considered to better support a person with FASD. Additionally, a change to more appropriate assumptions and expectations will create a better working/living/learning environment and produce successes instead of failures (Sood et al 2001).

If FASD is referenced or suspected, then treatment planning needs to reflect the adjustments, strategies and interventions that might be made in support of the person, examples of which are provided in the table below. Similar adjustments may be useful for a person with another form of mild cognitive impairment.

Examples of adjustments for FASD-related problems

To obtain a pdf of the following table, visit page 36 of the document:

• Complex Needs Capable (pdf).

Problem	Reason For Problem	Adjustments
Not remembering to attend appointments	Poor short-term memory Easily distracted	Provide reminders via SMS, phone, email. Enlist friends and family members as reminders. Facilitate transport and/or accompany the client to appointments
Issues when participating programs	People with FASD think differently and have usually felt like 'failures' at school and in previous programs. Because of this, they'll often have difficulty participating in a program where it's likely these issues will crop up again.	Provide programs that are suitable for a client with a cognitive impairment.
Nothing is making a difference	Inappropriate strategies, communication and/or intervention model for a person with an organic brain-based disability.	Strategies must be appropriate for a cognitive impairment. Workers need to consider that the person may be unable to work independently as planning and organising can be very difficult for a person with FASD. Therapeutic interventions such as cognitive behavior therapy may be effective. Spoken communication: Make sure language is concrete - don't use idioms or jargons (e.g. 'bitten off more than you can chew' may be interpreted literally). Written communication: Make sure any documents, reading material or resources have lots of white space and contain only one point at a time.

Counselling

Counsellors in drug and alcohol settings work from a variety of models. When counselling people with cognitive impairment, it's essential you have strategies to tailor sessions to their needs. A person requires numerous cognitive functions (verbal skills, memory, attention, problem-solving and abstract reasoning) to benefit from the many strategies used in drug and alcohol counselling (Teichner et al 2002 in Marsh et al 2007b).

If the person's level of cognitive functioning is not taken into account, they'll experience poorer treatment outcomes. For people with attention/concentration difficulties, Aharonovich et al (2003) recommend shortening the length of sessions and frequently rehearsing session content and feedback with the client (Marsh et al 2007b). Modifying content to include more concrete language and offering greater counselling support to assist the person in identifying and changing problematic beliefs and thought patterns are essential.

Similarly, narrative techniques that require a high degree of verbal competency and comprehension will need to be modified to include simplified language and diagrams or pictorial representations. Motivational interviewing has been highlighted by a number of authors as a particularly useful technique in working with people with complex needs (Taggart et al 2008; Gelb & Rutman 2011).

Cognitive Behaviour Therapy and Cognitive Impairment

Evidence suggests that people with ABI or another cognitive impairment are more likely to display maladaptive coping styles due to impaired executive functioning (Arundine 2009). Cognitive behaviour therapy (CBT) has been suggested as an appropriate therapeutic intervention for people with ABI or other cognitive impairment because of its structured format, flexibility and extensive range of therapeutic techniques that can be employed and potentially adapted (Arundine 2009; Kahn-Bourne & Brown 2003).

The following list of techniques, as described by Kahn-Bourne and Brown 2003, may help in delivering CBT to people with an ABI or cognitive impairment:

• Use memory aids such as written notes, cue cards, digital recorders or audiotapes
• Shorten the length of individual sessions
• Increase the frequency of sessions
• Involve a family member or support person to help remind /or reinforce therapy strategies and to assist with work out of the counselling session
• Use techniques such as summarising, or even agreeing on hand signals, to refocus clients.

Consider talking to a specialist service such as Synapse about how to adapt CBT when a cognitive impairment has been identified or is suspected.

No matter what counselling technique you use, it's important to remember that non- compliance with homework, being late or not attending sessions does not automatically translate into a person being ambivalent or unmotivated. Rather, this may be due the impact of their cognitive deficits.

Behaviour is a means of communication, and all behaviour has a functional element. 'Challenging' behaviour is often described as communicating unmet needs.

• Understanding challenging behaviour
• The spiral of negativity
• Strategies for dealing with challenging behaviour

Understanding Challenging Behaviour

People with complex needs have many unmet needs and often find it difficult to express them. Unexpressed needs can result in a person being perceived as having challenging behaviour. People can then find themselves being labelled by service providers as unmotivated, antisocial, offensive, treatment resistant, having a borderline personality disorder, or being aggressive or passive aggressive.

When people behave in a way that challenges us, we need to question why they're behaving in this way. Consider the origins of the behaviour and what the message behind the behaviour might be. This will help you to understand the meaning behind the actions and help avoid attaching labels to a person.

All clients who are part of a drug and alcohol program, including those with complex needs, at times will display behaviours perceived as challenging. Behaviours perceived by services as challenging may include: showing up late (or not at all) to group or other compulsory activities, not sticking to or participating in parts of the program, or breaking program rules (see the table below).

For you, these behaviours can impact on the running of the service or a program, or the dynamics and interactions of a group. This can be one of the biggest challenges facing workers, as it can be hard to find effective strategies to address the person's behaviour while managing the effect these behaviours on other clients and staff.

Some of these behaviours can be interpreted as 'resistant' and/or 'unmotivated', that is, indicating an unwillingness to participate in or cooperate with the program. However, we need to examine the possibility that the behaviours are a way of the client expressing an unmet need or a communication misunderstanding. For you as a worker, finding out what this unmet need is may provide clues to how to respond to the behaviour and help the person remain in treatment and experience a successful treatment outcome.

It's also important to separate behaviours that can be challenging in an individual from behaviours that can be challenging because you're working in a complex environment, such as a residential treatment setting.

Understanding behaviour - three approaches

There are three approaches to understanding behaviour:

• The internal approach views the behaviour as originating from the individual, including mood, mental health and character.
• The external approach views the behaviour as a result of the environment, including the physical environment (such as noise levels) and the systemic environmental (such as policy and procedures, staff-to-client ratio, work culture and level of freedom for clients).
• The interactional approach considers the interaction of both internal and external factors. This approach looks at the interactions among staff, clients and the environment and tends to prioritise an examination of the function of the behaviour.

Using an interactional approach will help you understand the internal and external factors influencing a person's behaviour, and help you identify the factors influencing both negative and positive behaviour. Taking the time to work with the person will help you identify what it is that's causing the problem and if it's caused by underlying complexity.

This table gives some handy tips on how to read people's behaviour and what to do about it.

It lists behaviours identified as challenging by drug and alcohol services through the consultation process of the NADA and CRC No Bars Project. It identifies a possible alternative reason for the behaviour to non compliance or non motivation, linked to the possibility of an underlying complex issue and suggests effective strategies to address these behaviours.

The Spiral of Negativity

The 'spiral of negativity' was identified in care staff working in residential settings with older people who had an alcohol related brain injury (ABRI). It refers to the impact of negative perceptions, views and labelling of challenging behaviours on both the client and the caregiver in a service setting (Smith 2006, in Rota-Bartelink 2012) and can occur in any care giving situation.

If staff don't have the appropriate knowledge and skills required, they may perceive the way a person with complex needs communicates or behaves as personally hurtful or offensive, and may behave negatively (subtly or overtly) towards the person. For example, staff may tell colleagues the person is 'unappreciative' or 'manipulative', or may simply avoid contact with the person.

By recognising that negative perceptions, views and labelling of people with complex needs contribute to developing a cycle of mutual distress (the client continues to have unmet needs that cause underlying stress impacting on their treatment, and the worker also suffers from anger, resentment, ineffectiveness and frustration), drug and alcohol workers can become attuned to how their perceptions and reactions can have an effect on the treatment and care a person receives.

Downward spiral of negativity

To obtain a pdf of the following diagram, visit page 35 of the document:

• Complex Needs Capable (pdf).

1. The person living with the complex needs is seen as 'difficult', 'hard to manage' or 'aggressive'
2. Staff work with the person to change their behaviour
3. If they're not successful, the person may be labelled as unmotivated, resistant to change, a 'pain', a problem, difficult and manipulative
4. No new interventions are tried because the person is seen as the problem
5. Staff 'cope' by imposing penalties on the person
6. The person is not comforted or assisted, and behaviours become more intense
7. Staff feel even more distressed and frustrated by the behaviours
8. Staff 'cope' by exiting the person due to multiple penalties, or incompatibility with the service
9. The person's behaviour continues and often intensifies; they may relapse

The figure above shows the consequences of the downward spiral in a drug and alcohol treatment environment when perceived challenging behaviours are misunderstood, leading to staff frustration and client expulsion.