Section 3: Monitoring Brief Interventions

In the previous section, we discussed stages of change and how we can support our client’s stages of action and encourage them to achieve change. What we need to focus on here is to dwell deeper into a specific scenario of substance use and understand more about how we can personalise feedback to our clients on their use of substances and the level of risk involved – which can eventually enhance client motivation to change substance use behaviour and hinder risk or harm to themselves.

Note: This part might sound like a repetition, but it will give you much more insight into science-informed elements of motivational approaches that effectively treat different disorders.

Any clinical strategy that enhances client motivation for change is a motivational intervention. Such interventions can include counselling, assessment, and feedback. They can occur over multiple sessions or during one BI and can be used in specialty SUD treatment settings or other healthcare settings.

Elements of effective motivational counselling approaches

Motivational counselling strategies have been used in a wide variety of settings and with diverse client populations to increase motivation to change substance use behaviours. The following elements are important parts of motivational counselling:

• FRAMES approach
• Decisional balancing
• Developing discrepancy between personal goals and current behaviour
• Flexible pacing
• Maintaining contact with clients.

FRAMES Approach

Miller and Sanchez (1994) identified six common elements of effective motivational counselling, which are summarised by the acronym FRAMES:

• Feedback on personal risk relative to population norms is given to clients after substance use assessment.
• Responsibility for change is placed with the client.
• Advice – the counsellor gives advice about changing the client’s substance use nonjudgmentally.
• Menu options – a menu of options and treatment alternatives is offered to the client.
• Empathy – an empathetic counselling style (for example, warmth, respect and understanding) is demonstrated and emphasised by the counsellor.
• Self-efficacy is supported by the counsellor to encourage client change.

Since FRAMES was developed, research and clinical experience have expanded and refined elements of this motivational counselling approach.

Feedback

Give personalised feedback to clients about their substance use; feedback presented in this way is effective in reducing substance misuse and other health-risk behaviours (Walker et al., 2017). This type of feedback usually compares a client’s scores or ratings on standard screening or assessment instruments with normative data from a general population or treatment groups. Feedback should address cultural differences and norms related to substance misuse.

For example, a review of the research on adaptations of BI found that providing feedback specifically related to cultural and social aspects of drinking to Latino clients reduced drinking among these clients to a greater degree than standard feedback (Gelberg et al., 2017).

Presenting and discussing assessment results can enhance client motivation to change health-risk behaviours. Providing personalised feedback is sometimes enough to move clients from the Precontemplation stage to Contemplation without additional counselling and guidance. Structure a feedback session thoughtfully.

Establish rapport before giving a client his or her score. Strategies to focus the conversation before offering feedback include the following:

• Express appreciation for the client’s efforts in providing the information.
• Ask whether the client had any difficulties with answering questions or filling out forms. Explore specific questions that might need clarification.
• Make clear that you may need the client’s help to interpret the findings accurately.
• Encourage questions: “I’ll be giving you lots of information. Please stop me if you have a question or don’t understand something. We have plenty of time today or in the next session if needed.”
• Stress that the instruments provide objective data. Give some background, if appropriate, about how the tests are standardised for all populations and how widely they are used.

Note: We will look at the Alcohol Use Disorders Identification Test (AUDIT) and the standard drinks guide alongside it further in this section.

As a counsellor, always show the score to your client when providing feedback on any screening or assessment instrument and explain what the score means. Use a motivational style to present the information. Do not pressure clients to accept a diagnosis or offer unsolicited opinions about the meaning of results.

Instead, preface explanations with statements like, “I don’t know whether this will concern you, but …” or “I don’t know what you’ll make of this result, but….” Let clients form their own conclusions, but help them by asking, “What do you make of this?” or “What do you think about this?” Focus the conversation on clients’ understanding of the feedback.

Strategies for presenting personalised feedback to clients include:

• Asking about the client’s initial reaction to the tests (for example, “Sometimes people learn surprising things when they complete an assessment. What were your reactions to the questionnaire?”).
• Providing a handout or using visual aids that show the client’s scores on screening instruments, normative data, and risks and consequences of his or her level of substance use. Written materials should be provided in the client’s first language.
• Offering information in a neutral, nonjudgmental, and respectful way.
• Using easy-to-understand and culturally appropriate language.
• Providing small chunks of information.
• Using open questions to explore the client’s understanding of the information. Using reflective listening and an empathetic counselling style that emphasises the client’s perspective on feedback and how it may have affected the client’s readiness to change.
• Summarising results, including risks and problems that have emerged, the client’s reactions, and any change talk the feedback has prompted, then asking the client to add to or correct the summary.
• Providing a written summary to the client.

Clients’ responses to feedback differ. One may be alarmed to find that she drinks much more in a given week than comparable peers but be unconcerned about potential health risks of drinking. Another may be concerned about his potential health risks at this level of drinking.

The key to using feedback to enhance motivation is to continue to explore the client’s understanding of the information and what it may suggest about possible behaviour change. Personalised feedback applies to other health-risk behaviours issues, such as tobacco use.

The Drinker’s Pyramid Feedback

The AUDIT questionnaire was developed by the World Health Organization to assess alcohol consumption, drinking behaviors, and alcohol-related problems. Your AUDIT score shows the level of health-related risks and other problems associated with your drinking. Higher scores can reflect more serious alcohol-related problems. AUD refers to an alcohol use disorder as defined by the American Psychiatric Association (2013).

^{(Babor, 2016; 2018)}

Alcohol Use Disorders Identification Test (AUDIT)

Instructions: Alcohol can affect your health and treatment. We ask all clients these questions. Your answers will remain confidential. Circle the best answer to each question. Think about your drinking in the past year. A drink means one beer, one small glass of wine (5 oz.), or one mixed drink containing one shot (1.5 oz.) of spirits.

AUDIT Scoring

Scoring

Exploring the elements of motivational counselling approaches

The following videos explore:

• FRAMES approach
• Decisional balancing
• Developing discrepancy between personal goals and current behaviour
• Flexible pacing

Brief Intervention & FRAMES

The presenter discusses the FRAMES approach. Answer the question that follows. 

watch

Motivational Interviewing approach to coaching: PACE and OARS

The presenter in this video explains motivational interviewing PACE principles (Partnership, Acceptance, Compassion, and Evocation) and OARS skills (Open questions, Affirming, Reflections, and Summaries). Answer the question that follows. 

watch

Developing Discrepancy in Motivational Interviewing

In this video, the presenter discusses the difference between a confrontational approach, and 'confronting' via developing discrepancy in Motivational Interviewing. Answer the question that follows. 

watch

motivational interviewing decisional balance

This video teaches people how to use the Motivational Interviewing Decisional Balance technique to elicit client "change talk" and encourage clients' own arguments for changing behavior in healthy directions. Answer the question that follows. 

watch

You know the importance of monitoring and reviewing counselling work with clients. Without reviews, counsellors could not monitor their work and check that they are headed in the right direction or if any adjustments are required in their work with the client.

Within counselling practice, the review style may depend on the counsellor’s personal style or may be informed by their organisation’s standards. One of the simplest ways to conduct reviews is to simply chat with the client to obtain feedback on the outcomes of the brief intervention. In this context, you could initiate a discussion in the following ways:

• “Let us look at the goals we had first decided on and review where we stand today….”
• “Are you satisfied with the changes that have occurred in your life due to our sessions?”
• “You had planned to give up drugs completely, but now you mentioned that you stuffed some weed in a cigarette on your weekend trip. How do you feel about that?”
• “Do you think your initial plan was realistic? Do you feel the need to make any changes to it?”

Behaviour change in the context of harmful practices can carry with it a lot of client guilt and social stigma. Therefore, it is essential that a good therapeutic rapport has been developed and the counsellor approaches these discussions sensitively. Informing the client in advance that you will be monitoring outcomes and conducting review discussions will help them prepare for these types of reviews.

Since brief interventions are usually very focused on just one behaviour/goal, the review process should examine the client's progress towards their goal. This may involve observing the outcomes of interventions with the client. If the client has not made the desired changes or has lapsed/relapsed, the counsellor may need to adjust the brief interventions being used.

For example, the client might need to be provided with additional support or may require help in addressing a new barrier that has been identified. However, if the counsellor identifies the presence of a serious issue or a client need that cannot be met via the brief interventions, then an appropriate referral may need to be made.

Continued monitoring and follow-up are integral parts of brief interventions. Even after the brief intervention has ended, planning follow-up meetings with the client to review their progress and support them if needed is wise. Such practices can help maintain client motivation and prevent relapse. Following up also provides useful information to the counsellor regarding the intervention's effectiveness and knowledge of what works and what doesn’t.

As with all other parts of the intervention, the client must be informed in advance regarding the nature of follow-up and their consent obtained. For example, towards the end of the brief intervention, the counsellor may say, ‘I would like to follow up with you through a meeting after a month and thereafter via the telephone to provide additional support to you. Would you be comfortable with that?’.

Follow-up is best conducted within one to three months of the intervention in a face-to-face setting. That said, telephone contact is acceptable and beneficial, while written communication may also be used when no other method is possible. Follow-ups usually include re-establishing rapport and discussions on the client’s current issues. A key focus of follow-up would be to determine if the client could meet the goals they had set in the intervention.

Record-keeping and documentation are an important part of the work of a counsellor. It also forms part of what it means to be an ethical practitioner. When a client comes to see you to begin a brief intervention, you would normally get them to complete an intake form that gathers demographic information, history of the problem and begins the therapeutic relationship. Most organisations will either have you doing the intakes and then seeing the client, or a separate intake officer will see the client and then pass client cases on (depending on the size of the service).

It is crucial that a comprehensive file on the client is developed, especially when recording their stage of change, support needs, decision-making, commitment to change, and any referrals made. Documenting each session is especially helpful in brief interventions as it is a step-wise process, and you can continue from where you left off in the previous session if you have documented it well.

When making notes about the client’s stage of change, it is important to include information about how you came to this judgement. For example, in addition to your regular case notes, you might include a statement like, ‘Jack is in a pre-contemplative stage as evidenced by his statement, ‘My alcohol drinking doesn’t have any negative impact on my life’. As you progress through the intervention, you can observe and record how the client’s perception of the issue changes. This is why the client’s stage of change must be noted at every interaction of a brief intervention. By referring to your notes from the previous session, you will know exactly what you need to follow up on and what strategy you will use next. 

In most therapeutic services, client notes are kept in folders in locked filing cabinets and/or an electronic version is stored on the counsellor’s computer, protected by a password. Records of brief interventions need to be similarly protected. It is both a legal and ethical obligation for practitioners to keep and maintain sufficient clinical records to document progress, risk, and approaches taken.

For clients engaging in brief interventions, it is especially crucial to ensure that the notes accurately capture what happened (in terms of directly observable events or explicit client statements) to ensure that the counsellor isn’t passing judgement on the client. Inferences or assumptions regarding the client could be damaging if the client were to review their record or if their records were subpoenaed.

If you decide to record interpretations and opinions, you must back it up with a justification. For instance, ‘Aamir seemed depressed as he didn’t make eye contact, was crying and reported an inability to sleep.’ Avoid recording psychological diagnoses unless you are qualified to do so. If another specialist has made the diagnosis, then ensure that you document with details of the source. When recording what the client has said, mention the same in your notes by saying, for instance, ‘Natasha said…’.

Additionally, follow your organisation’s policies and procedures concerning note-taking and record-keeping. Ensure you are aware of the existing documentation practices in your organisation and are guided by them in maintaining and storing your client’s file. Usually, a client’s file will include an intake form, a referral form (if applicable), detailed case notes, and test results (if any). 

Like many counsellors, we find the administrative and clerical duties associated with counselling a chore. However, it pays to keep detailed and up-to-date counselling session records. Ideally, report writing should be done immediately after the counselling session, while all the relevant information is fresh in the counsellor’s mind and before other inputs have had time to intrude. In today’s society, we can either type or dictate records using speech recognition software directly into a computer. Alternatively, we can keep handwritten records on printed forms or cards. Where records are computerised, adequate security measures are required to protect confidentiality.

Identifying the person seeking help

Records of people seeking help need to be clearly identified so there can be no confusion because, in large agencies, it is not unusual to find two people with the same name. Identifiers might include:

• family name (surname)
• other names
• date of birth (if known)
• address
• contact phone numbers.

Where handwritten records are kept, it can be an advantage to label each page of the record with the person’s full name so that the possibility of pages being inadvertently placed in the wrong file is minimised.

Additional demographic information about the person seeking help

Commonly, when the information is available, records may include any of the following:

• marital status
• name of partner or spouse
• names and ages of children
• referral source.

Notes about each counselling session

The notes for each counselling session may include the following:

1. date of the session
2. factual information given by the person
3. details of the person’s problems, issues or dilemmas
4. notes on the process that occurred during the session
5. notes on the outcome of the counselling session
6. notes on interventions used by the counsellor
7. notes on any goals identified
8. notes on any contract between the person and the counsellor
9. notes on matters to be considered at subsequent sessions
10. notes on the counsellor’s feelings relating to the person and the counselling process
11. the counsellor’s initials or signature.

Note: Handwritten notes need to be legible so that if a person transfers to another counsellor for some reason, notes can easily be read, with the person’s permission.

Keeping these 5 Ps in mind will ensure that your notes sufficiently cover all aspects of the client’s story. The following example of a session’s notes will help you understand what documentation in brief interventions looks like. Note: ‘Cl’ is a common shorthand for the ‘client’.

Case Study

Carlyle came in for counselling with the desire to reduce his intake of alcohol. Marita, his counsellor, started by filling out an intake form (this is the organisation's policy). She has created a file for Carlyle and keeps it in a locked filing cabinet in her room. She has informed Carlyle that he can access his file whenever he likes. She also takes his permission to make notes of their sessions together, and Carlyle consents to the same. The following are notes from their first session.

Carlyle Lee
Individual session, 13th September 2017
Session scheduled for 10 am. Client arrived at 1015 am. Concluded at 1105.
(Looks tired and sleepy but interested in the session)
Carlyle L. is a 38-year-old married man with three children and a professional lawyer.
Chief complaint is his inability to control his drinking.

Presenting issues

Cl. Is seeking help to reduce alcohol intake. Has been having a few drinks with friends every day and reaching home in an inebriated condition. Describes wife as being ‘upset and worried about my drinking and the resulting poor relationship with my children’. Cl also states, ‘My performance at work is suffering, and I am not sure I can continue the way I am drinking'.

Predisposing factors

Cl’s father and brother are alcoholics. He states, ‘guess I was meant to be an alcoholic…it is just in the family’. Mother left when client was aged 7. Shares that he has trouble expressing himself emotionally and tends to ‘stifle up all the stress’.

Precipitating factors

Reported for counselling as cl. had to be picked up by wife from a restaurant where he had passed out. States, ‘My wife said if I wasn’t taking help she would leave with the kids. She said she will not put up with having to pick up her drunk husband from random spots’

Perpetuating factors

Cl. has a big circle of drinking buddies. A lot of stress at work with deadlines and inability to express his emotions. Reports ‘I feel like I am good for nothing. My wife should leave me.’

Protective factors

Cl. loves wife and children. Reports, ‘I used to be an excellent lawyer’ and ‘I want to set up my own firm’.

Stage of change

Cl. is in a contemplation stage, as evidenced by his question, ‘Do you think I could quit? What will I need to do?’

Provided leaflet on effects of alcohol and shared support group info. Cl interested in joining. Also agreed on one goal for the week to come straight home from work. Cl. would like to take his wife’s support and be accountable to her and ‘make her happy’.

Next meeting: 20th September, 11 am.

Plan: follow up of week and detailed goal setting.

Signed: Marita G.

In this case study, you may have noticed how the counsellor was objective throughout and included the client’s statements where needed. She used the 5P’s technique which is very useful for the first session and also noted the client’s stage of change, supports, goal and plan for the next session.

check your understanding of the content so far!

Progress feedback can be provided to the supervisor by documenting information about the intervention, documenting client progress, client response, outcomes and identified problems related to the intervention. Progress feedback can also be delivered verbally at meetings or in response to questions from the supervisor about the client.

However, when delivering feedback about a client verbally, confidentiality issues must be upheld. Anyone not working with the client is not privy to information about the client, and those working with the client (such as other agencies) should only be given information on a need-to-know basis.

When documenting information, take important findings from other reports, consider if the information you have gathered supports or contradicts their findings, and discuss this in your report. Appropriate terminology should be used when documenting consumer response, outcomes and identified problems related to the intervention so those reading the document understand what is being said. The language, tone and terminology should be pitched at the audience.

If the audience is other mental health workers, names of drugs and lists and doses of pharmacy medications can be used to communicate information as precisely as possible, but if the audience includes family or other key stakeholders, terminology should be appropriate to their understanding of terms. Sensitive family information should be handled tactfully, considering that family members might read it. If there are difficult dynamics between key parties, care needs to be taken that the report's language does not appear to take sides.

Only include historical and background information relevant to the document's purpose. Do not include information in the formulation or recommendations not cited earlier in the report. Some information might be interesting but unrelated to the document's purpose, so it should be avoided if it does not add to or support what you are communicating. Multiple examples of the same issue should be avoided unless a contentious or legal issue is involved.

Information should be communicated:

• clearly and objectively and in a well-organised fashion
• with purpose and with demonstrated logic and analysis
• with careful consideration for the reader
• with consideration for the dignity of the client
• with sensitivity, using language that the readers will understand
• using the technology supplied (for example, computers and software).

In writing the document, any opinions should be written clearly and with some certainty, remembering all opinions are based on the information available at the time of report writing, but they should be expressed as opinions rather than as facts. Try to understand what is going on from the client's perspective, then try to be their voice. Occasionally, you will be the only person speaking for the client (via your report) in a manner that others will understand. Others might not understand the client's behaviour as you do.

In the recommendations section, do not avoid documenting what you think the individual needs because the resources might not be there to provide it. Make the recommendation or state the need, then discuss the difficulties in meeting that need. Do not make it your responsibility to decide what is possible or not, just state what is required.

Reporting any concerns and difficulties your client is having is also an opportunity for you to discuss any challenges you are facing in the case. Your supervisor must offer you clinical supervision and professional support in these situations. Evidence indicates that counsellors who receive quality supervision can better function across multiple domains, manage their stress better and are less likely to experience burnout.

Any difficulties or concerns of the person should be reported in a timely manner to the supervisor so that they can be addressed. When difficulties or concerns arise, the supervisor might make variations to the intervention, which should be implemented as instructed by the supervisor. Difficulties could include a lack of client commitment to the program, helplessness, lack of support, criminal activity of the client, a drop in attendance, self-harm, or anger.

For example, if your client is having anger problems and you notice their physiological cues during the session, such as heart rate increases, they are breathing rapidly, they may start to sweat, and they might say that they have an uncomfortable feeling in their stomach – these might be a cause of concern. Remember, we are all different. Each individual needs to identify for themselves what happens to them physiologically when they start to get angry, hence the counsellor should be able to use different counselling techniques on their client.

If a client has an angry outburst and is threatening you as the counsellor, recognise their physical cues – get the client to immediately say ‘STOP’ sharply but silently to themselves; this will help interrupt those angry thoughts. This method is called thought-stopping. Once a person has interrupted the thoughts promoting anger and stopped letting their thoughts hook them into an angry outburst, they can, if they choose, step back in their imagination by 10 metres so that they are, in effect, looking at themselves and their satiation from a distant vantage point.

They can then, if they choose, take a few slow, deep breaths and allow the muscles in their body to relax as they would when engaging in a relaxation exercise. Clearly, part of helping a person learn new ways of dealing with anger involves teaching relaxation. They can then use the method described. By learning how to relax and recognise their patterns of behaviour, they will hopefully be able to lower the intensity of their emotional feelings in future times of crisis and then be able to deal with their anger more appropriately.

If, during an intervention, a client is struggling with their anger management and has caused them to conduct self-harm or self-destructive behaviours such as vandalism or aggression towards others, the intervention plan might be varied to include referral of the client to a more experienced and qualified counsellor when necessary and/or to attend cognitive behavioural therapy which identifies antecedents to the behaviour and the thoughts and feelings that follow, so the client can be prepared to challenge them. A therapist can help the person with interpersonal skills training and communication skills to reduce the likelihood of anger leading to aggressive behaviour.

It is in this stage of the intervention, when the client is struggling and having difficulties, that you may encounter challenges in their behaviour and attitudes towards continuing treatment. You will be required to manage these situations using a range of skills and strategies, including conflict management and resolution, mediation and negotiation.

Conflict Management and Resolution

Often the AOD client’s agenda during intervention will fluctuate between being highly motivated to change and develop healthier habits to an overwhelming urge to use substances regardless of the consequences. This inconsistency in thought and desire is challenging for not only the client but also their support network, including the AOD worker. It may lead to disagreements and conflicts that need to be managed carefully. It is important that the timing of these interactions does not happen when the client is in a heightened state or when they are experiencing symptoms of withdrawal, if possible.

When clients are in the first stages of recovery, they have a lot to learn. Their previous strategies for coping with life were faulty, and they are trying to learn new ones but may occasionally fall back on maladaptive strategies. For example, they may be prone to defensiveness, bringing them into conflict with other people. Conflict can be upsetting, so avoiding it can be a good strategy. However, avoidance will only be a good option some of the time because some problems need to be faced, and attempts to avoid conflict can make the situation worse.

Some strategies will help you and your clients to deal effectively with conflict. Some suggestions from Family Drug Support Australia (n.d.) include the following. 

Ways to positively express and resolve anger

The following steps can help you and your client to recognise and express your anger:

• Recognise when you are angry – shouting in a loud and angry voice, “I am not angry”, is not recognising your anger
• Accept that it is OK and human to get angry
• Identify the source of your anger – who or what is causing the anger
• Understand why you are angry
• Identify the feelings that your anger is masking
• Find positive and effective ways to express your anger and release tension
• Understand that negative or abusive forms of expressing anger are never OK – this includes emotional and physical abuse and other violent behaviours
• Practice forgiveness for yourself as well as the substance user.

Coping with other people’s anger

If we react to others defensively by attacking or withdrawing, conflict often increases. If, instead, we respond assertively, we can help to bring the conflict to a level at which emotions can be reduced, and negotiation then becomes possible.

• Saying “enough” or “I don’t want your anger”. Firmly putting your hand up as if stopping traffic. Everyone has a right to say to someone else that they are angry with them. No one has the right to be abusive and aggressive with someone else.
• Making an “action-response-outcome” statement. The three parts of this are “When you. . . I feel. . . and I ask that. . . “ this is saying how someone’s behaviour leads you to respond and what you want to happen. For example, “When you break our agreement not to use drugs in our home, I feel so angry and exasperated with your behaviour. I ask again that you honour what we agreed” What is important is that action describes the user’s behaviour and not them as a person, the response is about your reaction and the outcome is about what you want and not just a demand.
• Being a “broken record”. Keep repeating what you want, and don’t let yourself be deflected away. For example, “I know you say you are making an effort, but I still find myself having to deal with your bad manners.”
• Compromising or playing for time now and negotiating later when dialogue is possible.
• If all of these feel too much of a risk because you feel threatened, withdraw from the situation. This could be anything from a few minutes apart to ending all contact.

Dealing with Conflict

Reflect on previous conflict situations you have had. To help, ask yourself:

• What were the triggers to conflict starting?
• Are there any fixed patterns to how conflict goes?
• What are the roles people adopt?
• What are the payoffs people get for the roles they play?
• What is my responsibility because this is the bit I can change? (This means taking a good look at yourself.)

In conflict, there are usually two or more monologues – people talking at each other and not communicating effectively.

Aim for dialogue, which can be done by:

• Choosing your moment, for example, when someone is not under the influence of alcohol or other drugs
• Slowing down the conversation
• Listening
• Being open and honest
• Respecting the other person. You do not have to like or respect some aspects of the person’s behaviour. Respecting someone is recognising that they are more than some of their behaviour and worthy of respect as another human being. We are all different, and we are all equal
• Accepting and understanding the other person’s point of view, even when we disagree.
• Using “I” statements to own what we say
• Acknowledging how we feel and how the other person feels
• Expressing feelings appropriately
• Recognising the need for all to exercise both rights and responsibilities.

Conflict involves two people, but others often get caught up in creating persecution, victim and rescuers. When two people have a transaction – including conflict – it involves both parties. Both parties create what happens; each influences the other and is affected by the other, and when a third person gets involved, a negative triangle can be created, usually exacerbating the conflict and making matters worse, for example:

Dad: “You’re stoned again – I’ve told you not to use drugs in this house!”

Son: “What I do is my business – why can’t you leave me alone?”

Mum: “You shouldn’t shout at your dad; he is only trying to help.”

Son: “Keep out of this – you are always butting in where you’re not wanted.”

[Mum starts crying]

Dad: “You’ve done it again! You are always upsetting your mother.”

Son: “Just leave me alone.”

This is a classic example of a negative transaction and the consequences of triangulation. If we examine each person’s feelings, they are all legitimate – the son feels nagged at, and ganged up on; the dad feels angry at the drugs in the house rule being broken; and the mum is distressed because she was yelled at. It’s how they express their feelings and the behaviour that follows that is problematic.

It may not matter who is to blame or whether the conflict is a particular person’s fault. Usually, people cope as well as they can, and the conflict is created inadvertently. If we can get away from the idea that we are right and the other person is wrong, we can start to find better ways to resolve these issues.

When we choose our responses and behave differently, other people often respond differently to us. Therefore:

You can’t change someone else, but. . . You can change your response to them. So, if you want to change someone, try changing yourself. In conflict, we either give up or feel powerless to affect how someone behaves, or we try to dominate and control them. However, the reality is somewhere between these two. We do have influence, but our influence is limited.

Conflict Resolution

Services Administration (SAMHSA, 2019) involves the following five steps:

Understanding and managing conflict is a critical relapse prevention skill for anyone with substance dependency. The reality is whether someone is in recovery or not, they will come across conflict at some point. The real test for those leaving AOD treatment is their ability to manage conflict without resorting back to previous addictive behaviours. It does not matter what the conflict is; the important thing is knowing how to apply healthy approaches to conflict resolution.

There are five main strategies for dealing with conflicts, all of which can be considered in terms of who wins and who loses.

1. Compete or Fight: This is the classic win/lose situation, where the strength and power of one person wins the conflict. It has its place, but anyone using it must know it will create a loser. If that loser has no outlet for expressing their concerns, then it will make the person resentful, and if it keeps happening, this will fester and ultimately explode at some point.
2. Collaboration: This is the ideal outcome: a win/win situation. However, it requires input of time from those involved to work through the difficulties and find a way to solve the problem that is agreeable to all. Often this approach is a tenant of family or couples work but requires the individuals concerned to be fully involved in the process.
3. Compromise or Negotiation: This will likely result better than win/lose, but it’s not a win/win scenario. Although both parties give up something in favour of an agreed mid-point solution, the outcome is not achieved in the same deep, meaningful way that collaboration and, in some ways, individuals can still come away from the process with some resentment because they had to give something up.
4. Denial or Avoidance: This is where everyone pretends there is no problem. This can be helpful if those in conflict need time to ‘cool down’ before any discussion. However, ultimately, this is a lose/lose situation if the conflict areas are never dealt with. Furthermore, if the denial and avoidance continue, it will lead to that person feeling resentful, and if it keeps happening, this will fester and ultimately explode at some point.
5. Smoothing over the problem: On the surface, harmony is maintained, but underneath, there is still conflict. This is similar to the previous situation, except that one person is probably okay with this smoothing while the other remains in conflict, creating a win/lose situation again. It can work where containing a situation is more important than dealing with the current conflict but is not a long-term solution.

Conflict Transformation vs. Conflict Resolution - What's the Difference?

The presenter in this video discusses the difference between conflict transformation and conflict resolution.

watch

So far in your Diploma, you have learned all about the legal and ethical considerations of counselling practice, such as:

• the client’s rights to privacy (for example, the right to control access to oneself and sharing of private information in private spaces)
• right to confidentiality (for example, keeping what happens in the therapeutic space undisclosed unless the situation deems it vital),
• issues of disclosure (for example, keeping a client’s disclosed information private and sharing only after obtaining their consent)
• codes of practice (for example, the rules and policies determined by the industry/regulatory bodies that inform the delivery of service and organisational policy)

All of these apply within the context of brief interventions.

When identifying other sources of assistance or making referrals according to the individual’s needs, it is important to first consult with your client about the information they are comfortable with you providing to the service/practitioner and ensure that the information you provide is relevant and targeted.

For example, if a client were terminating a brief intervention to go and see a registered psychologist to address their underlying depression that first triggered their substance abuse, you would want to inform the psychologist of the reason for the referral (for example, the client’s needs exceed that which can be addressed in a brief intervention) and the fact that the client has already committed to making a change by undertaking a brief intervention.

Unless other details are requested and have been permitted by the client to be discussed, it is best to leave the assessment of needs and case formulation to the psychologist to undertake rather than you relaying your potential inferences and conceptualisations of the client.

Ultimately, as part of maintaining the confidentiality and the security of a client’s information, the counsellor must consider the following:

• Have I discussed (with the client) the need to divulge information to other sources?
• Has the client given permission/has that been documented?
• What has been identified as essential information to disclose?
• Why does this information need to be disclosed?
• Who needs to know this information?
• How does my disclosure help the client?
• Is the client’s information being kept in a secure location both in my service and the other service I am referring to?
• What measures are being taken to protect the client’s information?

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In this section, we will consider the ethical requirements when it comes to counselling, whether it be online or face-to-face sessions.

Counsellor Expertise

Counsellors first need to be well-practised in face-to-face counselling before moving into internet counselling. Once face-to-face micro-skills are well developed, counsellors can adapt their skills to the online environment. Internet counsellors also need to increase their knowledge and understanding about working online, including the current research into adapting counselling skills and strategies to the internet. It is important for internet counsellors to become familiar with any relevant legal and registration requirements. Is it, for example, OK to offer counselling to people who reside outside your registration area? Counsellors may develop their skills and knowledge through training and supervision.

Informed Consent

As with any counselling relationship, informed consent must be obtained from the person seeking help before commencing counselling. This is particularly important when counselling online for two reasons. Firstly, as internet counselling is a relatively new field, people must be properly informed about the advantages and disadvantages, effectiveness and risks to understand the potential limitations before commencing support. Secondly, a person choosing to remain anonymous during online counselling can present difficulties when faced with a crisis. Therefore, it is always important to identify an individual to ensure the service offered is appropriate. For example, what if parental consent is required? What might be some ways for internet counsellors to identify the person seeking help?

Confidentiality

During the informed consent process, it is important to highlight how confidentiality could be limited by using the internet. In particular, it is important to share how the individual’s privacy is protected from unauthorised access. This might include how their electronic data and information are stored and backed up and what security measures are used, such as password protection and data encryption. Guidance or ideas may also have to be shared with the person seeking help regarding protecting the privacy of their counselling session, for example, password protection and not forwarding personal information to others.

Boundaries

The internet is used extensively for developing personal relationships; therefore, there is an increased need to protect professional boundaries. One way to maintain boundaries is to highlight them before commencing an online counselling relationship. Some questions to consider include:

• How quickly and often will you reply to emails?
• How long will the chat sessions run?
• Will you schedule sessions or reply to emails after hours?
• Will you offer impromptu sessions at a person’s request or only pre-scheduled sessions?

Maintaining your professional boundaries can also be made easier by using professional language.

Responsibility of the counsellor

Counsellors frequently experience a sense of conflict between their responsibilities to the person seeking help, the agency that employs them, and the community. You will, at times, need to make your own decisions about which of these responsibilities need to take precedence, and in our view, the decision is unlikely always to be the same. If you are in doubt about any particular decision, consult your supervisor.

The counsellor is responsible to the person seeking help and needs to directly address their request for counselling help. When someone comes to you for confidential help, you have an obligation to give them that, or alternatively, to be clear about why you cannot do that. You cannot ethically fulfil their needs if providing a person with confidential help would:

• involve working in opposition to the policies of the organisation that employs you
• involve a breach of the law
• put other members of the community at risk
• be impossible for you personally.

However, in these situations, you need to be clear with the person seeking help about the situation so that they understand the conditions under which they are talking to you.

Counsellors employed by an organisation or institution are responsible to that employing body. All the work they do within that organisation or institution needs to fulfil the requirements of the employing body and fit in with its philosophical expectations. Counsellors have to be aware at all times of their responsibilities to the community at large. As discussed earlier, this raises problems concerning confidentiality.

Whenever a member of the community is at risk, property is likely to be damaged, or other illegal actions are likely to occur or have occurred, then a counsellor needs to decide on what action is needed. Often such decisions do not involve choosing between black and white but rather between shades of grey, and sometimes counsellors find it difficult to decide what is most appropriate to serve the needs of the person seeking help and the community in the long term. At these times, the sensible approach is for the counsellor to discuss the ethical issues with their supervisor.

Note: The Code of Ethics and Practice is intended to provide standards of professional conduct that can be applied by the ACA (Inc) and by other bodies in Australia that choose to adopt them. Depending upon the circumstances, compliance or non-compliance with the Code of Ethics and Practice may be admissible in some legal proceedings.

Codes of Ethical Conduct

Many counsellors belong to professional associations with codes of ethical conduct. These codes are readily available on request, and it is sensible for a new counsellor to read through the relevant code for the relevant profession. Some important ethical issues are as follows. 

Respect for the person seeking help

Regardless of who the person seeking help is and their behaviour, they have come to you for help and deserve to be treated as a human being of worth. If you treasure them, through feeling valued, they will be given the optimum conditions in which to maximise their potential as an individual. Most helping professionals agree that within each of us is the potential for good, and for that potential to be realised, we need to feel okay about ourselves.

Counsellors, therefore, have a responsibility to facilitate the process that enables those who seek their help to feel okay about themselves and to increase their feelings of self-worth.

If we try to impose our moral values on the people who seek our help, we are likely to make them feel judged and damage their self-worth. Moreover, they are likely to reject us as counsellors and reject our values too. Paradoxically, if we are able to accept them, with whatever values they have, we are likely to find that as time passes, they will move closer to us in their beliefs. This is inevitable because, as counsellors, we are models for the people who seek our help, whether we like it or not. We have a responsibility to be good models.

In this regard, it can be useful to create opportunities for those who seek our help to give us feedback about their experience of the counselling process. By doing this, we can demonstrate respect for their views and their right to have some influence in the counselling relationship.

We must remember that the interests of the person seeking help must take precedence over the counsellor's during the counselling process. It is not ethical to use counselling sessions with people who seek help to work through our own issues. The correct time for working through our issues is in supervision sessions.

Limits of the counselling relationship

In all our relationships, we set limits. Each of us has a boundary around us to preserve our identity. The strength of that boundary, and its nature, depends on who the relationship is with and on the context of the relationship. The person-to-person counselling relationship is a special relationship established by the person seeking help for a particular purpose.

They enter into the relationship entrusting the counsellor with their well-being and expecting that the counsellor will, throughout the relationship, provide them with a safe environment in which they can work on the issues that trouble them.

As discussed previously, the person-to-person counselling relationship is not an equal relationship, and, inevitably, whether the counsellor wishes it or not, they are in a position of power and influence. Counsellors often work with people who are in highly emotional states and are consequently very vulnerable. The way that a counsellor relates to a person seeking help is not characteristic of human behaviour generally.

A counsellor devotes most of their energy to listening to and understanding the person, so the person sees only a part of the counsellor’s character. They may perceive a counsellor as unrealistically caring and giving in these circumstances. The counsellor’s power and the person’s biased perception combine to make the person very vulnerable to offers of friendship or closeness.

The counsellor is also vulnerable. In the counselling relationship, the person seeking help often shares innermost secrets, so inevitably, there may develop a real closeness between the person and the counsellor. Counsellors learn to be empathic and develop special relationships with the people they seek to help. If they are not careful, they too become vulnerable to offers of closer relationships than are appropriate.

Counsellors, therefore, need to be careful not to discount signs that the counselling relationship is being compromised.

Responsibility of the counsellor

Counsellors frequently experience a sense of conflict between their responsibilities to the person seeking help, the agency that employs them, and the community. You will sometimes need to make your own decisions about which of these responsibilities need to take precedence, and in our view, the decision is unlikely always to be the same. If you are in doubt about any particular decision, consult your supervisor.

Clearly, the counsellor is responsible for the person seeking help and needs to directly address their request for counselling help. When a person comes to you for confidential help, you have an obligation to give them that, or alternatively, to be clear with them about why you cannot do that. You cannot meet their needs if providing a person with confidential help would:

• involve working in opposition to the policies of the organisation that employs you
• involve a breach of the law
• put other members of the community at risk
• be impossible for you personally.

However, in these situations, you need to be clear with the person seeking help about the situation so that they understand the conditions under which they are talking to you.

Referral

Some circumstances may necessitate the consideration of referring a client to other professionals or services. This may be to obtain additional services or because you feel that the client requires responses beyond your level of skill and expertise. As mentioned in a previous section, it is vital that counsellors, social workers and AOD workers can appreciate their level of expertise and training but also can recognise their own limits and work within their own capacity.

Referring a client to a more suitable professional is an ethical practice that ensures appropriate treatment needs will be met, and requesting supervisor support can be useful in this practice.

When a counsellor cannot adequately meet a person’s needs, that counsellor has a responsibility to make an appropriate referral, in consultation with the person, to another suitable professional. However, it is inappropriate for a counsellor to avoid all difficult and unenjoyable work by excessively referring people to others.

There is a responsibility on all counsellors to carry a fair load and to be sensible about referral decisions. Such decisions are best made in consultation with a counsellor’s supervisor.

Instead of referring to a more qualified and experienced counsellor, it may sometimes be appropriate for a counsellor to continue seeing someone seeking help while undergoing intensive supervision. If this happens, the counsellor is responsible for informing the person and seeking their approval.

Often referral is useful where people have special needs. For example, people with particular disabilities, people from other cultures and people who speak another language may benefit from referral to an agency (or professional) that can provide for their specific needs.

When referring a person to another professional, it may be useful to contact the professional to whom the referral is being made, with their permission, to ensure that the referral is acceptable and appropriate.

Termination of counselling

Termination of counselling needs to be carried out sensitively and with appropriate timing. It is unethical to terminate counselling when the person seeking help still needs further help. If, for some unavoidable reason (such as leaving the state), you need to do this, then it is incumbent upon you to make a suitable referral to another counsellor who can continue to give the necessary support.

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Redefining Recovery

In his TEDx Talk, the presenter Tom shares the tumultuous journey of a recovering addict and how small steps to reach out made a big impact in his perspective of the world. This is a good real life story to bring to light the issues of addiction, to help better understand clients you will work with. 

watch

This module section helped you develop the knowledge and skills to monitor brief interventions, including discussing outcomes with the client, adjusting approaches, and ensuring appropriate documentation and legal and ethical practice.

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Babor, T. F., Higgins-Biddle, J. C., & Robaina, K. (2016). USAUDIT: The Alcohol Use Disorders Identification Test, Adapted for use in the United States: A guide for primary care practitioners. Retrieved from www.ct.gov/dmhas/lib/dmhas/publications/USAUDIT- 2017.pdf

Miller, W. R., & Sanchez, V. C. (1994). Motivating young adults for treatment and lifestyle change. In G. S. Howard & P. E. Nathan (Eds.), Alcohol use and misuse by young adults (pp. 55–81). University of Notre Dame Press.

Stone, J., Marsh, A., Dale, A., Willis, L., O’Toole, S., Helfgott, S., Bennetts, A., Cleary, L., Ditchburn, S., Jacobson, H., Rea, R., Aitken, D., Lowery, M., Oh, G., Stark, R., & Stevens, C. (Eds). (2019). Counselling Guidelines: Alcohol and other drug issues. Mental Health Commission

Substance Abuse and Mental Health Services Administration. (2019). Mental health and substance use disorders. Retrieved from www.samhsa.gov/fnd-help/disorders