 Hey everybody and welcome to today's installment of the review for the Alcohol and Drug Counselor Exam. Today we're going to be talking about understanding readiness for change and stage appropriate interventions. So we're going to start out with readiness for change. A lot of us have heard of those pre-contemplation, contemplation, preparation, yada, yada. So that means a person may not be 100% ready to do what they need to do. And one of the things that we want to do as clinicians, and I learned the hard way, is move them from one stage or phase of readiness for change to the next. Don't expect in 30 days or even less if they're in detox for three days. Don't expect to move them from contemplation into action. It's not going to happen. So we want to focus on trying to nurture that seed. The seed is the need for treatment and we want to nurture that to grow so they become ready to act. Treatment planning and placement must take into account how ready the client is for change for all aspects of every single problem. So for example, if one of my issues is I'm unhealthy and I want to get healthy, and that's a poor problem statement anyway, but we're just going to go with it, okay great. So that's one aspect of something that I need to work on. And maybe I'm also having sleep problems and I'm depressed. So those are three different problems. Maybe I'm really ready to work on the depression and getting healthier, okay, that's great. But then when it comes down to getting healthy, you know, maybe I'm ready to start exercising a little bit, but I am not ready to start changing my diet. So my readiness for change for that aspect of getting healthy is going to be different. So we need to pay attention to readiness for change and enhance readiness for change for every aspect of every problem. So the trans theoretical model of change was proposed by Purchaska and DeClemente and it's great. It's enduring. It works for mental health as well as substance abuse issues as well as physical issues. One thing you want to remember is it's not linear. That means you don't go from pre-contemplation to contemplation to preparation to action in this nice sequential step. People will go from pre-contemplation to contemplation and then back to pre-contemplation. And then they may work all the way up to action and it gets really uncomfortable. So then they jump back to contemplation. They're like, you know, maybe it wasn't that big of a deal. So it's more of a jumping around sort of thing. It's not a straight progressive line. Readiness for change differs for each goal and issue. Tip 35 put out by the Substance Abuse and Mental Health Services Administration called Enhancing Motivation for Change provides concrete stage appropriate intervention. So if this is something that you're a little weak on in your training, it's really important to go review tip 35 and it is a very well written, easy to read treatment improvement protocol. Another part of Readiness for Change is to remember that relapse is the rule, not the exception. And some of you may be like, oh my gosh, I can't believe you just said that. It doesn't mean people have to go and go into a full blown relapse. They can have an attitudinal relapse. They can have a part of a behavioral relapse. They can have a slip. They can have a lapse. There's a lot of things in there, but very rarely is somebody going to go into treatment and go through the entire process and not backslide at all. So we want people to recognize that relapses, whether it's a small one or a big one, are opportunities to learn and opportunities to strengthen and opportunities for us to understand why that behavior was more rewarding than the recovery behavior we were presenting. When people revert to old behaviors, their readiness for change drops back into contemplation or even pre-contemplation. So we're going to need to nudge them forward again and go help them see why it's worth the effort and why it's important. Relapse or recurrence does not equal failure or that the client has abandoned efforts for change. It means there was a hiccup, something they didn't expect. Think about when you're driving and you've got this beautiful course laid out and you're driving along and all of a sudden you hit this unexpected traffic jam and so you're like, well, do I really want to go to the mall if I'm going to have to sit through this or do I want to turn around and go back? Well, that's kind of what we're talking about with relapse here. It's something that you didn't really expect probably or you didn't have the tools to deal with, so you've got to figure out whether you want to push through it or go back. So this is an opportunity to learn. If the person decides to go back, if they relapse, we can say, all right, well, when that situation happens again, what are some other options? What tools do you need to strengthen? So the theoretical model of change starts with pre-contemplation. This is when the person's not considering change. They usually have not experienced any adverse consequences. They may be unaware that a problem exists or may be unwilling or too discouraged to attempt change and I've seen this in a lot of smokers especially who have tried to change so many times and it just didn't work and they're like, why should I try again? It's not even going to work. I'll just take my lumps where they come. So pre-contemplation, the person doesn't think there's even a problem. I try to make the analogy of getting into a cold pool and it's summertime and pre-contemplators are laying out on a chair beside the pool. They're not hot. They're not ready to get in the pool. They are just fine. There is no problem. You may see some sweat bubbling up on them and you know that the UV rays are high but they don't feel a problem yet. So what we want to do is provide pre-contemplators, information linking problems with current behaviors or issues and we can do this through education, motivational interviewing and family and peer commentary specifically about the client. So for a pre-contemplator, we may educate them about, you know, when we're talking about substances, how much do people actually use, how regular, how much does the average person actually use cocaine? How much problem could it cause you? Let's look at your assessment and see how many different areas this problem, this issue is impacting you in your life. Motivational interviewing would ask the person, okay, so you're telling me, you know, you've been using, you really don't see any problems. I'm wondering if you can identify five ways that the problem has impacted your life. And family and peer commentaries is when, you know, kind of like interventions when people say, you know, I know you don't see a problem but when you drink, you become very angry or very violent or very reclusive or depressed or whatever it is. That's when loved ones are providing feedback, not emotional feedback, just factual. When you do use drugs or alcohol, this is the influence it has on me or this is the effect that I see it having on you. It is what it is and the person who is struggling with the issue is either going to take it or leave it. So like I said, some pre-contemplators are reluctant. So we need to increase their knowledge of the problem and the personal impact. They may not want to give up drinking. They may not want to think about the fact that they can never drink again or they may not be ready to address it because it just sounds way too hard. And you know, I really don't have enough of a problem where I need to do anything about it is kind of what you're going to hear from them. Rebellious pre-contemplators are using, are afraid of losing control. They're afraid that if they stop doing this that they're going to be miserable and life's not going to be the same anymore and yada, yada, yada. So we want to shift their energy away from this fear of losing control to improving the next moment. So let's not do anything drastic. Let's not do anything rash. You know, let's just try experimenting. You know, maybe try going a week without drinking or smoking or gambling or whatever it is and have them experiment with it. Have them try it out. We're not saying you can't do it forever. You know, so they are in the driver's seat. They're in control. The resigned pre-contemplator is the one who's tried before and just kind of given up. So we want to rekindle hope and optimism by highlighting successes that they've had. Maybe they didn't use for a week or for six months or whatever it was and the strengths that they have. And we can also provide more information. We can talk about, you know, what did you try and learn about what triggered the relapses so then we can provide more information. Maybe they, maybe there are new treatments out or new medications out or new approaches to help the person deal with it. Or maybe they've got a co-occurring disorder that has never been diagnosed and you can see it plain as day and you're like, well, it's not surprising you have a hard time staying clean and sober because you've got, it appears you've got bipolar disorder. So you know, we need to get both of those under control. Contemplation. Reasons to see a cause for concern and reasons to change. They're becoming ambivalent. They may seek relevant information, reevaluate their behaviors or seek support. So back to that pool metaphor. In contemplation, the person starts feeling like they're getting hot and they look over at the pool and they go, yeah, every time I get in the pool, it's really cold and the kids are splashing and it just, no, not worth it right now. I will, you know, fan myself or move over into the shade a little bit, but I'm not ready to get in the pool yet. It's not that bad. So what we want to do is increase their awareness of the consequences of the current problem. You know, if you keep on this path, what do you think the results are going to be? Explore and address ambivalence by tipping the decisional balance scales. And tip 35 helps you learn how to do a decisional balance exercise by helping them see the pros and cons of change. Yep, there are drawbacks to change. We need to acknowledge those and address them and the pros and cons of staying the same. And again, yes, there are benefits to doing what they're doing now, or they wouldn't be currently doing it. So we need to address those, you know, they're serving a purpose. So how else can you meet those needs? If alcohol or cigarettes help you relax because you're just way too stressed or way too anxious or depressed. All right, it's a serving a function. It's got a purpose. So what else can we do to help you deal with those feelings so you don't feel like you have to drink or smoke or use? We also want to help clients address anxiety and grief about change. It's scary, especially if they've tried it before and they failed. It usually dings their self-esteem a little bit. So they may be anxious about trying it again. They may fear that they just can't do it, that it's going to be too hard. And grief, they've got to give up something that has basically been their lifeline for a little while. It is a solution to addictions are a solution to a problem, but a bad solution. So they may have some grief about having to give that up because they have some good memories and feelings associated with it, in addition to a whole bunch of bad ones. So we want to help clients visualize change, just like after we lose someone important or something important to us, we're closing that chapter on our life, but we want to visualize life without that person or thing in our life. So we want to help them visualize what they're working towards and what it's going to be and what's good about it, even if they don't have that substance or activity in their life. In preparation, the person's going, okay, you're right, it's a problem. If we stay with the pool metaphor, the person's going, all right, you know what? I'm getting pretty uncomfortable. So I'm going to go sit on the edge of the pool and I'm going to dangle my feet in and see how that feels. See if it's too cold or if I think I can tolerate it. So in preparation, clients are deciding that, yeah, it's time to do something. Their commitment to change is strengthened and more specific change planning begins. They start examining their self-efficacy for change, which means they start thinking about how capable am I of changing? Can I even do this? They still may be using, but they're also probably experimenting with ways to cut back. So they're trying some things. They're trying to figure out what treatment program they might go to. They're getting their ducks in a row, so to speak. In preparation, we want to help clients identify the benefits of treatment and there are going to be some drawbacks. You know, it can be money. It can be time. It can be childcare. It can be a lot of things. We need to help them address those too. In preparation, we need to help them get those ducks in a row. So treatment is something they can do and there's not a yes, but that's going to get in their way. Identify and address fears and apprehensions about treatment. Some people fear they're going to lose control. Some people fear that they're going to be locked up. You know, whatever their concerns are, let's address them. Give the client a list of options for treatment and that includes not only different treatment centers, but also different treatment approaches and different treatment levels. Even if somebody scores out on the ASAM as needing residential treatment, they may not be ready for residential treatment. They may not be willing for whatever reason. Maybe they've got three kids at home and they don't have anybody to take care of them for 90 days while they're in treatment. So, you know, there may be reasons that residential is not a good fit for them right now. So, okay, preparation. Let's look at what are some other options that you can look at, including intensive outpatient plus meetings or something. Clarify goals and strategies. Help them identify and address barriers to change. If they are living in a house where three other people live there and are actively using, that's going to be a barrier to change. If they are incarcerated because the milieu tends to have a lot of criminogenic addictive type thinking, that's going to be a barrier to change. So, we want to identify anything that might get in this person's way from achieving their goals. Highlight their strengths and past successful strategies. So, they're preparing to make this huge step. We want to build them up. Let them know they can do it. Just like a coach says, you know, you remember you beat this team, you beat this team, you've been, you know, practicing and all your game tapes look excellent. So, this is what a coach is going to do. This is what we're going to do. We're preparing people to go in for this fight of their life. Help them garner social support, you know, get social support from people that are out there that can send them letters and keep them company that can help them by watering their plants, keeping their bills paid, whatever it is. Continue to have them envision change and find motivating stories from other people. You know, who do you know who's gone through recovery, who is doing really well? And, you know, I, golly, I probably have two dozen people that I can name off the top of my head who've gone through the program, gone through the recovery process and different treatment centers, but they've gone through recovery and they're still clean. They're still sober and they are thriving. And those are the people that I draw on and, you know, obviously I have their consent. They're fully open about what they've been through. And I can share those if the person doesn't have any people that he can reflect on himself. Identify motivations in each area and create small successes for components of the goal. You know, we don't want to say, okay, your first goal is to be, remain abstinent henceforth and forevermore. That's not realistic. Your first goal is to stay abstinent today. And then tomorrow will address tomorrow. And the next day will address the next day. And before you know it, you'll have been clean for a week. So you want to make small changes. You want to increase self-efficacy, that can-do attitude, and their hardiness. We want them to commit to this. We want them to feel like it's a challenge, but a challenge that they can do. Just like when people start training for a marathon, you start thinking, oh my gosh, 24 miles, that is a long way to run. But they commit to it. They're like, all right, I can do this. And I want people to have that I can do this attitude. And I want them to be committed to doing it, because of all those other amazing things in their life that are important to them. So we say, you want to do this change. You want to get in recovery because you want to hold on to or draw closer to all these other really awesome things in your life. Strengthen their commitment to the process and begin learning about their issues, and they can begin learning about their issues. They can start learning about the effects of abandonment, or the effects that substances have on their neurotransmitters that create sort of a downward spiral mood-wise. And finally, they're in action. They are in treatment. They are ready to do it. So encourage them to choose a strategy for change and pursue it. And this involves a little education, may involve a little bit of experimentation to figure out what they think is going to work for them, especially if they haven't been in treatment before. But let's go. They are ready to go. And that's kind of like at the beginning of a football game, where the coach decides, okay, this is going to be a passing game, or this is going to be a running game. At the beginning of treatment, the client needs to decide, how am I going to approach this in order to win? We start actively modifying habits and the environment. If they're in residential, that's pretty easy to do. If they're in outpatient, then we want to start talking about their habits, getting dangers and triggers out of their environment. We want to start making a relapse prevention plan from the very beginning, so they can start working and living that recovery lifestyle. They may be faced with challenges related to withdrawal and a changing environment. So we need to make sure we buffer against those. If they start feeling cravings really bad, we need to have some method to help them out, whether that's going to meetings or coming to a drop-in center or whatever it is. Encourage them to reevaluate their self-image. Now, this whole process, this action phase, usually takes three to six months following termination of use. So if there's an extended taper period there, three to six months after that, when they start developing new skills, but it also takes the brain that long to rebalance the neurotransmitters so they can think more clearly. They can remember. They can learn easier. All those things that get mucked up when your dopamine and serotonin and everything get out of whack. So the person is tired of being hot. They are ready in action. They are ready to jump in that pool and make it happen. They're ready to cool off and feel more comfortable. So we want to help them implement their plan, help them identify ways to ensure motivation and progress is maintained. And one of the best ways to do this is mindfulness. And we talk about mealtime mindfulness in my practice. Breakfast, lunch, and dinner. I want people checking in with themselves and saying, how am I doing? What am I needing at this point? And emotionally, how am I feeling? What is my attitude? Does anything need to be adjusted to keep me on the right path? We want people to be aware of how they feel physically, mentally, and emotionally. We'll help them identify triggers, how those triggers could cause relapse, and how to deal with them. And triggers can be holidays. They can be something people said. They can be certain people. Whatever the trigger is for people. Sometimes it can be as innocent, if you will, as a commercial on TV. So what are the triggers for you and how do you deal with them? Provide practical tools in each session and discuss and role play application. So for example, if one of your triggers is the time of day, maybe in the evening, right before bed, is when one of the times that you've always used. So if that's a trigger, okay. What do we need to do or what can you do in the evening right before bed so you don't use? Let's role play that. Let's identify a list of three alternatives that you can do. Address obstacles to change, such as lack of transportation, scheduling conflicts with their job, finances, whatever it is. And acknowledge the client's feelings and experiences as a normal part of recovery. There are going to be good days and there are going to be some really crappy days and that's normal. One of the greatest things about recovery is people start feeling feelings. And one of the worst things about recovery is people start feeling feelings. And you know, they're not used to some of those intense dysphoric feelings anymore. The next stage is maintenance or vigilance. The person wants to sustain the gains made. Prevent vulnerabilities. That means live that recovery lifestyle. Eat a healthy diet so the body can make the neurotransmitters it needs to keep the mood adequate so they're getting enough sleep so they're not feeling like they need to overcharge on nicotine or caffeine or something else. So plenty of sleep, good nutrition, good sunlight. We want to make sure their circadian rhythms are set. A lot of vulnerabilities are there. And on all CEU's education's YouTube channel, we have an entire series of videos on vulnerabilities that people can look at. During maintenance they're going to become more adept at identifying and addressing triggers. There is no way we can identify every single trigger for every single person. So we need to help them become aware of things that might trigger them or become more self-aware of when they're feeling triggered. And how to deal with it. They need to have some general strategies if I start feeling triggered for some reason. The first thing I need to do is. And one of the things I have a lot of clients do is keep a note card with them or on their mobile device that has the number of their sponsor or somebody that they can rely on and two other interventions that they can use if they start feeling triggered in order to maintain safety. The maintenance phase lasts a minimum of six months. And in my philosophy, the maintenance phase really lasts a lifetime. It takes six months for all this stuff to become a habit. But then ideally the person still prevents vulnerabilities and sustains their gains and, you know, is aware and mindful after that. We're going to work in maintenance on relapse prevention, reassuring the client that occasional ambivalence is normal, that some of those dreams they may have are normal. We'll help them evaluate their present actions and redefine long-term recovery plans. So, you know, by the time they get to maintenance, they've been going through treatment for about a year. When they started treatment, they probably couldn't even envision being clean for a year. Well, now they're there and it's like, oh my gosh, look how far you've come. You did something that is so hard and you've accomplished it. So, that's awesome. You know, give yourself a pat on the back. You didn't think you could accomplish this. So, now let's look at what you think long-term recovery looks like. What do you hope for the future? Now that you know how powerful and strong you really are. Educate them about the relapsing nature of mental health and addictive disorders, especially if they've got a co-occurring mental health issue. It may, they may have a recurrence of that even though they're not using. So, we want to make sure that they're aware of the warning signs, the early warning signs of an impending mental health relapse because if they start to get depressed, anxious, if they have a bipolar episode, they are going to be more likely to relapse in their addiction as well. And likewise, if they use again, they're probably going to trigger a mood episode. So, we want to let them know that it's not uncommon to go back to stinking thinking for a little bit and you just have to pull yourself out of it and let's talk about some ways to do that. And it is not uncommon to have a mood episode sometimes, whether it's out of the clear blue or whether, you know, maybe somebody that you really cared about died and you get depressed, that's normal. But how are you going to deal with it? Develop a list of circumstances that may require a return to treatment. Review problems that emerged during treatment but weren't addressed and help the client develop a plan for addressing them in the future. You know, 90 days is not very long. So, if you're talking about the initial phase of treatment, we can't nearly cover everything. But if they've been in the program for a year or more, then they've probably addressed a lot of stuff, but there may be other issues that are still hanging out there, like maybe their relationship with one of their siblings is still on the rocks and they want to address that. And then develop strategies for identifying and coping with high-risk situations because they'll happen. So, we want to make sure that people have a really good relapse prevention plan in place. Teach the client how to capitalize on their personal strengths and emphasize their self-sufficiency. Encourage them to develop a plan for support, including family and community support. So, when you need to reach out, because you're not meant to bear everything on your own shoulders, when you need to reach out, who is there? And family doesn't have to be blood relatives. Family can be anybody the person feels they can rely on. But who are those people? And in the community, where can you go to get support? You know, it can be meetings, it can be church, it can be, you know, any place the person identifies where they feel like they are supported. Prepare the client to maintain positive changes through difficult times and identify potential stressors and challenges that lay in front of them. I've worked with a lot of clients that go through treatment, you know, and, you know, a year, year and a half down the road, they are still dealing with open warrants and legal stuff or financial stuff or divorce stuff. So, we want to talk about those potential stressors and challenges and make a plan for how the person's going to deal with it. Prepare them for changes to the environment because, you know, while they were changing, the environment may not have changed with them. So, they may have to change their environment or deal with people not knowing how to work with them quite as well. You know, it's a whole learning process to engage with somebody who is now in recovery. You know, it's a different person. At the end of treatment, ask the client to look into the future and describe where he or she intends to be six months a year or maybe even three years from now. Encourage the client to enjoy their successes and step back and look how far they've come. Stay mindful of continuing to work their program, whatever that means for them. It doesn't necessarily mean AA. It doesn't necessarily mean medication. It's different for every person. That's why it's called your program. And remain vigilant for relapse triggers, making minor adjustments as needed. Relapse, you know, we said is the rule, not the exception. You jump in the cold pool. It is uncomfortable, so you jump back out. Relapse means falling back into old ways of thinking and acting. The earlier you catch a relapse, the better. It's an opportunity for learning about what triggered it and what things need to be addressed to keep recovery the most rewarding choice. Like I said, relapse doesn't necessarily mean that the person has to go full blown back into use. It can mean that they drove to the liquor store and they sat in the parking lot thinking about going in. Or they started getting agitated and withdrawn and expressing some of those behavioral symptoms or emotional symptoms that they have when they're in their addiction. But catching it then makes it a lot easier to get back on track. A good relapse prevention plan will have strategies for identifying early relapse warning signs, triggers, and solutions. So that's great. Now we know pre-contemplation. We know some of the techniques and things we want to use for clients at different stages of readiness for change. But the first thing we got to do is engage them. So how do we do that? Well, first impressions are lasting. So you want to have a professional presentation. You don't want to walk in and all rumbled stuff and smelling and looking like you haven't taken a bath in three days. So have a professional presentation. It doesn't have to be fancy. It just has to be professional. Be prompt. Everybody deserves promptness because everybody's time is valuable. Be courteous and handle paperwork smoothly. Don't be shuffling your papers and seeming like you don't know what's going on or having to run and get additional addendums. Have your paperwork ready and be ready to go through it smoothly. That communicates a sense of competence and develops a sense of competence in the client. The environment that you do your assessment in should be calm, clean, and comfortable. And if you share an office with somebody, this can be a little bit challenging sometimes. But you want to have at least your area. Be presentable. You don't want to have seven stacks of papers all over the place and you're constantly looking for a pencil and half the stuff has coffee stains on it. That doesn't communicate competence. You don't want it to be too formal but you also don't want it to be too informal. You don't want to be in there in shorts and a t-shirt but you also probably don't want to be in a three-piece suit. Avoid interruptions and provide appropriate privacy. All of these things will help the client develop a sense of confidence in you as the clinician and encourage them to engage with you because they're like, hey, this person knows what they're doing. Maybe they can really help me. In engagement, we establish rapport and an effective working alliance in which the client feels heard and understood, which means we need to be respectful, non-judgmental, and attentive. Attentive. Let's focus on that. In this first session, you don't want to spend your entire session looking at a computer or looking at your papers as you write and just asking question after question where the client feels like they're nothing but a number. You want to be attentive to them. Make eye contact, smile, be genuine. Think about how you would feel if you were sitting in their place. Motivate and engage the client in identified service needs so help them get motivated to get their physical and to get on the waiting list and whatever they need to do. Engagement puts the clinician in the best position to negotiate with the client about what to do and how to do it. So if they feel confident that you are confident, then they are going to be more likely to listen to your advice. We can present that information. If the client is engaged and has faith in us, we have a lot more leverage. Engaged clients are more willing to participate willingly, be treatment compliant, and successfully complete treatment. It's important in the engagement process to create a welcoming environment. Remember I said not too casual, not too formal, but you also want to be sensitive to the age, gender, disability, sexual orientation, religion, and socioeconomic status. So again, on all CEU's education YouTube channel, we have several videos on culturally responsive counseling services that you probably want to review if you're not sure how to create a physical environment that is welcoming to people of varying cultures. Stigma can also impact engagement. So we want to make sure we dispel any stigma about the diagnoses or about help seeking. Be open about welcoming people. Be open about the problems that are there and help people understand that okay, so you have an addiction. It doesn't mean you're a bad person. It means you chose a method for solving a problem. It was not a great solution, but you wanted to live and that got you here. So now let's figure out a better solution to that problem. Expectations can also affect engagement. If they don't think it's going to be effective, they're not going to engage. So we want them to have the expectation that this is going to be an effective program. They want to have the expectation that they're going to have a certain amount of power in the treatment process, that everything's not going to be done to them, that they're going to have a voice in their treatment. And their expectations about the treatment process, if they know what to expect, an individual a week, nine hours of group, whatever, that will help them engage because it's not scary or ominous or anything like that. They know exactly what's going to happen and they're like okay, I can wrap my head around this. And likableness is another factor that impacts engagement. And this can vary based on the client's social skills, attentiveness, and attractiveness. It can be hard for us to engage with some clients, but it can also be hard for them to engage with us if they've got poor social skills. Hopefully ours are pretty good. If we're not attentive, they may not engage with us as well. And to a certain extent, if we are not attractive in their eyes, they may not engage with us as well. And you don't have to be a beauty queen. Again, you just have to be presentable. So building the helping relationship, once you engage, then you need to develop rapport or that sense of connection where both parties are contributing to the relationship. You're actively listening. You're actively and regularly demonstrating credibility and dependability. If you say you're going to do it, you do it. If you say that this is the way it is, that needs to be the way it is. If you don't know, be willing to say, you know, that's a good question. I don't know the answer. I'll check on it and get back with you. So be credible and dependable and respectful and responsive. Respectful doesn't really need an explanation. Responsive is more when the client says, I need an appointment now. I'm in crisis. Or if the client says that, you know, they're having difficulty getting their medication, you don't say, well, you know, send me a note and I'll try to look at it later today or sometime this week. That's not real responsive. You want to give them a date, you know, send it over to me and I'll take a look at it and I'll call you back by 5 p.m. That's responsive. The client feels like, okay, I'm important. I made it onto the calendar. Support the client by encouraging him or her to develop and build self-esteem, appropriately express feelings, and validate and recognize, but don't encourage negative feelings or behaviors. So what does that mean? That means clients are going to be angry sometimes or sad or feel guilty or any of those dysphoric emotions. Validate them. I can see how this would make you really angry, but don't encourage these feelings or behaviors. We don't want to stoke the fire and go, oh, I'd be angry too and let me tell you, you need to do this, this and this. No, we want to say, all right, I can tell that you're really angry and I'd be really angry too if I were in your position. So what is the next step in order to improve the situation? We don't want to stoke the fire of unhappiness. We want to help them improve the next moment. Provide empathy. That communicates shared feelings of hope. Down there with you and I see how much you're struggling and I will be here to help you along your journey. So the client has hope that they're not doing it by themselves and that you have faith in them. And provide acceptance and unconditional positive regard. Clients are going to do things just as everybody does that will occasionally make you angry or not be the right thing. But okay, if the client relapses, if the client no shows for an appointment, if the client, whatever they do, that's a behavior. We can dislike behaviors, but we need to accept the client and we really need to focus on communicating that. There's one client I can remember was just relapsed so many times and it broke my heart every time he relapsed. But he was a really good person and it frustrated me that he kept making these sometimes the same mistake over and over again. And I communicated that to him. I said, you know what? You are an awesome person. But I have to tell you, I'm feeling really frustrated that you did the same thing again. And I'm wondering how you got to that place. I'm wondering why you chose to go down that road again. Because until you get to the root cause, that behavior is not going to stop. So accept the person, validate them, be genuine with them. When you communicate, use active listening. Reflect what they say. So what you're telling me is clarify anything that seems unclear. You know, if they say, well, yesterday you said that this happened. But now today it seems like you're saying something different. So I'm wondering if you can clarify that for me. Focus and direct the client to a particular topic when you're talking. So you're reflecting and you're clarifying. But maybe this session is about self-esteem. So you're going to keep bringing it back to self-esteem and summarizing along the way. A lot of clients, especially in the recovery process that first year or so, have difficulty with memory. So you want to frequently summarize. Okay, so so far we've talked about this, this, and this and made these decisions. Now, the next thing I think is prudent to talk about would be to look at this other issue and help them gradually move along. When you question clients, try to make them open-ended, which means not yes or no questions. So ask them questions like, tell me what your childhood was like, not did you have a good childhood? You'll get a lot more information. Focus on one thing at a time. Don't ask six questions and then have the client. Okay, this is what I want to know. One thing at a time. Tell me about how you're sleeping. All right, you're not sleeping very well. Tell me about what that's like. Do you have difficulty getting to sleep, staying asleep, not sleeping enough? Tell me what that looks like. Go all the way through sleep and then move on to the next thing, which may be nutrition or something. Try to avoid the word why, because that can be perceived as confrontational. Why did you do that? Part of it is in your tone, but try to avoid why questions when you're communicating with people. You can say, you know, I'm wondering what made you think of that option. Focus more on your intonation and your nonverbals than getting really hung up, because sometimes you just can't think of a way around the word why, but try not to use why unless you really have to. And observe nonverbals. If clients are getting bored or they're feeling like you're not hearing them, they're going to close off or they're going to start looking at the door. So call out those nonverbals. You know, it seems like we're not connecting really well. I'm wondering what's going on or what I'm missing. Help me understand. Observe nonverbals communicate 80% of what the client is trying to communicate. So that will give you a lot more information if you look at their entire body and figure out what's going on. Nonverbals, you're looking for information and congruency. So nonverbals can tell you if the person is feeling unheard or they're closing off. But it can also, we also want to look for congruency. If you ask them a question, like do you plan to use this weekend? And they say, no. Well, obviously that shaking your head, yes, says yes and saying, no, that's not congruent. And it's generally not going to be that obvious, but we want to look for information there. Rate of speech. If somebody is talking really quickly, it could indicate anxiety or anger, apprehension. If they're speaking really quietly or really loudly, it could indicate, you know, either that they're feeling intimidated or they're getting angry. Look at their posture. Is it open? Is it closed? Is it slumped down and depressed? Look for gestures. You know, I talk with my hands a lot, so I make a lot of gestures. Eye contact is another good thing to look at. If suddenly their eye contact goes to nothing, that may give you an idea that there's a shame issue or you're not connecting in some way and you need to address it. And then facial expressions give you a lot of information. You can tell a lot about how a person's feeling by their facial expressions. When you observe nonverbals, you want to look at their dress and presentation because this can communicate their state of mind, for example. If they are dressed cleanly and, you know, maybe not pressed and starched, but, you know, they're put together, that indicates that they're probably feeling kind of okay. If they are, on the other hand, they look like they rolled out of bed and showed up in what they slept in, that could indicate that they may be in the midst of clinical depression or relapse or something. Dress and presentation can also communicate cultural values. Some cultures don't believe in showing any skin, so, you know, be cognizant of that. It can communicate body image. People with poor body image, some of them will, you know, wear really boxy clothing in order to hide how they look. Other people who are more on the histrionic end may wear clothing that's excessively provocative. So look at what that's communicating about the client's self-esteem and sense of self. Look for bodily signs of drug use, such as needle tracks or jaundice when the eyes, the whites of the eyes start getting yellow. It can indicate the liver is starting to fail. Physical abuse and poor nutrition. So these are all nonverbals that we want to look for when we're talking to clients, not just during assessment, but every single opportunity. This has been an introduction, if you will, into the stages of change and kind of developing, engaging with a client and developing rapport. Review the stages of change and motivational interviewing in tip 35 and brief interventions, which is tip 34. Both are available on the substance abuse and mental health services administration website. Be familiar with basic communication techniques, including active listening and observation of nonverbals. Those will be important on your test and understand the importance of empathy and acceptance in developing rapport and engagement. All of us at all CEUs wish you great success on your exam. Once you're certified or licensed, please remember to visit all CEUs for all of your continuing education needs. We offer unlimited CEUs for $59 for addiction and mental health counselors, social workers and marriage and family therapists. If you're still thinking about becoming an addiction counselor, all CEUs offers the training you need in three different formats. You can choose online multimedia self-study, self-study plus live webinars, or even face-to-face weekend intensives, which meet one weekend per month for 12 months. We can even present a training series at your facility. Just email support at allceus.com to schedule it. To learn more, you can also visit allceus.com slash acer. That's allceus.com slash a-c-e-r. Thank you.