Clinical Work with Substance-Abusing Clients

Clinical Work with Substance-Abusing Clients

Clinical Work with Substance-Abusing Clients

The purpose of conducting an interview is to gather as much information as possible about the person one is interviewing. The selection, interviewing techniques, communication strategies and types of questions to be asked, depend on the nature and setting of the interview. In the context of clinical intervention of substance-abusing clients, or any other related problem the interviewer is generally known as a counselor.

It is very important for the counselor or the interviewer to be an expert in personal communication with the client. The cure of the client is based on his communication with the interviewer. So it is very important for the client to be honest throughout the communication process. The success of the whole interview process depends on the interviewer. In this type of situation, it is a common behavior for clients to suppress certain facts. The reason for this might be that the client is feeling ashamed, embarrassed or shy to tell everything about his condition to a complete stranger.

Normally a detailed interview takes place at the beginning of an intervention. This is because a counselor cannot take any action without understanding the case thoroughly. Unfortunately this is the stage when the client cooperation is minimum because the person on the other end is a complete stranger. Though some people find it easier to confide in strangers, some find difficult to do the same. So the role of the interviewer should be to put the client at ease. Jumping at the main issue would be the most foolish thing to do. Rather letting the client to adjust with the setting and feel comfortable with the person on the other end would make the process easier and beneficial.

After the intervention process has begun, to find whether the intervention in going in the right direction or not both from the aspect of customer satisfaction and from the aspect of positive results, interview is again conducted. As mentioned in the Evaluating Socio Economic Development, SOURCEBOOK 2, “When conducted more than once or when conducted with someone who has been involved in programmes for a long period of time, interviews can show if any change has occurred over time.” (2003, para.6) In this stage one can expect much better level of cooperation from the client as he has become accustomed of the interviewer. If the client is satisfied and his condition is improving, then the level of cooperation improves all the more.

Selection

            It is very important to select an expert counselor. An expert knows how to get the most out of even an extremely introvert person and he also has the skill of showing empathy without crossing the borders. Hence the selection of a good interviewer is dependant on the following qualities:

·         High degree of professionalism

·         Substantial knowledge of his subject

·         Listening, and communicating skills

·         Ability to make the interviewee feel at ease

·         Ability to show empathy towards the clients

·         Respectful attitude towards the interviewee and the information he is delivering

·         Understanding nature and free of any judgmental attitude

·         Patience

Appointment

            Professionalism begins right from the time of setting an appointment. If the counselor has set an appointment with the client then he should try hard not to cancel it. In these types of interview settings, the main motive behind the meeting is the frustration of deteriorating condition and an innate desire of meeting someone who is a ray of hope of taking one out of his unwanted condition. Since the interviewees wait desperately for the meeting with the helping interviewers, the helping interviewers should not try to cancel it unless it is extremely urgent. Otherwise it is a cause of extreme anxiety for the interviewee. It might even happen that the client might not muster the courage to meet the counselor the next time.

            In the case of people suffering from substance abuse, they know that they are deteriorating their health but keeping themselves away from drugs is beyond their control. Some substance abusers do not want to meet a counselor at all. Those who are ready to meet are in dilemma till the very end. They keep on thinking of missing the appointment. It takes lot of effort for them to meet the counselor. If that opportunity gets lost then it is literally a battle between them and their inner self to gather courage for the next appointment.

Once the interviewee is in front of the interviewer, the interviewer should not underestimate his schedule. According to Evaluating Socio Economic Development, SOURCEBOOK 2, “Don’t presume that people have all the time in the world to give…. No interview should last more than an hour.  More time results in repetition not more information”. (2003, box 2) Though it is important to make the interviewee to feel at ease, it is necessary to stick to the main issue instead of wasting time. Next appointment should also be fixed in the current interview.

Features of interviewing a substance abuser

·         In this type of interview the interaction between the interviewee and interviewer is under one to one arena. This means that it is an individual counseling and there is strict confidentiality between what the interviewer and interviewee are discussing.

·         Because of the nature of this kind of interviewing, the client gets an opportunity to maintain a close relationship with the expert. According to Dryden and Palmer In Palmer and McMahon (1997, p.39) “This factor may be particularly important for some clients who have not developed close relationships with significant people in their lives and for whom group counseling, for example, may initially be too threatening.”

·         The people suffering from substance abuse are confused due to their deteriorating physical condition and their state of mind. In these circumstances they need undivided attention of the counselor and what better way than one to one counseling session.

·         People suffering from substance abuse are suffering because of their actions and not somebody else’s. They are themselves the reason of their distress. Hence individual setting of conversation is the best way to sort out the problems.

·         These people want a solution to a problem. They want someone to understand them and guide them step-by-step in order to help them in coming out of their current situations. For this, instead of holding a conversation in a group, it is better to talk with one person who will not only guide but also explain the short term and long-term implications of their choice to cure themselves and the short term and long term implications of their choice if they leave the clinical intervention in the middle.

·         In counseling a substance abuser the counselor has to adjust his interactive style with the state of mind of the client. In a single session the client might turn both very emotional and violent.

·         As the client interact with the interviewer in one to one situation, he might get over dependant on the interviewer. He might get so vulnerable in certain situations that in the absence of the counselor he might think of using substance to control his anxiety.

·         Since in this type of situation there is no one except the interviewer and the client, it might get intimidating for the client. He might find the situation very threatening and might not turn up in the next appointment.

·         Those who find the one to one setting too comfortable might not show any sign of improvement. They might consider this session just as any other normal conversation. It has been rightly mentioned in Dryden and Palmer In Palmer and McMahon that “Based on the idea that personal change is often best facilitated in situations where there is an optimal level of arousal, individual counseling may not provide enough challenge for such clients.”(1997, p. 47)

·         Some interviewees might be so shy that they might not feel confident if the interview is not in a group setting. Being in company of people suffering from the same problem might give him more courage to open up. In such cases the interviewer should consider to interview him in group situation.

Interactive strategy of the interviewer

The interviewer has to devise his interactive strategy with the client keeping in mind many things. According to Velleman In Palmer and McMahon, “If members of the general public are asked about people with these problems, common views are of …drugs addicts injecting heroine in dingy squats in run-down urban areas.” (1997, p.435) But reality is far removed from this. There is a vast range of people who suffer from substance abuse. Not only the range of clients is vast but also there are many types of substance that clients use, many types of problems they are suffering from, many types of interventions that is required and settings in which the intervention is required. The interviewer has to adjust his interactive skills keeping in mind this diversity. The questions for the interactive session too differ accordingly. The different features that rule the framing of questions in the arena of substance abuse are:

·         Age – clients might be in early teens or might even be those who have retired

·         Sex – Not only males but a considerable amount of females are substance abusers

·         Socio-economic status of the client

·         Type of their social group if they take substance in groups – The group can either is of housewives, depressed elderly people, school going children etc. It is not necessary that the housewife’s group can only consist of housewives, may be she is taking it with her daughter’s friends.

·         Type of drug being used – It can range from prescribed drug sold illicitly, illicit drugs like cocaine, heroine, hallucinogens, amphetamines, cannabis etc.

·         Method of use of the drug – Eating, injecting, sniffing, smoking etc.

·         Seriousness of the problem – constant, occasional, serious or mild

·         Types of problem – deteriorating of physical and mental health, high degree of addiction, problem in job or personal relationship etc.

Just as there is difference in the features of the client problem the question of counseling or interviewing are based on the different viewpoints and objectives of the individual counselor. These are:

·         Setting in which the interview takes place – whether it is treatment of speciality drug, rehabilitation house, detoxification unit, in patient general or psychiatric hospital, out patient clinic, self help group, community based drug service or local counseling, information, advice agency.

·         Viewpoint regarding the main problem due to substance abuse – curing of mental or physical health, relationship problem that needs to be solved, problem to face the law related to substance abuse, problem to deal with the society at large.

·         Aim of counseling or interviewing – to help the client in life long abstinence from drugs, help him in using it in a controlled way, minimization of harms, to help him bring changes in lifestyle, to help him in starting a fresh life, to help him in improving his personal relationship etc.

·         Techniques used to solve his problem – relapse prevention techniques, assertion training, social skills, cue exposure methods, gradual reduction of drug consumption, speedy reduction of drug consumption, using friends and family in the rehabilitation process, concentrating only on mental health issues, concentrating only on physical health issues, concentrating on both mental and physical health etc.

Thus with so much of diversity same principles in communicating during the interviewing session may not be applicable to all. Each individual would require different kind of communication strategy and pattern. The different types of communication are however based on four specific principles. The first principle indicates learning the nature of the problem and what the client expects to benefit from the session with the interviewer. This would help in adjusting his questions in such a way that he get an insight into how the problem can be combated and full detail on exactly what the demands of the situation is.

Second principle is to judge the vulnerability level of the client. Soon as the interviewer understands the degree of the problem, he adjusts his communication patter accordingly so that the client is at ease with the situation.

Third principle is that early in the interviewing session the interviewer should determine that whether substance abuse is the main problem or other problems relating to it is troubling the client more. Accordingly he should do the questioning so that he is able to get into the crux of the matter completely and decide about the type of intervention to be introduced.

The fourth principle is to adjust one’s interviewing strategy based on the cause of substance abuse. For example: marital discord may be one of the reasons of taking drugs, for adolescents it can be giving in to peer pressure, for elderly people it might be loneliness. Understanding of cause would help the interviewer to make use of the communication strategy accordingly to help the client tackle his problem.

Communication

To be successful in counseling or interviewing, it is important to be successful in communicating. A good communication is not only the responsibility of the interviewer but the interviewee as well. A message is send by the sender and decoded by the receiver.  The interviewing process thus requires for good encoding and decoding skills on both the sides. If one side (client’s) is weak the interviewer has the responsibility to facilitate a free flowing conversation to make the most out of the session. For this he can make use of three ways. These are:

·         Verbal communication

·         Vocal communication

·         Non verbal communication

Verbal communication means using language to communicate. Through our use of language like simple words or use of metaphors to describe something like ‘as harsh as a thorn’, content of talk and focus of talk we are able to communicating our feelings to whom we are talking. These features of verbal communication play a significant role in helping interviewer.

Apart from language, content and focus of talk, amount of speech also matters. Different clients use different types of speech and therefore interviewers should be skilled enough to learn the main points even when there is variation in amount of speech used by different people. According to Nelson-Jones, “…some clients may be talkative from the start, others warm up as helping progresses, and yet others talk haltingly throughout even though the helping may be successful.” (2000, p.48)

There should also be honesty in speech. The interviewer should make it known to the client that if he is not honest in the session then that it his own loss. Without giving proper and detailed facts it will be impossible for the counselor to introduce proper interventions. In the beginning, the client might give some untrue information or might not reveal much. It is the responsibility of the interviewer to create an atmosphere that the client starts interacting honestly.

 Our vocal communication accentuates our verbal communication. What we are speaking gets enhanced by how we are speaking. If during the interview, the interviewer finds that the words are not matching the voice and body framing communication pattern, then he should understand that there is not honesty in the client’s speech. According to Nelson-Jones, “Your vocal and bodily communications can either correspond to, heighten, lessen or contradict the intention of your verbal communication.” (2000, p. 49) This factor should not be understood by the interviewer as just a tool of determining a client’s honest but also as a means of showing that he cares. It is very important to show empathy to a client. Just verbal words would not make him understand your empathy towards him. It is also your vocal communication that would help in putting the message across and as a result making the interview session successful. There are five dimensions of vocal communication and each play a significant role in the helping interview scenario. The five dimensions are together known as VAPER. They are:

·         Volume

·         Articulation

·         Pitch

·         Emphasis

·         Rate

As the name signifies volume means softness or loudness of speech. The audibility of speech should be adjusted to the comfort level of the listener. It doesn’t mean that if the client’s voice is extremely soft you will have to match your volume to the volume of his voice. He might be speaking slowly out of shyness or a confusing state of mind. But the interviewer will have to speak in normal audibility for the client to hear him properly. It will also make the interviewer sound more confident. It will give an impression to the client that the interviewer will be able to solve his problem. So the ideal thing is to begin with a firm and confident voice and then make variations later as the situation demands. Speaking too loudly will increase the inhibitions of the client and he may not open up.

Clarity of speech is referred as articulation. The more clear your speech is the easier it would be for the client to decode your questions and the better it would prove in the process of grasping his problem.

Pitch is the different range of presenting one’s voice without giving strain to one’s throat. The depth and height of your voice can be analysed through the pitch. Being too high in pitch or too low in pitch than what the situation demands can be termed as errors of pitch.

            When we speak our voices use emphasis. Like volume and pitch emphasis should also be adjusted according to what is being said. Too much of emphasis looks very unreal and too little emphasis looks without any emotions. Not only this, there are places where emphasis can be put to maximize the effect. If it were put in the wrong places then the person on the other end would decode the message in the wrong way.

            Rate of speech refers to how quickly you speak and how much you pause during speaking. If the rate of speech is too high it looks that the interviewer is too anxious. The client will also not make out all that you have said. If you were too slow it would make interaction with you very boring. One important aspect of speech rate is to pause in thee right places.

            Non-verbal communication is as important as verbal and vocal communication. Nonverbal communication is also known as bodily communication. You disclose yourself in a face-to-face situation by your nonverbal communication. No matter how hard you try to show that you care for your client, if it is not evident by your bodily communication then you look dishonest. There are many forms of this kind of communication. E ach of these forms are necessary to establish your feelings. These are:

·         Facial expression

·         Gestures

·         Eye contact

·         Posture

·         Physical proximity

Through one expression your face has the power to convey all that you are able to explain by hundred words. We can emote, happiness, surprise, interest, sadness, disgust, fear and contempt through our mouth and eyebrows without uttering even one word. So we should always try to match our facial expression with our words to look and sound convincing.

Gestures are also ways of illustrating our feelings. For example when we are angry we clench our fist. Gestures vary according to one’s sex. If a male show gestures of a woman then he looks very funny and vice versa. Gestures are very important tools of description. Sometimes through gestures we are able to describe more accurately than through words. Gestures have the ability to take place of spoken words. When we have to say yes, if we simply nod our head up and down the message is understood. But the way in which we nod our heads to say yes or no is sometimes opposite in other cultures. So we should keep this fact in mind if the client belongs to some other culture.

While speaking if we are looking out of the window and not to the person to whom we are speaking we look uninterested. Eye contact is a direct way of sending a message.  So an interviewer should make good use of it both while explaining and understanding a point.

Posture also reveals your state of mind. They can communicate whether you are tense, anxious, disinterested or interested. The way you sit or stand reveals your confidence level. If you turn your body away from a client it looks as if you are not interested in what he is saying. If your body is facing him, it shows you are interested.

Just like other forms of non-verbal communication, physical proximity also helps in decoding the message. The degree of physical proximity that is considered normal varies from culture to culture. Not only this, within the same culture the degree of proximity depends on the relationship we are sharing with the other person. In the context of the helping interview it is very important to use the appropriate physical proximity. If the distance between you and the client is too close he might even misunderstand you.

Apart from all this it is very important for the interviewer to be well dressed and look neat and tidy. No matter what the state of mind of the client is your first impression encourages or discourages him from opening up to you. If you are not well dressed or if you look untidy the client might not consider you competent enough.

Questions

Two types of questions can be used while interviewing. They are:

·         Open-ended – e.g. How you feel when you are not able to control your addiction?

·         Closed ended – e.g. Do you feel insecure about your future?

Through the open-ended question the client gets an opportunity to let all his feelings known to the interviewer. Thus the interviewer gets the total picture of the client’s psyche and can determine the areas in which the client needs more help. Whereas through the close ended question the client tells only those things that the interviewer wants to know. Seager et.al. In Messer and Jones point out that “…by their very nature closed questions require only a limited response….Also, this format ensures that an interview is directed by the interviewer rather than the interviewee” (1999, p.100) Therefore it isadvisable to use as many open ended questions as possible.

Conclusion

To know about the individual with whom you are speaking in a helping interview setting, you should adopt a person centred approach. Since he is in trouble, he is vulnerable and needs your help; you will have to show him that you are there with him. You have to be excellent in the art of interviewing; you should be able to keep up to the set appointment. You should be well abreast with the strategies of dealing with different kinds of people suffering from substance abuse. You should be able to make the correct use of all the forms of communication and use the right types of question in order to get a clear insight of the client’s mindset and problems.

References

Messer, D., and Jones, F., (eds.) (1999) Psychology and Social Care. London: Jessica Kingsley Publishers Ltd.

Nelson-Jones, R. (2000) Introduction To Counselling Skills: Texts And Activities. London, Thousand Oaks, and New Delhi: Sage Publications Ltd.

Palmer, S., McMahon, G. (eds.) (1997) Handbook of Counselling. (2 Ed.) London and New York: Routledge

Evaluating Socio Economic Development, SOURCEBOOK 2 (2003) Methods &

      Techniques: Individual Interviews. Retrieved July 27, 2008 from

      http://209.85.175.104/search?q=cache:x8tWT2Qa1UQJ:ec.europa.eu/regional_policy/sources/docgener/evaluation/evalsed/downloads/sb2_individual_interviews.doc+advanced+techinques+in+selection+of+interviewees&hl=en&ct=clnk&cd=3&gl=in



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