1. UNPACK YOUR TOUGHEST CASES Patrice Swarbrick, MSW, LCSW
May 16, 2013
9:00 am – 4:00 pm
Rutgers University
Center for Continuing Professional Development
CAS (Center for Alcohol Studies)

2. Patrice Swarbrick, MSW, LCSW
Part Time Lecturer, Rutgers University Graduate School of Social Work
Owner, Wellness Strategies LLC
Faculty Practice at RU Center for Alcohol Studies, Women’s Treatment Project & Assistant Director of PACT
HIV Services – Early Intervention Program
UMDNJ-UBHC School Based Crisis Counselor & OP Clinician
Addictive Behaviors (Alcohol, Opiates, Cocaine, Cannabis, Nicotine, Prescription Pills, Internet Porn Addiction, Compulsive Negative Thinking, Sexual Behaviors, etc.)
NASW Certified Clinical Supervisor
Rutgers University Certified Field Instructor

3. Introductions
Name
Discipline
Work setting
Why you are here

4. Workshop Objectives
Participants will have the opportunity to brainstorm possible solutions to one of their most difficult substance abuse cases.
Participants will be exposed to the Wellness Recovery Model and the Wellness Domains (Physical, Emotional, Financial, Social, Spiritual, Environmental, Occupational and Intellectual) as a framework for approaching difficult case challenges from a strength based, whole person perspective.
Participants will be able to use the problem solving model to address case challenges.

5. Workshop Objectives
Participants will be exposed to the Stages of Change, Decisional Balance and Motivational Interviewing as interventions and techniques to motivate consumers to make positive changes in their lives.
Participants will have the opportunity to introspect and tune into their own resistances by gaining empathy through completing therapeutic tools they will share with their consumers.
Participants will gain a new perspective and be ready to address their case challenges effectively and efficiently.

6. What’s the Consumer and Helper Baggage?

7. Your Willingness as a Helper
Please be willing to introspect within yourself – we will complete all tools for ourselves first, then prepare their use with our consumers
Disclose and share as much as you feel comfortable of your own challenges with your toughest cases – be willing to take some risks
This is not Clinical Supervision – it is an opportunity to reorganize your case so it is lighter, neater, clearer and has gained new perspective

8. PROBLEM SOLVING S – Select the Problem or Situation
O – Observe, organize and define the problem or situation
L – Learn by questioning all parts of the problem
V – Visualize the possible solutions, select one and refine it
E – Employ the solution and monitor results

9. The 4 M’s Sheafor & Horejsi (2007)
Motivation
■ What does the client want to do about his or her problem or situation?
■ What discomfort or aversive factors are pushing the client toward action?
■ What factors of hope are pulling the client toward action?
■ What can be done to increase client motivation?
Meanings
■ What meaning does the client assign to his or her situation, and problems?
■ What ethnic, cultural, and religious beliefs and values are important to the
client and relevant to the current problem or situation?

10. The 4 M’s
Management
■ How can the worker best use his or her limited time, energy, and resources
to help the client deal with the problem or situation?
■ What overall plan or strategy will guide the worker’s activity with the client?
■ How will work with this client affect the worker’s other responsibilities?
Monitoring
■ How will the worker monitor his or her impact on the client and evaluate the effectiveness of the intervention?
■ How can the worker use peers, supervisors, or consultants to monitor and
evaluate intervention?

11. Pick One Case to Problem Solve Today Assessment Part One
Who (the consumer and their systems)? Use initials for anonymity
What are the Substance/Behavior Change challenges?
What is getting in the way of you helping?
What is getting in the way of the consumer being successful at solving the problem?
What are the challenges in the therapeutic relationship? (Is there rapport, trust, empathy, a mutual work contract)?
How do you feel about the consumer?

12. 8 Dimensions of Wellness
Adapted from Swarbrick, M. (2006). A wellness approach. Psychiatric Rehabilitation Journal, 29,(4)

13. PHYSICAL WELLNESS DOMAIN
• Recognize the need for regular physical activity and learn about diet and nutrition
while addressing the use of tobacco, drugs and excessive alcohol consumption.
• Pay attention to physical health needs (e.g., nutrition, exercise, smoking cessation,
symptoms of stress like anxiety & depression, stress reduction)
• Develop and follow a balanced daily routine (e.g., adequate sleep and rest, walking,
moderate levels of activity and productivity to promote health and counteract negative stress responses).
• Take personal responsibility and care for minor and major illnesses and also knowing when professional medical attention is needed.
Addressing sexuality, safe sex and responsible sexual behaviors; how you see and feel about yourself as a sexual person

14. EMOTIONAL WELLNESS DOMAIN
The capacity to manage one's feelings and the realistic assessment of one's limitations, and ability to cope effectively with stress.
Tolerance, and the awareness of and acceptance of a wide range of feelings in yourself and others,
The ability to live and work independently while realizing the importance of seeking and appreciating the support and assistance of others.
The ability to take on challenges, take risks, and recognize conflict as being potentially healthy. Involves self-acceptance and contentment in pursuit of daily activities. •
The ability to use coping strategies to deal with daily life hassles and stress.

15. FINANCIAL WELLNESS DOMAIN
Involves the ability to have financial resources to meet practical needs, and a sense of control and knowledge about personal finances.
Satisfaction with current and future financial situations
Refers to the objective perceptions and subjective indicators of individuals’ personal financial status.

16. SOCIAL WELLNESS DOMAIN
The social dimension encourages contributing to the environment and community and emphasizes the interdependence between you, others and nature.
• Establish and maintain better communication
with those around you.
• Enhance personal relationships, important
friendships, and build a better living space
and community.

17. SPIRITUAL WELLNESS DOMAIN
• A broad concept that represents one's personal beliefs
and values
Our spiritual dimension recognizes our search for meaning and purpose in being 'human’ and our existence. It includes the development of a deep appreciation for forces that exist in the universe.
Explore, respect, and incorporate personal values, beliefs, awareness of a being or' force’ that transcends the material life and gives a sense of connectedness to the universe.
• Link and connect with cultural, religious and/or spiritual
traditions which enhance self identity.

18. ENVIRONMENTAL WELLNESS DOMAIN
The environment includes our living, learning and working spaces and the larger communities where we participate as citizens.
• Find pleasant, stimulating environments that
support physical, social, and emotional
well-being.
• Places that promote learning, contemplation
and relaxation.

19. OCCUPATIONAL WELLNESS DOMAIN
The opportunity to participate in activities that are meaningful and rewarding.
• The opportunity to participate in activities that
are in line with personal values, interests and
beliefs.
• Personal satisfaction and enrichment in one's
life is derived from participation in work and
volunteer activity.
How we handle major tasks at work or school.

20. INTELLECTUAL WELLNESS DOMAIN
Recognize creative abilities and find ways to expand knowledge and skills while
Discovering the potential for sharing those gifts with others.
Spend time pursuing personal interests, reading books, magazines, and newspapers to keep current on issues and ideas.
Our capacity for problem solving and reasoning, creativity, insight, etc.

21. Wellness Domain Strengths
Complete this Tool for yourself as a helper first – PARTNER UP AND REPORT BACK
Now complete it for/with your client when you return back to work
Dimension’s Challenges and Examples

22. Stages of Change Diagram
Termination
Action
Maintenance
Preparation
Relapse & Recycle
Above arrow: Individual is in control of his or her own life
Below arrow: Unwanted behavior is in control of the individual’s life
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In Search of How People Change: Applications to Addictive Behaviors. American Psychologist, 47(9),
Contemplation
Pre-contemplation
Prochaska, Di Clemente, Norcross 1992

23. Stages of Change Stage Basic Definition 1. Precontemplation
A person that is not seeing a need for a lifestyle or behavior change
2. Contemplation
A person is considering making a change but has not decided yet
3. Preparation
A person has decided to make changes and is considering how to make them
4. Action
A person is actively doing something to change
5. Maintenance
A person is working to maintain the change or new lifestyle, possibly with some temptations to return to the former behavior or small lapses

24. Stages of Change & Therapist Tasks
Raise doubt - Increase the client’s perception of
risks and problems with current behavior
PRECONTEMPLATION
Tip the decisional balance - Evoke reasons for
change, risks of not changing; Strengthen client’s self-efficacy for behavior change
CONTEMPLATION
Help the client to determine the best course of
action to take in seeking change; Develop a plan
PREPARATION
Help the client implement the plan; Use skills;
Problem solve; Support self-efficacy
ACTION
Help the client identify and use strategies to prevent relapse; Resolve associated problems
MAINTENANCE
Help the client recycle through the stages of
contemplation, preparation, and action, without
becoming stuck or demoralized because of relapse
RELAPSE 24

25. Johann Wolfgang Von Goethe
If you treat an individual as he is, he will stay as he is, but if you treat him as if he were what he ought to be and could be, he will become what he ought to be and could be.
Johann Wolfgang Von Goethe

26. Qualities of a Good Motivational Counselor
Respect for individual differences
Tolerance for disagreement and ambivalence
Patience with gradual approximations
Genuine caring and interest in clients served 26

27. Motivational Interviewing Principles
Express Empathy
Develop Discrepancy
Roll Resistance
Support Self-efficacy 27

28. Video: Put Down the Duckie
Gaining motivation for change and putting down the challenge

29. Building Motivation To Change
Avoid at all costs:
Question-Answer Trap
Confrontation-Denial Trap
Expert Trap
The Labeling Trap
Premature-Focus Trap
The Blaming Trap 29

30. Handouts Ten Strategies for Evoking Change Talk
Prochaska & Diclemente’s Staghes of Change Model – Techniques and Goals within each Stage

31. Decisional Balance Worksheet
No Change Change
PROS (Behavior)
_______________
CONS (Behavior)
PROS (Change)
_______________
CONS (Change) 31

32. Exercise
Complete a Decisional Balance for some behavior and decision you are currently making
Can be personal or professional

33. Thinking About Drinking
Here is an example of a woman drinker. Remember, every person has different reasons in their decisional consideration about drinking
Good things about changing my drinking:
Good things about my drinking:
More relaxed
Will not have to think about my
problems for a while
More comfortable with drinking friends
More control over my life
Support from family and friends
Less legal trouble & Better health
Not so good things about my drinking:
Not so good things about changing my drinking:
Disapproval from family and friends
Increased chance of legal and job
trouble
Costs too much money
More stress or anxiety
Feel more depressed
Increased boredom 33

34. The Problem Solving Method Helen Perlman (1957)
Become aware of the problem
Define the problem
Choose the particular problem to be solved
Identify potential solutions
Evaluate the valid potential solutions to select the best one
Develop an action plan to implement the best solution

35. Your Case Assessment Part Two
Where are they in the Stages of Change?
How is it negatively affecting the consumer (what are the consequences)?
What Change Talk Have you heard from the consumer?
What are their Wellness Strengths?

36. What’s in Your Toolbox?

37. What’s in your Toolbox? Select the BEST approach to meet the consumers need
Identify Stages of Change for EACH substance and/or Behavior – Complete the Decision Balance
Motivational Interviewing
Harm Reduction
Cognitive Behavioral Therapy
Dialectical Behavior Therapy – Mindfulness
Smart Recovery
Biofeedback – Neurofeedback - Acupuncture
Other Evidence Based Practices
Wellness Planning Tool (see link)

38. MY TOUGHEST ADDICTION CASE RIGHT NOW
IV HEROIN
XANAX AND BENZOS
MARIJUANA
NICOTINE
OTC SLEEP AIDS
PERSONALITY DISORDER NOS (antisocial features)
GENERALIZED ANXIETY DISORDER
DEPRESSIVE DISORDER NOS

39. Problem Solving Tool
Complete this tool for Your Challenge with the Case
Bring this back to the consumer to complete

40. How can you help the consumer move it forward?
Your revised plan for helping based on your unpacking the case today?
Create a NEW treatment plan WITH your consumer (not FOR them) after you leave this workshop
Specify the GOALS and Objectives for each challenge/problem identified
How can you take care of yourself?

41. Pack it Back Up Neater Than Before

42. References
Bradford W. Sheafor, and Charles R. Horejsi. Techniques and Guidelines for Social Work Practice, 8th Edition. Pearson, 2007.
Connors, GJ, Donavan DDM, and DiClemente. C. Substance Abuse Treatment and the Stages of Change: Selecting and Planning Interventions. Guilford Publications, 2001.
Denning, Pat and Little Jeanie. Practicing Harm Reduction Psychotherapy: An Alternative Approach to Addictions, 2nd Edition. The Guilford Press, 2012.
Horvath, Tom. SMART Recovery. Self Help for Substance Abuse & Addiction. Smartrecovery.org Author(s): SMART Recovery. Publisher City, Mentor, OH, 2013.

43. References (More Tools)
Linehan, MM, Dimeff, LA, Sayrs JHR. Dialectical Behavior Therapy for Substance Use Disorder. New York: Guilford Press; in press.
McCrady, Barbara S. & Epstein, Elizabeth E. Overcoming Alcohol Use Problems: A Cognitive-Behavioral Treatment Program Workbook (Treatments That Work). Oxford University Press, 2009.
Miller, W. and Rollnick, S. Motivational Interviewing: Preparing People to Change Addictive Behavior. Guilford Publications, 1991.
Perlman, Helen. Social Casework: A Problem Solving Process. Chicago: University of Chicago Press, 1957.

44. References (More Tools)
Swarbrick, Margaret (2010). Defining wellness. Words of Wellness Newsletter, Vol 3, No 7.
Swarbrick, Margaret & Yudof, J. (2012). Wellness in the 8 Dimensions. Collaborative Support Programs of New Jersey, Institute for Wellness and Recovery Initiatives.
Swarbrick, M. (2006). A wellness approach. Psychiatric Rehabilitation Journal, 29,(4)

45. Wellness Recovery Online Resources

46. Tools Handouts Wellness Domain Strengths Decisional Balance
Problem Solving Worksheet
Prochaska & DiClemente’s Stages of Change Model (for each addictive behavior)
Tasks within each Stage of Change
Ten Strategies for Evoking Change Talk

47. Self Help for Drug Addiction Treatment