Aboriginal Alcohol and Other Drugs Worker Resource: A guide to working with our people, families and communities

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Contents Towards a Healed Future Working with the Four Circles Dreamtime, People, Land Impact of Colonisation Introduction of Alcohol Our Life Today Understanding Internalised Oppression Aboriginal Drug Impact Model Impact on Family Impact on Community Building Strong Futures Strong Family Strong Community

Working with Clients, Families and Communities

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Aboriginal Inner Spirit Model How alcohol and other drugs can affect our inner spirit Alcohol and other drugs affect the whole community Alcohol and other drugs can affect your client's life in many ways – Seven Areas Making Changes – Individual Stages of Change Making Changes – Community Stages of Change Choosing to keep drinking or using – (Precontemplation) Uncomfortable with drinking or drug use – (Contemplation) Motivational Interviewing Principles – Good/Not-so-Good Thinking about change – (Preparation) Seven Steps to Problem Solving Working with clients to set goals Taking action to change – (Action) Making Changes Action Plan Staying changed – (Maintenance) Identifying and Tracking High Risk Situations and Triggers Dealing with High Risk Situations and Triggers Oops! Gone back to old patterns – (Relapse) Working to strengthen family systems of care, control and responsibility References

Understanding Alcohol and Other Drug Use What is a drug? Why do people use alcohol and other drugs? Understanding the different kinds of alcohol and other drug use Drug use terminology How do people learn to use drugs? Types of drugs Mixing drugs What does it mean when someone is hooked/dependent on a drug? Ways of reducing harm Ways of reducing alcohol related harm What to do about an overdose/toxicity Drug types, doses and effects chart

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Towards a Healed Future 3 1754 IndigenousFlipChart19212.indd 3

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Working with the Four Circles In this series there are four models, which represent Aboriginal experience at different points in time. They can be used separately or in sequence. It is important when examining each circle that people look at the strengths, opportunities and threats of these times. These models can assist you to explore the client's or the community’s awareness of traditional Aboriginal life, colonisation, the introduction of alcohol and other drugs, and how these issues and events continue to impact upon their lives: The The The The

first circle represents the time before colonisation second circle shows the impact of colonisation third circle shows our life today fourth circle shows working towards a healed future

Dreamtime, People, Land ‘From the dreamtime came the people and the land. From the dreamtime came the laws for our people and the country. These laws guided us on how to look after each other and look after our country. From the dreamtime came our identity, sacred laws, culture, traditions, spirituality, stories, skin groups and families, sacred songs, language, communication, sacred sites and environment. Our people have belonged to this land for thousands of years. With one feeling, one spirit and one mind, working together we developed systems of care, control and responsibility which ensured the survival of our people, our communities, our culture and our country. Before colonisation our people did use substances that affected the way we think, feel and behave. However, the use, strength and availability of these substances were controlled by traditional practice, cultural law, and seasonal availability’.

Working with clients and community The first circle is a whole, complete and secure circle that represents Aboriginal life before the Whiteman came. Exploring the first circle by considering the strengths, opportunities and threats of this time allows individuals, families and communities to think about their culture prior to colonisation. This provides the opportunity to emphasise the strengths of those times including their cultural identity and responsibilities, their family systems and social obligations, and spiritual and cultural practices. It is important to use this approach as a way of establishing an empowering strength focused intervention that acknowledges the importance of traditional Aboriginal cultural systems and their continuing relevance today.

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Impact of Colonisation ‘Colonisation had a huge impact on our people. The ways that had kept our culture strong for thousands and thousands of years were not understood by the Whiteman. During colonisation our ways started to break down. Families were separated and our children taken away. We weren’t allowed to keep our country or practice our law and culture or speak our language. But our people were resilient and we stayed strong where we could, we learned new skills and we survived. With Colonisation came drugs like alcohol and tobacco. In those early days there was binge drinking and this led to fighting and other destructive behaviours by some Whitemen. Many of our people watched and learned from these behaviours. This is highlighted in the following illustrations’.

Working with clients and community The second circle is a jagged and fragmented circle. This image represents the impact of colonisation on Aboriginal life. Exploring the second circle by considering the strengths, opportunities and threats of this time allows individuals, families and communities to understand how colonisation began the breakdown of Aboriginal systems of care, control and responsibility. This affected our peoples’ cultural identity and responsibilities, their family systems and social obligations, and spiritual and cultural practices. Many Aboriginal people are not fully aware of this history and how it has affected them, their family and community. It is important to use this approach as a way of establishing an empowering, strength focused intervention that acknowledges the resilience of Aboriginal people during this time of rapid change. It acknowledges the overwhelming distress that our people experienced and highlights the skills that contributed to our survival. It provides the opportunity to reflect on the lives of their family and elders who lived through these times. When exploring this circle be aware of our peoples' on-going distress, anger and sadness relating to these times. It is important to allow people to express their feelings in a safe environment and at the same time this should be balanced by placing emphasis on the development of new skills, strengths and endurance of Aboriginal people. This circle acknowledges the importance of the historic influences and their continuing relevance to Aboriginal peoples today.

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ABORIGINAL LIFE AFTER COLONISATION

Alcohol and tobacco introduced Whiteman's law - Whiteman's diseaseS Acts and policies - Native Welfare Act Missions - Children taken away Freedom taken away - Racism Keeping culture alive where possible Strength and resilience New skills and education

LAND D

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Introduction of Alcohol

Image reproduced with permission from Mitchell Library, State Library of New South Wales

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Image reproduced with permission from Mitchell Library, State Library of New South Wales

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Our Life Today ‘There are many problems in our communities today, such as poverty, poor health, family violence, housing and unemployment. Hazardous and harmful use of alcohol and other drugs can be a part of these problems, and can make these problems worse. Even with these problems our people have remained strong. We are healing as a people and our families are strengthening. Our culture is still alive and our spirit is strong. Through understanding the effects of alcohol and other drugs our people are changing. We are reducing the harms for ourselves, our families and communities’.

Working with clients and community The third circle is a partially jagged and partially whole circle. This image represents Aboriginal life today and demonstrates how we are healing and rebuilding our lives and our culture. Exploring the third circle by considering the strengths, opportunities and threats allows individuals, families and communities to identify some of the issues and challenges that we face today. This includes understanding how the hazardous and harmful use of alcohol and other drugs impacts on our peoples’ cultural identity and responsibilities, our family systems and social obligations, and spiritual and cultural practices. Most importantly it focuses on positive change that emphasises strengthening of spirit and empowering individuals, families and communities to take back the care, control and responsibility of our people to build a healthy future.

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ABORIGINAL LIFE TODAY

Harmful and nd d hazardous hazardo ha rdouss use u e of o lcohol and nd d other ot oth othe drugs dr

Los of Loss L identity id entity y Reduced duceed respect rrespe essp spect for spect for elders ders

People healing Families healing Cultural maintenance and revival SPIRIT STRENGTHENING COMMUNITY STRENGTHENING

Weaken We W nd ne spi sp ppirit pir it and and d po poor ooorr health he h alt lth

Fam mily m ily violenc vi violen len en ncee - Poverty Po - Ch Chi hi d a hil abu e 11 1754 IndigenousFlipChart19212.indd 11

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Understanding Internalised Oppression ‘The arrival of Whiteman was the beginning of the oppression of our people. For over two hundred years our people have experienced many forms of racism, like having our freedom, choices and options taken away. Our people have heard many negative messages during this time about ourselves, our culture and our way of life. If you are told that you are no good for long enough then you start to believe you are no good. When we begin to believe the negative messages, we have internalised the oppression. We can hear that oppression talking when we put our people down. Blaming and jealousing one another are all part of this. Hurt and anger that has built up in our families and ourselves is now turned on our own people. It is our people who suffer the most. Sometimes people use alcohol and other drugs at hazardous and harmful levels to cope with this hurt and anger’.

Our people are the only people who can break this cycle Ways of challenging oppression are: Sharing our survival stories and personal experiences Understanding our history, and how Acts and Policies impacted on our families and community over the generations. Understanding the on-going effects of grief and loss, and how this impacts on ourselves, our families and our communities. Being aware about the strength of our spirit, drawing on our cultural wisdom and the skills that we have, and developing the new skills needed for our people to heal. Working together to build a better and healed future. NB: Remember when discussing internalised oppression with individuals, families and communities the importance of using a sensitive approach to these issues as this concept may be very challenging for some people.

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INTERNALISED OPPRESSION Turned in on yourself

Anger, Rage and Hurt

Self

Others

Turned on our people

Blaming others and putting our own people down. Not trusting and fighting with our own people. No unity

Leads to feelings of: Self doubt, self hatred, powerlessness, hoplessness, shame These feelings can lead to ADULT - Harmful alcohol and other drug use, stress, self harm, depression and anxiety CHILD - Alcohol and other drug use, sadness, learning difficulties, behavioural issues, stress

These feelings can lead to ADULT - Family violence, abuse, neglet and lack of respect for children and elders, limits self determination and empowerment CHILD - Truancy, fighting, vandalism, stealing, lack of respect for family and elders

PREVENTS SELF DETERMINATION AND EMPOWERMENT

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Aboriginal Drug Impact Model Understanding the impact of alcohol and other drugs ‘Our people live very closely with our families and communities - so the things we do and say have a big impact on everyone around us. When someone in our family or community is using alcohol and other drugs at hazardous and harmful levels it doesn’t just cause problems for that person - it causes problems and stress for their family and their community. It doesn’t have to be like this - we can take care of ourselves, our families and our communities by making better choices about our alcohol and other drug use’.

Using this model This is a complex model that explains that the alcohol or drug use experience must be seen in the context of the person (individual), family and community. This model emphasises the role of the family and community in addition to the individual. It can be used to assist clients to understand how their drug and alcohol use can impact on family and community. The drug experience is the outcome of a number of factors The personal drug using experience is a result of individual, environmental factors (culture, price, availability, role models, legality) and family and community factors. The same person using the same drug may have a different experience if the environment is different. There are reasons why people use drugs Drug use has real effects, which the drug user expects to happen. The effects help a person decide whether or not to use drugs, how often they will use drugs and in what situations they will use drugs. The positive effects may include feeling ‘high’, feeling relaxed, coping, keeping awake, finding it easier to get on with people, etc. This shows that people use for functional reasons however one can not exclude the unintended consequences of alcohol or other drug use that could have negative outcomes. People learn to use drugs People learn to use alcohol and other drugs in the environment in which they live. Learning happens through what people see, think, and feel. Our peoples’ ways of teaching traditionally relied on watching others and learning from them. People see parents, family, and others using alcohol and other drugs in their community. They may see alcohol or other drug use on TV, in videos and in magazines. Also, they may enjoy the effects from being intoxicated on a drug, and so keep using that drug or drugs on a recreational or regular basis.

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ABORIGINAL DRUG IMPACT MODEL

YOU

DRUGS YOUR COMMUNITY

YOUR FAMILY 15 1754 IndigenousFlipChart19212.indd 15

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ABORIGINAL DRUG IMPACT MODEL

YOU

DRUGS YOUR FAMILY

YOUR COMMUNITY

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ABORIGINAL DRUG IMPACT MODEL

YOU

DRUGS YOUR FAMILY

YOUR COMMUNITY

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Building Strong Futures ‘As we move towards our future we bring the strengths of the past, a strong spirit, our strong families and our strong communities to heal our culture. An important part of healing our future is to understand how the use of alcohol and other drugs at hazardous and harmful levels impacts upon our spirit, our people, our culture and our country. We need to understand this and use this knowledge to help us make better choices. When our spirit is strong our mind feels strong and we make good decisions. Strong inner spirit is what keeps our people healthy and connects them together. Strong inner spirit keeps the community strong and our country alive. Strengthening our inner spirit is a step towards a healed future’.

Working with clients and community The fourth circle is a whole and complete secure circle. This image represents Aboriginal life in the future. It acknowledges that although life will never be exactly the same as the first circle, nevertheless, in a contemporary society we can be strong in spirit and mind, and through the strength of our people we can develop a healed culture and future. Whilst acknowledging the challenges of the past this circle brings together the strengths of all the three circles to build a healed future for our people. This includes our cultural identity and responsibilities, our family systems and social obligations, and spiritual and cultural practices that have evolved across time and ensured our survival. Developing a fourth circle with individuals, families and communities can be an empowering approach to develop culturally secure interventions that support change and provide a vision for our future. This approach can be used in individual or family counselling but is also helpful in community development work. Empowering communities to develop their own fourth circle, their future circle, can provide a community action process and strengthen their capacity to engage in interventions that address the hazardous and harmful use of alcohol and other drugs. This is an important step towards building a healed future for our people.

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ABORIGINAL LIFE IN THE FUTURE

Strong communities Strong families Strong people

HEALED CULTURE Strong spirit

Bringing together the strengths of these times to build our people's future

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Understanding Alcohol and Other Drug Use 23 1754 IndigenousFlipChart19212.indd 23

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What is a drug? ‘Drugs that affect our brain can change the way we think, feel and behave. These drugs are known as psychoactive drugs. These drugs can cause physical and psychological changes. Some people do not understand that alcohol is a drug. When we refer to drugs this includes alcohol’.

Why do people use alcohol and other drugs? ‘People use drugs for a lot of different reasons. Usually it is because they like the feelings that they get or because drugs help them manage feelings that they don’t want to have. Sometimes people take drugs to try out the drug or because they want to feel like they are part of the group. Some people take drugs to help cope with their everyday problems, but sometimes that can make their problems worse’.

Understanding the different kinds of alcohol and other drug use Trying it out - Some people use a drug because they are curious or they may want to experience different feelings or moods. Peer influence may be a factor and use often occurs in the company of one or more friends who are also experimenting. Use may be once or short-term. Being sociable - Some people choose to use a particular drug on particular social occasions, e.g. drinking or smoking gunja at a party or at the footy, or other social setting. This pattern generally refers to experienced or controlled users who know what drug suits them and in what circumstances, rather than experimenters. If they like the effects and the company they may not be concerned about the drug being illegal. Circumstantial/Situational - This pattern is associated with use in specific situations and/or for a set period, e.g. a truck driver using stimulants to stay awake on an overnight trip or a person with a medical condition being prescribed appropriate drugs. Intensive/Too Much - Is often related to an individual’s need to achieve relief or to maintain a level of performance, e.g., taking large doses of tranquillisers or analgesics to cope with anxiety, or using too much gunja or alcohol to cope with feelings of distress and worry. Dependent/Hooked - Is a pattern of regular and frequent high doses producing dependence where the user is unable to discontinue use without experiencing significant withdrawal symptoms e.g. drinking alcohol in the morning to avoid ‘the rats’. Peoples’ lives may become centred on getting and using the drug.

Drug use terminology There are many terms you hear in the community to describe drug use. Some of this terminology is not appropriate and can lead to distorted views or misunderstandings around drug use. From an Aboriginal perspective some terminology could be viewed as labelling or disempowering. Abuse/misuse are not useful concepts because the terms involve value judgements. The World Health Organisation (WHO) uses the following terms to describe the different levels of use: Hazardous use - will probably lead to harm Dysfunctional use - leads to reduced psychological or social functioning, including problems of regular use. Harmful use - known to have caused tissue or physical damage, including dependence. 24 1754 IndigenousFlipChart19212.indd 24

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How do people learn to use drugs? ‘Our people have always learned from their elders, family and other community members on a day-to-day basis through watching, listening and trying it out. This was true for all areas of life. This is something we have done as a people for thousands of years and this remains a part of our ways today. By watching, listening and trying out some of Whiteman’s ways our people learned to use alcohol and other drugs in harmful ways. Today our people are still learning by watching, listening and trying it out. However, now we learn harmful ways of using alcohol and other drugs from within our own families and communities. Our children learn by watching us. If we are using alcohol and other drugs at hazardous and harmful levels our children may take on this way of using as well. It is important to think about what we are teaching our children and how we want their future to be.’

Social Learning Theory This approach acknowledges that drug use is a learned behaviour and that people learn to use drugs in the environment in which they live. It takes into consideration that the drug use experience is a complex interaction of four factors, the drug, the individual, their family and the community/environment in which they live. The social learning approach complements traditional Aboriginal ways of learning. Our people have always learned from their elders, other family and community members on a day-to-day basis through observing, listening and trying it out. This is a process that has been practised by our people for thousands and thousands of years and was applied to all aspects of life. It remains an on-going process today. Given that social learning was a core component of Aboriginal way of life, it was easy for our people to adopt and learn destructive drinking patterns through observation of alcohol and other drug use as practiced by some of the incoming culture. Today our people are still social learners, however, now they learn and observe alcohol and other drug use behaviour from within their own families, communities and social environment. In addition, our people continue to be influenced by alcohol and other drug use from the broader Australian community. This is further compounded by the accumulated effects of oppression and the marginalisation of Aboriginal people in Australia today. These underlying issues still impact our peoples’ alcohol and other drug use, general health and social, emotional and spiritual well-being.

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Types of drugs There are four main groups of drugs that affect the brain: depressants, stimulants, hallucinogens and others. Uppers (Stimulants) These types of drugs speed you up. This can make you feel happy, brave and deadly. They can also make you feel paranoid, fearful, jealous, agro and suspicious. These drugs can be dangerous. 'Coffee, tea, cola drinks and nicotine in tobacco are all mild stimulants. Stronger stimulants include speed, ice or crystal meth and cocaine.'

Downers (Depressants) These types of drugs slow you down. This can make you feel happy and relaxed. They can also make you have no shame, feel down, agro or jealous. These drugs can be dangerous and can cause unconsciousness, vomiting and death. 'Alcohol, benzos, tranquillisers, heroin, some painkillers and solvents are downers.'

Crazy (Hallucinogens) These types of drugs can make you see and hear things that aren’t there or things that are there may look really strange. The effects can be different each time. These drugs can be dangerous. LSD or acid, magic mushrooms, mescaline and PCP are all hallucinogens.'

Others (some drugs belong to two groups) 'Gunja is a depressant and a hallucinogen. Ecstasy is a stimulant and a hallucinogen.'

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Mixing Drugs Mixing drugs from the same group can increase the effect. 'Mixing grog with heroin can slow down your heart rate so much that you can stop breathing and die. Mixing speed with ecstasy can make your heart beat faster, you can get overheated, dehydrated and this can even cause death. Mixing grog with gunja can make you really spin out; you may throw up or pass out’.

Mixing drugs from different groups can make one drug cover up the effects of the other. 'If you mix grog and speed you could use dangerous amounts of both drugs without knowing it. This can harm your body and make you very sick’.

What does it mean when someone is hooked (dependent) on a drug? Being hooked or dependent on drugs can vary from a mild urge to use to out of control use. 'People who become hooked (dependent) on a drug may become tolerant to that drug. This means they need to use more and more of the drug to get the same effect or avoid withdrawal symptoms.' 'When people are hooked (dependent) they believe they have to use the drug to do certain things or feel a certain way.' 'When someone is hooked (dependent) their body has changed. If they suddenly stop taking the drug they may experience really unpleasant symptoms. Some times this can be life threatening. This is called withdrawal and can include feeling really sad or angry, or physical symptoms like vomiting, fits and cramps. Sometimes withdrawals require medical supervision.' 'When someone is very hooked (dependent) on a drug they may begin to behave in unexpected ways - this can be very difficult for their family and community to manage.'

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Ways of reducing harm The best way to prevent or reduce the problems caused by using drugs and alcohol at hazardous and harmful levels is to not use. For example, it is important for pregnant women not to use alcohol and other drugs because it can affect their unborn baby. However, often people who are using alcohol and other drugs in harmful ways do not want to give up using, but it is possible to do things that will reduce the harm. For example, when people who use intravenous drugs share equipment they may be at risk of harm from blood borne viruses like hepatitis C and HIV. An essential way of reducing harm is to make sure they have clean equipment and never share. Family and friends can also play an important role in reducing drug and alcohol related harm. For example, sticking together is a very useful harm reduction strategy. If someone is angry, has argued with loved ones or family and is intoxicated do not let them go off alone, as they may be at risk of self-harm.

Risk scale (the different levels of risk)

Working with clients

Some behaviours have less risk of harm and are called ‘low risk’. Other behaviours can have harmful outcomes and these are called ‘high risk’. The following is a scale from low risk to high risk behaviours for injecting drug users:

Encouraging clients to put into practice harm reduction strategies is a negotiated process.

1. 2. 3. 4.

5. 6.

Steps to consider:

The safest way to minimise the risks (harms) from injecting drugs is not to use the drug/s at all The least risky method is to swallow the drug rather than sniffing, inhaling, shafting, smoking or injecting This is followed by the other non-injecting methods of using the drug/s, including sniffing, inhaling, shafting or smoking Injecting the drug/s with new equipment and washed hands every time, and without sharing or reusing any injecting equipment, is the next most risky behaviour Re-using someone else’s injecting equipment after cleaning the equipment with bleach is the next level The most risky behaviour is to inject drug/s and share or re-use any equipment without taking any precautions to reduce the risks

1. 2. 3.

4. 5. 6.

Give clients harm reduction information Make sure your client and their family are safe Build on their existing strategies (remember, all clients already have some sort of harm reduction strategies in place and it is important to take an empowering approach by assessing the safety of what they do and building on it.) Look at the good and the not-so-good things in developing harm reduction strategies Develop a making changes action plan You may not always agree with your client’s choices It is important to tell them if you believe their decision is risky or harmful However in the end the decision is theirs

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Ways of reducing alcohol related harm Alcohol Guidelines for Men

Alcohol Guidelines for Women

To avoid long term harm

To avoid harm from drinking on any one day

To avoid long term harm

To avoid harm from drinking on any one day

No more than 28 standard drinks in a week

Up to 6 standard drinks a day no more than 3 days a week

No more than 14 standard drinks in a week

Up to 4 standard drinks a day no more than 3 days a week

On average no more than 4 standard drinks a day

On average no more than 2 standard drinks a day

One or two alcohol free days a week

One or two alcohol free days a week

This drinking level is not recommended if you are under 18, below average body size, pregnant, on medication or have a physical or mental condition made worse by drinking.

If you do choose to drink there are some other things you can do to reduce harm

If you are having a party these are some things you can do to reduce harm to your guests

Eat before drinking - a proper meal not just snack food Avoid salty foods - you will drink more Drink slowly, pace yourself, space your drinks and put your glass or can down between sips Drink lite beers, low alcohol wines, half measures of spirits, mix wine with soda and ice Count your drinks, use a standard glass and don’t let people top up your glass Start with a non-alcoholic drink and make every other drink a non-alcoholic drink Drink plenty of water to avoid dehydration Stay busy doing other things like dancing, singing, playing pool Drink in a safe place and have a plan to get home safely - do not drive or get in the car with someone who has been drinking Refuse drinks when you have reached your limit - it’s your choice Do not drink alone, when planning to drive, operate machinery, do skilled activities or do water sports

Provide food or get people to bring food - not just salty snacks Provide plenty of non-alcoholic drinks - like water or soft drinks Provide some entertainment so there is more to do than just drink Make sure someone is not drinking and can take care of the children and ensure that elders are cared for Do not let someone drive home drunk Do not pressure pregnant women to drink - it could harm their baby

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What to do about overdose/toxicity What is an overdose? Overdose occurs when the quantity of a drug or a combination of drugs causes severe bad effects. Overdoses can be life threatening.

What causes overdose? Overdose can occur for many different reasons. There are a number of different factors or combination of factors that can contribute to an overdose: Drug Too much Stronger than expected Mixing different drugs Unfamiliar route of administration What the drug has been cut with

Individual Lowered tolerance (released from jail/detox/residential setting) Discharged from a pharmacotherapy program Physical health, mental health Emotional and social well being Knowledge of drug used

Environmental Using alone Homeless or unfamiliar environment Cost/availability Unfamiliar supply People panic and don’t know what to do Frightened to call an ambulance

What to do about a depressant overdose

What to do about stimulant toxicity

Stay together - do not let someone go off alone. If someone experiences any bad effects or passes out make sure you call an ambulance straight away. By doing this you could save their life.

Drug related psychosis can be unpredictable - ensure your own safety. If the person is very distressed or passes out call an ambulance. Stay with the person and do not let them go off alone.

1. 2.

1. 2. 3. 4. 5. 6.

3.

Check the area for dangers to yourself - used syringes If someone has passed out put them on their side, clear their airway. If they cannot breathe, breathe for them Dial 000 for an ambulance. (Police won’t come unless there is violence, serious injury or death)

Stay with your friend until the ambulance arrives - never leave them alone.

Be confident - reassure them ‘this will pass’. Use simple language Do not get into arguments If possible find family, friends or someone the person trusts Move into a cool quiet area but avoid isolation Cool them down and give sips of water Encourage the person to breathe slowly and deeply

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Drug Type

Short-term Effects of Moderate Dose

Short-term Effects of Hazardous Dose

Long-term Effects of Hazardous Dose

ALCOHOL

Relaxation, breakdown of inhibitions, euphoria

Stupor, nausea, reduced coordination, slurred speech, unconsciousness, hangover, death

Impotence, ulcers, malnutrition, liver and brain damage, DTs, psychosis, death

MINOR TRANQUILLISERS (Benzodiazepines)

Relief of anxiety and tension, treatment of insomnia, muscle relaxation

Drowsiness, blurred vision, dizziness, slurred speech, stupor

Significant withdrawal effects of anxiety, insomnia, depersonalisation and possibly convulsions

Depressed respiration, coma, death

Lethargy, constipation, weight loss, impotence, withdrawal

DEPRESSANTS

OPIOID BASED ANALGESICS

Relaxation, euphoria, pain relief, (inc heroin, morphine, codeine, synthetic decreased alertness and semi-synthetic opiods)

VOLATILE SUBSTANCES

Relaxation, excitement, hallucinations, Stupor, convulsions, death euphoria, impaired coordination, sudden death syndrome

Liver, kidney, bone marrow and brain damage (may be reversible in some cases), fatigue, weight loss, depression

AMPHETAMINES

Increased alertness, confidence, excitation, reduced appetite, dilation of pupils, talkativeness

Thought disorder, insomnia, restlessness, hallucinations, psychosis, death

COCAINE

Intense exhilaration, self-confidence and Sweating, pallor, erratic behaviour ‘in control’

Damage to nasal septum, insomnia and restlessness, hallucinations, psychosis, death

TOBACCO

Relaxation, increase in heart rate, blood Headache, loss of appetite, nausea pressure, drop in skin temperature

Impaired breathing, heart and lung disease, cancer, death

CAFFEINE

Increased alertness, metabolism, body temperature and urination

Chronic insomnia, anxiety and depression, stomach disorder

STIMULANTS Restlessness, dizziness, psychosis, residual hangover, panic

Restlessness and insomnia, headache, palpitation, diarrhoea

HALLUCINOGENS LSD, MAGIC MUSHROOMS

Heightened perception, increased Panic, exhaustion, tremors, energy, insomnia, hallucinations, anxiety hallucinations

Flashbacks, psychosis (in susceptible people)

CANNABIS

Heightened perception, increased Stupor, hallucinations, panic attack energy, insomnia, hallucinations, anxiety

Chronic fatigue, de-motivation, respiratory problems etc. if smoked. See effects for tobacco. Psychosis in susceptible people

ECSTACY

Well-being, confidence, anxiety, sweating, high body temperature, increased heart rate

OTHER

Dehydration, irrational behaviour, muscle Anxiety, panic, confusion, liver damage, ‘meltdown’, vomiting, hallucinations, psychosis, depression, impotence ‘hangover’ effect, convulsions

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Working with Clients, Families and Communities 39 1754 IndigenousFlipChart19212.indd 39

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Aboriginal Inner Spirit Model ‘Our inner spirit is the centre of our being and emotions. When our spirit feels strong our mind feels strong. When our spirit feels tangled our mind feels tangled. Strong inner spirit is what keeps people healthy and keeps them connected together. Strong inner spirit keeps our family strong, our community strong and our country alive’.

Working with the client We talk about “inner spirit” because many Aboriginal peoples will use these resources. Many language groups from around Australia have a name for the concept “inner spirit”. If your client knows the name that their people use for inner spirit use that word Even if your client does not know the name for the inner spirit they will most likely understand the concept Because too much alcohol and other drugs can impact badly on someone’s inner spirit, it is useful to introduce your clients to the concept of monitoring how their spirit is feeling You can ask questions like; – How is your inner spirit feeling today? – How did that affect your inner spirit? – How do you think reducing your use would affect your inner spirit? You can ask your clients to describe how their inner spirit is feeling by getting them to do a drawing or painting. This can be helpful as a self-awareness exercise so the client can see how alcohol or other drugs is affecting their inner spirit. It can also be helpful to have clients paint or draw their healed spirit. This can support goal setting and make changes more meaningful Encourage clients to use positive self talk with their inner spirit. For example: – talking to your spirit by telling your spirit to stay strong – talking to your spirit about how you will reduce your use and how it will get strong again – talking to your spirit to stay safe when you are in a high risk situation

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ABORIGINAL INNER SPIRIT MODEL

Aboriginal cultural ways of looking after emotional, social and spiritual wellbeing

Mind Aboriginal Culture, Beliefs and Traditions

Inner spirit - Centre of

our being and emotions

LAND PEOPLE The country and Aboriginal people being with it

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How alcohol and other drugs can affect our inner spirit ‘Our way of being healthy is to look after ourselves by making good choices, and to care for our family, community and culture. Alcohol and other drugs can tangle and weaken our spirit and mind. This can affect our emotional, social, spiritual and physical well being. This can weaken our connection to family, community, culture and country. When we use alcohol and other drugs in harmful ways our spirit becomes weaker and our thinking gets tangled. But if we stop or reduce our use our spirit can grow strong and our thinking becomes clear again’.

Explaining this model This model shows the breakdown of the connection between inner spirit and mind as it becomes increasingly broken or tangled up by the effects of alcohol and other drugs. As the person uses more and more alcohol and other drugs their inner spirit weakens, the connection becomes broken, their thinking gets tangled, and finally the spirit leaves. All of this impacts on their family, their community and their country. The model allows clients to assess how their alcohol and other drug use may be affecting their inner spirit and their connections to family, community and country. This model demonstrates that people can move back through the stages and that reducing use can strengthen their inner spirit and connections to family, community and country.

The red area shows people who are dependent on alcohol and other drugs and who use all the time. They start to loose their connection to their inner spirit. They also start to loose their connection to their family, community and country, and forget their cultural and social obligations.

Working with the client There are many different ways of working with these models; you will develop your own approach depending on your clients.

These are some suggestions: Introduce the client to the concept of inner spirit You can use this model with the client and ask them to show where on the chart their inner spirit is Some clients may like to draw, paint or colour in a model to represent themselves and their inner spirit Ask them if they remember a time when their spirit was strong and their thinking was not tangled - what was that like? Ask them who in their family and community has a strong inner spirit and who can support them Always reassure your client that by cutting out or cutting down their use to safe levels their thinking can become untangled and clear, and their inner spirit can grow strong again

What the colours mean The green area shows people who don’t use alcohol and other drugs or use at safe levels, maintain a strong inner spirit. Their connections to family, community and country remain strong. The orange area shows people who use alcohol and other drugs above safe levels on a regular basis. This starts to weaken their inner spirit, their connections, and their cultural and social obligations towards their family, community and country.

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Alcohol and other drugs can weaken your spirit and your connections with family, community and country SPIRIT STRONG FAMILY STRONG COMMUNITY STRONG COUNTRY STRONG

PEOPLE WHO DON’T USE AND USE A BIT

SPIRIT WEAK FAMILY WORRIED/ANGRY COMMUNITY WORRIED COUNTRY OK

PEOPLE WHO USE A LOT

SPIRIT GONE FAMILY SAD COMMUNITY SAD COUNTRY ALONE

PEOPLE WHO USE ALL THE TIME

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Alcohol and other drugs affect the whole community ‘Everyone in the community is affected when alcohol and other drugs are used at hazardous and harmful levels, even the people who don’t use at all’.

People who use a bit - Problems of getting drunk or stoned (intoxication) These problems usually result from the short term effects of the drug. These are the problems our families and communities see most often. For example, if someone who uses only sometimes gets drunk and drives a car they may cause an accident and hurt other people - this can affect everyone in the community. Some of the other problems associated with intoxication are; drunkenness, getting totally off your face, shame, criminal damage, assault, drink driving, manslaughter, homicide, accidents, arguments with family and friends, harm to self or others, family violence, child/elder neglect and abuse, spending all their money, unwanted or unsafe sex, not going to work, harm to unborn baby, and health problems like hangover, vomiting, stomach problems, selfpoisoning (overdose), risk of blood borne viruses e.g. hepatitis C or HIV, and other injuries.

People who use a lot - Problems from using too much on a regular basis These problems come from continued use over a period of time. This means the person’s body may not have recovered completely from the last time they used, so each time their health may get a little bit worse. Money problems may develop because of regular spending on alcohol and other drugs. For example, if someone is using a lot of gunja they may humbug their family for money, or steal to pay for their drugs - this affects the whole community. Or if someone is using all the time they may spend all the money. This means kids go hungry and bills don’t get paid. Some of the problems associated with regularly using too much are; legal problems, debt, theft, fraud, work difficulties, family difficulties, community difficulties, money problems, child/elder abuse or neglect, relationship problems, family violence, and health issues like brain and tissue damage, hepatitis, obesity, diabetes, heart disease and respiratory problems like chest infections.

People who use all the time - Problems from not being able to stop using alcohol or other drugs (dependence/being hooked) This happens when a person spends more and more time thinking about, getting or using alcohol or other drugs. Dependence ranges from mild to severe. Someone who is really hooked may use drugs to hold off withdrawals. This means they spend less and less time doing other important things like looking after their family, community and country, and maintaining their cultural and social obligations. Even worse, when someone's memory starts to be affected they forget their cultural knowledge and this means it can’t be passed on to the next generation. Some of the other problems include debt, family breakdown, can not keep a job, homelessness, isolation, shame, serious psychological, health and mental health problems.

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ALCOHOL AND OTHER DRUGS CAN AFFECT THE WHOLE COMMUNITY

WHO DON E L ’T P O US PE E

PEOPLE WHO USE A BIT PEOPLE PEOPLE WHO USE WHO USE A LOT ALL THE TIME

P

EO PL E

E S U WHO DON’T

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Alcohol and other drugs can affect your client’s life in many different ways The Seven L’s/Seven Areas model is a useful way of assessing the areas in which your client may be experiencing difficulties. Sometimes clients will use alcohol and other drugs to cope with problems already in their life, and this can contribute to making those problems worse. And sometimes the client’s alcohol and other drug use can cause the problems. Sometimes the client will not realise their alcohol or other drug use is causing problems for themselves, their family and their community. The lists below are some of the more common problems experienced. When you and your client are tracking the good and not so good things about their alcohol and drug use consider each of these areas.

Health

Family and Community Relationships

Your body is getting sick Your inner spirit is feeling tangled You may be feeling confused, stressed, worried, sad or depressed, angry or fearful

Putting pressure on your family Fighting with your partner, elders and your children Your family are worried and angry about your behaviour Not observing your family and community responsibilities

Money and Work

Aboriginal Law, Culture and Country

Spending too much money on alcohol and/or other drugs Not buying food for the family, not paying the rent or bills. Humbugging your family for money Lose your job or can’t be bothered looking for work Can’t be bothered with finishing school or getting a career

Not keeping your social and cultural obligations Breaking Aboriginal Law when drunk or out of it on drugs Not respecting, passing on or learning your culture Not looking after and respecting your country

Legal You’ve been busted for drugs You’ve been charged with assaults, breaking and entering, homicides, manslaughter, drink driving, or other crimes while you were drunk or out of it You have been to jail or have a criminal record Outstanding fines/loss of licence

Grief and Loss You use alcohol and/or other drugs to cope with issues of: Family and friends passing away Loss of family connections due to stolen generation issues Family members being in jail Experiencing painful events within your family and community

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CULTURE C ULTUR LT RE AND AND COUNTRY C UN NTRY TRY

GRIEF G GR RIEF EF F AN A AND ND ND LOS LOSS LO

ABORIGINAL A BORI RIGIN RIG GINAL A LA LAW

TH THE TH HE E SEVEN S SE EV E VEN AREAS A REA RE EAS AS

HEALTH H EA ALTH H

FA FAMILY F AMILY AM LY YA AN AND ND CO COMMUNITY OMM MU IT TY

LEGAL L LEG EGA EGA AL MONEY M ONE ON NEY Y AND A ND W WORK RK RK

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Making Changes - Individual Stages of Change The following section explores the process of behavioural change. Whether working with individuals, families or communities it is useful to look at change as a process that involves a series of stages. This section is divided into six parts, each focussing on a stage of change and identifying ways of working that are appropriate and helpful in assisting clients to progress through that stage. Choosing the right way of working will help clients move towards making successful and permanent changes in their alcohol and other drug use. In addition, each part provides information as to how family and friends can support the client at each stage.

Working with clients Stages of Change is a useful model for understanding how people change, and how you can be most effective in assisting the change process and supporting the client to achieve their goals. When working with clients it is important to remember; Change is a process that involves many different stages Different people can be in different stages for different lengths of time People may move back and forward between stages many times before they are ready to move on Intervention strategies are most effective when they are matched to the stage of change Change is cyclical - people may recycle through the stages several times before reaching their goal of cutting down or cutting out their alcohol or other drug use Relapse is common and normal - most people do not successfully change behaviour on their first attempt. It is important to build relapse prevention strategies into interventions

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STAGES OF CHANGE Choosing to keep drinking or using drugs

Uncomfortable with drinking or drug use

Thinking about change

CHANGE?

OOPS!

CHANGE Gone back to old patterns

Staying changed

TAKING ACTION TO CHANGE

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Making Changes - Community Stages of Change The Stages of Change model can also be very useful when working with families and communities. Where is the community at in terms of addressing alcohol and other drug use problems? Communities have a collective process similar to that experienced by individuals. After observing life and talking with people in the community, assess where you think the community is in the change process. This can be very useful in terms of planning and facilitating community action meetings. Aboriginal Alcohol and other Drug Workers can play a key part in supporting communities to take action to address their concerns. This can be considered a part of community development work and assists in building the capacity of communities to address alcohol and other drug problems. 1.

Living with the community the way it is In community terms, drinking or drug use is happening and there appears to be little collective sense of the community having troubles as a result of it. Alternatively the community may be very troubled by what is happening but believe there is nothing that they can do to change the situation.

2.

Not happy about issues in the community The next step is recognition of the collective sense of not being happy with drinking or drug use in the community, but not having decided what the main problems are, or even whether to do anything about it yet.

3.

Thinking about making positive changes in the community Once the collective sense of not being happy is recognised, communities can progress to considering what changes they might want to make for their members. This can lead to developing action plans through holding community meetings to address the concerns and delegating specific tasks to community members. At this stage it is vital that the community has a sense of owning the action plan, and that the proposed outcomes are meaningful for them.

4.

Taking action to make changes in the community Having developed the plan it is time to put it into action. Collectively the community members take responsibility to implement their action plan once they have identified action strategies to address the concerns. It is important that action plans have realistic and achievable outcomes. This empowering approach reinforces the positive benefits of achieving their action oriented goals for their community. It enables a whole of community approach to address the concerns and supports the opportunity to review, monitor and evaluate achievements.

5.

Keeping action going/staying changed The next step is keeping the action going to sustain the change. This involves empowering the community to see the benefits of their achievements and supports community ownership of the process. By reviewing the outcomes, acknowledging successes and developing ongoing strategies, the community is encouraged to continue affective action to maintain change.

6.

Oops! Action stopped - start again At any stage the action can stop for a variety of reasons. It may mean the community has to re-think and try something else. Or maybe just pick up from where they left off. It is always a good idea to look at past action and see what can be learned, what worked well and what could be improved.

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Oops!! Action stopped - Start again 51 1754 IndigenousFlipChart19212.indd 51

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Choosing to keep drinking or using (Pre contemplation) Ways of working with clients at this stage These people are not thinking about changing their alcohol and drug use. The good things they get from their use are more important than the problems, and they don’t see making changes as being of any benefit. For some people continuing to use alcohol and other drugs is more important than stopping or cutting down even when they are having problems. Others may not be considering change because change is too hard or they have been unsuccessful in the past. Maybe they are afraid of giving up or modifying their use because their life will change.

Ways of working with the client’s family/friends at this stage It can be difficult for families managing family members who are at this stage. In addition, sometimes whole families can be in this stage. Ways in which the client’s family and friends can help someone not willing to change their behaviour are: Not put them down or judge them for continuing to use Give them information about risks and problems and where to get help Talk about ways to reduce harm Do practical things to help reduce harm Offer to support them if they want to make change Get support for themselves if the person’s alcohol and other drug use is causing family and community problems

Although clients may not be willing to change their behaviour they may want information about how to reduce personal and social harms associated with their drinking or drug use.

To do this you need to: 1. 2.

3. 4. 5. 6.

Have accurate information about harms and risks associated with drug use Assess the risks and harms associated with client’s drug taking behaviour • Risks and harms of getting the drug • Risks and harms of using the drug • Risks and harms of withdrawal Provide information about the physical, psychological and social harms and how they could be avoided Help client identify harm reduction strategies which they would be willing to use Develop a harm reduction plan and review it when client is willing Let the client know that you would be willing to support them to make changes in their alcohol and other drug use should they decide to stop using or cut down

Ways of working with the community at this stage Working with communities at this stage can be difficult but you can still provide them with AOD services. Being available for counseling and providing information about how to reduce personal and social harms associated with drinking and other drug use in the community is an important part of community intervention.

To do this you need to: Not put them down or judge them for continuing to use Maintain continuity of service delivery. This is an important part of establishing trust in the community Continue to see clients for counselling when providing outreach services Make contact with the community council, administration and other services e.g. school, clinic etc., as networking is essential Provide resources and information about your service, harm reduction strategies and establishing local drug action groups Support alcohol and drug free community events Be seen, let people know your role and how you can help

Remember You may disagree with your client’s choices. It is important to tell them if you believe their decision is risky or harmful, however ultimately the decision is theirs.

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Individual

Family or Community

Choosing to keep drinking alcohol or using other drugs

Living in the community the way it is

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Uncomfortable with drinking or drug use (Contemplation) Ways of working with clients at this stage

Ways of working with the client’s family/friends at this stage

Sometimes people have mixed feelings about their use. They may enjoy it, find that it takes away painful feelings or provides other benefits. But they may be starting to experience some not-so-good effects from their use. These may include problems with family and community, health, Aboriginal Law, legal issues, work and money, grief and loss, and country and cultural responsibilities. They are undecided about their alcohol and other drug use. This is an uncomfortable feeling that may vary from slight to intense. Although the intensity suggests more unease and likelihood of change, it can also be so stressful that the anxiety stops the person doing anything. They remain stuck.

Although this can be a difficult time for families it can be an opportunity to really make a difference by supporting their family member to start thinking about change. Ways in which the client’s family and friends can help someone at this stage are: Talk to them about the Good/Not-so-good things for them, their family and the community Talk about how alcohol and other drug use is affecting their inner spirit Offer to support them if they want to make changes Help them to find professional assistance and support networks

Because clients at this stage often feel of two minds about their alcohol and other drug use, the role of the AOD Worker is to assist the client to track the good and not-so-good things about their use in order to make a decision about continuing, reducing or stopping use.

Ways of working with the community at this stage

To do this: Motivational interview. Assist the client to track the good/not-so-good things about their use for themself, their spirit, their family and their community Show client the Inner Spirit Model - ask them where they think they would be on the continuum. Reassure them that reducing use can heal and strengthen spirit Acknowledge the client's discomfort at being in two minds about their use. Sum up the not-so-good things and work with these - this can motivate clients to think about change Use the Seven Areas model to explore areas where they may be experiencing difficulties You could use the story telling board to produce a visual map for tracking the good and not-so-good things about their use Assess the client’s belief about their ability to make change and strengthen self effectiveness Assist the client to identify supportive people (again the story telling board might be useful here so they can map safe support systems)

Working with communities at this stage can be an opportunity to assist the community to identify concerns about alcohol and other drug use in the community. To do this: Facilitate a meeting or workshop with interested community members Ask participants to identify the good and not-so-good things about alcohol and other drug use in their community. You can do this by brainstorming with them or get them into smaller groups and get them to feedback their suggestions Generate a discussion with participants based on information provided by them Get participants to consider what they might like to do with this information Offer suggestions of ways forward from here Organise a follow up meeting with them next time you’re visiting.

Remember the roadblocks to empathy Solving their problems, being confrontational, arguing or telling people what to do, judging, labelling or moralising.

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Individual

Family or Community

Uncomfortable with drinking or drug use

Not happy with the issues in the community

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Motivational Interviewing Principles Motivational Interviewing can be used in a variety of ways depending on the client’s stage of change. For example, you might use it to increase the uncomfortable feeling the client has from being in two minds about their alcohol or other drug use, or you might use it to strengthen their determination to change. Regardless of when you use it there are six basic principles:

Express empathy Accept what the client is saying (this does not mean you approve of their behaviour or agree with their choices) this helps build a therapeutic relationship Listen respectfully even if you disagree, do not be judgemental Reflect back what the client has been saying to show you understand Summarise the client’s story to make sure you have the facts

Work with resistance Resistance is common and can take many forms including arguing, interrupting, denying, ignoring, being non-compliant, self-harming, acting aggressively towards the AOD Worker or other agency staff and breaking appointments. There is usually a reason for the resistance. Your job is to understand the reason and assist clients to overcome it. Some strategies that are useful in working with resistance include: Track the client’s story Change track Review the good and not-so-good things Ask about and support their preferred choices Empower them to believe they can do it and provide information to support them

Working with the client's discomfort about being in two minds Clients are often in two minds about their alcohol and/or other drug use They are more likely to change their behaviour when they present their own reasons for changing without feeling pressured The reason to change needs to be meaningful to them Track the good and not-so-good things about their use Get the client to think about how they would like to be and how they are currently behaving Remember even small changes in attitude are a positive outcome and need to be acknowledged

Support self-effectiveness Self-effectiveness is a person’s belief that they are capable of doing something, completing a task or meeting a challenge Encourage clients to take personal responsibility for making change Encourage positive self talk and encourage client to talk to their spirit Set appropriate goals and focus on achievements Acknowledge successes like cutting down use or not giving in to a craving

Avoid arguments Do not argue with your client it will create barriers and undermine your therapeutic relationship. Angry clients are unlikely to hear what you are saying If you find yourself arguing with the client it is time to change direction/ shift attention to something else

View life holistically Any change in one area will impact on other areas of life. The client is part of a complex network of relationships - changes in their alcohol and other drug use will impact on their relationships with family and community. 56

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Good/Not-so-Good Tracking and then weighing up the good things and the not-so-good things about your alcohol and/or other drug use helps you to decide whether you want to make some changes. List the good things about your alcohol and/or other drug use for:

List the not-so-good things about your alcohol and/or other drug use for:

Your inner spirit

Your inner spirit

You

You

Your family

Your family

Your community

Your community

Thinking about the Good and Not-so-Good things about alcohol and drug use can also be helpful for families and communities who are thinking about making some changes.

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Thinking about change (Preparation) Ways of working with clients at this stage

Ways of working with the client’s family/friends at this stage

These people are thinking about how to make change because they can see that the not-so-good things about using alcohol and/or other drugs are greater than the good things. They have decided to look at ways to make change. They may be worried and fearful, and the task confronting them may seem overwhelming. Any step in the direction of positive change is useful. The changes and treatment options will depend on the client’s level of use, the client’s choice and their personal circumstances.

Ways in which the client’s family and friends can help someone at this stage are:

Use Motivational Interviewing steps to track their discomfort. This will increase the reasons they want to change and decrease their desire to use Assist them to identify the reasons they want to make change Continue to build self-effectiveness through teaching them about positive self talk and empowering them to believe in themselves Identify how cutting down or cutting out will have positive effects on their inner spirit, physical, psychological and emotional wellbeing Identify how cutting down or cutting out will improve their relationships with family, friends and community Identify client’s fear about change Identify barriers to change and potential problems Identify treatment choices Provide advice and information about treatment choices Assist client to clarify the problem and set goals Assist client to identify their support network (mapping this on the story telling board is a useful way for clients to visualise safe support systems) Explore how they can still maintain their cultural and social obligations whilst cutting down or cutting out

Remind them of the reasons why they want to make changes Talk about ways to make change Talk about how changing will strengthen and untangle their inner spirit Talk about the benefits of making change for them and their family Help them set goals and support them to achieve these

Ways of working with communities at this stage Working with communities at this stage can be an opportunity to assist the community to identify and develop strategies that can address alcohol and other drug use in the community.

To do this: Review the good and not-so-good things that participants identified in their meeting/workshop. This will increase their reasons for wanting to see change in their community Provide information to participants on successful action initiatives that other communities have achieved Facilitate a brainstorm activity or small group exercise with the participants so they can start to think about ideas for action Generate a discussion by asking participants to feed back and share their ideas for action Get participants to make a decision on ideas that are realistic for them to achieve and develop an action plan for implementation Ask participants to delegate responsibilities and tasks required to successfully implement their plan Organise a follow up meeting with them next time you are visiting

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Individual

Family or Community

CHANGE?

Thinking about change

Thinking about making positive changes in the community

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The Seven Steps to Problem Solving Step 1: Look at the problem as if it is happening to someone else

There are three rules that help this technique work: 1.

Everyone experiences problems and these are a part of every day life. Problems need to be seen as challenges rather than thinking of them as catastrophes. Encourage your client to take a step back and look at the problem as if the problem was happening to someone else, and they were an observer on the outside looking in. Many people respond to problems with the first idea that comes into their heads. This is often not the best solution and sometimes can make things worse. It is important for clients to step back and think about the situation rather than act immediately on a decision that may set them up to fail. Frequent let downs for our people are not uncommon and teaching them problem solving skills can help them overcome this. Therefore, it is vital here that the window of opportunity is utilised well to avoid the feeling of failure as this may discourage them from continuing to try.

2. 3.

No criticism or put downs of any suggestion. Judgement is delayed until a later stage Think broadly. Any idea is acceptable at this stage The more ideas the better as this increases the possibility of finding useful solutions

Step 4: Select the best idea (Decision Making) Have the client cross off the list any ideas that are obviously not practical. Assist the client in examining the good and the not-so-good things on the remaining strategy options. Ideas may be combined or added to. Finally, have your client select the one that they consider will be the most effective, realistic and achievable.

Step 5: Develop an action plan

Step 2: Identify the problem A clear understanding of the problem is critical to the problem solving process. Our people often experience multiple problems and therefore prioritising problems maybe necessary. The problem needs to be clearly and exactly stated. The counsellor can assist the client clarify the problem by using good listening skills and probing for more information. Work with the client to break a bigger problem down into small parts. Being specific about the problem is a crucial part of problem solving.

Step 3: Brainstorming ideas to address the problem This is the fun part of problem solving where you and the client have permission to come up with a range of ideas no matter how outrageous or wild they might be. Brainstorming is a technique for generating ideas, possibilities and alternative courses of action that may assist the client in addressing the problem. You can use the whiteboard to write these down or pen and paper.

Once the best strategy is selected, develop a concrete and specific action plan. How exactly are they going to carry out their selected plan? What time frame are they working in? What are they going to do first? When will they do it? How will they do it?

Step 6: Try it out To assist the client put their plan into action they may need to think through or practise the plan. Then try it out.

Step 7: Evaluate and review how it went Whatever happens, evaluate the results carefully. Did it resolve or go part the way to resolving the problem? What were the consequences for the client? If it was only partially successful, or not effective at all, consider whether the plan can be improved (go back to Stage 5), or whether a new strategy is needed (go to Stage 4).

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Problem Solving Steps My problem is Ways to address my problem are

1. 2. 3.

What are the good and Good/For not-so-good things about my suggestions Suggestion 1

Not-so-good/Against Suggestion 1

Suggestion 2

Suggestion 2

Suggestion 3

Suggestion 3

The idea/suggestion I choose is My plan is

What Where and When How Who will help

Carry out plan Evaluating my plan How well did it work? Where to from here?

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Working with clients to set goals Working with clients to develop short-term goals allows them to experience success. This is a good way of reducing ‘learned helplessness’, a common and intergenerational problem experienced by some Aboriginal people as a result of marginalisation and the colonisation process. Therefore achieving a short-term goal highlights to the client their success and boosts their confidence to want to keep trying. This staged approach of setting a series of achievable short-term goals will support the client to reach their long-term goal.

The role of the AOD worker is to facilitate the goal setting process with their client. Setting goals are important for the following reasons: They assist successful behavioural change Need to be suggested and owned by the client Strengthens the client’s inner spirit and boosts their confidence to want to keep trying A rewarding process for the client that increases their self-effectiveness Are a learning tool. When goals are not fully achieved this provides valuable insight for future goal setting Need to be solution focused, positive and support behavioural change How to set SMART goals: The goal is negotiated with the client so it is their goal and meaningful to them. As a worker, you help to make sure the goal is SMART. You should also advise them of any risks associated with the goal chosen. (There may be situations where you disagree with the goal the client wants to set because you believe it is too risky or unrealistic. It is important to discuss your reasons with the client, if they are willing to listen - however the final choice is the client's).

SPECIFIC

REALISTIC

This is something real (concrete) and can be done

The goal must be something which is manageable and which the client can achieve An unrealistic goal increases the chance of failure, and this may discourage the client from attempting to make other changes in the future

MEANINGFUL Relevant to the client and related to their long-term goals, their situation, and their stage of change. People are more likely to work towards meaningful goals

TIME LIMITED Short-term Set a start date and a target to work towards Set a date for review

ASSESSABLE The achievement can be measured. The client needs to be able to see they have been successful

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Goal Setting My long-term goal is My short-term goal is The specific changes I want to make

These changes are important to me because

How will the changes affect my family and community

The steps I plan to take 1. 2. 3. 4. 5. Some of the things that could get in the way of my plan

People who can help me

I will begin on

I will know my plan is working when

I will review these changes on

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Taking action to change (Action) Ways of working with clients at this stage

Help them to identify high risk times and develop a plan to cope in situations where they may feel pressured to use Develop a family support network which can help them achieve their goals and look after them during high risk times e.g. funerals Get information and support to help the family understand what they are going through

These people have decided to change and are ready to do something about their use. They may be actively engaged in cutting down or cutting out alcohol and/or other drug use. Some of the things you might do are: Develop a making changes action plan with your client Assist client to identify appropriate treatment supports Assist with identification and management of withdrawal symptoms if present Assist client to develop skills that may be of assistance to them: – coping skills – assertiveness, staying strong – problem solving – goal setting – relaxation and recreational skills – cultural strengthening activities – communication skills – behavioural and self-management skills Identify high risk situations/triggers and develop a plan Develop strategies to cope with cravings Link clients to other services if they have other needs e.g. housing and so on

Ways of working with the community at this stage Working with communities at this stage can be an opportunity to support the community to implement their action plan

To do this: Review the action plan with community members Ensure participants take responsibility and understand their individual roles Proceed to support implementation strategies as specified in their action plan e.g. establish a Local Drug Action Group Support participants to identify specific tasks that may require additional expertise e.g. sources of funding or writing a funding proposal Get participants to consider ways they can promote their action plan in the community. This could help generate more community participation Maintain regular contact throughout the implementation phases to ensure the participants keep the momentum going Support any activity that may fall out of the action plan when possible e.g. attending an alcohol free event in the community Meet with participants on a regular basis to encourage them and review progress

Ways of working with the client’s family/friends at this stage Ways in which the client’s family and friends can help someone at this stage are: Support their decision and remind them of the reasons they are making change Help and support them to make change Talk about how taking action will strengthen their inner spirit Encourage and support them to find alternatives to alcohol and other drug use 64 1754 IndigenousFlipChart19212.indd 64

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Individual

Family or Community

CHANGE Taking action to change

Taking action to make change within the community

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Making Changes Action Plan Working with the client It is not enough to develop a few goals and then go away and expect them to happen. Clients need to consider how they are going to achieve these goals. This requires the development of an action plan. Action planning can support clients achieve their goal by ensuring that they have thought through carefully everything that is required to reach that goal. This includes identifying potential barriers and considering alternative actions.

Action plans need to consider: The goal Strengths and resources that the client already has that will assist them in achieving their goal Additional resources (if any) that your client may need to achieve their goal. This needs to include where and how they can get these resources.

The steps they need to take to achieve the plan Explore the potential pressures and barriers that may interrupt them achieving their goal Develop strategies to overcome pressures and barriers Review and evaluate how things are going

Action plans need to be: Realistic, time limited, detailed and flexible

Action plans can also be developed for families and communities using this format as a template. For example: Families

Communities

The thing/s we would like to see changed in our family are:

The thing/s we would like to see changed in our community are:

These changes would be important to our family because:

These changes would be important to our community because:

These changes would benefit our family by:

These changes would benefit our community by:

Our short-term goal is:

Our short-term goal is:

The steps we as a family plan to take to help us reach our goal are:

The steps we as a community plan to take to help us reach our goal are:

People who can support our family include: (AOD services, health and welfare People who can support our community include: (AOD services, health and agencies, schools and so on) welfare agencies, schools and so on) Some of the pressures or barriers that might get in our way and prevent us from reaching our goal are:

Some of the pressures or barriers that might get in our way and prevent us from reaching our goal are:

Ways of managing these pressures if they happen are:

Ways of managing these pressures if they happen are:

We will know our action plan is working when:

We will know our action plan is working when: 66

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Making Changes Action Plan The things I would like to change are These changes are important to me because How will these changes benefit my inner spirit? How will these changes benefit my family and community? My short-term goal is The steps I plan to take to help me reach this goal

1.

2.

3. Other people who could help me Some of the pressures/things I need to be aware of that might get in the way of me reaching my goal Some things I could do if these pressures/things happen I will know my plan is working when If I need more help I can contact

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Staying changed (Maintenance) Ways of working with clients at this stage

Ways of working with the client’s family/friends at this stage

These people have successfully changed their alcohol and other drug use behaviour. This could mean they have stopped using or cut down their use. They have stayed changed for six months and may have taken up new behaviours. Things you can do to continue to support them are:

Ways in which the client’s family and friends can help someone at this stage are:

Acknowledge and identify what has worked well Strengthen alternative behaviours Acknowledge the decision to change by identifying positive outcomes such as stronger spirit, better emotional and mental health, better physical health, better relationships with family and community Encourage them to accept ongoing external support from family, friends and community, and yourself Problem solving may be required to deal with the outcome of issues which arose prior to their change Assist with relapse prevention and management - identify and manage high risk situations, coping with cravings, managing lapses

Things that can lead to relapse Things vary from person to person, and may be beyond the control of the individual: Stressful events e.g. funerals Strong emotions - good and bad Arguments and conflict Pressure from family and friends Using other drugs and reminders of drug use

Continue to be there for them and give them support Continue to support them to identify and develop ways to deal with difficult situations Continue to support them keep safe particularly when they are in high risk situations e.g. funerals Talk about the positive changes in their life since they stopped or cut down their use Increase their awareness about how their spirit is getting strong, their mind is becoming clear and their connection to family/community is stronger Talk about what has been working well for them and encourage them to keep doing it

Ways of working with the community at this stage Working with communities at this stage can be an opportunity to provide on-going support. In addition, the review, monitoring and evaluation of their action plan is an important way to keep the momentum going, celebrate their achievements, consider new ideas and progress the good work they have been doing for their community. Review the action plan with community members Support and encourage involvement from new members Encourage them to share their successes with the broader community Monitor participants' roles and responsibilities and review if required. Sometimes people like a change Continue to provide new information, research, funding opportunities and so on to help inform them for future planning Ask participants to brainstorm ideas for future projects to extend their action plan Maintain regular contact to ensure the participants keep the momentum going and meet on a regular basis

Things that help prevent relapse Knowing about yourself Learning to be aware of and cope in high risk situations Learning to cope with triggers, cravings and urges Lapse/relapse management skills Sorting out lifestyle issues and developing new living skills 68 1754 IndigenousFlipChart19212.indd 68

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Individual

Family or Community

Staying changed

Keeping action going – staying changed

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Identifying and Tracking High Risk Situations and Triggers A high risk situation (HRS) is defined as any situation or condition that challenges a person's sense of control and increases the risk of relapse. A trigger is a reminder or cue which may lead the client to consider engaging in the behaviour they are trying to avoid. Triggers can be physical things like walking past a pub, smelling gunja or getting dehydrated. Sometime triggers are things like feeling down, having an argument or feeling really happy. Triggers are specific to the client, and can be anything that increases the possibility of a lapse. The first step in developing a relapse prevention plan is to identify the HRSs and triggers. Initially the client may lack awareness of their particular HRSs and triggers. In order to help identify these it is useful to get the client to keep a record, then explore this in a session to identify high risk situations/triggers and consequences. It is also really useful to explore situations where the client had a positive outcome to identify coping strategies. Using the story telling board is useful here as it provides the opportunity for the client to map out HRS’s in their community and visualise these.

Identifying and tracking high risk situations (HRS) or tricky situations and triggers

High risk situations vary for each client. Their trigger may be a single factor or a combination of factors

Identifying where, when, who, doing what and associated feelings helps clients become aware of triggers and HRS associated with their AOD use. The use of a diary or a tracking record can be helpful in tracking different events, urges and cravings, moods and feelings and action taken which may trigger or stop alcohol and/or other drug using events. However, keeping a diary can have limited use for some of our people and counsellors need to be aware of this. Looking at alternative methods to ensure clients keep track of different events maybe required. This could include more regular client contact to allow regular review of plan and reflection of events and may require safe family mentor/ friend support to assist this process.

Working with the clients to identify their HRSs and triggers 1. 2. 3. 4. 5.

Explore with the client the social setting - where they were, who were they with, what was happening and what were they doing Ask what they were thinking when the lapse occurred Ask about their mood and feelings and their physical state What did they do? What was the outcome?

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Tracking High Risk Situations and Triggers Where were you

Was anyone with you? Who?

What was happening?

What were you thinking?

How did you feel?

What did you do?

(Belief)

(Feeling)

(Action)

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Dealing with High Risk Situations and Triggers In the initial stages the client may benefit most by avoiding high risk situations. This way the client will gain confidence in succeeding and increase their self effectiveness e.g.: “I can do it (refrain from drug use) and it's worth doing”. This is sometimes difficult for our people who are expected to maintain family, social and cultural obligations. Some Aboriginal people experience overwhelming pressure from their family/friends to have a drink. Therefore it is important to assist the client to: Connect with safe family/friend support systems that are less risky so the client can maintain their sense of belonging to their people Think about times when they can be with their family without the pressure to use. For example, if a client wants to avoid drinking maybe it would be better not to visit family members who drink heavily on payday as there will probably be a lot of grog about. Visit another day Initially avoiding high risk situations may be a useful strategy. However, over time this will need to be replaced by a range of skills and coping strategies, which the client can confidently implement when HRSs and triggers emerge. These skills need to be identified, learned and rehearsed during relapse prevention sessions with their AOD worker as well as practiced by the client in their own environment.

Working with the client to develop coping strategies 1. 2. 3. 4. 5.

Be specific about the HRS or trigger - a coping strategy which works well in one situation may not be useful in another Have the client identify why that situation is risky for them Brainstorm with the client to generate a coping strategy or number of coping strategies Identify other family, friends or community members who can assist the client manage the situation and keep them safe If the HRS/trigger occurs try out the strategy - if it works use it again, if it doesn’t explore what went wrong and think about a new coping strategy

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Coping Strategies The HRS/trigger is

Why is it risky?

My coping strategy is

Person/people who can support and keep me safe

How well did it work? What could I do differently?

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Oops! Gone back to old patterns (Relapse) Ways of working with clients at this stage

Ways of working with the client's family/friends at this stage

Relapse can happen at any stage. People can just have a little slip and they may get back on track without too many difficulties. For others, they may return to using at harmful levels. People may relapse several times before they finally stayed changed. People can learn from their relapse and this can help them find new ways to stay changed.

Ways in which family and friends can help someone at this stage are: Understand relapse is a normal part of changing, they can still get back on track Talk about what led up to the relapse and help them to see it as a learning experience, rather than a failure Help them to identify and look at high risk situations and ways of coping with these Ask them how their inner spirit is feeling and remind them that their spirit and mind will continue to strengthen if they get back on track Remind them of the reasons they wanted to make change for them, their family and community Remind them of the success they have had so far and look at the benefits of continuing to make changes Encourage them to get professional help

To do this: Develop relapse prevention strategies Ensure the client understands that a lapse is normal and does not mean they have failed Be aware that they may feel shame about the lapse Strengthen their commitment and remind them of the positive reasons they wanted to change Strengthen spirit and increase self-effectiveness, encourage lots of positive self talk Identify individual high risk situations and triggers Acknowledge and build on client’s past successes Teach coping skills and tips to manage cravings Prepare for a slip or lapse, and address other lifestyle issues

Ways of working with the community at this stage

Lapse vs. Relapse A lapse means your client has had an ‘oops’ in their plan to cut down or stop using, and it is different from a relapse. Relapse is the return to old patterns of use and the client has given up trying to abstain or reduce their use.

Coping with cravings Cravings are a normal part of cutting down drug use. In time cravings will reduce becoming less intense and less frequent, if they are not reinforced by using.

The 3Ds approach can assist clients manage cravings Delay - delay the decision to use - the urge will pass, and will lessen over time Distract - distract from thoughts of using - help the client create a list of alternative behaviours. The intensity of the craving will reduce if the client’s attention is focused on another activity. Decide - Review the reasons for deciding to stop or reduce use

An oops or relapse means that community action has stopped. This can happen for a range of reasons and doesn’t mean that they have failed or not had some positive achievements. Sometimes action activities are time bound and community participants have completed their project. Other factors include changes from within the group, other community priorities and community crisis impacting on action activity. Communities sometimes start again or can go back to any of the previous stages to get back on track. Working with communities at this stage can be an opportunity to: Review the issues and barriers that have blocked their ability to be able to maintain their plan Review membership of the group and support and encourage involvement from new members so they can get going again Remind them of the community's successes to date and acknowledge their role in this Evaluate what they have achieved and consider where to from here Brainstorm and develop a new action plan if they wish to continue The group may have gone back to a previous stage of change, and you may need to identify and follow the steps for that stage Maintain regular contact and continue to meet on a regular basis

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Individual

Family or Community

OOPS!

Oops! Gone back to old patterns

Oops! Action stopped – start again

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Working to strengthen family systems of care, control and responsibility The Aboriginal Kinship System ‘From the Dreamtime came the laws for the people including our identity, skin groups and family. Skin group systems are highly developed and very complex. Blood ties and skin ties both have equal value in the kinship system and this is still a part of our cultural practice today, particularly in remote areas. Skin group systems vary around Australia. When working with traditionally oriented Aboriginal people one needs to be aware of the multitude of rules that regulate behaviour’. (Roe J, 1998). Although diverse, our culture has always had well developed systems of care, control and responsibility. Aboriginal people who live less traditional lifestyles, or who are from urban areas, still maintain strong extended family kinship ties that stem from traditional systems. Colonisation and the effects of forced separation of our people from their natural families have impacted on these systems. Therefore when working with individuals, families and communities it is important to understand their unique circumstances from within this context.

Ways of working

Opportunity to create awareness of the issues, share experiences and express feelings Counselling can greatly assist reducing the ongoing effects of colonisation, forced removal and address hazardous and harmful alcohol and other drug use within the family

When working with individual clients, or family groups it is important to remember: The complexity and diversity of Aboriginal family systems Aboriginal family structure is a central part of Aboriginal life Work within Aboriginal values and belief systems The importance of social and cultural obligations Individual responsibility for change is understood and respected Where responsibilities and decisions are shared by family, reaching agreement may take time Impact of colonisation, marginalisation, forced removal and inter-generational effects

Benefits of working with the whole family

Family support structures that can help When working with clients it is important to identify safe family support systems that can assist family members wishing to cut down or stop their alcohol and other drug use. It is also important to identify risky family situations to reduce the risk of relapse. Ask your client which people in their family or community can help them make change. Get them to identify their support systems.

Provides the opportunity to strengthen family systems of care, control and responsibility Can be the start of healing for the family (issues can often be inter-generational) 76 1754 IndigenousFlipChart19212.indd 76

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Aboriginal Alcohol and Other Drugs Worker Resource References This resource provides a guide for Aboriginal AOD Workers, and other clinicians who are providing alcohol and other drug services to Aboriginal people, their families and communities. It is a good practice guide that has developed from a combination of Aboriginal academic, professional and community knowledge, mainstream evidence-based theoretical approaches and the expertise of Aboriginal frontline workers. The development of this guide has been informed by: The knowledge and expertise of Aboriginal AOD Workers, community members and Aboriginal health care professionals Evidence based and universally relevant mainstream AOD models, re-constructed to reflect the Aboriginal lived experience and world view Theoretical frameworks developed, applied and validated by Aboriginal AOD Workers and professionals

References Allsop, S 1990, ‘Relapse prevention and management’, Drug and Alcohol Review, vol. 9, pp. 143-153. Bacon, V 1992, Drugs, Dreamtime and Dispossession, WA Alcohol and Drug Authority, Aboriginal training resource. Bandura, A 1977, Social Learning Theory, Prentice-Hall, Englewood Cliffs, New Jersey. Casey, W 1997a, ‘Empowering Approaches to Aboriginal Addictions’, Drugwise, Winter, pp. 9-25. Casey, W 1999b, ‘Stages of Change and Community Stage of Change Models’, Remote Aboriginal Communities Alcohol & Drug Worker Training Program, Kimberley Community Drug Service Team (Northwest Mental Health Service), Broome, Western Australia. Casey, W, Collard, S, Garvey, D, Pickett, H, & Bennell, S 1994, ‘Aboriginal Cultural and Historical Realities – Substance Use: Developing an Appropriate Intervention Model’ Proceedings of the Second International Conference: Healing our Spirit Worldwide. Casey, W & Garvey, D 1995, ‘Intervention Model: Aboriginal Substance Use’, paper presented at the Annual Conference of the Australian Psychological Society, Perth, Western Australia. Casey, W, Garvey, D & Pickett, H 1997, Empowering Approaches to Aboriginal Addictions, Discussion Paper No. 8, Curtin Indigenous Research Centre, Curtin University of Technology, Perth, Western Australia. Casey, W, Heath, T & Wilkinson C 2001, In touch: Working with Aboriginal and Torres Straight Islander Students, WA Alcohol and Drug Authority, Aboriginal training resource. Casey, W & Keen, J 2004, ‘Strong Spirit Strong Mind’, Aboriginal Alcohol and other Drugs Program, WA Drug and Alcohol Office, resource series. Casey, W & Little, G 2004, Aboriginal Alcohol and other Drug Worker Training Program, CHC30802 Certificate III in Community Services (Alcohol and other Drugs), Aboriginal Alcohol and other Drugs Program, WA Drug and Alcohol Office. Dudgeon, P & Mitchell, R 1991, Internalised Racism and Drug Abuse: Some consequences of racial oppression in Australia, Annual Conference of Australian Psychological Society, Adelaide, South Australia. Marlatt, GA & Gordon, JR 1985, Relapse prevention and maintenance strategies in the treatment of addictive behaviour, Guildford Press, New York. Miller, W & Hester, R 1986, Treating Addictive Behaviours: Process of Change, Plenum Press, New York.

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Miller, W & Rollnick, S 1991, Motivational interviewing: preparing people to change addictive behaviour, New York, Guildford Press. National Commission on Marijuana and Drug Abuse 1973, Drug use in America: Problem in perspective: Second report of the National Commission on Marijuana and Drug Abuse, Washington. Prochaska, J & DiClemente, C 1986, ‘Toward a comprehensive model of change’ in W Miller & N Heather (eds), Treating Addictive Behaviours: Processes of Change, Plenum Press, New York, pp. 3-27. Roizen, R 1983, ‘Loosening up: General Population Views of the Effects of Alcohol’, in R Room & G Collins (eds), Drinking and disinhibition: Nature and Meaning of the Link, Research Monograph No 12, National Institute on Alcohol Abuse and Alcoholism, Maryland, pp. 236-257. Roe, J, & Casey, W 1998, ‘Aboriginal Circles, Dreamtime People Land’, (adapted from V Bacon, Drugs, Dreamtime and Dispossession), Ways of Working Together: Cross Cultural Training, Kimberley Drug Service Team, Broome. Roe, J 2002, ‘Ngarlu: A Cultural and Strengthening Model’, in P Dudgeon, D Garvey & H Pickett (eds), Working with Indigenous Australians: A Handbook for Psychologists, Gunada Press, Curtin Indigenous Research Centre, Curtin University of Technology, Perth, Western Australia, pp.395-401. Thorley, A 1980, ‘Medical Responses to Problem Drinking’, Medicine (3rd series) 35: 1816-1822. Zinberg, N 1984, Drug, Set and Setting: The basis for controlled intoxicant use, Yale University Press, New Haven.

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Produced by the Aboriginal Alcohol and Other Drugs Program

Artist: Barry McGuire (Mullark), born in Kellerberrin, which is located in the Balladong Nungar Boodja. His artist name is given to him by his family, it was his Grandfather’s name and he paints to keep the name alive. Illustrations: Patrick Bayly, Workspace Design The Aboriginal Inner Spirit Model (Ngarlu Assessment Model) was developed by Joseph ‘Nipper’ Roe, who belongs to the Karajarri and Yawru people. His skin group is Purungu and his Aboriginal name is Ngulibardu. Written by Wendy Casey and Jennifer Keen

Funded through the Australian Government as part of the COAG Illicit Drug Diversion Initiative © Drug and Alcohol Office 2005

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