Training and Clinical Supervision Guidelines

“The great aim of education is not knowledge but action.”

Herbert Spencer (1820 - 1903 CE)

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Contents Introduction

1

The PsyCheck Training Package USING THE SLIDES EXERCISES ACTIVITIES AND OTHER MATERIALS RECOMMENDED PRE-READING MODIFICATIONS FOR YOUNG PEOPLE

2 2 2 2 3 3

Training Tips HOW ADULTS LEARN STRUCTURING TRAINING GROUP DISCUSSION MANAGING DIFFICULT BEHAVIOURS DURING TRAINING

4 4 4 5 5

Module 1: PsyCheck Mental Health Screening Tool

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Module 2: Cognitive Behaviour Therapy

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Module 3: Pres-session preparation: Assessment, formulation and treatment planning

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Module 4: Implementation of the brief mental health intervention

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PsyCheck clinical supervision

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A step-by-step guide to clinical supervision for the PsyCheck Program

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Appendices Appendix 1: PsyCheck training needs analysis Appendix 2: Sample session plan Appendix 3: PsyCheck Screening Tool Appendix 4: Decision Tree Appendix 5: What works for you Appendix 6: Mix ‘n’ Match cards Appendix 7: The Cognitive Model Appendix 8: Unhelpful Thoughts Worksheet Appendix 9: Self Monitoring Sheet Appendix 10: Worksheet 7: Managing unhelpful thought patterns Appendix 11: Sample certificate of attendance Appendix 12: Clinical supervision – extension material

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Introduction

The PsyCheck Training and Clinical Supervision Guidelines, and the accompanying Program Implementation Guidelines, have been developed in order to facilitate the implementation of the PsyCheck Screening and Intervention in alcohol and other drug (AOD) settings. The program uses a standardised screening tool and a manualised intervention and seeks to sustainably build the capacity of AOD treatment services to undertake mental health intervention. Training and clinical supervision are essential for the reliable delivery of screening and brief intervention to those clients with alcohol and/or other drug issues and co-occurring anxiety and depression problems. The PsyCheck Training and Clinical Supervision Guidelines are designed for senior clinicians, managers and/ or trainers to support clinical staff to adopt mental health screening and intervention into routine practice. They outline key areas for training and provide notes for trainers. Clinicians learn how to use the screening tool and to deliver the components of the intervention. They also identify important aspects of clinical supervision for AOD clinicians undertaking mental health interventions. Clinical supervisors may also find it helpful to familiarise themselves with the Clinical Supervision Resource Kit, Clinical Supervision: A practical guide for the alcohol and other drugs field, developed by NCETA (available at http://www.nceta.flinders.edu.au/). It details best practice clinical supervision as well as suggestions for establishing a clinical supervision program. It is a useful resource designed specifically for the AOD field and provides complementary information to these guidelines. As the program is designed so that clinical supervisors provide both training and clinical supervision, both these aspects are combined in these guidelines. They are supported by the accompanying PsyCheck PowerPoint Training Presentation and the other PsyCheck resources: • • • • •

PsyCheck Program Introduction PsyCheck Screening Tool (for clinicians) PsyCheck Screening Tool User’s Guide (for clinicians) PsyCheck Clinical Treatment Guidelines (for clinicians) PsyCheck Program Implementation Guidelines (for managers and senior staff )

Support from key staff (clinical staff as well as management) is vital to creating an environment conducive to organisational practice change (Liddle et al., 2002). Yet clinicians often find it difficult to move away from their ‘preferred’ counselling style to one they are less familiar or comfortable with (Roman, 2002), even when they are interested in taking up new interventions. A key finding of the PsyCheck Implementation Project was that training and clinical supervision were essential components of the implementation, combined with support from management in the change process (see the PsyCheck Program Implementation Guidelines).

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The PsyCheck Training Package The PsyCheck Training and Clinical Supervision Guidelines consists of four modules, which are self contained and delivered in four separate sessions. A PowerPoint Training Presentation has been created for use in the delivery of training and is included in the resources for the PsyCheck Program. The package involves both theoretical and experiential learning and is ideally conducted by an experienced clinician with a good understanding of the principles and practices of cognitive behavioural therapies. All of the modules allow flexibility in the time to deliver the material, which maybe delivered as a two day training session or as four half day sessions. The latter might be more suitable for less experienced clinicians as it will allow time to consolidate each module before moving on. Undertaking the brief PsyCheck training needs analysis (see Appendix 1) may assist in determining whether a full-day or half-day training session is required. A group of clinicians well trained in cognitive behaviour therapy (CBT) may not require as much training time as an inexperienced group of clinicians. In a heterogeneous group, it is recommended that training is targeted at the least experienced in the group; more experienced clinicians can assist in either delivering some of the training or mentoring less experienced clinicians during the training sessions. The PsyCheck Training and Clinical Supervision Guidelines is designed to be used in conjunction with the PsyCheck Program Introduction, the PsyCheck Screening Tool User’s Guide and the PsyCheck Clinical Treatment Guidelines, which contain all the practical and theoretical information required for training. Clinical supervision should be initiated with the training modules in order to facilitate the consolidation and implementation of new knowledge. Individual supervision is recommended, with group or peer supervision as a useful adjunct.

Using the slides The slides that accompany the PsyCheck Program are designed to assist trainers to systematically work through the material needed for a basic understanding of the PsyCheck Program. They may be modified to suit particular circumstances, but it is recommended that on the whole, they are delivered as outlined.

Exercises The exercises in the PsyCheck Training and Supervision Guidelines are designed to be a fun and nonthreatening way for participants to gain skills required to implement the PsyCheck Program. Each module also contains a ‘warm-up’ exercise that is consistent with the topic covered in the module but is primarily designed as a break between modules (if training is conducted over tow consecutive days) and/or as an icebreaker.



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Activities and other materials There are a number of exercises throughout the training program. Many come with additional materials such as cards. Due to copyright restrictions, PsyCheck is unable to reproduce images for activities such Celebrity Squares, Celebrity Challenge and Celebrity Survivor. You will need to source your own images or photos for these activities. The additional resources are provided on the accompanying CD-Rom, which also contains a copy of all the PsyCheck Program materials. The additional resources are also provided in the appendix in the event that they need to be reproduced and the CD-Rom is misplaced. You will need to print out the resources and in some cases do additional preparation. Ideally, they could be laminated for future use.

Recommended pre-reading It is recommended that participants read through their resource materials prior to training. If training over several shorter sessions it is advisable to set pre-reading that corresponds to the modules. Module 1: PsyCheck Program Introduction

PsyCheck Screening Tool User’s Guide

Module 2:

PsyCheck Program Introduction



PsyCheck Clinical Treatment Guidelines (Principles of Practice)

Module 3:

PsyCheck Clinical Treatment Guidelines (Pre-session Preparation)

Module 4:

PsyCheck Clinical Treatment Guidelines (Sessions 1-4 + extension material)

Modifications for young people In many sections of the PsyCheck Clinical Treatment Guidelines, there are alternative activities for young people. The principles are the same, but the activities have either been graded, simplified or modified to take account of the young person’s developmental level. When training clinicians who primarily deal with young people, some of the exercises may be substituted with activities more aligned with the youth modifications to the PsyCheck Clinical treatment Guidelines. Alternatively, these modifications may be discussed in clinical supervision. These modifications may also be suitable for use with clients with mild to moderate cognitive deficits, such as an acquired brain injury.

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Training Tips How adults learn Townsend (2005) summarises some key points about adult learning: 1. Adults learn best: • • • •

if they want to and/or need to; by connecting information to past, present or future experiences; by putting new knowledge into practice; and if both left (logical) and right (creative) brain processes are activated.

2. The brain: • goes into shut down after 10 minutes – so it is important to switch media frequently; • remembers only 10% of a message given once but 90% of a message given six times; and 3. Cognitive dissonance is created when people hear or see something that clashes with their beliefs or values. To overcome their discomfort of this clash, people usually either: • justify their present beliefs or behaviour; or • distorts the new information so it fits with their current beliefs or behaviour. When training, to help overcome this, start from the participants point of view and bring them along with you. Think about ‘what’s in it for them?’ It may be useful to do a warm up exercise to address this.

Structuring training Appendix 2: Sample Session Plan is designed to assist you to structure the timing of the PsyCheck training. Modifications can be made to this structure depending upon the experience of the trainees. In addition, Townsend (2005) also outlines a design structure that can assist in preparing for training: 1. Start with a bang – this does not have to be a big show. The warm up exercises in PsyCheck are designed to give the session a lift from the start and to get the participants moving. It is important to make a clear start that signals the training is underway. 2. Before the content: • establish a gap between present skill/knowledge and those required – make sure the participants understand the gap and are committed to close the gap; • outline course coverage, stressing outcomes for skill/knowledge.



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3. During training: • • • •

explain each skill; demonstrate skills as often as possible; allow participants to practice skills; and reinforce gains and correct inadequacies.

4. At the end of the training: • Review learning points at end of each module; • Agree on action plan for transfer of skills; and • Agree on follow-up, refreshers, supervision. 5. End with a ‘bang’ – a succinct summary of the learning experience. Like the ‘bang’ at the start, it does not need to be a performance, but a clear finish rather than a tailing off anticlimax is important to give the participants as sense of the power of the training.

Group discussion Four ways to encourage group discussion (Townsend, 2005): Building on incomplete answers by adding comment and asking for agreement or disagreement. Boosting reluctant participants confidence by reinforcing their contributions and encouraging extra comment Blocking dominant participants by asking what others think. Bantering with outgoing participants to create a non-competitive atmosphere.

Managing difficult behaviours during training From Townsend (2005). 1. Difficult questions • Reflect back to the participant what you thought the question was to allow them to reframe it more positively. • Reflect back to:

» Group: ‘has anyone had a similar problem?’, ‘what does everyone else think?’



» Other individual: ‘Sandy, you’re an expert in this area – what do you think?’



» Questioner: ‘you’ve clearly been thinking about this – what’s your view?’

2. Outbursts • Consider the outburst as a positive contribution. • Reflect the feelings back to the participant. • Don’t get defensive.

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Managing personalities Adapted from Townsend (2005) Type

First try

If not working, then….

Heckler

• Express merit

(argumentative and aggressive)

• Wait for incorrect statement of fact then use group to correct

• Appoint as class ‘devils’ advocate – ask them to criticise wherever they see you leading class astray

Know-It-All

• Wait, don’t interrupt, thank them and move on

• Agree with and amplify contributions

• Throw them a tough question to slow them down

• Ask for expert judgement when none is forthcoming

• Jump in and ask for group comment

• Ask them to demonstrate or teach parts • Refer to their expertise frequently

Whisperer

• Stop talking, wait for attention, move on

• Use paradoxical technique of stating time is short so if anyone doesn’t understand, ask their neighbour

Silent Ones

• If timid – ask easy questions, ones to boost confidence, refer to by name when giving examples

• Encourage shy ones not to participate

(timid or bored)

• If bored – ask tough questions, use as helper, refer to by name frequently



• Make a note that some people are shy and don’t want to participate, but doesn’t mean they haven’t understood

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Module 1: PsyCheck Mental Health Screening Tool Module 1 is designed to provide some basic knowledge about comorbidity and to introduce the PsyCheck Screening Tool. The focus is on how to administer and interpret the PsyCheck Screening Tool. Further information about how to imbed the PsyCheck Screening Tool into clinical practise is covered in Module 4.

Aims The aims of Module 1 are to: r Familiarise the clinician with the area of comorbidity r Provide information about the development and psychometric properties of the PsyCheck Screening Tool and Intervention r Train the clinician in the scoring and interpretation of the PsyCheck Screening Tool

Materials r PsyCheck PowerPoint Training Presentation r PsyCheck Program Introduction r PsyCheck Screening Tool User’s Guide r PsyCheck Screening Tool (Appendix 3) r Celebrity Squares r Decision Tree (Appendix 4)

Training components The components of this module are: r Introduction to the training modules r Module 1 overview r Introduction to comorbidity r PsyCheck development and overview r Psychometric properties of the PsyCheck Screening Tool r Negotiating the PsyCheck Screening Tool User’s Guide r Administering the PsyCheck Screening Tool r Interpreting the PsyCheck Screening Tool r Rounding off Module 1

Exercises for Module 1 r Exercise 1: Who Here Do You Think... r Exercise 2: How Are You Thinking - Feeling - Doing r Exercise 3: Celebrity Squares r Exercise 4: Celebrity Squares - Whats Next?

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Background information for trainers Resources that provide the background knowledge required for this module include: r PsyCheck Program Introduction r PsyCheck Screening Tool User’s Guide r PsyCheck Clinical Treatment Guidelines Familiarity with this information is essential for training. It would also be beneficial to have local knowledge of the mental health service system and intake procedures. The local mental health service could be contacted for training in this area.



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Training components Introduction to the training modules This brief section consists of two warm-up exercises and an overview of the training. A single slide outlines the 4 modules and their components. Go through the slide to give participants a sense of how the training will progress. Exercise 1: Who here do you think… Purpose This exercise is designed as a warm-up for the training and demonstrates, in a light hearted way, that everyone makes assumptions and has beliefs about themselves, other people and the world, and that these beliefs may be different from those of other people. It also gets participants out of their seats and talking to each other from the beginning. Instructions Show one statement at a time and ask participants to stand near someone in the room they believe to have the attribute shown on the slide. Only allow about 10 seconds per item before moving on. Discussion points You could ask participants how they formed these opinions and what they were based on. Timing This exercise should take a maximum of 5 minutes. Exercise 2: How are you thinking – feeling – doing Purpose This exercise is designed as a warm-up for the training and allows participants to raise their concerns about the training, the program or organisational expectations of them, and also how they might respond to these. This is framed in the thinking – feeling – doing cycle for consistency with the PsyCheck approach. Instructions and discussion points Generate discussion around the three questions on the slide: • What are your thoughts about working with clients with comorbidity? • What are your feelings about this training? • Notice how you behave when I say you have two days to get this on board You can draw out expectations of the day and manage any misperceptions or concerns. If readiness to engage appears low, a motivational approach to responding may be helpful. Questions such as: • Is there anyone here who has never had to manage a client with mental health symptoms? Timing This exercise should take 10 minutes but may take more or less time depending upon the group’s readiness to change.

training and clinical supervision guidelines



Module 1 Overview Use the slides to overview the aims and training components of Module 1. Introduction to comorbidity The primary focus is on setting the scene and introducing the clinician to current understanding of theories of comorbidity and best practice, as outlined in the PsyCheck Program Introduction. Prereading of the introduction section may facilitate the delivery of this section. If clinicians are already familiar with this material, discussion based on pre-reading of this section, rather than strictly following the PowerPoint training presentation may be more appropriate. PsyCheck development and overview The focus is on providing a rationale for the PsyCheck Program to facilitate an understanding of the components of the program. Psychometric properties of the PsyCheck Screening Tool The focus is on understanding the development of the PsyCheck Screening Tool to facilitate an understanding of the components of the screening tool and how to use it. Clinicians may ask why these particular components were used. Reference to best practice methods and the validation of the PsyCheck Screening Tool should be emphasised. Negotiating the PsyCheck Screening Tool User’s Guide This component is brief and focused on understanding the PsyCheck Screening Tool User’s Guide for future reference. The PowerPoint Training Presentation will assist in ‘walking’ the participants through the User’s Guide as you outline each part. Administering the PsyCheck Screening Tool Details of the PsyCheck Screening Tool are outlined in the PsyCheck Screening Tool User’s Guide. Trainers should familiarise themselves with the PsyCheck Screening Tool and User’s Guide thoroughly before delivering this component. The PsyCheck Screening Tool is designed to be administered by clinicians unfamiliar with mental health assessment. Potential areas of difficulty include: • not knowing how to use formal screening tools • not knowing how to ask the suicide/self-harm questions • being unfamiliar with mental health terminology If participants are not familiar with the idea of screening and asking questions, this component may need to be covered in greater detail. The exercise for this component is designed to give participants practice at administering the PsyCheck Screening Tool. For an experienced group, this material may be undertaken in a shorter period of time, but it is recommended that it is still covered and participants are given the opportunity to practise interviewing skills specific to the PsyCheck Screening Tool.

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The suicide risk questions Some clinicians may become concerned about the suicide risk questions. They may be worried about how to ask these questions sensitively and they may also be concerned that they will open a ‘Pandora’s box’. It is important to emphasise that this is part of their usual activities as an alcohol and drug clinician and that this is merely a new framework for ensuring that the right questions are asked and the answers recorded systematically. If the participants’ service or organisation has procedures, protocols or clinical pathways that relate to suicide risk among their clients it would be useful to familiarise yourself with these prior to the training so that you can respond to these queries in the context of their required clinical practice. Exercise 3: Celebrity Squares Purpose This exercise is designed to practice, in a humorous and non-threatening way, the administration of the PsyCheck Screening Tool. Instructions Ask participants to form groups of three (no more than four), or assign them to groups of three/four. *Please note that due to copyright restrictions, PsyCheck is unable to reproduce images for Celebrity Squares. You will need to source your own images or photos for these activities. Hand out a Celebrity Squares card or allow groups to select a celebrity square. It is more helpful if someone in the group knows something about their celebrity. Ask the participants to undertake PsyCheck screening with their celebrity.

Ask the participants to undertake PsyCheck screening with their celebrity. Ask one person to play the celebrity while the other two assist each other in administering the PsyCheck Screening Tool. They should go through each of the 3 sections in as much detail as they need to complete the task. Discussion points Encourage discussion of areas of difficulty and ways to address these. Emphasise the use of clinical judgement in administration. Timing This exercise may take up to 40 minutes. Give participants as long as required to feel comfortable with administration of the PsyCheck Screening Tool and to discuss any areas of concern.

Interpreting the PsyCheck Screening Tool Interpretation of the PsyCheck Screening Tool is outlined in the PsyCheck Screening Tool User’s Guide and on the screening tool itself. The PsyCheck Screening Tool is designed for easy interpretation. Intervention or further assessment is required if: • the client reaches 5 or more on the SRQ • the client is at risk of suicide/self-harm • the client has a mental health history Emphasise to the participants that the outlined interpretation of the PsyCheck Screening Tool is offered as a best practice guide and that they should use clinical judgement in deciding which intervention is most appropriate for a particular client. Two important areas for consideration (outlined in the PsyCheck Clinical Treatment Guidelines) are:

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• client readiness to change • current symptoms The following exercise is designed to give participants practice in interpreting the PsyCheck Screening Tool. An additional exercise for this session could include case presentation and interpretation of participants’ real clients. Exercise 4: Celebrity Squares – What next? Purpose This exercise follows on from Exercise 3: Celebrity Squares. It is designed to assist participants to interpret the PsyCheck Screening Tool and determine a suitable clinical pathway for the client. Instructions In the same group of three, ask participants to determine what their next steps would be for their celebrity. This can be based on any of the components of the PsyCheck Screening Tool. For example, if their celebrity is at high risk of suicide, this would be the priority and be foremost in their decision making whereas if they did not show signs of suicide risk, they might base their decision on the SRQ section of the PsyCheck Screening Tool. Give out a copy of the decision tree to use with this exercise. Discussion points Encourage discussion of any areas where decision-making was difficult. Ask each group to outline what they decided to do in which order and what their rationale was. It may be helpful to ask the participants briefly introduce their client and to report in a brief client presentation format e.g.: • Brief background • Assessment results • Recommended next steps Timing This exercise should not take more than 15 minutes in total, including discussion. Ten minutes should be sufficient. Rounding off Module 1 The final part of this module is a check-in and summary. Use the final slides as an invitation for participants to describe their thoughts about Module 1. Summarise the main components of the module and ask for any feedback before moving on to Module 2 or closing the training if you are training in separate modules.

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Module 2: Cognitive behaviour therapy This module is designed to provide essential information about cognitive behaviour therapy (CBT) as a background to the PsyCheck Intervention. It focuses both on the theory of CBT (the ‘why’) and the practice of CBT (the ‘how’). Even if clinicians feel confident in their knowledge of CBT as practiced in AOD treatment, it is still useful to undertake this training module as there are likely to be some aspects unfamiliar to a primarily AOD audience.

Aims The aims of Module 2 are to: r Provide a rationale for the use of CBT in the Psycheck Program r Provide clinicians with an understanding of the principles of application underpinning the PsyCheck Intervention r Provide clinicians with an understanding of the practice of CBT

Materials r PsyCheck PowerPoint Training Presentation r PsyCheck Program Introduction r PsyCheck Clinical Treatment Guidelines r What works for you Worksheet (Appendix 5) r Mix and Match cards (Appendix 6) r Cognitive Model Worksheet (Appendix 7) r Video – Richard and Lynn part 1

Training components The components of this module are: r Introduction to module 2 r The theoretical underpinnings of CBT r Evidenced-based practice r The CBT model r CBT in practice r A stepped care approach r The therapeutic relationship r Clinical judgement r Integrating treatment r Rounding off Module 2

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Exercises for Module 2 r Exercise 5: What works for you? r Exercise 6: Mix ‘n’ Match r Exercise 7: The Cognitive Model r Exercise 8: CBT Demonstration (Richard and Lynn part 1) r Exercise 9: Therapeutic Process

Background information for trainers Trainers need to have a good understanding of cognitive behavioural theory for this module. The background knowledge for this module is presented in detail in Section 1 of the PsyCheck Clinical Treatment Guidelines and in the PsyCheck Program Introduction. Recommended reading (for clinicians and trainers) for this section includes: Beck, A.T., & Emery, G. (with Greenberg, R.L.). (Rev. Ed. 2005). Anxiety Disorders and Phobias: A Cognitive Perspective. New York: Basic Books. Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive Therapy of Depression. New York: The Guilford Press. Beck, A.T., Wright, F.D., Newman, C.F., & Liese, B.S. (1993). Cognitive Therapy of Substance Abuse. New York: The Guilford Press Beck, J.S. (1995) Cognitive Therapy: Basics and Beyond. New York: The Guilford Press. Greenberger, D. & Padesky, C. (1995) Mind Over Mood: Change How You Feel by Changing the Way You Think (Client Manual). New York: The Guilford Press Hawton K., Salkovskis P., Kirk J., & Clark, D. M. (Eds.) (1989). Cognitive behavior therapy for psychiatric problems. Oxford: Oxford University Press. Padesky, C. & Greenberger, D. (1995) Clinician’s guide to Mind over Mood. New York: The Guilford Press. Sobell, M. & Sobell, L. (2000) Stepped care as a heuristic approach to the treatment of alcohol problems. Journal of Consulting and Clinical Psychology, 68, 573 –579

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Training components Introduction to Module 2 This section starts with the aims and overview of Module 2 and a warm up exercise for the module. Exercise 5: What works for you? Purpose This exercise is designed to get participants reflecting on the primary model they work with. The purpose is primarily warm-up so participants are required to exchange ideas and interact with each other. It is designed to prepare them for the introduction of the scientist-practitioner approach. Instructions Hand out the ‘What Works for You?’ worksheet. Ask participants to complete the worksheet individually. Once they have done this, ask them to identify their PRIMARY model of practice. Then ask them to find someone else in the room that has a DIFFERENT primary model. Ask the pairs to discuss why they each use the model they have identified and how they know it’s working. Discussion points Focus on how they know what they do works? Encourage discussion about measuring change. Timing This exercise should take no more than 10 minutes. The theoretical underpinnings of CBT For clinicians who are unfamiliar with cognitive behavioural theory, it may help to make links to AOD treatment where appropriate. Areas of core competency in AOD treatment – including relapse prevention, coping skills therapy, problem solving and goal setting – are all key components of cognitive behavioural theory. By grounding the PsyCheck Intervention in terms that clinicians are already familiar with, learning can be enhanced and resistance more easily countered. The PsyCheck Program was designed to be integrated into routine AOD practice and has used this approach throughout. Slide 36 identifies a planned, single theory approach as optional. Many clinicians who prefer an ‘eclectic’ or ‘ad-hoc’ style may find this notion confronting. Allow some time for discussion of this point, taking a specifically motivational approach if necessary to examine reasons why a coherent personal theory about therapy might be more helpful than one that draws different strategies together without a comprehensive framework. Some of these reasons include: being able to identify successful and unsuccessful techniques more easily, enables the client to be more involved in their treatment because they understand their therapy better, makes it easier to identify which strategies are likely to be effective if it is framed around a coherent hypothesis about what might be happening for the client. Evidenced-based practice The ideas of hypothesis testing, case formulation and monitoring are all interconnected with the importance of evidence-based practice in CBT and should be emphasised in training. An understanding of, and commitment to, evidence-based practice is crucial in the CBT model. This should be emphasised to participants and more time spent on this if is it unclear to them.

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What is CBT? This section is designed to provide a brief overview of CBT and put it in the context of other common therapies. It is important to emphasise the collaborative nature of CBT and in particular the reliance on the clients active participation. This is important for the clinicians to convey to their clients.

Exercise 6: Mix ‘n’ Match Purpose This exercise is designed to familiarise participants to a wide range of techniques in CBT and also to emphasise that the use of skill based strategies cannot be used in the absence of therapeutic process. The techniques themselves are collaborative and therefore enhance the therapeutic relationship. Instructions Place the 4 marker cards (A4 size) on a wall or on the floor if there is no wall space (see figure 1. below). Give participants one or two cards and ask them to place their card/s in the appropriate place on the grid. Discussion Points Draw discussion around whether the cards are in the ‘right place’ and why they believe any should move or stay. Focus discussion on the mix of process and context in both cognitive and behavioural therapies as a preparation for exercise 9 later. Timing This exercise should take 15-20 minutes including discussion time. Variations Give participants one card, put the rest of the cards on the floor and ask them to choose…

Cognitive Techniques

Behavioural Techniques

Therapeutic Process

Therapeutic Skills

Figure 1. Mix ‘n’ Match marker card placement

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Alternative Activity Plan Give everybody approx 5-6 (numbers will depend on the size of the group) cards, place the remainder in the middle. Ask participants to determine if the cards they hold replicate the some of the ways they work with clients. If not, participants are to negotiate with others for cards that reflect more closely their current practice with clients. They may take a limit of 2 cards from the central pile but must put 2 back. Once they are holding a set of cards they align with they then place selves on a continuum - cognitive practices at one end and behavioural at the other. Note: Small groups can have a larger number of cards each

The CBT model This component goes through the cognitive behavioural model used in the PsyCheck Program. Understanding this model is of paramount importance for practice. Explanation of the model is important for both the client to understand their problems and to enhance the therapeutic relationship. An important skill in CBT is the ability to translate everyday experience of the client into the cognitive behavioural model. It takes practice to become adept at adapting the CBT model to a range of client experiences and describing the cognitive model in terms the client can understand. Training should provide clinicians with opportunities to practise this skill to ensure understanding and equip them to successfully incorporate this skill into their clinical practice.

Exercise 7: The CBT Model Purpose This exercise is designed to consolidate participants’ understanding of the CBT model. The activity uses self-practice to better understand how the model works in practice. Instructions In pairs, the participants take it in turns to use the CBT model worksheet. They should choose a simple target problem for example, eating chocolate, public speaking, learning a new skill. Use a recent real-life example or a made up one. Complete the CBT model sheet with thoughts, feelings and behaviours. Discussion points Discussion should encourage self-reflection and focus on any insights gained from practicing the model, especially if the participants used a real example from their own life. Also discuss any potential challenges in identifying thoughts, feelings or behaviours. Timing This exercise should take 10-15 minutes.

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CBT in practice This training component is based around didactic learning and discussion. The trainer should present the material according to the PsyCheck PowerPoint Training Presentation and answer any questions about this material. Training should cover the main elements of the standard CBT session as they relate to the implementation of the PsyCheck Intervention within AOD clinical practice. 1. Review and feedback – an opportunity to check how the client has been in the past week with an emphasis on checking their mood or anxiety symptoms. Check on any homework tasks. Build on the previous session by checking briefly on the client’s understanding of the session and summarising the content. Set the agenda for the current session. 2. Information – an explanation and discussion about the session topic should occur here. Ensure any issues are resolved as much as possible. 3. Practice – rehearse skills for the session in a safe environment in preparation for the real world. Troubleshoot any problems and anticipate any issues outside the session. 4. Session summary – summarise the session content. Ensure the client understands what has been discussed and practised. Set homework and troubleshoot anticipated problems. Make arrangements for the next session/termination.

Exercise 8: CBT Demonstration (Richard and Lynn part 1) Purpose This video is of a therapist and a client discussing the CBT model. It demonstrates the basic structure of the session. It is designed as a demonstration and discussion point. Instructions Play the video. Note to participants that this is framed around AOD treatment. Discussion points Discuss any issues raised by the participants. Prompt them to identify now mental health and AOD issues are integrated. A stepped care approach Outline the stepped care approach. Stepped care approaches are based on a specific decision making process and require some level of measurement to be effective. The decision tree may be of assistance. You may spend some time discussing how to measure change at this point as it is necessary for the stepped care approach to monitor the clients progress in order to know whether to increase the intensity of treatment or not. The therapeutic relationship This is a brief point but an important one to emphasise and is the basis for the final exercise for this module. Emphasise the use of the basic counselling skills and encourage participants to brush up in this area if they indicate the need. There is a misunderstanding among some clinicians that because CBT is skills-based, it lacks attention to the therapeutic relationship. It is vital to emphasise how therapeutic processes can be integrated into CBT and are key to the success of CBT.

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Clinical Judgement Again a brief but important point that PsyCheck is designed with some flexibility and therefore requires clinical judgement. This is also necessary for clinical decision-making in relation to the stepped care approach and for integrating mental health and AOD components of PsyCheck. Integrated Treatment PsyCheck was designed to be an integrated AOD practice. This requires clinical judgement to both know when this should be done and how it should be interpreted. An important point to emphasise is the need to constantly make links with the client between their AOD and mental health problems, taking a motivational approach.

Exercise 9: Therapeutic Process Purpose Ask the participants to form small groups of 3 or 4 and discuss how therapeutic processes can be used within a relatively structured skills based therapy like CBT. Ask them to think about therapeutic alliance in particular. Instructions and discussion points Ask each group to present their discussion and ask the larger group to comment. Timing This exercise should take no more than 15 minutes.

Rounding off Module 2 The final part of this module is a check-in and homework. Use the final slides to overview what has occurred so far. Ask participants to identify the skills they have learnt. Summarise the main components of the module and ask for feedback before moving on. Address any concerns. Consistent with the CBT model, the setting of homework here will assist in understanding both the need for homework, the CBT model and next session how to respond to homework non-compliance.

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Module 3: Pre-session preparation: Assessment, formulation and treatment planning This module provides a step-by-step guide to pre-session assessment, formulation and treatment planning in preparation for the clinician’s presentation of case formulation to their client in Session 1. This training module is an important one as it sets the scene for the interventions on which training in Module 4 is based. Clinicians usually find the pre-session material more difficult than the techniques, which are generally more familiar to them. Pre-session preparation is particularly important for those unfamiliar with CBT. An understanding of how general therapeutic principles relate to CBT will enhance application and prevent clinician resistance based on misperceptions of CBT as an outcome- rather than a process-based therapy. Clinicians are often unfamiliar with the cognitive behavioural case formulation, which takes a different approach to typical AOD formulations. An understanding of the processes of cognitive behavioural therapy, covered in Module 2, is crucial to applying CBT techniques effectively.

Aims The aims of Module 3 are to: r Provide a context for screening aid and prepare feedback for the client r Explain how to undertake a cognitive behavioural assessment r Develop an understanding of how to develop a cognitive behavioural formulation

Materials r PsyCheck PowerPoint Training Presentation r PsyCheck Clinical Treatment Guidelines r Celebrity Squares cards r Finding Nemo video clip (Scene 8)

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Training components r Check-in r Introduction to Module 3 r Negotiating the PsyCheck Clinical Treatment Guidelines r Undertaking screening and preparing feedback r Undertaking a cognitive behavioural assessment r The 7Ps r Preparing a preliminary case formulation r Rounding off Module 3

Exercises for Module 3 r Exercise 10: The Young and The Restless r Exercise 11: Something Fishy r Exercise 12: Fishy Formulation r Exercise 13: Gummy Shark

Background information for trainers The background information for this module is contained in the PsyCheck Clinical Treatment Guidelines. Trainers should be familiar with this material before delivering training. The PsyCheck Intervention has two components. The first (covered in this module) outlines pre-session preparation, which is designed to ready the clinician and their client for undertaking a cognitive behavioural intervention. It involves: • cognitive behavioural assessment • cognitive behavioural formulation • treatment planning This preparation can be conducted over several sessions and should be integrated into existing assessment and treatment planning. During the preparation for the intervention, the clinician will also devise and prepare a cognitive behavioural formulation to present to the client in the first session of the intervention. In the first instances, this formulation is best devised with your supervisor. The second component (covered in Module 4) consists of the intervention itself, which comprises four sessions incorporating cognitive behavioural techniques. Recommended Reading for this section includes: Nezu, A., Maguth Nezu, C. & Lombardo, E. (2004). Cognitive-Behavioral Case Formulation and Treatment Design: A Problem-Solving Approach. New York: Springer Persons, J.B. Cognitive Therapy in Practice: A Case Formulation Approach. New York: Norton.

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ssment

l asse gnitive behavioura Screening and co ) ck he yC Ps (e.g. the

Case formulation

(hypothesis)

Treatment plan

Regular monitoring

and evaluation

ns et al., 2001) apted from Perso ion process (ad lat mu for se Ca Figure 1:

Training components Check-in At the end of the last training module homework was set for the participants. Consistent with the CBT model, you should check-in with the participants to ensure the content was manageable and allow them to raise any issues. It is also important to follow up on homework tasks set. Exercise 10: The Young and the Restless Purpose This is a warm up exercise for Module 3. It is designed to start participants thinking about how to interpret information about a person. It is presented in a light-hearted way to demonstrate that ‘formulation’ is undertaken in many contexts. Instructions In groups of 3, ask participants to write a ‘story’ including: • • • • • •

Current problems Mood/feelings Thoughts Behaviour What’s driving the behaviour Consequences of the behaviour

There is an example in the slides.

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Ask the groups to present their magazine ‘article’ to the larger group. Discussion points Allow participants to treat this in a frivolous way. There is no need for a great deal of discussion for this exercise. Timing This exercise should take no more than 10-15 minutes in total.

Introduction to Module 3 This module starts with an overview of Module 3 and the previous warm up exercise that reflects the topic of the module. Negotiating the PsyCheck Clinical Treatment Guidelines Ask the participants to refer to their clinical treatment guidelines and ensure they understand the way it is laid out. Important areas to note are the three main sections: • Principles of intervention (covered in module 2) • Practice guidelines (covered in module 4) • Extension guidelines (covered in supervision) Refer to the worksheets and note that they are designed to be photocopied and given to clients. Note that there are modifications for young people contained in many sections. Undertaking screening and preparing feedback Refer to Module 1 which outlined how to use the PsyCheck Screening Tool. This brief component is designed to put Module 1 into the context of the Clinical Treatment Guidelines. Note to participants that screening is a first pass or snapshot of need. It is designed to give an indication of whether something further is required – assessment, brief intervention, referral. Clinicians should feedback the results of the PsyCheck Screening Tool to the client and other information they have gathered. Undertaking a cognitive behavioural assessment This training component covers: • • • •

introducing the cognitive behavioural approach to the client the development of the problem behavioural analysis other relevant information

A cognitive behavioural assessment focuses on creating a functional analysis of the target problem that is sufficiently detailed to determine the factors that maintain the problem. The focus of the analysis is to develop a theory about the problem to discuss with the client in Session 1. This is different from a diagnostic assessment, for example, which focuses on classifying symptoms against set criteria.

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An appropriate way to demonstrate how to conduct behavioural analysis would be to use case examples from your own clinical practice. Refer back to the material covered in Module 2 The Cognitive Behavioural Model and work through another example if necessary. The 7 Ps The 7 Ps is a common mnemonic used in CBT to gather information for the cognitive behavioural assessment. Each P represents information required to complete the cognitive behavioural assessment and to develop a comprehensive formulation. Further details about the 7Ps are outlined in the PsyCheck Clinical Treatment Guidelines. Go through each of the Ps and ensure the participants understand them.

Exercise 11: Something Fishy Purpose This exercise is designed as a fun way to practice identifying the 7 Ps. Instructions You will need to locate a copy of the video Finding Nemo for this exercise. Permission is currently being sought to use the video as part of the package. The relevant section is Scene 8 in which Marlin and Dory come across Bruce and two of his shark friends at a fish-eaters anonymous style meeting. Play the scene up to the section where Bruce chases Nemo and Dory through the sunken ship. Ask participants to identify as many of the 7 Ps as they can. You will use this information later to develop a formulation for Bruce, so it would be helpful for the participants to write down their answers. Discussion points To further enhance the participants’ learning and extended discussion could include areas that require further investigation. Timing This exercise should take 20 minutes. The video clip runs for about 10 minutes. 10 minutes for discussion is ample.

Preparing a preliminary case formulation This training component is concerned with the development of a case formulation from the information gathered in the cognitive behavioral assessment. Refer to the PsyCheck Clinical Treatment Guidelines when explaining this training component. Case formulation draws the elements of the case summary into a meaningful pattern and provides an interpretation of the information collected during assessment. A good case formulation will lead to an obvious cognitive behavioural treatment plan. The following exercise will assist in consolidating the understanding of case formulation. This is an important component and extra time may be needed here.

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Exercise 12: Fishy Formulation Purpose This exercise is designed as a fun way to practice developing a formulation and follows on from the previous exercise. Instructions Ask the participants to use the information they gained from the video of Bruce to put the 7 Ps into words. The PsyCheck Clinical Treatment Guidelines has examples of both a formal formulation and a formulation framed for a client. In small groups (3-4) ask participants to develop first the formal formulation then one suitable to share with the client. Emphasise that the difference will be in the language used. The formal formulation shouldn’t contain anything that would not be shared with a client. Discussion points Ask the groups to share their formulations with the larger group and ask for any comment or feedback. Timing This exercise should take 10-15 minutes. Exercise 13: Gummy Shark Purpose This exercise is designed as a fun way to practice developing a treatment plan and follows on from the previous exercise. Instructions Ask the participants to use the formulation they have just developed to identify a treatment plan for Bruce. Refer to the PsyCheck Clinical Treatment Guidelines as a guide to developing a treatment plan. Then one person in the group plays the ‘client’, Bruce, while another presents the case formulation to him with assistance from others in the group. Remind participants to think about stage of change and insight in the way the formulation is presented to him. Discussion points Ask the groups to share their treatment plans with the larger group and ask for any comment or feedback. Prompt for long and short term plans for treatment and for referral options. Ensure that the treatment plans are specific. Timing This exercise should take 15 minutes. Rounding off Module 3 The final part of this module is a check-in and summary. Use the final slide as an invitation for participants to describe their thoughts about Module 3. If you are running the training over two consecutive days it will also service as a ‘breather’. Summarise the main components of the module and ask for any feedback before moving on to Module 4 or closing the training if you are training in separate modules. If you are presenting the material in four separate modules, you might like to negotiate another homework task at this point.

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Module 4: Implementation of the brief mental health intervention Module 4 is designed to ensure participants understand the basics of the 4-session intervention. Extension material is not covered in this module and should be discussed in clinical supervision as required.

Aims The aims of Module 4 are to: r Provide clinicians with sufficient knowledge of cognitive behavioural practice to undertake the PsyCheck Intervention

Materials r PsyCheck PowerPoint Training Presentation r PsyCheck Clinical Treatment Guidelines r Decision Tree (Appendix 4) r CTG Worksheet 4: Self monitoring (Appendix 9) r Unhelpful thoughts Worksheet (Appendix 8) r CTG Worksheet 7: Managing unhelpful thought patterns (Appendix 10)

Training components r Introduction to Module 4 r Negotiating the 4-session PsyCheck Intervention r Session 1: Psychoeducation r Session 2: Identifing unhelpful thoughts r Session 3: Managing unhelpful thoughts r Session 4: Relapse Prevention r Rescreening r Clinical supervision r Rouding off Module 4 and the training

Exercises for Module 4: r Exercise 14: First Response r Exercise 15: Self Monitoring r Exercise 16: Please Explain r Exercise 17: Spot the Unhelpful Thought r Exercise 18: CBT Demonstration II r Exercise 19: Celebrity Challenge r Exercise 20: Celebrity Survivor

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Background information for trainers The background to the material in Module 4 is contained in the PsyCheck Clinical Treatment Guidelines and the PsyCheck Screening Tool User’s Guide. The training for the PsyCheck Intervention closely follows the step-by-step instructions and materials presented in the PsyCheck Clinical Treatment Guidelines. You may wish to follow these step-by-step instructions for the inexperienced group of clinicians. For more experienced clinicians, you may wish to focus on implementing these skills in a real life setting, referring to case examples and managing contingencies. The PsyCheck decision-making process is based on the decision-making flowchart (the Decision Tree) presented in the PsyCheck Screening Tool User’s Guide. Recommended reading for this section includes: Beck, J.S. (1995) Cognitive Therapy: Basics and Beyond. New York: The Guilford Press. Padesky, C. & Greenberger, D. (1995) Clinician’s guide to Mind over Mood. New York: The Guilford Press.

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Training components Introduction to module 4 This module starts with the aims and overview of Module 4. There is an initial warm up exercise consistent with the topic of the module.

Exercise 14: First Response Purpose This is a warm up exercise. It serves to get participants active after either a break from training or at the beginning of the second half of a day. Instructions Ask participants to write down their first response – emotions, thoughts or behaviours – to the list of situations. The situations will unfold one at a time on the screen. Give participants only 510 seconds to write down their response. Discussion points Discuss their responses, emphasising that each person has the potential to see each situation differently. Highlight any differences in response among the group. If further discussion is required discuss how these responses could have developed differently. Timing This exercise should take no more than 10 minutes.

Negotiating the 4-session PsyCheck Intervention The four sessions were designed to be flexible enough for both experienced and novice clinicians to use. Inexperienced clinicians will require much more emphasis on the step-by-step aspect of the PsyCheck Clinical Treatment Guidelines. For clinicians experienced in mental health intervention and/or CBT, a focus on the application of interventions may be more useful. Ask participants to follow with you as you go through the clinical treatment guidelines. Make sure the participants understand the logic of the four sessions and emphasise that each builds upon the previous session. Also point out the extension material and the modifications for young people. Emphasise that this additional material will be covered on an individual basis during supervision.

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Session 1: Psychoeducation Refer participants to the PsyCheck Clinical Treatment Guidelines throughout this module. Session 1 is generally about psychoeducation. In the PsyCheck Intervention a broad definition of psychoeducation has been taken. The session is focused on educating the client about three main areas: 1. Present the case formulation and educate the client about what is likely to be going on for them 2. Provide information about current symptoms to normalise their symptoms 3. Explain the CBT model, including the importance of self monitoring, so that clients are fully involved in their treatment.

Exercise 15: Self Monitoring Purpose The purpose of this exercise is to emphasise the importance of self monitoring and generate discussion about roadblocks in self monitoring. Instructions and Discussion Points Facilitate large group discussion around three questions: • What assists clients to understand self monitoring? • What can clinicians do to get in the way of effective self monitoring? • How do you know if you are being effective or obstructive? Discuss any other issues that are raised. Use a motivational approach to emphasise the importance of this activity to CBT. Timing This exercise should take no more than 15 minutes.

Session summary At the end of each session, clinicians should summarise what has occurred during the session and negotiate homework tasks with the client. Revisit and emphasise the importance of homework for CBT. Extension material Outline the extension material for this CBT session and remind the clinicians that this will be discussed in clinical supervision.

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Exercise 16: Please Explain Purpose This exercise is designed to allow some practice time to reinforce the psychoeducation component of the PsyCheck intervention Instructions One person plays the client, one the practitioner and one the observer. Use the celebrity’s PsyCheck screen, initial formulation and other information the participants have gathered previously to inform this session. Ask them to develop a formulation with their celebrity, then explain it to the client; integrate any other psychoeducation material that the client would benefit from. Discussion Points Discussion should primarily focus on any areas of difficulty or points of contention. Timing Allow up to 20 minutes for this exercise. Session 2: Identifying unhelpful thoughts This training component starts with a pictorial demonstration of the concept of thought patterns. Briefly revisit the idea that perception is the focus, rather than the event itself. How to address homework non-completion is covered in this training component but applies to each of the sessions. You could use an example from one of the participants who did not complete their homework task from the last module and discuss why they did not complete their homework and brainstorm ideas of how to encourage them to do so in the future. Self-monitoring is a vital part of this session, as it is the means by which thoughts are identified. Reiterate the importance and the role of self-monitoring to the participants. Exercise 17: Spot the Unhelpful Thought Purpose This exercise is designed to allow some self-practice to reinforce the identification of unhelpful thoughts. Instructions Hand out the Unhelpful Thoughts Worksheet (Appendix 8) and ask participants to complete the checklist. It is not designed to be a questionnaire, rather as a framework for reflecting on general patterns of thinking. Emphasise it is not an activity designed to give a client. Discussion Points Discussion should focus around whether they were able to identify a pattern of thinking in themselves. They DO NOT need to share what type of thinker they are with the larger group. Ask the participants to brainstorm ways in which most people are able to manage these thoughts. Encourage insight that the clients they are likely to see with comorbidities do not necessarily have the skills to automatically manage their thinking patterns, or if they do they may not use these skills. Timing This exercise should take 15-20 minutes

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Exercise 18: CBT Demonstration (Richard and Lynn part II) Purpose This video is designed demonstrate how to explain the thinking-feeling-doing cycle to a client and incorporate the identification of thoughts. It is also designed so that the participants gain practice in doing this. Instructions Ask the participants to watch the video and think about the key elements that are being demonstrated as they do. Then in small groups, one person plays the celebrity while the other/s explain the thinking-feeling-doing cycle using the celebrity’s information that you have gathered previously and to identify some of their unhelpful thinking Discussion Points Discuss issues in the application of this skill. Timing Allow up to 30 minutes for this exercise. Session 3: Managing Unhelpful Thoughts This training component is focused on the two primary methods to help clients manage unhelpful thoughts. Trainers should be familiar with the information contained in the PsyCheck Clinical Treatment Guidelines about this section. The main points are outlined in the PsyCheck PowerPoint Training Presentation. Exercise 19: Celebrity Challenge Purpose This exercise is designed to allow some practice in assisting clients to manage their unhelpful thoughts. Instructions Ask the participants to work in groups of three. Hand out Worksheets 4 and 7 from the PsyCheck Clinical Treatment Guidelines (Appendix 9 and 10). One person plays the client, one the practitioner and one the observer. Remind them to swap roles from last exercise. Use the celebrity’s previous CBT model to assist. Help the celebrity identify and challenge one of their unhelpful thoughts. Discussion Points This is primarily a practice exercise. Any areas of difficulty should be addressed. Timing Allow up to 30 minutes for this exercise. Session 4: Relapse prevention This training component should be reasonably familiar for most participants as it mirrors the strategies used in routine AOD practice. Trainers should briefly outline the material contained in the PsyCheck Clinical Treatment Guidelines using the PowerPoint Training Presentation and refer the participants to the relevant sections in their guidelines. The focus is on the practice component.

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Exercise 20: Celebrity Survivor Purpose This exercise is designed to allow some practice in assisting clients to plan for and prevent relapse Instructions Ask the participants to work in groups of 3. One person plays the celebrity client, one the practitioner and one the observer. Remind the participants to swap roles from last exercise. Summarise for the client and assist them to develop a relapse prevention plan. Discussion Points This is primarily a practice exercise. Any areas of difficulty should be addressed. Timing Allow up to 30 minutes for this exercise.

Rescreening Emphasise the importance and benefits of rescreening either using the PsyCheck Screening Tool or other measures. Clinical Supervision This is a brief discussion of clinical supervision to prime the clinicians for participating in clinical supervision practice. Emphasise that it is the single most important factor in the good practice of CBT and that training is just the beginning of gaining knowledge about the PsyCheck intervention. A single consistent clinical supervisor is recommended so that clinicians can establish a safe relationship and weekly individual clinical supervision is recommended. Group or peer supervision can be an adjunct. If clinical supervisors get support or supervision themselves, this can be useful to mention as it provides good modeling, especially to clinicians who are wary of clinical supervision. This may be a time to discuss any concerns about clinical supervision or to establish a separate forum for this. Rounding off Module 4 and the training The final part of this module is a summary of each of the four modules. Use the final slides as an invitation for participants to describe their thoughts about the training and to identify areas that they feel comfortable with and areas that require further work. By framing these two questions in this way you are giving permission for everybody in the group to have areas they feel expert in and importantly areas that they can say they feel less sure about. It may be helpful to go around the room, so everyone is required to identify these two areas of their practice. If the group is particularly uncertain about their skills, it may help to start this sum up with a senior staff member or someone who feels confident enough in their skills and themselves to identify areas to work on without feeling embarrassed. Finally, ask everyone to identify at least one thing that they will take away from the training that will change their practice in the next week and in the next year. All that remains is to thank the participants and congratulate them on their efforts over the four modules. If required, there is a sample certificate in the package (Appendix 11) that can be used as a Certificate of Attendance. This can be modified if required.

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PsyCheck clinical supervision What is clinical supervision? As the name suggests, clinical supervision is a process whereby one individual with specific knowledge, expertise or skill provides support while overseeing and facilitating the learning of another individual. Clinical supervision vs line management Clinical supervision is concerned with knowledge that directly impacts on client outcomes and may cover areas such as the counselling relationship, client welfare, clinical assessment and intervention approaches. Clinical supervision is a formal process, which may also offer professional or disciplinespecific support and education. Clinical supervision may overlap with other interventions such as management and peer support; however, it is a distinct and unique process. Line management is a type of supervision, but is different from clinical supervision. Clinical supervision focuses on the clinician’s capacity as a reflective practitioner, while line management focuses on their capacity to function as part of the organisation (Ask & Roche, 2005). Ideally, the line management and clinical supervision of an individual are provided by different supervisors. This will enhance the clinician’s ability to reflect openly on their own practice without fear of reprimand about their work performance. Education vs clinical supervision Although clinical supervision is a teaching process involving a ‘teacher’ and ‘student’, it does not follow a strict curriculum and there may not be uniform goals for all individuals. Clinical supervision is always tailored to an individual clinician and their specific client load and needs. Counselling vs clinical supervision At times a clinical supervisor may help a clinician to examine their own thoughts about and feelings towards clients and techniques. This process, however, should only ever be in the interest of helping the clinician to become more effective with their clients. Clinical supervision is not a time for examining personal feelings and goals that are unrelated to clients. Consultation vs clinical supervision Consultation is similar to clinical supervision in that it often involves discussing client issues with another health professional. Clinical supervision, however, differs from this process because it involves the ongoing skill development of the clinician.

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Models of clinical supervision Three of the most popular models of clinical supervision are: • the skill development model • the personal growth model • the integration model (Hart, 1982) Skill development model This model has two distinct goals: 1. To help the clinician conceptualise clients. 2. To acquire specific therapeutic skills to be utilised with the client. There are numerous techniques involved in monitoring and evaluating skill development. They include: • studying case notes to assess session structure and therapeutic techniques being utilised • studying psychological reports to help the clinician to assimilate and collate information to provide a clear clinical picture of a client’s problems • role-playing skills to help in the acquisition of specific techniques • observation via direct sitting in during sessions or via audio or video tape • coaching after viewing a session or during • co-therapy (e.g. running a group together) • group work • peer supervision The three stages of this model are: Skill Development >> Personal Growth >> Integration Personal growth model The distinction of this model is that the supervisor attends to the clinician’s statements regarding personal thoughts and feelings. The techniques involved in monitoring and evaluating skill development include: • self-report, where the clinician discusses his/her thoughts and feelings relating to specific clients or therapy processes • role-playing particular attitudes of a client to examine the handling and reaction to it • group work • peer observation The three stages of this model are: Personal Growth >> Skill Development >> Integration Integration model The primary goal of this model is to build on the previous knowledge of the clinician to assist them in becoming optimally effective in their clinical activities. This model is often used for more advanced clinicians. The techniques involved include techniques from the personal growth and skills development models; however, it is a more collaborative process in which clinicians are often reflecting on their own performance and making their own suggestions for improvement. The four stages of this model are: Skill Development >> Personal Growth >> Integration >> Skill Development

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The role of the clinical supervisor Clinical supervision is not a common feature of AOD treatment settings and many clinicians are wary of it. It is often confused with line management and other forms of supervision. For this reason, a clinical supervisor may need to spend some time ‘building belief ’ in the clinical supervision process (Ask & Roche, 2005). In many ways, the belief-building process is similar to increasing motivation to change in clients and many of the same strategies can be used. Characteristics of a good clinical supervisor (Powell & Brodsky (2004) are similar to those of a good clinician: open, honest, approachable, non-judgemental. The supervisor’s role is to create an environment that is welcoming and understanding, so that a clinician feels comfortable disclosing and discussing areas of their practice that may require development and undertaking critical reflection of their practice.

The clinical supervision agreement A collaborative agreement must be reached between supervisor and clinician, prior to commencement of the clinical supervision. Clinical supervision for the PsyCheck Program differs from traditional clinical supervision; however, it is essential that there is a clinical supervision agreement which covers the following: • • • • •

expectations, goals, desirable outcomes for the clinician expectations, goals, desirable outcomes for the supervisor the goals of clinical supervision the purpose and focus of clinical supervision the administrative commitments of clinical supervision (e.g. how frequently you hold clinical supervision)

Clinical supervision for the PsyCheck Program The clinical supervision process for the PsyCheck Program outlined here takes a little from each of the three models (skill development, personal growth and integration). The process of evaluation and skill development is paramount; however, clinical supervision must also be customised to the needs of clinicians and their clients. Flexibility should be applied in the supervisory relationship; however, the clear focus of clinical supervision is the implementation of the PsyCheck Screening Tool and PsyCheck Intervention. Individual clinical supervision is ideally conducted weekly for one hour. There will be times when group clinical supervision is appropriate; however, before conducting group sessions, consideration for the different level of understanding among clinicians is essential. It is also important that clinical supervision is structured to complement the material covered in the training modules. You may wish to set up specific clinical supervision arrangements for PsyCheck or it may be more feasible to integrate into existing arrangements. If clinical supervision is currently ad hoc, PsyCheck may provide a basis for establishing good clinical supervision practice in a service.

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Aims of clinical supervision for PsyCheck The aims of clinical supervision for the PsyCheck Program include: • • • • •

valid administration and interpretation of the PsyCheck Screening Tool integrated CBT-based formulation to inform treatment planning appropriate implementation of the PsyCheck Intervention troubleshooting from both the client and clinician point of view development of cognitive behavioural skills and knowledge

In this way, clinical supervision for the PsyCheck Program is limited to and defined within the parameters of the PsyCheck Screening Tool and PsyCheck Intervention. Despite these parameters, the essence of the clinical supervision models outlined above is still maintained.

Supervision note It is intended that the PsyCheck clinical supervision be delivered in a way that is fluid, human and responsive to client and clinician needs. PsyCheck clinical supervision acknowledges that clients are complex, sometimes challenging individuals who may fluctuate in their readiness and appropriateness for the strategies outlined in the intervention on the basis of their daily, weekly or immediate personal states. The intervention is therefore not prescriptive, rigid or inflexible to the human experience of a crisis, bad week, bad day etc. Clinical supervision seeks to mirror this flexibility by structuring time for ‘pressing issues’ for the clinician from the outset.

Linking the training modules and clinical supervision Clinical supervision will differ in its structure depending on how the PsyCheck training is administered. Linking the two processes demands consistency across the material covered and integration of the concepts outlined in the training modules. If training and clinical supervision are to be conducted by different individuals, an opportunity for communication between the two is essential for consistency. Providing clinical supervision sessions module by module, in accordance with the training, will help the clinicians to build confidence and consolidate new learning when using the PsyCheck Screening Tool and PsyCheck Intervention. The PsyCheck Project implementation trial found that this approach is particularly helpful for those clinicians who are new to screening, formulation and cognitive behavioural therapy. Further assistance for clinical supervisors is presented in the following step-by-step guide to clinical supervision. This guide is based on experience gleaned from the PsyCheck Project implementation trial and provides tips and ideas about the content and timing of clinical supervision for each of the training modules.

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A step-by-step guide to clinical supervision for the PsyCheck Program Module 1: PsyCheck Screening Tool – properties, administration, scoring and interpretation Primary areas for clinical supervision • General scoring and administration for the PsyCheck Screening Tool • General Mental Health Screening Tool • Suicide/Self-Harm Risk Assessment • Self Report Questionnaire (SRQ) • Giving appropriate feedback

General scoring and administration for the PsyCheck Screening Tool During this phase of clinical supervision, refer to the information contained in PsyCheck Screening Tool User’s Guide as well as to the PsyCheck Screening Tool. Check that the clinician recalls how to administer the PsyCheck Screening Tool and discuss any contingencies or areas of concern. Providing the client feedback about their results on the PsyCheck Screening Tool is an integral part of using the Screening Tool. It can be useful at this time to run through a role-play or to go through the PsyCheck using a client as a case example. The aim of this clinical supervision session is to consolidate the information provided within the training session. It is also possible that a clinician may want to talk further about the training material, if they are still unclear on how decisions were reached during the training. It is important that the clinician feels comfortable to raise any questions or concerns throughout the supervisory experience. This will increase their confidence in using the PsyCheck Screening Tool, which will in turn increase the likelihood of them utilising the screen in their clinical practice. General Mental Health Screen The most important point to emphasise is that administering the PsyCheck Screening Tool should fit naturally into the clinician’s usual style of engagement with an existing client or new client. If the clinician already has the information to complete this section (for example, from a clinical assessment), it is unnecessary to re-administer such questions. The clinician may, however, want to use the opportunity to clarify any areas regarding mental health issues.

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Suicide/Self-Harm Risk Assessment The Suicide/Self-Harm Risk Assessment can cause some anxiety with clinicians who have less experience and are lacking confidence in their clinical judgement. It can be useful to run through some different client scenarios to help the clinician practise their interpretation of potential risk. At this point, discuss the service’s existing processes and policy on risk of harm and emphasise that the integration of the Suicide/Self-Harm Risk Assessment into these existing practices will be necessary. It is also important to address when to refer and when not to refer to mental health services (on the basis of the Suicide/SelfHarm Risk Assessment). Knowledge of the local mental health intake criteria and the use of appropriate language when communicating risk are other areas that may be covered in clinical supervision. Self Report Questionnaire (SRQ) Reinforce with the clinician that this section of the PsyCheck Screening Tool may be given to the client to self-administer or may be administered verbally during a session. Alternatively, the client may complete the initial questions on their own and then the clinician may administer the ‘circles’. It may be useful to discuss the different situations that can warrant the alternative method of administration, such as literacy, level of anxiety, age, brain injury etc. Giving appropriate feedback Giving clients appropriate feedback about their results on the SRQ can be a powerful engagement strategy and motivational technique. Interpreting clients’ scores on the SRQ and determining the range into which they fall can give clients a real sense of how their symptoms compare to the general population. They can get a sense of the severity of their cluster of symptoms, and their experience may be normalised by placing a potentially confusing group of symptoms into a meaningful picture. The most appropriate feedback can be given by discussing both the client’s score and the individual items they have rated. Many of the symptoms associated with anxiety or depression impact on several areas of a client’s life, such as their appetite and sleep, and feedback about how these symptoms interact is also important from a psychoeducation perspective. In the early stages of screening, it is advisable that clinicians score the SRQ and develop feedback for each client in conjunction with their clinical supervisors. Troubleshooting

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Problem

Possible strategies to assist

SRQ: Client has had no period in last 30 days without alcohol or other drugs

• Ask about recent time without alcohol or other drugs, or ask about periods when not acutely intoxicated or withdrawing. Failing that, SRQ is valid without the modification – it is likely to be overly sensitive, but when measuring comorbidity, over detection is better than under detection.

Suicide risk: Clinician is concerned that asking about suicide will ‘open a can of worms’ that they will not be prepared to manage.

• Support the clinician and address concerns. • Clinician may need some skill development in managing suicide risk. • Emphasise that suicide risk assessment is core business and PsyCheck is just a framework for reporting this.

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Module 2: Cognitive behavioural therapy Primary areas for clinical supervision • Cognitive behavioural theory and the CBT model • Negotiating the PsyCheck Clinical Treatment Guidelines • Behavioural assessment Cognitive behaviour theory and the CBT model The PsyCheck training will have orientated the clinicians to the principles of cognitive behavioural theory and its theoretical underpinnings. The CBT model may be understandable in an abstract form; however, its application to client formulation is often difficult to comprehend. Opportunities for practice using the CBT model to make sense of a real or hypothetical client are essential in consolidating this skill. The level of past exposure to CBT may determine how quickly a clinician will be able to adopt client formulation based on this model. Beginning with simple examples of the application of the model and working towards increased complexity will lay the groundwork for the application of CBT theory. Adherence or exposure to conflicting theoretical models often present a particular difficulty in adopting the CBT model to advise formulation. Clinical supervision is an appropriate forum to process some of these discrepancies and difficulties. It may also be necessary to emphasise the self-help focus of CBT to ensure that therapeutic processes are consistent with the approach outlined in the PsyCheck Clinical Treatment Guidelines. Negotiating the PsyCheck Clinical Treatment Guidelines Clinical supervision is a structured process and it should require some level of preparation from both the supervisor and the clinician. Encourage the clinician to raise their own questions about the PsyCheck Clinical Treatment Guidelines and their use, as this will lead to necessary negotiation of the materials. Cognitive behavioural assessment Clinical supervision around cognitive behavioural assessment should follow closely the material provided in the PsyCheck Clinical Treatment Guidelines and during training. As in the case of CBT theory, use ‘case-based learning’ – where principles are explored and applied to existing clients – to consolidate these high order therapeutic skills. Troubleshooting Problem

Possible strategies to assist

Clinician doesn’t agree with the CBT model

• Discuss model/s they currently work with, draw parallels between how they work and the CBT model where they exist. • Discuss beliefs about evidence-based practice and use a motivational approach to improve the clinician's commitment to evidence-based practice. • Emphasise that their existing primary AOD work is CBT based.

Clinician doesn’t understand the CBT model

• Use current or past clients to practice applying and understanding the CBT model.

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Module 3: Pre-session preparation: Assessment, formulation and treatment planning Primary areas for clinical supervision • Case formulation • Appropriate information gathering • Thorough behavioural analyses

Case formulation Case formulation is a skill that is crucial for the appropriate application of the CBT intervention. A formulation is used to make predictions about how an individual will respond to an intervention or treatment. Strategies and interventions are client focused. Initially, the supervisor will generate much of the formulation; eventually the clinician will develop greater autonomy as formulation becomes more familiar. The most appropriate use of clinical supervision time is to encourage the clinician to continue to attempt formulating and to continue with case-based learning. This will be a difficult module for those clinicians who are not familiar with CBT, formulation or an hypothesis-testing approach. Progress in this module will be highly individual and it is recommended that as many clinical supervision sessions as are required are taken to consolidate this skill, as it is considered the cornerstone of CBT. Setting up some group clinical supervision sessions to consolidate this module could be helpful, as it will allow for a broader range of clients to be discussed. This gives all clinicians a chance to see how formulating works for clients with varying levels of mental health and alcohol and other drug problems. It may also be necessary to revisit the link between formulation and treatment. Appropriate information gathering In the initial stages of clinical supervision, it is advised that the clinical supervisor prompt the clinician in relation to the questions they need to ask their clients, in order to build an appropriate formulation. It may be appropriate for clinicians to be given the opportunity to collect the information about their client over several sessions, with clinical supervision between each session in order to guide the information gathering process. As clinicians develop greater confidence and autonomy, they will develop their formulation on their own and then present it to the supervisor before the client. It is appropriate at this stage for the supervisor to highlight gaps in the formulation, requiring further information gathering. Group clinical supervision is also an important forum for clinicians to develop assessment skills, while listening to how others have phrased questions to clients or elicited sensitive information in the behavioural analysis. Thorough behavioural analyses A thorough behavioural analysis forms the basis of any cognitive behavioural formulation. The central principle of assessment, from a cognitive behavioural point of view, is that the ways in which an individual behaves are determined by immediate situations and the way in which they have been interpreted. The behavioural analysis reviews the problems in detail and aims to discover how the problem is maintained. Using the underlying principles of learning theory, the supervisor and clinician together will establish patterns and links between situations, thoughts, feelings and behaviours. Hypothesising these links is the primary skill in building a behavioural analysis. If the situation, thoughts, feelings or behaviours that are maintaining the problem are identified, they can then be changed.

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Troubleshooting Problem

Possible strategies to assist

Clinician doesn’t understand case formulation

• A  ssist the clinician to understand the elements of the formulation (7Ps) separately initially and slowly help to build a picture for the clinician.

Clinician is not sure how to ask questions of the client

• Role play during clinical supervision.

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Module 4: Implementation of the four-session PsyCheck Intervention Session 1: Presenting the formulation and beginning psychoeducation and self-monitoring Primary areas for clinical supervision • Case formulation • Psychoeducation • Introducing the CBT model • Developing a joint treatment plan with the client • Introducing self-monitoring • Session termination Case formulation Before embarking on any of the techniques to be used, it may be important to revisit some of the general principles of CBT covered during the training modules. Particular emphasis on engagement and rapport in terms of the CBT therapeutic alliance and preparation for a collaborative approach to therapy is recommended. Presentation of the preliminary case formulation to the client • Check the clinician has a full understanding of the formulation. • Clinical supervision should be used to role-play presenting the case formulation. • Remind the clinician to use the client’s language while in session to assist the client’s understanding of the formulation. • Encourage the clinician to be collaborative with this process to assist with rapport building. Psychoeducation • Encourage role-playing of psychoeducation during clinical supervision. • If necessary, model for the clinician how you would provide psychoeducation for some of their clients. • Encourage the use of language aimed at the client’s level. • Refer the clinician to the information sheets provided within the PsyCheck Clinical Treatment Guidelines.

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Introducing the CBT model Explaining the CBT model and working through an example with the client • Explain the CBT model, using examples to reinforce. • Work with the clinician to develop their own examples, as not all clients will identify with the example given in the guidelines. • Run through the explanation during clinical supervision, using the whiteboard, paper or analogy. Note: The full CBT model is more complex than the simpler alternative CBT models that are provided in the extension materials for the PsyCheck Clinical Treatment Guidelines. The full model is very client specific. Initially, the clinician may require the supervisor to assist with devising a client-specific example beforehand. • Allow the clinician to guide how much assistance they require. • Remind the clinician that an important focus of CBT is increasing the client’s self-efficacy (the belief that they will be able to manage their ongoing difficulties on their own), using strategies they will learn in the sessions. Developing a joint treatment plan The links between formulation and treatment • Check on the clinician’s understanding of the link between formulation and treatment. • Begin generating a treatment plan for the target problem with the clinician. • Build on the strengths of the clinician by getting them to devise alcohol or other drug use interventions. Developing a joint treatment plan • Devise a treatment plan during clinical supervision for the inexperienced clinician, then encourage the development of autonomy as clinical supervision progresses. • Provide tips for how to continue to collaborate with the client in the treatment planning process in the case of a pre-prepared treatment plan. • Encourage the clinician to check each treatment area with the client and ask them about their thoughts on the different components involved. • Stress to the clinician the importance of the collaborative process, as it is a crucial point for engagement, rapport building, treatment adherence and success. Finalising and recording treatment plan • Integrate the PsyCheck Intervention into existing agency processes for treatment planning as much as possible. • Remind clinicians to keep a record for themselves within the client’s file. Introducing self-monitoring Explaining self-monitoring and working through an example with the client • Help the clinician to clarify the rationale that they give to the client. • Setting up a strong rationale from the beginning can impact homework compliance and, therefore, outcomes throughout the intervention.

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Session termination Summary, feedback, homework and arrangement of next session • Reinforce the importance of the session termination process with the clinician – that it allows for the client to voice any concerns, consolidates information and reminds the client of homework tasks set. • Covering the content within the timing of the first session will be difficult for inexperienced clinicians. These elements may be incorporated over several sessions until the clinician becomes more practised. Session 2: Identifying unhelpful thoughts Primary areas for clinical supervision • Review and feedback • Provide information about identifying unhelpful thoughts • Practise identifying unhelpful thoughts • Encourage self-monitoring of thoughts Review and feedback • Review the previous week, set agenda and review homework tasks. • Encourage the clinician to consider this part of the session as equally important as the content following. • Read through the suggested problem areas and tips presented in the PsyCheck Clinical Treatment Guidelines and brainstorm contingencies with the clinician. Provide information about identifying unhelpful thoughts This is one of the most important first steps in helping a client to identify how their thoughts impact on their feelings and how they behave (particularly in relation to alcohol or other drug use). Helping the clinician to identify a few examples to help them elicit this understanding within their clients is paramount. Work with the clinician on the best way to frame a rationale. The following points may be of assistance: • Be aware that many clients will take a while to identify their own thoughts and how their thoughts affect their feelings. • If a client is having difficulty identifying their thoughts, encourage the clinician to provide some scenarios and ask the client what they might think in these different scenarios. Although they might not be ‘real life’ examples to begin with, this process can orientate a client to think about their thoughts. • It is likely that many clients may be able to identify their feelings, but not their thoughts. If this is the case, work backwards and focus on eliciting the thoughts that led to the feeling. • The best tip here is to encourage the clinician to be as ‘example based’ with their clients as possible.

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Practise identifying unhelpful thoughts Identifying and labelling unhelpful thoughts • Run through Worksheet 5: Identifying unhelpful thought patterns and elicit example thoughts for the different thinking patterns. Encourage self-monitoring of thoughts Practise developing a strong rationale for self-monitoring Supervision note Troubleshooting and contingency planning will be important at this stage of the intervention. Many clients will have trouble identifying their thoughts or differentiating thoughts from feelings. Thus clinical supervision may need to focus on helping clinicians to identify different ways to elicit thoughts from clients. Clinical supervision should also provide a chance for clinicians to gain further clarification on labelling unhelpful thoughts.

Session 3: Managing unhelpful thoughts Primary areas for clinical supervision • Review and feedback • Provide information on challenging unhelpful thoughts • Practise challenging unhelpful thoughts (cognitive intervention) • Session summary Review and feedback See review and feedback steps from Session 2. Provide information on challenging unhelpful thoughts This stage of the intervention is aimed at helping clients to gain further insight into their thinking patterns and to learn how to challenge them. It is important that the process of thought challenging is framed in such a way that the client sees the importance. A good rationale is that thinking is a learned process, and those with long-term problems have probably had their thinking errors for a long time. The process of challenging is about ‘unlearning’ these patterns and training the mind to think in an alternative way. Points to stress in clinical supervision may include: • Thoughts can be very resistant to change. • Encouragement is needed for most clients to persist with practice to see results. • Challenging thoughts can be a difficult process for the clinician, especially if a client is not very good at identifying their thought patterns. • Challenging may require the clinician ‘digging’ further into the client’s thoughts to identify the actual distortion. • If clients haven’t completed thought monitoring, this exercise can still be done; however, it will be necessary to find an example of a distortion that they had during the week and work with it.

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• Thought monitoring may not have occurred over the week as it can be very difficult with clients who have limited insight into their thoughts and feelings. Don’t worry – continue to encourage and stress the rationale. • Challenging takes practice. • Challenging is not an argument and continues to be an empathic process. • Patience … clients must identify the alternative thoughts. The clinician should not feed it to them. • Begin with guidance, then encourage clients to generate their own alternative thoughts. Clinicians need to foster a new skill in their clients, which they can consolidate outside therapy. • Remember, it is about evidence collecting. Sometimes the clinician will find that there is evidence for a certain thought if you think creatively. • Help the clinician to think of a way to remember the four prompts easily. They may need the prompts written in front of them to help as a guide. They can take notes throughout the session and even give this sheet to the client at the end of the session as a concrete example for them to refer to throughout the week. Practise challenging unhelpful thoughts This stage of the intervention is aimed at clients consolidating knowledge by practice during the session. Practising develops skills and also assists the clinician to identify any areas of difficulty. Points to stress in supervision include: • Practice is an essential part of the intervention and shouldn’t be overlooked by the clinician • Clinicians sometimes feel uncomfortable or self-conscious role-playing or practising in session; it may be helpful to undertake some role-play during supervision. • It may take some practice for the client to consolidate knowledge about challenging unhelpful thoughts. • The best practice for teaching this is for the clinician to run through the examples with the client. • Strengthening rationale and troubleshooting are important here. Session summary • When appropriate, it will be necessary to discuss with the client the termination of the brief intervention in the final session. • Discussion around any possible reactions from different clients can be useful to prepare the clinician for introducing termination. • It may also be necessary to discuss the level of treatment termination with the clinician. Termination of a client from treatment altogether will require more planning than termination of the PsyCheck intervention as part of an ongoing AOD treatment. In the latter case, raising termination the session before may be sufficient. In the former case a long lead up time is recommended and the PsyCheck intervention may form part of that termination by acting as a structured end to AOD treatment. Supervision note Thought challenging is not an argument. It requires sufficient counselling micro-skills to be delivered in an empathic way that maintains rapport. Use clinical supervision to practise and role-play potentially difficult client scenarios. Providing a strong rationale for self-monitoring may also need to be discussed during sessions if clinicians are having trouble with clients not completing homework tasks.

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Troubleshooting Problem experienced

Possible strategies to assist

The client did no monitoring and is still having trouble identifying their thoughts or they don’t believe they make any of the cognitive distortions.

• Use imagery. The client closes their eyes and thinks about the last time that they were in an uncomfortable situation. Then they describe it for you like a postcard. Then probe for thoughts.

The clinician is having problems with challenging unhelpful thoughts.

• Encourage the clinician not to be too concrete with the prompts given in the treatment guidelines.

• Setting a scene can help prompt thoughts. • Thought challenging does require practice to be beneficial. The clinician may need to assist the client in identifying their thoughts over a couple of weeks and provide them with written examples that they have given you. This will help to guide them through the week.

• Go through examples with them and roleplay. • Reiterate the rationale to highlight the importance of perseverance. • Try to schedule clinical supervision with them directly after they have had a challenging session so that the difficulties they experienced are fresh in their mind. • Reiterate that it is a difficult technique and takes time to master.

Session 4: Relapse prevention Primary areas for clinical supervision • Review and feedback • Provide information about relapse prevention • Develop a relapse prevention plan • Session summary and treatment termination Review and feedback • See review and feedback steps from Session 2. Provide information about relapse prevention Identify triggers for relapse and early warning signs • Continue with case-based learning. • Some clients will have difficulty identifying trigger situations for themselves. Referring back to the maintenance of the problem and the history gathered in the pre-session preparation is a good technique. Breaking the rule effect • Many clients initially find this a difficult concept to understand. • Encourage the clinician to persevere, trying several methods of identifying triggers, increasing level of detail and intensity as required.

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• ‘Dissect’ the last lapse or relapse to depression and anxiety if necessary. • Some clients may find it easier to look at the breaking the rule effect with their AOD use, especially if they have had some contact with relapse prevention therapy before. Develop a relapse prevention plan Anticipate difficult situations • Revisiting past relapse/lapse behaviour is essential in highlighting some of the potential risk situations, which will require contingency plans. • Some risk situations may not be able to be avoided (e.g. loss of a parent). However, highlighting that the client now possesses new skills to prevent depression or anxiety from escalating and being maintained is an important boost to an individual’s sense of self-efficacy. Regulate thinking patterns • Retraining a client to believe and act on their alternative thoughts can be difficult. Once the skill has been acquired, it may be effectively maintained through ‘booster sessions’ scheduled four weeks to six months later. • Assist the clinician in framing the rationale of relapse prevention for the client in a way which names the client as their own therapist, or as a way of continuing the therapy process throughout their everyday lives. • The clinician needs to encourage the client to continue self-monitoring, and to continue (on their own) to generate different ways of thinking and behaving. • Encourage the clinician to continue to use the tools of CBT: for example, to refer to monitoring forms and continue to update and revise their formulation. Emphasise the need for additional skills and supports • Clinicians may need help in making a judgement about which further skills to offer from the additional materials in the PsyCheck Clinical Treatment Guidelines. Again, this decision should be formulation based and should be discussed collaboratively with the client. Self-care and nurturing • Clinicians may need prompting to revisit the ‘Strengths’ part of their CBT assessment and formulation, and to assist clients to build on these areas and continue to reward themselves. • Revisiting positive reinforcement and behavioural theory will provide the rationale for reward, and reinforce its potential in maintaining new, more adaptive behaviours. Session and treatment termination • The clinician should be given the opportunity during supervision to practise terminating a session with their client before the final PsyCheck session, especially the first few times a clinician faces this step with a client. • The clinician should have an opportunity to practise all aspects of session termination, including providing the client with a summary of the formulation, the intervention, the new skills acquired and the tips for relapse prevention.

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Supervision note Relapse prevention is obviously of paramount importance for lasting behaviour change. Building on the clinician’s familiarity with relapse prevention principles for alcohol and other drug interventions will assist in the consolidation of relapse prevention skills for anxiety and depression. Referring back to the revised formulation at this stage will also be essential in devising a valid relapse prevention plan.

Troubleshooting Problem

Possible strategies to assist

Client can’t identify triggers

• Work backwards from a relapse in minute detail (practice with the clinician)

Clinician is having difficulty explaining the breaking the rule effect

• Revisit the abstinence violation effect if they are more familiar with the concept as it applies to AOD relapse.

A client has little or no insight into how their thoughts impact on their feelings.

• Use behaviours or feelings that the client has had in the past week/fortnight and work back with them, ‘digging’ for the associated thoughts. • Work visually – use a whiteboard/paper and pen. • Provide clients with examples you have generated during the session.

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Appendix 1: PsyCheck training needs analysis Name: Discipline:

Qualifications:

Current position: Years in AOD field:

Years in current position:

Please list your past experience in using screening tools for mental health issues.

Please list your past experience and previous training in cognitive behavioural therapy (CBT) (where, when, length of course or training, trained by whom).

How confident do you feel about your knowledge in the following areas:

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Not at all confident

Moderately Very confident confident

Using screening instruments





Undertaking a cognitive behavioural formulation





Explaining the CBT model to clients





Understanding therapeutic alliance and processes





Identifying cognitive distortions





Challenging cognitive distortions





Identifying triggers for mental health relapse





Integrating mental health and AOD intervention





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Appendix 2: Sample session plan

Day 1 Time

Topic

9:00am

Welcome introductions & housekeeping Exercise 1: Who do you think…..? Exercise 2: How you’re thinking feeling doing?

10:00am

Module 1: PsyCheck Mental Health Screening Tool

Presenter

Introduction to the training modules Module 1 overview Introduction to comorbidity Psycheck development and overview Psychometric properties of the Psycheck Screening Tool Navigating the Psycheck Screening Tool 10:30am

Morning Tea Administering the Psycheck Screening Tool Exercise 3: Celebrity Squares Interpreting the Psycheck Screening Tool Exercise 4: Celebrity Squares –What’s next Round off Module 1

12:30pm

Lunch

1:15pm

Module 2: Cognitive Behaviour Therapy Exercise 5: What works for you? Theoretical underpinning of CBT Exercise 6: Mix 'n' Match The CBT Model Exercise 7: The Cognitive Model

2:45pm

Afternoon Tea CBT in practice Exercise 8: CBT demonstration Part I Stepped case approach Therapeutic relationship Clinical judgement Integrated treatment Exercise 9: Therapeutic process Home based tasks Day 2 overview

4:00pm

Close

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Day 2 Time

Topic

9am

Welcome back Check-in

9:15am

Module 3: Pres-session Preparation: Assessment, Formulation and Treatment Planning

Presenter

Exercise 10: The young and the restless Introduction to Module 3 Negotiating the PsyCheck Clinical Treatment Guidelines Undertaking screening and preparing feedback 10:30am

Morning Tea

11am

Undertaking cognitive behavioural assessment The 7 Ps Exercise 11: Something Fishy Preparing a preliminary case formulation Exercise 12: Fishy Formulation Exercise 13: Gummy Shark Rounding off Module 3

12:30pm

Lunch

1:45pm

Module 4: Implementation of the Brief Mental Health Intervention Introduction to Module 4 Exercise 14: First Response Negotiating the 4-session PsyCheck Intervention Session 1: Psychoeducation Exercise 15: Self Monitoring Session summary Extension material Exercise 16: Please Explain

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2:00pm

Session 2: Identifying Unhelpful Thoughts Exercise 17: Spot the unhelpful thought Exercise 18: CBT Demonstration (Richard and Lynn part II)

2:45pm

Afternoon Tea

3:15pm

Session 3: Managing unhelpful thoughts Exercise 19: Celebrity Challenge Session 4: Preventing relapse Exercise 20: Celebrity survivor Rescreening Clinical supervision Rounding off Module 4 and the training

4:30pm

Review, evaluations, close

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Appendix 3: Psycheck Screening Tool

Clients Name:

DOB:

Service:

UR:

Mental health services assessment required?

No

Suicide/self-harm risk (please circle):

High

Date:



Yes Moderate

Low

Screen completed by:

Clinician use only Complete this section when all components of the PsyCheck have been administered. Summary Section 1

Past history of mental health problems

No

Yes

Section 2

Suicide risk completed and action taken

No

Yes

Section 3

SRQ score

0

1–4

5+

Interpretation/score – SRQ Score of 0* on the SRQ No symptoms of depression, anxiety and/or somatic complaints indicated at this time. Action: Re-screen using the PsyCheck Screening Tool after 4 weeks if indicated by past mental health questions or other information. Otherwise monitor as required. Score of 1–4* on the SRQ Some symptoms of depression, anxiety and/or somatic complaints indicated at this time. Action: Give the first session of the PsyCheck Intervention and screen again in 4 weeks. Score of 5+* on the SRQ Considerable symptoms of depression, anxiety and/or somatic complaints indicated at this time. Action: Offer Sessions 1–4 of the PsyCheck Intervention. Re-screen using the PsyCheck Screening Tool at the conclusion of four sessions. If no improvement in scores evident after re-screening, consider referral.

* Regardless of the client’s total score on the SRQ, consider intervention or referral if in significant distress.

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SECTION 1: General Screen Clinician to administer this section The following questions are about your emotional wellbeing. Your answers will help me get a clearer idea of what has been happening in your life and suggest possible ways that we might work together to relieve any distress you may be experiencing. We ask these questions of everybody, and they include questions about mental, physical and emotional health. 1. Have you ever seen a doctor or psychiatrist for emotional problems or problems with your ‘nerves’/anxieties/worries?

No

Yes



Details

2. Have you ever been given medication for emotional problems or problems with your ‘nerves’/anxieties/worries? No, never

Yes, in the past but not currently

Medication(s):



Yes, currently

Medication(s):

3. Have you ever been hospitalised for emotional problems or problems with your ‘nerves’/anxieties/worries?

No

Yes



Details

4. Do you have a current mental health worker, psychiatrist, psychologist, general practitioner or other health provider? If ‘No’, go to Question 5.

Psychiatrist

Psychologist



Name:

Name:



Contact details:

Contact details:



Role:

Role:



Mental health worker



Name:

Name:



Contact details:

Contact details:



Role:

Role:



Other – specify:



Name:

Name:



Contact details:

Contact details:

Role:

Role:

General practitioner

Other – specify:



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5. Has the thought of ending your life ever been on your mind?

No



Yes



If ‘No’, go to Section 3



No



Yes



If ‘Yes’, go to Section 2

Has that happened recently?

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SECTION 2: Risk Assessment Clinician to administer this section If the person says ‘Yes’ to recently thinking about ending their life (Question 5), complete the suicide/self-harm risk assessment below. Specific questions and prompts and further guidance can be found in the PsyCheck User’s Guide. Risk factor

Low risk

Moderate risk

High risk

1. Previous attempts: Consider lethality and recency of attempts. Very recent attempt(s) with moderate lethality and previous attempts at high lethality both represent high risk. Recent and lethal attempts of family or friends represent higher risk. History of harm to self

Previous low lethality

Moderate lethality

High lethality, frequent

History of harm in family members or close friends

Previous low lethality

Moderate lethality

High lethality, frequent



2. Suicidal ideation: Consider how the suicidal ideation has been communicated; non-disclosure may not indicate low risk. Communication of plans and intentions are indicative of high risk. Consider non-direct and non-verbal expressions of suicidal ideation here such as drawing up of wills, depressive body language, ‘goodbyes’, unexpected termination of therapy and relationships etc. Also consider homicidal ideation or murder/suicide ideation. Intent

No intent

No immediate intent

Immediate intent

Plan

Vague plan

Viable plan

Detailed plan

Means

No means

Means available

Means already obtained

Planned overdose, serious cutting, intervention possible

Firearms, hanging, jumping, intervention unlikely

Minor self-harm Lethality behaviours, intervention likely

3. Mental health factors: Assess for history and current mental health symptoms, including depression and psychosis. History of current depression

Lowered or unchanged mood

Enduring lowered mood

Depression diagnosis

Mental health disorder or symptoms

Few or no symptoms or well-managed significant illness

Pronounced clinical signs

Multiple symptoms with no management

4.  Protective factors: These include social support, ability or decision to use support, family involvement, stable lifestyle, adaptability and flexibility in personality style etc. Coping skills and resources

Many

Some

Few

Family/friendships/networks

Many

Some

Few

Stable lifestyle

High

Moderate

Low

Ability to use supports

High

Moderate

Low

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SECTION 3: Self Reporting Questionnaire Client or clinician to complete this section First: Please tick the ‘Yes’ box if you have had this symptom in the last 30 days. Second: Look back over the questions you have ticked. For every one you answered ‘Yes’, please put a tick in the circle if you had that problem at a time when you were NOT using alcohol or other drugs. 1. Do you often have headaches?

No

Yes

2. Is your appetite poor?

No

Yes

3. Do you sleep badly?

No

Yes

4. Are you easily frightened?

No

Yes

5. Do your hands shake?

No

Yes

6. Do you feel nervous?

No

Yes

7. Is your digestion poor?

No

Yes

8. Do you have trouble thinking clearly?

No

Yes

9. Do you feel unhappy?

No

Yes

10. Do you cry more than usual?

No

Yes

11. Do you find it difficult to enjoy your daily activities?

No

Yes

12. Do you find it difficult to make decisions?

No

Yes

13. Is your daily work suffering?

No

Yes

14. Are you unable to play a useful part in life?

No

Yes

15. Have you lost interest in things?

No

Yes

16. Do you feel that you are a worthless person?

No

Yes

17. Has the thought of ending your life been on your mind?

No

Yes

18. Do you feel tired all the time?

No

Yes

19. Do you have uncomfortable feelings in the stomach?

No

Yes

20. Are you easily tired?

No

Yes



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Total score (add circles):

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Appendix 4: Decision Tree Past mental health diagnosis or treatment?

Y

N

Administer PsyCheck Screen

N

Current Current suicidal suicidal ideation? ideation?

Client in contact with mental health services?

Y

• Complete ‘release of information’ form

Y

•  Seek collaborative care approach

Active psychotic symptoms

Complete risk assessment – high risk?

Y

• Refer to specialist mental health service

N

• Review regularly

• Arrange urgent assessment by mental health service or other appropriate response as per workplace policy

Y

• Develop action plan

• Develop contract

N N

SRQ score of 5 or above?

• Review daily until suicidal ideation remits

• Offer four sessions of brief intervention

Y

Y

• Review at one month

• Review monthly as necessary

Improvement?

N

• Seek mental health opinion

• Seek specialist mental health opinion

• If score of 1–4 on SRQ, offer session 1 of brief intervention and self-help material

N

• Review at one month • If no improvement, offer 4 sessions of brief intervention • Review in one month. If no improvement, arrange mental health assessment

Observe significant distress?

SRQ score of 5 or above?

Y

• Seek specialist mental health opinion

• Offer four sessions of brief intervention

N

• Review at one month • Seek mental health opinion

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• Review monthly as necessary

Improvement?

N

• Seek specialist mental health opinion

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Appendix 5: What Works For You Working individually write down: 1. What models you have an affinity with

2. What model/s you currently work with

3. What works for you?

Now find someone else in the room that uses a different model to the one you typically work with Discuss with your partner • Why you use this model/strategies you do • How you know its working

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Appendix 6: Mix 'n' Match Cards Self Monitoring Thoughts

Self Monitoring Feelings

Mix 'n Match

Self Monitoring Behaviour

Mix 'n Match

Managing Unhelpful Thoughts

Mix 'n Match

Looking After Yourself

Mix 'n Match

Monitoring ABC’s Mix 'n Match

Interpreting Situations

Mix 'n Match

Activity Log Mix 'n Match

Slow Breathing Mix 'n Match

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Mix 'n Match

Activities List Mix 'n Match

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Progressive Muscle Relaxation

Mindful Walking

Mix 'n Match

Relaxation Imagery

Mix 'n Match

Relaxation Practice Log

Mix 'n Match

Identifying your Communication Style

Mix 'n Match

Psychoeducation about Mental Health Issues

Mix 'n Match

Tips for Resolving Conflict Mix 'n Match

Listening Skills Mix 'n Match

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Mix 'n Match

Better Sleep Checklist Mix 'n Match

Engagement in Therapy Mix 'n Match

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Challenging Thoughts

Self-Reflection Skills Mix 'n Match

Interpreting Situations

Cognitive Restructuring Mix 'n Match

Activity Scheduling Mix 'n Match

Self Care

Mix 'n Match

Identifying High Risk Situations Mix 'n Match

Assertiveness Skills Mix 'n Match

Self Esteem Skills Mix 'n Match

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Mix 'n Match

Mix 'n Match

Schema Therapy Mix 'n Match

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Deep Muscle Relaxation

Identifying Triggers for Relapse Mix 'n Match

Relapse Prevention

Mix 'n Match

Breaking the Rule Effect

Mix 'n Match

Mindfulness Therapy

Mix 'n Match

Counselling Microskills

Mix 'n Match

Thought Labelling Mix 'n Match

Assertive Communication Mix 'n Match

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Mix 'n Match

Refusal Skills Mix 'n Match

Problem Solving Mix 'n Match

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Cognitive Behavioural Assessment

Self Reward Mix 'n Match

Mindfulness Meditation

Mix 'n Match

Communication Skills Mix 'n Match

Cognitive Therapy

Mix 'n Match

Coping Skills

Mix 'n Match

Interpreting Situations

Mix 'n Match

Identifying Early Warning Signs Mix 'n Match

Harms & Consequences of Problems

Distraction Mix 'n Match

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Mix 'n Match

Mix 'n Match

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Appendix 7: The CBT Model Early experiences

Core beliefs

Trigger

Unhelpful thoughts

Behaviour

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Feelings

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Appendix 8: Unhelpful Thoughts Worksheet Do you have any of the following unhelpful thought patterns? Take a minute to answer the following questions Are you a black and white thinker?

Yes

No

Are things either all good or all bad with nothing in-between? Do you think that because something has gone wrong once, it will always go wrong? Do you have strict rules about yourself and your life? Eg Do you think that in order to be good at something you must do it perfectly or not at all? If things don’t work out right do you feel hopeless and like you have failed completely? Have you ever thought even if I relapse once I’m a failure? Do you believe that in order to be a good person, everyone must like you all the time? In thinking about your depression, do you think things like ‘Either I’m depressed or I’m completely happy, no in-betweens’ Do you jump to negative conclusions? Do you automatically draw a negative conclusion about something more times than not? Do you sometimes act like a mind reader? You can tell what others are really thinking of you? Do you do a bit of fortune telling? That is, believe that things will turn out badly for you? In thinking about your drug use do you believe you will never be able to change this? Do you catastrophise? Do you tend to give too much meaning to situations particularly negative ones? Do you convince yourself that if something goes wrong, it will be totally unbearable and intolerable? If you have a disagreement with someone do you think, ‘that person hates me?’ Are you a personaliser? Do you blame yourself for anything unpleasant that happens? Do you take a lot of responsibility for other people’s feelings and behaviour and often confuse facts with feelings? Do you often put yourself down or think too little of yourself? Are you a should / ought person? Do you use ‘should, ‘ought’ and ‘must’ when you think about situations? Do you set unrealistic expectations for yourself? Do you find yourself getting frustrated with people when they don’t do what you think they should?

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Sunday

Saturday

Friday

Thursday

Wednesday

Tuesday

Monday

Example

Anxious, sad, angry, embarrassed, worthless, lonely.

They’re laughing at me. No one wants to hang out with me. I’m a loser. I’m so lonely.

At party, didn’t know anyone. A group of people laughing near me.

What was I feeling?

What was I thinking?

Where were you? Who were you with?

Feelings

Thoughts

Situation

Kept drinking more. Got really drunk. Stormed off. Went home and kept drinking.

What did I do? What did I drink/use?

Behaviours

Appendix 9: Worksheet 4: Self Monitoring sheet

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Sad, Angry, Useless, Worthless

I should be out doing something, but I’ve got nothing to do, nobody to do it with, life sucks

Sitting at home, bored, nothing to do

I am not my thoughts

This is just a thought

Jumping to -ve conclusions Personalising Shoulds/oughts

Which unhelpful thought is this?*

What is another explanation?

My depression is telling me I don’t have anything to do. It would be nice if I had someone to do stuff with, but I can choose to do something myself and still enjoy it.

Does it fit the facts?

Not really – I’ve got some friends but they are at work, & I do have some things to do that I like

* catastrophising, personalising, jumping to negative conclusions, black/white thinking, shoulds/oughts (see Worksheet 5: Identifying unhelpful thought patterns)

Feelings

Thoughts

Situation

A bit happier, a bit more in control, a bit more motivated, worthwhile

Feelings now

Appendix 10: Worksheet 7: Managing unhelpful thought patterns

(Segal et al., 2002; Beck et al., 1979)

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Appendix 11: Sample Certificate of Attendance

CERTIFICATE OF ATTENDANCE This is to certify that

«Name» attended a two day training course on the date here covering the following topics

PsyCheck Mental Health Screening Tool » Introduction to, use and interpretation of the PsyCheck Mental Health Screening Tool Cognitive Behavioural Theory » Educational sessions on the theory and practice of Cognitive Behavioural Therapy (CBT) to prepare clinician to undertake the PsyCheck intervention, using an evidence based practice approach Pre-session assessment, formulation and treatment planning » Screening clients for mental health/other issues and preparing for feedback » Undertake a CBT assessment and develop a CBT formulation Implementation of the brief mental health intervention » Negotiating the step by step guide to 4 session PsyCheck intervention » Implementation of CBT strategies

Date: 31st October 2006

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Appendix 12: Clinical supervision – extension material Note: This information is not covered during training, but it is provided in the PsyCheck Clinical Treatment Guidelines. General clinical supervision tips and troubleshooting have been addressed below.

Introducing the cognitive model (alternative) The ABC model is outlined in the PsyCheck Clinical Treatment Guidelines extension material as an alternative to the cognitive model. Important points to note in clinical supervision include: • The ABC model is just a different way of presenting material from Session 1. • Some clients will find it easier to understand this format, so a run-through in clinical supervision is important. • As the model forms the basis for the brief intervention, it is imperative that the client has an understanding of it. So the clinician needs to be able to present it in either way to ensure client understanding. • Generating different practical examples to fit the ABC model during clinical supervision will also help the clinician’s ability to aim their explanation at the client’s level.

Behavioural activation As is important for all strategies, a strong rationale is necessary for behavioural activation to work. An example rationale is provided below. The importance for clinical supervision is that the clinician be able to practise their own rationale. • When someone is depressed or anxious or experiencing somatic complaints, they can limit the amount of positive reinforcement that they get during their daily lives. Helping a client get back into some level of pleasurable and masterful activities can provide them with some positive reinforcement. This, in turn, can help them to build back up to a higher level of functioning. This strategy is also based on the premise that behaving in a more positive way will impact positively on thoughts and feelings. • It can be very difficult to ‘activate’ depressed or highly anxious clients, so sometimes it may be necessary to start small. • Get the client to be as involved as possible with setting the actual tasks and their timing, as this will increase the likelihood of them following through with it outside of therapy. • It is important for the clinician to encourage the client to continue with this task until they are feeling better, as practice for one week alone is unlikely to have a long-lasting benefit. • With extremely unwell clients, this process should start slowly and build up. • With more motivated clients, help them to set at least one pleasant activity and one achievement activity for each day. • Remember to work at the client’s level. If the clinician pushes too hard or is not collaborative, problems will arise. • Some clients may find the activity log daunting. Encourage the clinician to fill it out with the client during the session, as this will increase the likelihood of it being followed.

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Relaxation strategies Within the range of relaxation techniques used for this intervention, it will become evident that a number of the clients have actually tried or used these strategies (either successfully or unsuccessfully). It is important to provide a clear and motivating rationale to encourage the clinician to re-cover the relaxation technique with their client. Provide a range of rationales for the relaxation techniques. Teaching relaxation skills appears easy, but for each exercise it is important to cover the following points with a clinician to ensure that they are teaching the skill correctly. Slow breathing • Get the clinician to try the strategy for themselves (trying it yourself is the best way to learn). • Emphasise the importance of not overbreathing during this technique, as it may lead to hyperventilation or dizziness. • If the clinician is having difficulty with breathing practice, show them how their stomach should rise and fall as they breathe in this way. A good way to test is by placing their hands palm down on their abdomen with their fingers not quite touching. As they breathe, point out that they should notice that their fingers move apart a little. Following are different scenarios that might be encountered with some examples of points necessary to cover during clinical supervision: Example scenarios

Points to include in the rationale for slow breathing

Straightforward:

• Relaxation is an active process in which one can work to reduce their own levels of stress and discomfort.

The clinician has not used this relaxation technique (diaphragmatic breathing) before and needs to understand the rationale they should give to their clients.

• It is an easy technique, but can be difficult to get the hang of and so requires lots of practice. • The breathing works as it allows the client to focus their attentions on their breathing and attend to reducing any possible feeling of hyperventilation. • This method can also help to reduce the fear around an environmental state by bringing the focus inwards. • Train the client to say the word ‘relax’ in their head each time they breathe out. This can help them to remember that they are trying to relax. • This technique is easy to ‘sell’ as a client can use it anywhere and anytime, and may even find it a relaxing exercise to use when they just want to unwind a little. • It is necessary to practise this technique while relaxed for a little while before using it in an anxiety-provoking situation.

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Past experience 1:

• Emphasise that everything is worth a second try if it may provide some benefit.

The clinician has tried these techniques before unsuccessfully and is reluctant to try again.

• Discuss how they did the technique in the past, and listen to their concerns and problems about the technique. • Ask them if they think it is an important technique (and discuss their answer). • Encourage the clinician to try it again with one of their clients as an ‘experiment’ to see if they have more success. • If the clinician is very resistant, consider guiding them through the technique and seeing if they feel relaxed.

Past experience 2:

• Emphasise the common goals (e.g. you both think relaxation is good).

The clinician has their own style of doing this technique and is reluctant to change.

• Help the clinician to think of it as a chance for them to learn a slightly different way of using the technique and encourage them to explain how their way is different (this will help to build a little rapport).

Reluctance:

• Run the clinician through the technique that they are sceptical about.

The clinician does not believe that relaxation will assist their clients in any way.

• Explain the importance of their feedback and concerns, and reiterate that it will be very useful information for you if they are able to try the technique and then report back as to how it did/didn’t work and why. • They might be reluctant to try it because they are unsure of exactly how to teach it to their clients. Check into this area and help them become more confident by role-playing if you think it will help them.

Adherence problems: The clinician has had trouble getting a ‘difficult’ client to engage in these types of activities before and is unsure of how to handle the situation.

• Get the clinician to spell out the rationale, using this information and information specific to the client resistance. Help the clinician brainstorm different approaches they might take to encourage the client. • Go through problem solving with a client to attempt to increase their likelihood for trying it (e.g. planning a time to do it in their day etc.).

Troubleshooting for problems experienced or anticipated • Adherence from the client: If a client isn’t doing it during the week, the clinician will need to help them to problem solve and set a specific time each day that they can try it, based on their schedule. • It doesn’t work: If a client returns after practising their breathing and says it doesn’t work, the clinician should not worry. Not all relaxation techniques work for everybody, and this may be an indication that the next techniques to be covered in Sessions 2 and 3 may be more helpful. The alternative explanation may be that the client did not really understand the rationale. Encourage the clinician to question the client around why they did not feel the technique worked and what they believe the reason they are doing it is. It may be the client did not understand the importance or possible benefits. Progressive muscle relaxation (PMR) Teaching PMR is not overly difficult, as a script can be followed. The tricky part of teaching PMR is ensuring the clinician knows how to check if a client can tell the difference between tension and relaxation within their muscles. To help a clinician learn this skill, here are some pointers:

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• Get them to do some tensing and relaxing of their own muscles to feel the difference. • If they are having trouble with the script, allow them to try it out during clinical supervision for practice. • Work on their tone of voice while they are reading the script (this is important and may be difficult for them). • Help them to work out whether a client needs specific guidance for the muscle groups. Following are some different scenarios that might be encountered, with some examples of points necessary to cover during clinical supervision:

Example scenarios

Points to include in the rationale for PMR

Straightforward:

• Relaxation is an active process in which one can effectively work to reduce one’s own levels of stress and discomfort.

A clinician has not used this relaxation technique (PMR) before and needs to understand the rationale they should give to their clients.

• It is an easy technique, but can be difficult to get the hang of and so requires lots of practice. • PMR works as it allows the client to become more aware of their body and their ability to differentiate between the relaxed and tense state of their muscles. • It is important the client continue their abdominal breathing during this technique. • The clinician can encourage the client to say the word ‘relax’ in their head each time they breathe out with each muscle group. This can help them to remember that they are trying to relax. • The main aim of this technique is to give people more insight into the tension that they may hold in their body when they are anxious or stressed. • This technique is aimed at creating a relaxed tensionfree feel in all muscles throughout the body.

Past experience 1: The clinician has tried these techniques before unsuccessfully and is reluctant to try again.

• Emphasise that everything is worth a second try if it may provide some benefit. • Discuss how the clinician did the technique in the past, and listen to their concerns and problems about the technique. • Ask them if they think it is an important technique (and discuss their answer). • Get them to try it again with one of their clients as an ‘experiment’ to see if they have more success. • If they are very resistant, you may even consider guiding them through the technique and seeing if they feel relaxed.

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Past experience 2: The clinician has their own style of doing this technique and is reluctant to change.

Reluctance: The clinician does not believe that relaxation will assist their clients in any way.

• Emphasise the common goals that you have with the clinician (e.g. you both think relaxation is good). • Help the clinician to think of clinical supervision as a chance for them to learn a slightly different way of using the technique and encourage them to explain how their way is different (this will help to build a little rapport between you and the clinician). • Run the clinician through the technique itself that they are sceptical about. • Explain the importance of their feedback and concerns and reiterate that it will be very useful information for you if they are able to try the technique and then report back how it did/didn’t work and why. • They might be reluctant to try it because they are unsure of exactly how to teach it to their clients. Check into this area and help them become more confident by role-playing, if it will help them.

Adherence problems: A clinician has had trouble getting a ‘difficult’ client to engage in these types of activities before and is unsure of how to handle the situation.

• Get the clinician to spell out the rationale, using this information and information specific to the client’s resistance. Help the clinician to brainstorm different approaches they might take to encourage the client. • Guide the clinician through the exercise of problem solving with the client to attempt to increase their likelihood for trying it (e.g. planning a time to do it in their day etc.).

Troubleshooting for problems experienced or anticipated • Adherence from the client: If a client isn’t doing it during the week, the clincian can help them to problem solve and set a specific time each day that they can try it, based on their schedule. • It doesn’t work: If a client returns after practising PMR and says it doesn’t work, the clinician should not worry. Not all relaxation techniques work for everybody. This may be an indication that the techniques covered in Sessions 1 and 2 may be more helpful. The alternative explanation may be that the client did not really understand the rationale. Encourage the clinician to question the client around why they did not feel the technique worked and what they believe the reason they are doing it is. It may be the client did not understand the importance or possible benefits. It is also advisable for the clinician to run through the technique again during the session to give the client a better understanding of what they need to do. • The client found it difficult to remember which muscles to use: If a client states that they forgot which muscles to use first, the clinician can refer them to Worksheet 15: Relaxation practice 2 – progressive muscle relaxation in the PsyCheck Clinical Treatment Guidelines. Encourage the client to start with their feet and move up through the muscles in their body, as they will then be doing everything in the right order. They also may find that some muscles don’t feel totally relaxed after going through the tension and relaxation process. If this is the case, it is good to advise your client that repeating the process for very tense muscles is beneficial.

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Mindful walking • The main reason for teaching mindfulness to a client is to prevent their negative thought patterns from ‘setting in’. • It provides a client with a strategy to help them step out of an automatic negative thinking pattern and pay attention to the present moment. • It can assist clients in taking away the judgement they may make about their progress or feelings. • The overall aim of mindfulness is to switch the client into ‘being mode’ as opposed to ‘judging mode’. • This can be a very helpful strategy for clients who over-think or overanalyse problems, thoughts, feelings or behaviours they might have. • Running through this exercise together during clinical supervision can assist the clinician in their level of understanding. • Encouraging the clinician to run through this with their client during the session can help them to identify and address any difficulties experienced by their client immediately. Note: This is a very practical exercise and is different from any of the other relaxation exercises. Keep the clinical supervision around mindfulness very practical and encourage the clinician to keep the teaching of the strategy to their client very practical also.

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Imagery/visualisation Teaching imagery might not look difficult but, for some clients, it will be a difficult exercise as their imagery skills may be limited. Here are some points to assist: • Try the imagery technique on the clinician. • Help them to hone in on asking questions about the client’s image to help them clearly define it (e.g. Are there noises? Is there a breeze? etc.). • The tone of voice first used to guide the client through this exercise needs to be relaxing and calming (practise this in the clinical supervision session if needed). • Be aware that, when asking a client about their body sensations, they may snap out of their relaxed state and attend to their physical state. If this happens, try feeding the physical questions in with questions related to their relaxing image (e.g. ‘You say it is warm on the beach. Sometimes when we are warm, our muscles feel relaxed and warm. How do your muscles feel right now?’) • Be ready for some clients to find this exercise difficult. They may feel silly closing their eyes or they may feel as though they can’t get a clear image in their mind. The clinician can help guide them there! The following are examples of scenarios that might be encountered, with some examples of points to cover during clinical supervision: Example scenarios

Points to include in the rationale for imagery

Straightforward:

• Relaxation is an active process in which a client can effectively work to reduce their own levels of stress and discomfort.

The clinician has not used this relaxation technique (imagery) before and needs to understand the rationale they should give to their clients.

• Imagery is an easy technique, but can be difficult to get the hang of and so requires lots of practice. • Imagery works as it allows the mind to go into a state of relaxation, which has a carry-over effect and helps the body to relax. • This method (like the breathing) can also help to reduce the fear around an environmental state by bringing the focus inwards. • This method works very well for some people. Focusing on breathing also helps to relax the mind completely. • This technique is easy to ‘sell’ as a client can use it anywhere and anytime. They may even find it a relaxing exercise to use when they just want to unwind a little. • Again, when providing the client with a rationale, it can sometimes be good to first ask them how relaxed they would feel if they were lying on a warm beach or sitting in a field on a sunny day etc. Once the client has identified that they would feel relaxed, then the clinician can use this as the basis for trying imagery. • It is necessary for the client to practise this technique while they are relaxed for a little while before using it in an anxiety-provoking situation (when a person is stressed, it is hard to access pleasant memories or images).

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Past experience 1:

• Emphasise that everything is worth a second try if it may provide some benefit.

The clinician has tried these techniques before unsuccessfully and is reluctant to try again.

• Discuss how they did the technique in the past, and listen to their concerns and problems about the technique. • Ask them if they think it is an important technique (and discuss their answer). • Get them to try it again with one of their clients as an ‘experiment’ to see if they have more success. • If they are very resistant, consider guiding them through the technique and seeing if they feel relaxed.

Past experience 2:

• Emphasise the common goals (e.g. you both think relaxation is good).

The clinician has their own style of doing this technique and is reluctant to change.

• Help the clinician to think of it as a chance for them to learn a slightly different way of using the technique and encourage them to explain how their way is different (this will help to build a little rapport).

Reluctance:

• Run the clinician through the technique that they are sceptical about.

The clinician does not believe that relaxation will assist their clients in any way.

• Explain the importance of their feedback and concerns, and reiterate that it will be very useful if they can try the technique and then report back to you how it did/didn’t work and why. • They might be reluctant to try it because they are unsure of exactly how to teach it to their clients. Check into this area and help them become more confident by role-playing, if you think it will help them.

Adherence problems: The clinician has had problems getting a ‘difficult’ client to engage in these types of activities before and is unsure of how to handle the situation.

• Get the clinician to spell out the rationale, using this information and information specific to the client resistance. Help the clinician to brainstorm different approaches they might take to encourage the client. • Go through problem solving with a client to attempt to increase their likelihood for trying it (e.g. planning a time to do it in their day etc.).

Troubleshooting for problems experienced or anticipated • Adherence from the client: If a client isn’t doing this exercise during the week, the clinician will need to help them to problem solve – set a specific time each day that they can try it, based on their schedule. • It doesn’t work: If a client returns after practising and says it doesn’t work, the clinician should not worry. Not all relaxation techniques work for everybody. This may be an indication that other techniques may be more helpful in this instance. The alternative explanation may be that the client did not really understand the rationale. Encourage the clinician to question the client about why they did not feel the technique worked and what they believe the reason they are doing it is. It may be the client did not understand the importance or possible benefits. The client may also say that they don’t have a very good imagination. If this is the case, suggest that the clinician could try to focus on the more physical techniques like the breathing and muscle relaxation.

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Caution for this technique As a supervisor, you need to highlight with the clinician that guiding a client through imagery might not be a good idea if the client is very flat in affect or their mood seems to be unusually unstable. Using imagery with a client in a prodromal psychotic state can be unhelpful, so emphasise to the clinician that they should use it only if they are confident that it will not do any damage to a client’s mental state. Reassure the clinician not to be overly concerned about this possibility; however, as most often they will find that a client in a prodromal phase will be unable to engage with them anyway. Communication skills An underlying problem contributing both to negative mood states and alcohol and other drug use is poor or inconsistent communication. A lack of assertive communication skills is a relatively widespread problem but, like any skill, it can be learned and becomes easier with practice. The clinician should phrase the rationale behind assertiveness at whatever level is appropriate for their individual client. • The main principle is that assertive communication helps us to express our needs, feelings or thoughts in a non-demanding, non-threatening way. • The best way to increase the clinician’s understanding of this technique is to provide them with examples of the different communication styles and get them to say which type of communication it is. • It is quite likely that a client may communicate in a certain way that is a mixture of two or more of the styles. Encourage the clinician to recognise that identifying the client’s communication style(s) is important. • Linking assertive responses to alcohol or other drug refusal to gain the client’s interest and cooperation is an important part of this technique. • Part of this section of the intervention involves the client identifying which styles of communication a clinician is using. In clinical supervision, encourage the clinician to roleplay different styles, so that they fully understand examples for each style to use in session with their client. • Another important aspect of the intervention is linking assertiveness to the ABC model. It is very important to gauge the clinician’s understanding of the link between the two. • It is also necessary for a client to role-play this style of communication during the session. It is important that the clinician is comfortable with role-playing – again, practice during clinical supervision can make this easier.

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Troubleshooting for problems anticipated or experienced • A client has difficulty identifying their style of communication: Encourage the clinician to take a few specific examples of the client’s communication and use these to illustrate the different styles. Then encourage the clinician to make a few examples of their own and ask the client to identify the different styles used. Examples are the best way to solve this difficulty. • A client thinks they are assertive, when really they are aggressive: Again, encourage the use of examples here to draw parallels to the different styles. Encourage the clinician not to make strong claims about their client’s communication styles, but rather to lead the client to the same conclusion. • A client is already good at being assertive: This is a very beneficial scenario. Use this section of the treatment as a reinforcing education session. Encourage the clinician to draw out positive examples and praise the client for their effective use of assertiveness to date. It may be helpful to generate some possible future situations that could be hard for the client and get them to brainstorm how they would respond in these possible situations. Strategies for better sleep Sleep has an effect on mental state; for example, too little sleep can lead to an exacerbation in anxiety and depressive symptoms. Talk with the clinician about his/her attitudes towards the importance of addressing sleep as part of an intervention. A rationale given to a client should include: • • • •

Sleep can have a significant impact on mental state. Long-term alcohol or other drug use can affect sleep patterns. Retraining the body is necessary if sleeping problems are occurring. Sleep hygiene is not fun; however, the long-term benefits are very helpful for the client’s mental state and overall wellbeing.

Encourage the clinician to generate examples of how they feel with little sleep compared to how they feel with a good night’s sleep, and use this as a basis for helping the client to see how sleep hygiene may benefit them. The client needs to believe the rationale for sleep hygiene to be effective, as it is a difficult process. Discuss the meaning of sleep hygiene with the clinician, to develop their understanding of the different factors involved (e.g. environmental). Go through each of the 10 techniques listed in the intervention with them and gauge their understanding of each one. It is important that the clinician understands the rationale for each of the 10 techniques. These rationales are presented below and you should encourage the clinician to reiterate these rationales with clients who are having difficulty with the technique.

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Sleep hygiene technique

Rationale for the technique

1. Go to sleep as soon as you feel tired.

This technique is to be used at night time. Encourage the clinician to try to create a strong case for going to bed when tired as opposed to watching the rest of a TV show, as sleep may be difficult if the client ignores the cues that the body gives.

2. Set an alarm to wake at the This is the beginning step to better sleep. It is about retraining the body into same time every morning. good sleeping patterns. Doing this every day is very important for the initial routine to be set. 3. Use the bed only for sleeping and for sex.

Suggest that the clinician talk to the client about associations they may have formed that they understand well (e.g. drug use and increased cravings in certain environments). They can then explain that association we have with our bed is similar to this. If the client reads in bed or watches TV in it then they will start to associate it with being awake and alert, which is not a conducive state for sleep.

4. Get out of bed when you can’t sleep after trying for 30 minutes.

The clinician should explain to the client that if they stay in bed when they can’t sleep, they will start to form associations about their bed and their inability to sleep. Getting up helps prevent these associations from forming.

5. Do not watch the clock if you are lying awake.

Watching the clock leads to excessive worry and less likelihood of sleep occurring. The clinician can encourage the client to understand that if they stop watching the clock, sleep may actually come a little faster.

6. Write your problems on a piece of paper before going to bed.

This helps to get problems out of the mind and allows for a relaxed state to occur that will lead to sleep. Sleep is about body and mind being in a relaxed state.

7. Avoid consuming caffeine after mid-afternoon.

Obviously, caffeine products are a stimulant and may keep a person awake. If the client is partial to a hot drink after dinner and before bed, the clinician could suggest that they try decaffeinated tea or warm milk.

8. Avoid alcohol at dinnertime or afterwards.

Alcohol may lead to the client’s body not getting any quality sleep, so they may wake up and feel tired and lethargic.

9. Practise relaxation before bed.

Practising relaxation before bed helps to put a person into a state of relaxation. This may help to reduce the worrying thoughts the client may be having and help to relax their body’s tension.

10. Sleep with a minimum of coverings so that you don’t overheat.

This is important as is the comfort of the pillow, the amount of light in the room, the amount of outside noise and so on. The clinician should talk the client through the importance of environmental factors on their sleep.

Troubleshooting for problems anticipated or experienced • Sleep hygiene is not fun for the client. • Prepare the clinician to expect resistance to this task. • A major difficulty for the clinician will be trying to get their client into a sleep routine. • When problems are experienced, talk to the clinician about setting a contract with their client. For example: ‘You try it your way for a week and then we’ll try it this way for a week and compare’. • Be specific about which technique the client is having difficulty with and discuss the rationale in clinical supervision. This may help the clinician to formulate a rationale specifically relevant to their client.

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