Facilitating Client Centered Learning for LPC, LMHC, and Addiction Counselor CEUs

Hi and welcome to tonight's presentation, facilitating client centered Learning. This class is actually based on a new best practice that was put out by the Registered Nurses association of Ontario. So although it's designed specifically for nurses, there's a lot of overlap because it talks about how nurses educate the patients in furthering their care once they're discharged from the hospital or when they leave the doctor's office. So with that being said, we're going to move on. Now, as most of you know, this is a live presentation, so we're going to ask you for some questions. At the beginning, we want to get your name and your email address. This is just so we can prove that you're here, you're participating, if your board should ever question it. Now, your name and email address never do go out to be to the general public. So that's a wonderful thing. And obviously we're having some issues right now with our technology. So let's just take a break for a second and we'll get right back. Do you have it fixed? Okay, so we're going to ask for your name and email address and we will not give that out to the general public. That's just for our record. So we can link all of your responses to your name and email. Couple of important points, you need to stay on the same computer once you start this presentation. That way again, we can link your IP addresses with your responses. The other thing is, in order to get credit for the live interactive presentation, you will need to answer every single question. So bear with me. This presentation will be between an hour and an hour and a half. So let's just go ahead and move on. The first question we ask for is for your first name and your last name, for obvious reasons. At the conclusion of this presentation, anyone who decided to purchase CEUs will get an email and you will be able to log in, take the quiz, yada Yada, get your CEUs, print out your certificate, Everything's wonderful. Okay, so tonight we want to explain why client centered learning is important. Differentiate traditional teaching methods from client centered teaching methods. Define the learns model, identify ways to create a safe environment, explore different learning preferences and teaching methods, and discuss ways to evaluate the effectiveness of client centered learning practices. So let's go ahead and move on. Now, we need your email address and I'm going to move on with the presentation. You can continue to type in your email address. That way we can get in and out as fast as possible tonight. So why is it important to have client centered learning? Well, client centered learning means that we're really focusing on the client. We are trying to figure out what is going to help that individual person have the most success. It will prevent medication errors. It will help with people who have difficulty interpreting labels and health messages. It will reduce increases in hospitalizations due to being re hospitalized or having to have people stay stay longer because the nurse isn't able to effectively communicate what they would need to do if they were released sooner. A lot of us have been in the hospital. I know when I had my children, we got to the hospital, this seemed like we were sitting there forever. I'm like, I could have done this at home. I think I pretty much got this covered, especially on the second one. But they like to have you there early to make sure that nothing goes wrong. Now if we were able to provide explicit instructions to people, they may be able to not come to the hospital as early or in the case of like after surgery, they may be able to leave sooner. This is true. Ambulatory detox is becoming a trend as insurance companies don't want to pay as much or for as long for people to be in detox facilities if they're detoxing from things like opiates, which typically does not have a life threatening withdrawal. So we reduce hospitalization lengths and readmissions. We reduce use of emergency services because we don't have people getting to the point where they're in crisis or they haven't had their meds for four days and they're decompensating. So they have to call 911. They're aware of early warning signs that may say, hey, you might need to go to the doctor. We will increase the use of preventative services such as mammography and vaccination because we're going to educate people about why these are important and how they can help and how it's done. So it's not so scary, it's not so intimidating, it's not so embarrassing. Whatever the case may be, we want to make sure that people know where to get it, why to get it, what happens when you get it. And the other thing that's always this big mystery it seems, how much it costs. We also want to help improve the overall health status and reduce the risk of mortality for our senior population. My grandmother, I love her to death, but she's getting to that age now where sometimes she gets confused. And like a lot of our, our grandparents and great grandparents, she has a lot of pills to take and she's got a blood pressure pill and a this pill and a that Pill and she doesn't want to worry the doctor, so she doesn't go to the doctor when she needs to or she doesn't want to cause a fuss. We need to educate people about what it looks like. When do you need to cause a fuss and when is it that you can call the doctor and go, I'm having these side effects right now. Can you tell me if it's normal? So let's go ahead. Why is it needed? Again, we talked about people can discharge earlier from hospitals. Now, this was written obviously for nurses, but in the case of detoxification or residential treatment, if we can help people develop a relapse prevention plan and or a peer support plan to help them stay clean and sober when they are at home, we're going to reduce their stays in residential. We're going to reduce the number of people that need to be in residential because if they can make it sleeping at home, then maybe they can do IOP or php, which we know is far, far more cost effective. It helps people understand complicated treatment plans. Now, for mental health, that's not necessarily something that they're going to be doing, but if you've got somebody, I've worked with a lot of patients who are on five, six, seven medications. Whoa, I can barely remember to take my vitamin in the morning. So having people who are taking multiple medications experiencing different side effects and maybe they're on medications for HIV or hepatitis or fibromyalgia in addition to psychotropics, how does that work? What side effects or what warning signs might they need to be aware of so they know when to call their doctor. So there are complicated treatment plans in mental health and substance abuse services as well as your general run of the mill physical health stuff. We want to help people make informed decisions. If they tell you you need to go in and have these six tests, a lot of us unfortunately are going to go, okay, and go and get the six tests because the doctor said we needed to. If we start educating our patients, they'll understand why they need to. Of course, there's also that other group of us who don't like needles and don't like going to doctor's offices. So we may not go get the tests. It's like, well, he said I needed to get these tests, but I feel pretty fine right now. So educating people about why, why is this necessary? Why do I need to do this now? How much is it going to cost? What's the process going to be? We want to help people learn how to maintain a healthy lifestyle. You would be surprised, or maybe you wouldn't, at how many people have no idea how to begin a fitness plan, what it means to eat a healthy diet. Now, I'm not talking about over the top, crazy, rigid diet. I'm talking about getting some vegetables in there and drinking enough water. You'd be surprised at how many people don't even think about it or have any clue how to do anything but cook, maybe frozen vegetables. So part of client centered education is, is asking them, we want you to eat a healthy diet. Do you know what that means or what does that mean to you? Have them tell you so you know where you're starting. A lot of our clients have some knowledge, so it's boring and they'll tune you out if you start at the very beginning, whereas other clients who need you to start at the beginning, if you start in the middle, they're going to be like, I have no idea what you're talking about. So we need to ask the client. We'll talk about that again more as we go through the presentation. We need to help clients communicate their perspective and their needs and values about things we're not telling them. We want to help people learn how to live within difficult socioeconomic conditions. Okay, you need to be on this antipsychotic medication. It's going to help improve your quality of life greatly, but you can't afford it. So how do we make that work? How do we make it work within your current budget? How do we make it work within your current lifestyle? It could also be that the person's taking medication that makes them very sluggish, but because they work an hourly job, they can't afford to miss work and they can't afford to be off. Maybe they work at a factory. My grandma worked at a factory and she worked on an assembly line, and there were certain productivity requirements. We need to understand that. We can't just say, well, you know, just tell your boss you're having an off day or ask for reasonable accommodations. You might be able to ask for reasonable accommodations, but you have to know what that is, and you have to know whether there are ways that you can accommodate without having to start asking your employer. Because a lot of people don't want to go and start, as Grandma would say, making a fuss at work. Managing chronic conditions. How long is this going to last? What can I do to make it better? What makes it worse? People need education, not just, okay, well, you've got fibromyalgia and you need to take this medication and you need to Go to physical therapy. Why? How did I get it? What causes it? What makes it worse? These are things that we don't usually tell our patients. So we need to get better about that. Because the more information they have, the more they understand the whys and the hows, the more invested and motivated they can be. Helping people access community resources. Most people, regardless of socioeconomic status or upbringing, have no idea how to access or even figure out what resources are in the community helping people figure that out, whether it be finding places to volunteer, finding ways to get medication, or finding ways to help out people who need help in the community. And it's also needed to help healthcare professionals interact and our consumers, our clients, our patients, whatever you want to call them, interact with a variety of healthcare professionals. Not to be afraid of the white coat, not to be intimidated, but to go in and say, I'm informed. I know what I want. I know what my needs are. So let's talk right now. In most areas, we use a traditional expert model. The client comes in, has a problem, sits down, and we say, okay, so I'm going to teach you about this. I'm going to teach you all these different things, and like magic, it'll be better. New information is distinct and it's not linked to prior learning experience experiences. Oh, my gosh. The client's strengths say it isn't. So. So we're reinventing the wheel, and we're not even providing linkages. If you've worked in education, you know that the more linkages there are to things that the client already understands, the stronger the new information is going to be remembered and retained. The client just takes this new information and implements it. Okay, the therapist said I need to go to 90 and 90. My therapist said I need to avoid people, places, and things. My therapist said, no, we want to suggest things. We want to provide alternatives. We want the client to do it because it is what works for him or her. All information is given at once. This is one of the things that frustrates me in some ways, But I can understand why we do it in residential treatment, because we have people at varying stages. Some people have been through the program before. Some people are newbies, some people have been in therapy, some people not. So we can't take a group of 30 people and start at the same place. We have to be sort of flexible with what we provide. But in 28 or 30 days, people are inundated for four, five, six hours a day with this information. They can't retain all that. It's not Possible they'll get little glimpses here and there, and that's great. One of the things that I would tell staff as well as some of the patients, is I don't want you to get too frustrated if you can't remember everything. That's why we have worksheets, that's why we have handouts. You're not expected to remember everything. What we want you to do this first month, while you're still kind of shaking the fog out, is to get back into routine, get some structure and be accountable. If you come to group, you stay awake, you try to participate, some things are going to stick. Not everything, but that's okay. And whatever you need worksheets on or tune ups or refreshers, we can do that. Health messages are one size fits all in our traditional model. Like I said, we have 30 people in residential treatment and we put them in a group or two groups. Ideally, you're not going to have even 15 people starting at the same place. Most likely, they all have different strengths, experiences, thoughts about how things should go. So providing a group to a diverse set of people like that requires something other than necessarily a one size fits all. But typically that's what we do. It's a one size fits all. Okay. I don't care how many times you've been through the program, we're going to talk about triggers today. Who can define a trigger? For me, it's great. The people who are old timers or who have been through the program before can help facilitate the trigger group. And I guess we'll get to that in the client partnership model in a little bit on how you can tailor some of these diverse groups so it's not a one size fits all. Another one of those messages we use in recovery is that abstinence is the only way. Now, for some people, that may be true, but I am not ready to say everybody on earth. That is the only solution. Learning is cognitive. Yes, it is. Learning is cognitive, but it's also affective, social and behavioral. So the traditional model says, I'm going to teach you something on this cognitive level and you're going to learn it just like your multiplication tables. How useful are those multiplication tables to you today? My daughter's learning fractions right now, so I'm kind of pulling them out of my head. But you've got to remember that you need to attach it to something that's meaningful and motivating. Which takes us over to the client partnership model. The client and teacher identify learning goals and methods together. Oh, so we Ask the client, what do you want to work on? And they say, nothing. And then you say, okay, well, you're stuck with me for the next 20, 28 days. We got to do something. Specific questions. You came in, you recently detoxed from alcohol. You have been drinking X number of drinks per day for a while. Do you think you have a problem? What do you think addiction is? What does that mean to you? How many times have you been through treatment? If you've got somebody who's been through treatment, 1, 2, 6 times, you're going to ask different questions than you're going to ask of somebody who has never been to treatment before. So read the file. At least do a cursory glance to figure out where they are in this process. Link new information to prior learning. This is what the whole strengths based model is about. Instead of reinventing the wheel, we say, all right, Jim Bob, Jim Bob, my favorite client, Sally sue is my favorite female client. But anyway, I digress. It's late. Jim Bob, in the past, when you've been able to stay clean for even a day, what have you done differently? What are your strengths? What's going to help keep you clean and sober this time? These are the things that we can ask, but we can also ask about what caused your past relapse. That's not a strength necessarily, but it is new knowledge. It's prior learning. Yep. Working in a bar, probably not the best thing for me. Oh, well, there we go. So we figured that out. Help them link all of these things together. Figure out for themselves what their mitigating circumstances, mitigating factors are. What is it that makes you want to drink less? What is it you enjoy doing besides drinking? And the exacerbating factors? What things trigger a relapse? What things make you think, oh my gosh, if I could only have a drink. New information. Take that, all that stuff that's kind of bobbling around in there and not necessarily attached. Bring it together and help the client synthesize it into something that's meaningful and then link it to. Alright, so now with all this new knowledge, what are we going to do with it? The client has to undergo an unlearning process before new information is implemented. If you've ever hired somebody, if you've been a supervisor, some of us really prefer to get clients who either. Not clients, I'm sorry, staff who did their internship with us, because then we don't have to unteach all of the bad habits or different habits they may have learned somewhere else. Our patients have the same thing. They've been doing this particular behavior, which is not what they want to do anymore, but they have to unlearn that, which means we're going to have to put discriminative stimuli in the way prompts. We're going to have to help them figure out how to break that behavior chain. There's an unlearning process a lot of times. It's not going to be perfect the first time out of the shoot, but that's okay. Information is given over time, small doses. We say, okay, this is a broad subject here. You're probably going to take. And I ask my patients, when they're in a group with me, to take one to three things out of the group that they're going to be able to use. My patients that are in aftercare, they go to 12 step meetings, smart recovery meetings, whatever works for them. But I tell them, when you come out of that meeting, I want you to write down in your journal one thing that you got out of that meeting that you can apply for the next week. Why? Because it makes them pay attention. It makes them link what they learned or they heard in that meeting to their prior experiences and it makes it meaningful. So it's not just I went to a meeting because I was supposed to go to a meeting. It was I went to a meeting and wow, this is what I heard. This is what it reminded me of. It woke up that thought back here that said, you need to be doing X, Y and Z. Information is given over time so they know where to go back to get it again. We'll go over the whole addictive process and triggers and all that stuff in the first 28 days. They're not going to remember it. So what do they do when they're trying to figure something out? Who do they go to? Do they go to their sponsor? Do you have resources? Is there an aftercare group? Where is it that they can get more information, help people figure out where those links are in the community as well as in your organization. Information is tailored to the diverse needs of the individual. It was not uncommon for us to have people in our program who couldn't read or write well. When we're having them fill out worksheets and read the big Book, that's not really helpful. So we had to figure out a way to tailor this to meet their specific needs without embarrassing them or making them feel self conscious. Having big groups where everybody passed around the big book and read aloud was quickly thrown out the window because that was not empowering. To the clients. We got the big book on tape. We had people read in groups where one person would read for the whole group. It would be a facilitator and then they would discuss it. We tried to make it as useful as possible. We had a client who had a seizure disorder, couldn't write, There were too many. He would have these tics that would prevent him from writing and feeding himself if he got too nervous. We had him record things. Instead of filling out his autobiography, he used an audio recorder. So there are things that we can do to make information delivery and give back. What's the opposite of delivery? Whatever. Useful and meaningful for the client. As I said earlier, learning is cognitive. No doubt there's information there, but it has to be affective too. Why do I care if I don't care, I'm not going to remember. People tell me their phone number now I put it in my device, I forget about it. I don't care to remember it anymore because it's in my device. We need to make them care and care to keep it in the forefront of their mind. Social. Social support for doing the next right thing. Wonderful. But learning can also be social through observational learning. I see Sam doing X, Y and Z, and these are the consequences. If I want those same consequences, then I'm probably going to do X, Y and Z. Or at least start there and then figure out how to make it my own and behavioral. You can care, you can know how to do the right thing. You can have all the social support in the world, you can watch people do it. But until you actually put one foot in front of the other, you're not implementing anything. And we have to learn new behaviors. Moving on to the learns model. Listen to clients. Strengths, needs, attitudes and preferences. What do they do well? What do they need as far as information, types of information, quantity, quality, what level? Don't give somebody a college textbook if they only completed the 8th grade. What are their attitudes towards medication, towards 12 step meetings, towards. Towards fill in the blank. And what are their preferences for how treatment will go? Some people want active, interactive. Some people are thinking more psychoanalysis. Ask them what their preferences are. How do you want to work this out? When you do your autobiography, which was one of those mandatory activities, we had to figure out how to make it meaningful for people. What are your preferences? Do you want to write it down and then read it to me? Do you want to write it down and give it to me? Do you want to write it down? And none of the above. And we'll Just talk about what you found meaningful at this point. Autobiography was one of those things that people did really early in treatment. And I don't know how comfortable I would be writing my entire life history and burying my soul and handing it to someone who's just short of a perfect stranger. So what are their preferences for how to handle their personal information, how to handle their sessions? You want to establish a therapeutic partnership, I'm not going to tell you you have to do this, this and this, because I said so. We're going to talk about what your options are, what you want to do, and what information you need to be successful. And I'm here to support you. We want to adopt an intentional approach to every encounter. Not just every person, but every encounter with that person because they may be having an off day. For some of our clients, they are so disengaged from being mindful that they don't really realize when they're having an off day. So we can point it out and go, you know, you seem like you're a little foggy headed today. Tell me what's going on. They may go, oh, you know, you're right, an intentional approach. If they're foggy headed, you may need to back up and slow down whatever you're going to give them. If they come in that day and you can tell they've been boohoo crying for days, you may not hit that agenda that you had all laid out because the patient is not able to hear it right then because they're in crisis about something else. However, the intentional approach to every encounter also means figuring out how every encounter fits into moving the patient along the path to recovery. Don't let them get you sidetracked. That's part of what our clients do in order to protect themselves. So be aware of that, talk about it. Reinforce health literacy and curiosity. When they ask questions, give information. If you don't know information, say, you know what? I don't know. Really. You're supposed to know everything. No, we're not. We don't know everything. And the key is to helping our patients understand we don't know everything. And actually they know more about themselves than we know. We can just kind of put things in a different perspective and help them see it a different way. Have them name new knowledge via Teach Back role playing, giving examples, applying it to their life. When I do groups, we spend the first 5, 10 minutes reviewing the past week. We move into the, what I call the psychoeducational segment and then we spend the last 20 to 30 minutes going around the group and talking about, okay, how could this tool have been useful to you over the past week? Or how might you use it over the next week and what might you need to do to make it yours so it feels comfortable to you? Because not everybody is comfortable doing the same things. Have people give examples because it links it to prior knowledge. It has them articulate exactly how they could have or will apply it. So then it's not like, oh well, maybe I didn't understand it as well as I thought I did. Now's the time to get that out in the open and go, I think you might have missed something. Strengthen Self management via links to community resources we hopefully are not the 24 hour on call 247365 for the rest of their life person. That's dependency. We want to empower our clients to reach out and tap into local resources. Now for some clients, we may need to initially do that in session. Teach them how to reach out to community resources. Role Play what would it be like to call the Medicaid office? What would it be like to do this? Because they don't feel comfortable in the systems or they get confused in the systems or bossed around or whatever the case may be. Figure out where the patient is. If they feel comfortable picking up the phone and calling on their own, great. The majority of my clients have often wanted to do it in session or even watch me do it the first couple of times. Ask your client what their preferences are. Ask them what doesn't feel comfortable to them about reaching out to these community resources. Is it a pride thing? Are they embarrassed to ask for help? Is it they're embarrassed that they don't know the right words to say. Are they afraid of authority? Brainstorm. Because once you figure out what their barriers are, then you can problem solve. So learning is effective. Motivation is effective. We get out of bed and we're like, I don't want to do that. We're not motivated. If we get out of bed and we're like woo hoo, we get to go. Do fill in the blank today. It's more exciting when I work with patients who have trauma histories and anxiety issues. I work with equine assisted therapy and animal assisted therapy and it's amazing how how much more motivated they are to work on things if they know that if they complete certain tasks at the end of the week, they will get to have a session with one of the animals. Figure out what motivates your clients. Why do they care? What makes it worth Their while to listen or do whatever you're asking them to do. Is it their family? Is it their health? Is it their comfort? Is it their bank account? You know your clients and they know themselves. Caring and empowerment. If people are not empowered, if people feel intimidated, no matter how motivated they are, they may shirk away from it because they're afraid. So when we teach information, we don't want it to be overwhelming, we don't want it to be intimidating, and we do want it to be motivating. We want clients to walk out of our office or a group session going, I can do that. Behavioral learning is behavioral. It means actually taking all this knowledge and doing something with it. People need to be motivated before they act cognitive. They need the material to get excited about and implement. And then social. Social support a cheering squad, people who believe in them. That helps motivation as well. Because when people make a verbal promise to other people, they're more likely to keep it than if they just have it in their own head. And they're like, okay, my new year's resolution for this year is, I'm going to quit smoking. But they don't tell anybody. So then they don't have to admit they didn't do it. If they don't do it, if they go out and tell somebody, then it's, ooh, somebody might hold me accountable. So social can provide support, motivation, and observational learning. In groups, people can observe how other people have implemented tools. They can share experiences. Get all four of these in there in order to have really good solid learning. And remember, Rome wasn't built in a day. They don't have to learn the entire substance abuse counseling curriculum in 28 days. Figure out what they need to move from a 1 to maybe a 2 or a 3 on a scale of 1 to 10. And then over the next 11 or 12 months, they'll continue to move forward. But let's make our first steps really solid and strong. How can you help your clients care about the issues that you deal with them? Ask them how things would be better if they didn't have the current problem. Sure. What are you hoping is going to be different if they're in your office, they have hope that something's going to change. They're not going, yeah, I'm coming to you because I really want to make my life suck. It's not going to happen. So what would be better or what would be different that helps them care? For some of my clients, when I first started and I was working with felony drug court, their goal was to get off papers. That's what they cared about. How confident they are that they can change the situation? Sure. On a scale of 1 to 10, how confident are you that you can change the situation? And if they say five in your mind, go, okay, great. And ask them, why aren't you a three? And they'll give you all these reasons why they're not a three, and you might be able to come back and say, hmm, that almost sounds like you're more like a seven. So the technique is called aiming low. Have them tell you all the reasons that you're ballparking. A little bit too low on their motivation. And that increases their motivation because they have to articulate why. Okay. What would they like to see change? Sure. Ask them what motivates them? Why do you want help? And depending on your client, obviously you're going to work on your wording. I go sort of off the cuff here, but we don't want people to feel like we are interrogating them. But ask them, what is it that you are hoping that we can do today or this week or this session? How would things be different if you changed? What would be different if you changed? Talk about how the issue is currently impacting their family. What's the impact of this? Because you probably don't live all by yourself in a cave. So is it impacting your family or your job or your health or anything? Ask them what they think might be hardest about treatment. They may care, but remember I said if they're intimidated or afraid or overwhelmed, they may not be motivated. So let's talk about what might be hardest so we can start removing those barriers together and have them feel empowered, like they can take at least the next baby step. All right. All excellent. All excellent responses. So we want to create a safe environment where clients feel comfortable asking questions. If your clients are like, you know, they don't feel comfortable, if you can honestly say you go an entire week without having a client ask you a question, it's probably not a safe environment or not a stimulating environment. You may have to look at which one it is. Clients need to feel comfortable and not feel like they're going to be laughed at or ridiculed in any way if they ask questions. You know that thing that some of our teachers used to say, no question is a stupid question. I don't know that I agree with that. But we don't want to make people feel embarrassed or self conscious. Clients are able to bring someone with them to appointments. Not everybody feels comfortable talking to doctors or nurses. Not all patients, especially some of our patients who may have early onset Alzheimer's or who are in the early stages of ambulatory detox or getting ready to get out of detox, they're still in a fog. If we can have a sober social support person there to help hear things, ask questions, know who to contact if they need more information, that's awesome, because then that provides someone that the client can go to at 8 or 9 o' clock in the evening and go, you know, the doctor said something. Professionals are aware that some clients are ashamed or anxious when they don't understand. Many of our clients grew up in systems where they were ridiculed, they were put in classes and called slow. They were always looked down upon because it may have taken them a little while longer to grasp certain things. Now, recently, probably in the past 10, 15 years, we're starting to understand learning disabilities more. But a lot of our patients grew up in times when there was not really an understanding of dyslexia or ADHD or anything like that. So they were just considered dumb, and then they were made to feel bad. We want to empower clients and help them understand that they're smart, they know a lot about them, and a lot of times the questions they have are the result of us not explaining things well. I had a client one time, it was my first internship, and I went in to do group and I was gung ho, and I started throwing around all these words like cognition and intentionality and discriminative stimulus. And one of the clients finally said, we don't have a clue what you're talking about. It was run of the mill for me because that's what I talked. That's how I talked every day in grad school. So going, oh, okay, my bad. Breaking it down and using real terms, not jargon, helping patients understand that, you know, sometimes we don't explain things really well. When I was teaching my daughter how to make scrambled eggs, perfect example, I kind of skipped the step of putting all the eggs in the bowl and then putting milk in and then whipping them up and then putting them in the pan. First time she made them, she was just cracking the eggs in the pan. And I'm like, you haven't scrambled them yet. She said, well, you didn't tell me to scramble them. I was going to do it later. That was my bad. It wasn't that I was using technical jargon. I just kind of skipped over a step that seemed common sense to me because I'd done it for 30 years, same thing for our clients, make sure they understand that we're not perfect. And even if you are a teacher by trade, doesn't mean that you explain everything perfectly all the time. Professionals are aware of clients knowledge and beliefs about their conditions. If they believe it's a disease, if they believe it's a condition, if they believe it's incurable, if they believe that they can stop using anytime they want, we need to be aware of what their beliefs are. Because if you're talking to a group of people that are still in pre contemplation, they can stop using anytime they want. They're just here because they have a law enforcement problem, not because they've got a drug problem. You're going to need to approach things a little bit differently than you would if you were sitting in a room with a group of people who go I'm sick and tired of being sick and tired and I've got a drinking problem. Professionals understand how clients perceive the condition or treatment may impact their family. Okay, how does alcoholism or drug abuse or gambling or sex addiction or clinical depression, bipolar, schizophrenia, whatever the case may be, how does it affect your family? Some clients don't care. They're like, I could take them or leave them. And we also need to talk about how they define family. Those closest to you, how does it impact them? But we also need to talk about how will treatment impact them. If it means you're going to have to be at work from eight to five and at treatment from six to nine, four days a week, how's that going to impact your family? The costs associated for treatment, some things your financial department can work with. But we also have to talk about how might that affect your family? I've worked with some prominent people and wives of prominent people who come to treatment and they're like, this can't get out because it would negatively impact my significant other's career standing in the community. Whatever the case may be, it's really important that we understand that and understand how people are going to act and react. If they're afraid of somebody else finding out that they're in treatment, they may be less forthcoming, they may be less coming, making sure they have privacy and as much confidentiality as possible. Those are things that we need to do to create a safe environment. Barriers to a safe environment, too much information. You can take a person who has come out of detox and give them the five minute scenario of this is what we know about addiction and this, these are the treatment options or you can give them the five day version they're going to tune you out after the first five minutes anyway. Most of us have an attention span of about 11 minutes, just as long as the normal Tom and Jerry cartoon, which is probably why I'm a cartoon fanatic. If we start dumping a bunch of complex information on people all at once, at a certain point they're going to tune out. They'll get one or two pieces and they're going to be over here trying to process that and you're still yammering in this other ear. Break it up, small bits, write it down so they can go back and review anything that you may have been talking about while they were processing. Don't use jargon. Talk in plain simple terms. Like you would talk to your neighbor. Well, you know, of course some of you are going to go, well, my neighbor's a nuclear physicist. Great. Like you would talk to your grandma or your great grandma or someone who may not be in the same field as you. Avoid complicated forms and brochures. And that doesn't mean just big words and a lot of jargon, but lots of detail all over the place. Distinct and to the point, larger type. Try to get your point across and not have leave things hanging for people. Avoid relying on just words. If you've got patients who don't have as strong of a reading ability or who may be dyslexic, they may benefit from having some pictographs that say, okay, this is where I look to figure out how to get help. This is where I look to figure out where to find a 12 step meeting. It cues them in and then they can hone in on that and use their energy, reading the material that is most important to them. Periodically check for understanding. If you don't, then those people who are intimidated or overwhelmed or who just turned tuned you out, you're losing all of them. Difficult to navigate systems. Well, first you've got to go in for your pre assessment. Then you've got to go in for your assessment assessment. And then we're going to set you up with a therapist who might refer you out to a doctor and maybe bring in a case manager. No, most people make it to the pre assessment and never come back. Too overwhelming, Too much to navigate. One stop shop is ideal. If you start sending people all over creation, regardless of whether transportation is an issue or not, they're probably not going to follow through. Make the system understandable. If this is your problem, these are the three steps that you'll take. The veterans association, the va, Probably a lot better now. I don't know. I haven't interfaced with them in probably five or six years. But the veterans I used to work with used to lament how difficult it was to get set up in certain programs because you knew the program was there, but you didn't know how to actually get enrolled. Pictograms are helpful for that, too. Step one, do this. Step two, do this. And lack of reinforcement and support. Sometimes there are going to be multiple steps. So how can we reinforce every single step and provide support for people so they don't feel like, well, nobody gives a crap if I do it or not. What barriers to learning and health literacy exist in your current work environment? Lack of understanding about how new behaviors address problems. We're teaching these new behaviors, but we're not linking them and we're not giving them the why. So we're only providing the cognitive, not the affective and the behavioral being overwhelmed at all. That has to be done. So again, we're teaching cognitively and maybe effectively, but we're not providing the social support that they're motivated, but they're overwhelmed at the same time, and they kind of cancel each other out. The cost of care, number one, the cost itself can be overwhelming if your facility is not able to work with patients. But a lot of times there's this question mark at the end of the cost of care. Well, it'll probably be about. I don't know about you, but if we're talking 5, 6, $8,000. I don't want an about. I want an exact figure. Limited access to resources. There's only so much that we can get your insurance company to pay for. There's only so much available in this particular community. I've been very blessed to be in communities that have a lot of community resources, but I've also worked in communities where there's Nothing. There's like one 12 step meeting a week and virtually nothing else. It's very, very rural. So we need to make sure that we identify what those barriers are and figure out how we might be able to help people overcome those. They can't stay focused on learning what they should do because of what they want to do. Excellent. They want to feel better. They want to stop the pain. For example, all these shoulds up here, all these tools that we're giving people, they're great tools, but they don't work as well as what we've been doing to stop the pain. So it's hard to focus on learning all these shoulds and getting through it. There's also an element of what I used to do is a lot more fun. What I should do, not so much fun. So that's talking about motivation and getting people engaged in getting excited about all the reasons that they can do something different. Many of the people who work directly with the clients do not have the education or experience needed to help them. Oh yes. And it's not for lack of wanting, not for lack of wanting to help, but it's not necessarily available. So making sure that our patients know that, yeah, we don't have somebody who can really address fibromyalgia at this clinic. However, here are some resources that we might be able to point you to. It's time consuming, but as you go through this process over the first year or two, you develop quite a library of resources and, and United Way information and referral in most communities is awesome. About helping hook you up with some of your more basic things. Those are the things that we need to help clients understand. This one agency right here, we may not be able to meet all your needs, but I'm not just going to tell you that and kick you out the door. I'm going to support you and try to help you figure out how to link with something or, or someone who can help you meet those needs. Not everyone in group has the same education level. Teaching a doctor and a high school dropout at the same time can be very challenging because again, they're starting at two vastly, vastly different points. However, there is some common ground. Neither one of them knows how to stay clean and sober clearly, or they'd be doing it or why they can't stay clean and sober. Finding that common ground, making groups interesting, making it so people can apply the information to themselves as they're going through group instead of trying to tailor to each one can help. But you're right. I never had a doctor and a high school dropout, but I did have an engineer and people who hadn't completed college or high school in the same group. And it was a bit challenging. But another issue that we can look at specifically with the doctor sometimes is are you holding onto this title? I'm an engineer, I'm a doctor, I'm a lawyer, I'm a fill in the blank. And we all have the same thinking problem. Let's start there and try to find commonalities instead of differences. I had one colleague that I worked with and she specifically worked with professionals and she told people, check your title at the door. You are not doctor so and so or attorney so and so in here. So you can Hang it up. And she meant it too. That can be helpful. It doesn't work 100% of the time. You have some people who may not have a degree and they're just stinking brilliant anyway, who may process information faster. Figuring out how you can involve them. Let them help you. Let them help co facilitate. Break people up into groups and have them teach portions of it. Figure out ways to use your client's strengths, because that doctor is really, really smart in some areas. But you also may have a mechanic over here who is really, really smart about mechanics. Kind of see where I'm going here. Hopefully you can find that common ground and find the strengths and pull them all into the group to make it a really strong, cohesive and energetic group. I think I addressed everything that you guys put up here. Thank you. Those are awesome responses. So one of the things that they talk about in creating an environment like this is a universal precautions approach. We want to decrease the complexity of the information provided. What I'm teaching is addiction 101. If you want more detailed information, if you want the real research and articles and all that kind of stuff, here are these resources that I can give you to read after group. If you're not interested in that. I get it. If you have a learning style where you like to fill out worksheets. Here are some worksheets over here. We're not making it too complex for the person who's over here in the beginning stages, but we're trying to keep the other people invested and maybe have them explain it in a way that you can't explain it. Use concrete examples, not something out here. In theory, if you have this situation and this situation, stop and say, okay, Jim Bob, tell me about a time when you had to use refusal skills, concrete example, or create scenarios that you have them role play that are concrete. They have names, they have, you know, obviously fake names. And the situation is concrete. So you're not talking about. Well, sometimes you may have to say no. Yeah, so. But that's not concrete. When you're riding on the bus and somebody tries to sell you drugs, when you're going on the bus stop or you're going on the metro stop past where you used to get off to go meet your dealer, how do you deal with that? Those are concrete. Limit the number of topics covered in one session. In group, we do one skill and we apply it to something from the prior week and we forecast how we might apply it to something in the upcoming week, and that's it. One skill that takes the Entire session. We may have to kind of go over it a few times, but I would rather do that or heaven forbid, let group go a little early than go over too much stuff and have people walk out and go, well, I really like that. But then I quit thinking about that and she half taught this and no, that doesn't work. Teach. Use teach back to ensure comprehension. Some of the ways I like to do teach I don't like. No, stop, finish your sentence. I don't like to do teach back where I teach somebody something and then I say, okay, now tell me what I just said. The only time I do that is when I'm working with my children and they haven't done their chores and they're in trouble and they know that that's not a good phrase to hear. Tell me what I just said. So using teach back, find creative ways to have the clients show you or tell you what they just heard. Role playing is a great example. Like I said, what I do is I have them apply it to something from last week and forecast how they might apply it in the future. And then as a group, we talk about whether we think that's going to work and maybe fine tune it for each person if they're stuck or if they talk about how they're going to apply it and it completely misses the mark. This is my chance to go, okay, maybe I was unclear or find some segue that is not condescending or not harsh in any way that says, you know, oops, I guess I didn't explain it so well. Focus on critical behaviors. And that's not criticism, but the ones that are most important. Not using. Identifying, relapse warning signs. We can talk about communication skills and relationship skills and this, that, and the other until doomsday. I mean, just about anybody could probably spend a fair amount of time in therapy and learn something new or reading books and learn something new. That's too much information. What are the critical behaviors for your client who has just gotten out of Detox, who has 28 days to develop the skills so he or she can live at home, not use and actively participate in the next stage of treatment, which is generally iop, Those are your critical behaviors. So refusal skills, identifying relapse warning signs, identifying and removing triggers. If we're talking about depression, same sort of thing. Relapse warning signs for depression. You know you're starting to get depressed when these are all things that we want our clients to know. These are the critical behaviors. We can fine tune everything as we go. So let's talk about. I'll try to give you an example for nutritional counseling using motivational or scare tactics, lacking a focus on a few critical behaviors, not giving concrete examples and not not teaching back would go something like this. Hi, Sally. I am so glad you're here today. Now, it is really important that you start learning how to eat a good diet, because with your weight right now, you're really on the verge of diabetes, and you could also have some more problems like heart disease and high blood pressure. And you really. You've got young children at home, so you don't want to die any sooner than you have to. So we need to look at all the things that you're doing now. In order to do this, you need to eat from every single food group in the food pyramid. You need to have a bunch of servings of grain, a bunch of servings of vegetables, a few servings of meat and some dairy in there. And you need to drink a lot of water. You need to really increase your water and stop drinking caffeine. So now that you understand all that, oh, and I forgot to tell you, your minerals, like copper and selenium and those things you need to make sure you're getting plenty of. So a multivitamin can help, but you also need to eat foods that are rich in those different minerals. All right, so I'm going to write all that down for you, and I'll see you again in a week, and you can tell me what your progress has been. Now, most of you are probably sitting there going, what just happened? Some people may have tuned me out. When I started telling her how she was going to die, I would tune that person out. At that point. I'd be like, okay, you were just, like, over the top. The nutritionist person didn't give any concrete examples. You need to eat more vegetables. Okay, so I should eat a lot of tomatoes and apples, right? No, those are fruits. The nutritionist didn't ask, what do you know about nutrition? What are your favorite vegetables? What are your favorite fruits? Let's make a meal plan. Those are all concrete examples. None of those were used. And she didn't have the client teach back anything by saying maybe. Can you give me an example of two things you might do in the next week to increase your water consumption and increase your consumption of green leafy vegetables? Then you can have a dialogue. And if she gives you an example of, I don't know, something that's not a green leafy vegetable, you can say that. Okay, so I guess I didn't explain really? Well, what I was talking about with green leafy vegetables, we're talking about kale and spinach and lettuce, those sorts of things. So let's go on and try to give a good example. She walks in and I say, hi, Sally, I see you're here to learn a little bit more about nutrition so you can work on controlling your weight. Because you've got a history in your family of type 2 diabetes. Now, that doesn't necessarily mean you're going to get it, but since you're here, that tells me that you're interested in learning ways you can prevent it. That's an empowering statement. So we're going to. There's a lot to nutrition, but we can really kind of make it more simple to start out with in order to figure out what's going to work for you. Because if you go from eating the way you're eating right now, however that is to trying to do something that's really regimented, it's going to be hard to stick with. This is a lifestyle change. So what I'd like to talk about today is ways we can increase your water consumption. So you're drinking at least eight 8 ounce glasses of water. Now an 8 ounce glass, a regular glass is like 12 ounces, so an 8 ounce glass is about 2/3 of that or a regular glass with ice. You want to drink eight of those a day. We want to increase your consumption of green leafy vegetables like spinach and kale. And so we may need to talk about ways to make those more palatable if those aren't things you like. And I'd also like to talk about maybe reducing how much red meat you're eating or figuring out ways that we can reduce your saturated fats. And those are found in red meat. So maybe like grilling instead of frying things. So are you open to talking about ways we might address those three things or a fourth one you could put in there? Eating colorfully. There's a lot of information about eating on the food pyramid. And you know, I don't have the time or the attention span to actually count my own servings. So I'm not going to ask you to do it. What I want you to do is eat colorfully. And that means I want you to have three colors on your plate at every meal and different shades of white don't count. So what you're going to do over the next week is, and before you leave here, we'll write down an action plan. Ways to increase your water consumption to eight 8 ounce glasses. Ways to increase your consumption of green leafy vegetables, even just a little bit. And how you might have three different colors on your plate at every meal to help you start tapping into all those food groups. And then we talk about how might you do that? What types of foods do you like that maybe are red that are green? Purple is difficult except for eggplants. So that's in my mind and you can tell me more at the end, but in my mind that's a lot less overwhelming. As Sally I can say, okay, those are three things I can do. And we don't want to give patients more than three things to do at a time, any more than that. And if they do all of them, they're going to do all of them halfway. So they can only successfully focus on three behavior changes at a time. Have them give examples. That's that teach back component Assessing clients Learning needs how are you feeling right now? Tap into that anxiety, that apprehension, that feeling of being overwhelmed. Tell me what you know about. We often fail to start there. We start at the tell and then maybe go to the ask. Ask, tell asks. I can't even say that right? Ask, tell. Ask says, tell me what you know so I know where to start. I don't want to start and give you more information than you need, but I also don't want to start up here when you need some foundation information. So tell me what you know about addiction. Tell me what you know about depression, anxiety, nutrition. Tell them sort of the things that you think are the critical behaviors or critical information that you think they need to know. Maybe not. All right, now, over the next eight weeks, we're going to talk about and then ask them if that sounds like it makes sense. Does that seem like it'll fit for you? Does that sound like it makes sense? Does that sound like something you're willing to do with me? Ask them what questions or concerns they have. If you're asking them to go into residential treatment, there may be some concerns. If you're asking them about iop, if you're asking them about whether they're comfortable starting to take a different regimen of medications. These are all things that we want to open the door and say, it's okay to tell me you don't feel comfortable with this. Ask people how they learn. And I always give the example of a computer or a dvr. Most everybody has some sort of a cable box DVR thing in their house. And I say, when you get a new DVR and you're trying to Figure out how to use it. Do you read the manual? Do you have somebody tell you or show you? Or do you just start pushing buttons and figure out what works? And most people are a combination, but the button pushers are your kinesthetic learners. They need to hear something and do it. Hear something and do it. Read something and do it. The people who read the manual are your visual learners. And the people who want to be told how to do it, they're the people who can just sit in a lecture class and absorb everything. And like I said, I have an attention span of a mouse, so I'm not an auditory learner. This way we can present information in a way that's meaningful to them. If you're doing a group A again with doctors, engineers, high school dropouts, make sure you present the information. You're talking about it, you're applying it. But also give them worksheets or reading material that they can review. And the reading material should be succinct. Bullet points. I love bullet points, especially in early recovery. Help them figure that out. Ask them what helps them to learn new things. Practice makes perfect. They do better if they watch somebody. What helps them? So in what ways can you help your clients improve their understanding of the material? Multiple methods of presenting information, even if you're talking about it. Having it up on PowerPoint so they can look at it. Asking questions that help them apply whatever you're talking about. Meet them where they are. Ask the group at the beginning, what do you know about nutrition, exercise, wellness? And then start picking there. And the people who know a lot, you may ask them for their input and their feedback on the things they know a lot about. Because most everybody knows a lot about something. Like the person who worked on cars. I would have them draw parallels between keeping a car running well and keeping themselves running well, tying it to something that is meaningful to them. Have them explain how the material presented applies to them. Sure. Ask them, what was one thing you got out of the group today? Pretty simple. One of the things I love about that question in a group setting is you hear back what you taught well and what was useful and meaningful, and maybe what you didn't teach so well. Ask them if there's anything they don't understand so you can clarify it. Certainly. And I like that approach, saying, is there something, anything that I was unclear about? Let me clarify it or try to clarify it for you. That's telling them that it's okay to ask questions because I'm not perfect. Provide examples, roleplay scenarios. Give them Material to take home and read that reinforces what they learned. You can also, you know, I said, in group, I spend the first 10 minutes reviewing the prior week. That's when I take all that information that they tried to apply and I say, okay, now you took what we learned last week on anger management and you tried to apply it. Tell me how that went so we can fine tune it a little bit. And it also connects the weeks and it brings it to the forefront of their mind. Encourage them to bring a support person to the appointments. Even if they do understand everything. Having somebody else hear it may also help. Multiple methods of presenting. Okay, I think I've got all of these. We're rapidly coming close to the end of the presentation, so just bear with me a little bit. Techniques. Tailor your approach and educational design by collaborating with the client and the interprofessional team. Tailor it to the client. If they prefer to read, let them read the material. Now, you know, I'm really grateful for all of you who are in attendance tonight. However, since I'm not an auditory learner, I would rather die than sit through an hour and a half presentation. Give me something to read and let me highlight it, let me manipulate it, do whatever I do with it in order to internalize it. But sitting and just watching a presentation, I'm not good at. Engage in more structured and intentional approaches when facilitating client centered learning. Don't just wing it when you go in there. Have a treatment plan. Remember how I said earlier, you want to know how what you're doing is getting the patient from point A to point B. Even if you take a little detour, you need to understand how that fits in to the travel plans, and you need to be able to help the client understand how that fits into the travel plans. I gave the example of the client being in crisis, and you had this wonderful activity planned on identifying relapse traps. And they come in and they're in crisis and you're like, well, crap, I guess we can't do that today. So you talk about the crisis, but then you can also bring it back to say, okay, so let's talk about how you handled this differently now than you may have a month ago. What new tools did you use? How did it make you feel being able to experience this without using? What can you take from this in order to strengthen your relapse prevention plan? Bringing it all back to this is you. This is how you're figuring out how to deal with emotions now that you feel them and how to deal with life. On life's terms. And every encounter is about dealing with life on life's terms. Use plain language, pictures and illustrations to promote health literacy. When you tell somebody about how to work out, you don't want to say, flex your arm at the elbow. You want to give them an example. Show them a picture of somebody doing this. I learned how to crochet by watching YouTube videos. Because I can watch a video, pause it, do the stitch, unpause it, and so on. That kinesthetic learner in me watch and do, watch and do. But the illustrations help me. Looking at a picture of somebody tying a knot, I don't know which way they're going and that frustrates me. So talking with clients about how they learn best using that plain language. Use pictures when appropriate. Use videos when appropriate. Printed or online materials. Not everybody has printed materials anymore that they give you in your hand. There are e books, there are things they can look at on the Internet. Just make sure you help them figure out how to separate the wheat from the chaff. Reading and comprehension is very important. You don't want to send somebody to the National Institute of Health's technical publications if all they need is the consumer publications. Be aware of their reading and comprehension level. Use pictograms. This is especially helpful with elderly patients or patients who have a lot of medications that they're taking for medication compliance. It's also helpful with exercise, nutrition. There are a variety of things that people can see a picture and go, okay, check off the fruit. I already ate one of those. Or check off the bicep curl. I already did that. Interaction. Use workbooks where they can fill out, fill in the blanks, finish the sentences, whatever you want to do. Diaries, I will fill out. Workbooks. I will not keep a diary. Didn't when I was 16, won't do it now. I just can't even get started with that. So asking your clients what is going to work for you? To help you internalize and process this information, I'll do charts. I love charts. Charting behaviors, charting frequency, intensity, duration, calories consumed, whatever. I'm a list person and a chart person. That goes part partly with my temperament, but making different options available. And as you work with patients, you'll find out, okay, here's this concept. And There are probably 17 different ways we can present it. That's the wonderful thing about interns. You can make each intern do a different worksheet. You can also have clients work together to create worksheets that will help them monitor and the ones that you really like, you can say, hey, that's awesome. Do you mind if I use that in the future? Most clients end up beaming if something they developed is something you like. Telephone or video chat can be very helpful in between sessions, sort of coaching. And this is a concept that dialectical behavior therapy has sort of picked up to emphasize those new behaviors and help the client while they're going through that unlearning process, they're at this point and they're like, okay, now I know I really don't want to cut anymore, but I can't remember what I'm supposed to do. And keeping that information in the forefront while they unlearn the automatic response or the knee jerk response to cut and learn a new behavior to put in its place. Sponsors are real helpful for this too. It doesn't have to be the therapist that is the telephone person. Support groups are great for observational learning, role play, and just general social support. You can tell people the same thing. And if you've got kids, you probably know this. You can tell people something. And my husband will come behind me and tell my children the exact same thing that I just told them, just using different words. And they get it when he tells them. And I'm like, I just said that. But I said it in a way that they didn't understand. So you may be teaching a concept, and you may teach it really well to 85% of your group. The other 15% hears the same concept when they go to a meeting and it clicks. That's fine. That's okay. That's the beauty of having, you know, social support and social groups. Audio tapes help to learn new material. Some people like to listen to podcasts. When I was studying for my board exams, I would put on my headphones and I'd get on the treadmill. Now, again, I'm not an auditory learner, so I don't know why I thought that would be helpful. But I just would hear things and repeat them to myself. And people thought I was nuts, but that's okay. Some people find it really helpful to listen to audio tapes. If you're a person who can do books on tape, then audio tapes may be awesome for you. Facilitate client behavior. You can find tapes that actually walk patients through progressive muscular relaxation or guided imagery. Those are awesome. The patient doesn't have to learn how to do it for themselves. And they can tap into this. They can download it from the Internet. Wonderful. But of course, again, listen to it first. Make sure it's quality stuff because not everything out there on the Internet is for real video now. This is more for active behaviors. I've seen videos on refusal techniques and most of them, there may be some really good ones out there, but all the ones I've seen have been laughable. So videos can help on certain things, like if you have to administer insulin injections or to yourself, or if you are trying to learn a new fitness technique or relaxation, or maybe you're trying to help patients learn how to eat a healthier diet. So you're talking about different cooking techniques. These are all great things that you can find little videos for. Again, short ones, if you go to YouTube, you can use a filter and find videos that are under 20 minutes. And computer based technology that's more for interactive computer type things. There is one cognitive behavioral therapy program that is a computer based interactive program that they've had a lot of success with over in Europe. And other than that, I'm not aware of any other computer based technology specifically that interacts with the patient. But we also have to remember that telemedicine and telemental health can help us reach out through audiovisual means to patients who may not be able to come into our clinics. So we can interact in live real time via video chat with our patients who may not be able to come for whatever reason. Assessing client learning occurs over time. Assess it every time they come in. Assess how they're learning every time they come in. Assess their literacy level, their understanding of what you're presenting. What three things will you do over the next week to help you achieve this goal? Or ask them, what risks do you see to implementing this or to not implementing it? What do you think will be hardest for you? What support do you need? For some of my new interns that I'm working with or new clinicians, I will have these written down on the end of their progress note sheet. So they're visual prompts. They don't ask every single one of these questions, but it's a visual prompt for them for closing the session to ask the patients this in order to really assess their understanding and their motivation and their learning on all levels. Affective, cognitive, social, and what's the one I'm missing? Behavioral. Remember to consider learning preferences. Auditory, visual. One we didn't talk about was active versus reflective. Some people process the entire time and stay with you. Some people take all the information and they put it in this box. And then when they have a quiet moment, they process it and. And they have an aha moment. I usually take little thinking breaks every 15 to 20 minutes in my group to let people process what we've talked about and they can either write down on their worksheet or just think, I don't let them get up and leave the room because then they don't come back for 20 minutes. Thinking breaks are very helpful for reflective learners because it gives them a chance to reflect and figure out what they still have questions about. We want to assess the family role in the treatment process. Is it where the client wants it and needs it to be? What about their social support if their family is not it? What can we do to help them with social support if they need it? We want to look at the effectiveness of interventions over time. Questions like tell me what you did to fix this or address this since our last visit. What benefits do you see in what we're doing right now? What's working and what's not? I regularly tell patients I'm not interested in what you're not going to do. I want you to tell me what you are going to do. So if I tell you something and you're like, there's no way I'm doing that, that's fine. Tell me what you're going to do instead. How is this helping you or what challenges do you anticipate in implementing this? This can all tell you how effective the interventions are working and how you might need to tweak it to make it individualized for that patient. Slow it down, speed it up, Go a slightly different direction. Communicate with your team. Identify with your team what key points you addressed when you talked with the patient, what concerns he or she expressed, what actions were agreed to, how learning effectiveness was assessed. What did you ask them? Do you have any clue? And this keeps us all honest in making sure that we're assessing learning effectiveness at every session and what the follow up plan is. A lot of this should be in your progress note, so it shouldn't be brain surgery to come up with this for your teen. Purchase information or create it in MP3 only, audio, video and print. Again, interns are wonderful for this and some clients really like helping out. Make information accessible to clients via your website, DVDs that they can take home, brochures or books that they may be able to check out or maybe read in a lounge area. Develop a skill sheet for common areas of treatment that lists all the skills and essential tasks. I'm going to sneeze. Excuse me. For the client to go through and when you have patients who've been through treatment before, you may be able to knock off 5, 6, 15 of those from the top of the list. That way you know, okay, we've already covered all these clients, mastered these things. So we need to focus more down here. That not only helps you, but it helps the client remember what he or she's already learned and it helps communicate between clinicians. Encourage client participation and feedback. Maybe you learned these top 15 things, but something's not sitting right. Tell me about that. What is one thing you can do beginning in January to make your treatment approach more client centered? And I'll give you a hint after this, I believe is the summary slide. Provide a worksheet for each group. A worksheet is great because it gives you a go by for going through the group and may help keep you a little more structured. I tend to be one of those people who squirrel, I'm off in left field somewhere. So I like having a go by where I know what points I need to cover. Have clients tell me how they intend to accomplish a particular goal. Tell me how you're going to do that. That way we can talk about things they may not have considered and they may share with us things that we may not have considered. Encourage clients to ask more questions. Maybe have them come in and fill out a little index card or something or, or a strip of paper with a question they have about the current topic and maybe have them do the same thing. On their way out for break. Start offering to record the learning part of sessions and let the patient take them home. Now, we don't want all their personal stuff out there, but if you're doing individual therapy and there's a segment where you're going over a new skill guild or you're role playing something, you may offer to videotape it for the client and let the client take that flash drive home. Make sure it's an encrypted flash drive and yada, yada, yada, but ask them what they would like to change. So start by asking the client. So ask, tell, ask. Working with children in the schools is always a challenge. But one of the things that if I were working with children, I would ask them, what is it that you think my job is? What do I do? Because most kids have no clue, most parents have no clue what a school counselor or school psychologist or whatever your position is is going to do. So if you can set the parameters and help them understand what your goal is and what your job is. For kids, especially demystifying the process and just saying, you know, maybe sometimes you get really angry and you want to come talk and I'M here and depending on what age you're working with, you may have some toys or play DOH or something that they can work with and you guys can talk, helping them understand that what your role is and what it's going to be like if they come use you or come try to talk to you. Okay, so a sample skill sheet for addiction. The knowledge, things you know, I talked about specific skills. People need to know what addiction is, what the definition is, what causes it, the impacts or effects of addiction, and in general how we treat it. But this is all really general. Specifically, they need to understand how the definition of addiction applies to them, what causes or triggers their addictive behavior, how addiction has impacted them now and how they anticipate it impacting them in the future if they continue on this current track, and what needs to be addressed to treat their addiction. I haven't ever had two patients that had exactly the same treatment plan. So what do they need right now to get from point A to. To point A? 2. We're not even talking about B yet. We're just talking about the first baby step. Health literacy is vital to improve treatment outcomes, empower the patient, reduce relapse and reduce medical errors. Improving health literacy involves ensuring client understanding and buy in. If we just tell them and dismiss, we're not going to improve health literacy. We need to make sure they understand and they care about what we're saying. Create a blame free and shame free environment for asking questions and improving literacy and create collaborative, attainable, stage wise treatment plans. Collaborative. What do they want to do? Let's talk about small steps to encourage and empower our clients. All right, last question. What questions do you have? And it's okay if you don't have any questions, but if you do, I definitely want to be able to answer them. I know a lot of people are itching to go visual aids. Now. One of the things that are challenging to find for mental health is visual aids. One of the things I would suggest is googling free mental health worksheets or free depression worksheets. You can also go to SAMHSA S A M H-S A.gov and they have a ton of printable materials that you can use, posters and visual aids. And they can link you also to some training curriculums if you're working with younger children. One of the other things that I might suggest with if you're working with children is not only asking them what they need to know and what they want to know, but immersing yourself as much as possible in that culture, whatever that culture is, for a period of time between now and then, in order to try to get a perspective of where they're coming from and to understand a little bit about what they're coming from. In January, we're going to be starting a podcast called Counselor Toolbox, and each week I'm going to present different tools and activities that you may be able to use in your practice. In the meantime, we also have a LinkedIn group by the same name, Counselortoolbox on LinkedIn, where we're currently sharing free resources, visual aids, free printable worksheets that you can find online in order to help you help your clients. Because most likely whatever you need has been created in some way, shape or form before. And if it's out there for free, then it's a great resource. And even the things you have to pay for are often well worth it. But not all of us that work in agencies or even in private practice have a huge budget for buying lots of copyrighted materials and for profit stuff. So okay, finding those resources United Way Information and Referral. Also Google free printable worksheets for depression, anxiety, ptsd and it will give you a good start. And please feel free to join our LinkedIn group, Counselortoolbox. All right, thank you and have a wonderful rest of your evening. And this is the last presentation before the New Year, so happy holidays.