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Book Reference Perkinson, R. R. (2012). Chemical dependency counseling: A practical guide (4th ed.). Thousand Oaks, CA: SAGE. 14 The Clinical Staff Source: ©iStockphoto.com/Alina555. T he staff of any treatment center is the lifeblood of treatment. A good staff can do effective treatment anywhere. The clinical staff had a great deal of respect for each individual member of the staff and listen carefully to each other. No one staff member is more important than another is. All are equal and essential for recovery. They work together like a symphony all playing the same masterpiece.

A good staff is fun. The staff members enjoy working together and supporting each other in the war against addiction . A good staff laughs a lot. Sometimes you have to laugh to keep the disease from getting you down.

Everyone has input into the clients' treatment plans, but everyone has his or her own area of specializa­ tion. Professional boundaries are important and should be respected and guarded. To question another person's skills or decisions when you do not know their profession is silly Let them do what they are trained to do and trust that they have you and the client 's best interest at heart . If you stay within your own boundaries-the boundaries of the chemical dependency counselor-then you will be a lot better off, you will feel better, and you will give better quality treatment. All staff members are experts in their chosen fields. They are licensed or certified by their respective boards, and you have to believe that they know what they are doing. 223 224 CHEMICAL DEPENDENCY COUNSELING The Physician /Addictionologist Source: Comstock Images/I'hinkstock. The medical doctor is in charge of all medical treatment . This physician has the most training in the total disease process. A physician completes a premedical bachelor's degree, 3 or 4 years of advanced medical training, and at least 1 year of interning . Many physicians go on to specialize in one or more areas of medi­ cine. Physicians can have a specialty in addiction called addictionology All clients must have a complete history and physical examination given by a physician . If you have any questions about any type of physical disease or medical treatment , then the physician is the person to rely on . It is important to establish a professional working relationship with the physician. He or she is a wealth of information . Do not be intimidated by professionals with advanced degrees. They are just people like you-fallible and human . Discuss your client 's case with them, and respect their judgment. Good physicians are easy to talk to and readily admit that they do not know everything. They often need you to tell them how the client is responding to treatment.

The physician will be in close contact with you, particularly if your client has a medical condition that requires treatment. Close consultation with the physician will prevent you from assuming that behavior caused by an organic disease is a psychological problem.

The physician is in charge of any medication order. If you believe that your client needs pharmacological treatment, then you need to tell the physician or nurse . Once you have discussed this issue carefully with the medical staff, your job is over. The physician will examine the client and make the determination based on his or her own clinical judgment. Do not argue with the physician or the nurse about what they are doing .

They know more about it than you do. Trust them to do their job. You must keep the medical staff advised about your client's condition if they are not doing well or might be having side effects to the medication. Let them know your concerns and leave it to them to treat the medical condition. The Psychologist/Psychiatrist All treatment centers should have a consulting psychologist or psychiatrist. The psycho logist /psychiatrist has advanced training in the diagnosis and treatment of mental disorders. A psychiatrist is a medical doctor with 3 years of residency in psychiatry. A psychologist has a 2-year master's degree and a 4-year doctorate degree ·er 14 The Clinical Staff 225 -_ 1 y ear of internship during the doctoral training and 1 year postdoctorate. These two professionals are best-trained mental health professionals . Only psychiatrists can order medications, and usually only psy­ ogists are heavily trained in psychotherapy, particularly evidence-based cognitive behavioral therapy and olo gical testing.

Tw o thirds of chemically dependent clients have a concomit a nt psychiatric diagnosis. They have prob­ suc h as depression, anxiety, and/ or personality disorders in conjunction with their addiction . Clients ~ n ot do well in recovery unless these disorders are treated effectively (Frances & Franklin, 1988 ; Ries & er, 2009; Talbott , Hales, & Yudofsky, 1988; Woody eta!. , 1984) . It is important to have a professional in c e nter who can deal with these coexisting problems.

Th e Joint Commission on Accreditation of Health care Organi zations GCAHO) and the Commission on __ cr editation of Rehabilitation Facilities (CARF) requires that all clients in inpatient substance abuse treat­ em receive a psychiatric /psychological evaluation. This examination includes a mental status examina- n, a determination of current and past psychiatric /psychological abnormality, a determination of the ..;eg ree of danger to self or others, and a brief neuropsychological assessment. It is from this examination --!at you will learn about any secondary diagnosis and will develop a treatment plan. The psychiatrist or • syc hologist will tell you what to do. Follow his or her directions as precisely as you can. Use this profes­ : io na l as a valuable information source. This professional understands the development of personality and -· e forces that motivate behavior. If you are confused by a client , talk the situation over carefully with the psychiatrist or psychologist. The Social Worker/Mental Health Counselor So cial workers and mental health counselors are wonderful mental health professionals . T hey usually have b ee n through a 2- to 3-year graduate program a nd are licensed by the state. These mental health profes- io nals have many fine qualities. They are excellent therapists and group leaders. They understand the community of mental health professionals and are often charged with testing and treating co-occurring d is orders and arranging for continuing care placements in continuing care, including referrals to other pro fessionals , halfway houses, and group homes. These professionals are good at about anything and can h andle almost any mental health task except ordering medication . They are a lot like mental health profes- io nals or professional counselors who have a master 's degree in counseling and have many things to offer y o u and your clients . The Nurse There are two types of nurses: (1) registered nurses and (2) licensed practical nurses. Registered nurses c omplete a registered nurse's degree from an accredited institution. Most go on for a bachelor's degree.

Licensed practical nurses complete a 1-year vocational-technical program in nursing .

Nurses are frontline medical personnel. They take responsibility for the client in the absence of the physician. In an inpatient setting , the y usually are guiding the ship and are av ailable 24 hours a day. There is a tendency in some centers for there to be some conflict between the nursing staff and the counseling staff. This is a big mistake for all concerned . A good clinical staff has little of these turf battles . Each staff member should feel comfortable with his or her unique function in the treatment setting.

Nurses are second in command in medical treatment . Only the doctor has more medical authority. The physician writes the orders , and the nurses carry them out. In many facilities, there are standing orders that allow nurses to make medical decisions . This is necessary to reduce response time and to ' 226 CHEMICAL DEPENDENCY COUNSELING prevent the physician from being called every time a decision is made. If a nurse tells you to do something, then you should carry out this order as if it came from the physician.

Nurses will listen to you and help you. You will find them to be supportive. They tend to be caring people who are willing to go the extra mile to provide good quality care. They are used to charting and usu­ ally are wonderfully self-disciplined. The Clinical Director The clinical director has the primary responsibility for making sure that the clinical team provides the best possible treatment. This individual develops and implements the whole treatment program. He or she has advanced training and experience in treating addiction and co-occurring disorders. The clinical director makes sure that the team is working well together and is accomplishing its goals. The clinical director decides who does what , when, how , and with whom. This person leads the clinical team and the client population. The clinical director has administrative experience. This individual usually sees the clients and the staff who are having more severe problems. All program and policy changes go through the clinical director. The Clinical Supervisor The clinical supervisor is an addiction counselor with several years of experience in counseling and supervi­ sion. This individual's primary responsibility is to supervise the counseling staff. The clinical supervisor will be doing some hands-on work with the clients and will be sitting in on some of your individual sessions and groups. He or she makes up the work schedule. You should use this person often . The clinical director and clinical supervisor are your mentors. This person will set a good example for how to take a client through treatment effectively. If you have any questions about treatment planning, charting, or therapy, then these are the first people to ask. You should receive continuing education from the supervisory personnel. If you feel as though you have any weak points in your training, then ask them for in-service training sessions to build your expertise. The clinical supervisor will be going over your charts to be sure that you are treating the clients accord­ ing to ]CAHO or CARF. ]CAHO and CARF require specific standards of care to be met before it will allow a facility to receive accreditation. (You can order a copy of the standards by contacting JCAHO , 875 North Michigan Avenue, Chicago, IL 60611 or CARF International, 4891 E. Grant Road, Tucson, AZ 85712 USA, 520- 325 -1044 or 888-28106531 voice(fTY, 520-318-1129 fax .) The Chemical Dependency Counselor Chemical dependency counselors must meet state standards set by a certification board. They take special­ ized college courses and work for at least 1 year in a treatment setting under a qualified supervisor. In most states, they have to pass a national examination and are state certified. Counselors must show competency in 12 core function areas: (1) screening, (2) intake, (3) orientation , (4) assessment, (5) treatment planning, (6) counseling, (7) case management, (8) crisis intervention, (9) client education, (10) referral, (11) reports and record keeping, and (12) consultati on. Many counselors are involved in their own recovery programs , but many are not. It does not seem to matter. It is the on-the-job training in addictions and personal experi­ ence that gives addictions counselors their unique professional character. They are excellent highly qualified health care professionals. Ch apter 14 The Clinical Staff 227 The Rehabilitation Technician or Aide Re habilitation technicians, sometimes called aides, usually are individuals with no formal training in addic­ tio n. Sometimes they are people who are getting their degrees in addiction and need experience. These people do a variety of work assigned by supervisory personnel. They work with the clients, sometimes indi­ Yid ually and sometimes in groups. They work under the direct supervision of the counseling staff. It is yo ur respons ibility to help them to function effectively around the client popu lation. Many times, the tech or aid ay s just the right thing at just the right time to turn a client toward recovery. Never forget that they are mart, willing, and able to go the extra mile for you and your clients . There often is some conflict about how far these people shou ld go in treating clients. For the most part , th e care they offer should be highly structured and supervised by someone on the clinical staff. You will find t h at much of the real work in treatment is offered by these individuals. You must see to it that they offer q uality care. The only way of doing this is to listen to them, talk to them , and educate them. They might be in recovery and know the 12-step program well, but you can still improve their skills by extending yourself to support , educate , and encourage them. They are working harder than you often think and are having more effect than you can possibly imagine. The Recreational Therapist Source: Paul Sutherland/fhinkstock. The recreational therapist is a certified coordinator in charge of getting the clients involved in fun, construc­ tive exercise and leisure time activities. This individual will be doing an activities assessment to see what the clients are doing for entertainment, play; or fun. The activities coordinator will develop an exercise program f or each client. Most addiction clients have lost the capacity to have fun in sobriety They need to be encour­ a ged to develop healthy recreational activities and hobbies. They need to learn how to have fun clean and sober . It is important that you encourage your clients to become active in plea sure - oriented activities in recovery The clients who enjoy sobr i ety will be more likely to stay sober. One of the most important things that clients can do in their recovery program is to establish regular exercise habits. All clients should be encouraged to exercise on a daily basis. The recreational therapist needs to be a l ot of fun to be with and 228 CHEMICAL DEPENDENCY COUNSELING very encouraging. Most addicts have not exercised or enjoyed recreational activities in a long time, so they need someone fun to encourage them to try new activities . Clinical Staffmg The clinical staff makes up the treatment team. The staff usually meets once a day, usually at each shift change, to discuss the clients' status. Once a week , the staff meets for a more formal clinical staffing. Here the clients will be discussed in more detail, and each problem on the problem list will be evaluated .

The staff must be constantly kept informed about how the clients are doing in treatment. In these meet­ ings, treatment plans will be updated. A multidisciplinary staff can take clients through treatment much more effectively More expertise comes into play, and many heads are much better than one.

Clinical staffing is your opportunity to discuss a client with the whole team. You can get advice and help from everyone at the same time. The client is reassessed throughout treatment to determine current clinical problems, needs, and responses to treatment. The assessment includes major changes in the client, family, or life events that could complicate or alter treatment. A client could have just learned that his wife is divorc­ ing him or that he is being prosecuted for a crime. Someone in the client's immediate family could die or become ill. All changes in treatment need to be documented in the client record. The atmosphere of clinical staffing is a professional one . The principal matter of concern is the cli­ ents. You must assume that all members of the professional staff are willing and able to help. The staff members should be supportive of each other. Treating addiction is emotionally draining, and everyone occasionally will make mistakes. The atmosphere in clinical staffing should be one of mutual respect. You should enjoy clinical staff meetings. They should be educational , and they should help you to develop your professional skills. How to Present a Client You will present each of your clients to the clinical staff and will discuss how treatment generally is going. If you have any questions , now is the time to ask them. The first time that you present a client, you need to be thorough. As the client remains in treatment, you need to cover just the pertinent issues. An outline for case presentation is handy to use your first few times. The outline might look something like this:

1 . Identifying data 2. Present illness 3. Past history 4. Family history 5 . Social history 6. Medical history 7. Mental status examination 8. Most likely diagnosis 9. Formulation a. Predisposing factors b. Psychosocial stressors c. Stress that precipitated treatment 10. Further assessment you propose -..ap ter 14 The Clinical Staff 229 11. Treatment plan 12. Prognosis Yo ur presentation should sound something like this:

J ason Roberts is a 43-year-old black male who just got his third DWI. He has been drinking heavily for t he past 20 years. He is divorced with two children. He lives alone. He came to treatment after spending t he night in jail. He is working on his chemical use history and prob lem assessment form. He is doing w ell around the unit so far. He is in good physical health except for some mild wit hdr awal symptoms.

His CWJA scores have averaged around 8 to 14. He seems to be getting along well with his treatment peers. In group, he did admit to a drinking problem. He seems committed to treatment. He says he does not want to go on living this way anymore. I talked to his oldest son this morning, and the family is sup­ p ortive of treatment. He is in some withdrawal , but he seems to be handling that okay He needs to visit with the psychologist to rule out other psychiatric disorders. He is depressed and reports he is not sleeping we ll. His diagnosis is alcohol dependence-severe-with a possible substance induced depres­ sion or a major depression. He will be working through the steps, and we will probably address his depression depending on the psychologist's report.

The case presentation globally advises the treatment team of the client's condition and describes how the client is doing in treatment. After you present the client, each member of the treatment team can com­ m ent. The physician or the nursing staff may have something to share about withdrawa l or the medical c o ndition for which the client is being treated. The dietitian may make a report on the client's diet. The r ec reational therapist may have a comment on how the client has been using his or her lei sure time. The other counselors may have something to say about what they see. As the primary counselor, you collate this m aterial and enter the staff's input into the client record. These progress notes do not have to be very long, b u t they do have to show that the treatment team is reassessing the client and chang ing the treatment plan w here necessary Team Building A good staff is constantly building the team. These staff members are actively encouraging each other and r einforcing each other's work. When you see someone do a good job, you say so: "You did a good job with M ark this morning. I was impressed with how you handled yourself. " These comments are very reinforcing to fellow staff members. The staff members often put so much energy into the clients that they forget that t hey have needs , too. This is emotionally difficult work, and everyone needs support. A good team knows t his. Each member goes out of his or her way to treat each other well.

New team members are welcomed and are assisted in ad justi ng to the flow of treatment. Every treatment c enter is different, and new staff members need orientation on both an intellectual and an emotional level.

A good team's members constantly talk each other up to insiders as well as outsiders. They never talk s omeone on the staff down. You can share the truth about someone without damaging his or her reputation .

The members of a good staff communicate well together . They share openly how they feel and what they think. They work together as a group. If a personal prob lem develops between staff members, then the problem is handled by a supervisor.

A good staff 's members never gossip about each other. Gossip is one of the most harmful things that c an occur in any staff organization. Gossip will cause a team to fail. Everyone 's life outside of the center should be private. Unless someone decides to confide in you, keep out of the issue. Do not spread damaging rumors about anyone. A good way of checking yourself is to refuse to repeat anything unless you have the permission of the person in question . 230 CHEMICAL DEPENDENCY COUNSELING Good staff members get support , not treatment, from their fellow staff members. It is a mistake for someone in recovery to think they no longer need their 12-step meetings because they have the support of the clinical team. The clinical staff does not exist to treat you; it exists to treat the clients. If you want to see someone on the staff for a brief consultation about a problem, that is fine, but keep it short. Do not be afraid to seek outside help for your problems. Your mental and physical health directly affects your job performance. If your problems are bogging you down , then you cannot be effective. Becoming involved in a good program of recovery will make you a better counselor and a better person. One of the best ways of learning about good therapy is to go to a good therapist . Make sure that this therapist is highly qualified in his or her field .

A good clinical staff does not "subgroup " against each other. This is where a smaller group of staff mem­ bers gets together and talks about the other members. This is very common, and it is a disaster for the clinical team. If you are having problems with a staff member, then go to that staff member first and try to work the issue through. If you are unable to resolve the problem, then go to your supervisor and get him or her to help you. If you and the supervisor cannot handle the problem, then it needs to be addressed before the clinical staff as a whole . Do not let problems fester. The only way of resolving problems is to get everyone together and have each person share how he or she feels. Any problem can be solved in an atmosphere of love and truth. The staff needs to practice what it preaches to the clients.

The following guidelines are excellent for maintaining productive staff interaction. Commitment to Coworkers As your coworker with a shared goal of providing excellent care to our clients , I commit myself to the following: 1. I will accept responsibility for establishing and maintaining healthy interpersonal relationships with you and every member of this staff. I will talk to you promptly if I am having a problem with you. The only time I will discuss it with another person is when I need advice or help in deciding how to com­ municate to you appropriately 2. I will establish and maintain a relationship of functional trust with you and every member of this staff. My relationships with each of you will be equally respectful , regardless of job titles or levels of edu­ cational preparation.

3 . I will not engage in the "3 Bs " (bickering, back-stabbing, and bitching) and will ask you not to do [so] as well.

4 . I will not complain about another team member and ask you not to do [so] as well. If I hear you doing so, I will ask you to talk to that person.

5 . I will accept you as you are today , forgiving past problems, and ask you to do the same with me.

6 . I will be committed to finding solutions to problems, rather than complaining about them, and ask you to do the same. 7. I will affirm your contribution to quality client care.

8 . I will remember that neither of us is perfect and that human errors are opportunities, not for shame or guilt but rather for forgiveness and growth. (Manthey, 1991) Signature and date :=ha pter 14 The C linical Staff 231 Boundaries i:\·ery one on the clinical team needs to know and respect each other's professional boundaries. You need to -ow what each person's function is in treatment. Once you know that a part of treatment is not in your area :ex pertise, stay out of that area. Everyone on the staff wants to hear what you think-that is helpful-but o not concern yourself with client care outside of your area of specialization. You are an addiction coun ­ selo r, not a physician or a nurse. You should not concern yourself with who gets certain medications, but :uu should express your concern about your client's signs and symptoms. Many counselors spend long :o urs worrying about whether or not their clients are being properly treated by the medical staff. If you ~-o rry that your medical staff is inadequate, then work somewhere else. Never accept a job in an institution dla t gives substandard care. Once you decide to accept a position, act as if your staff is the greatest. Be grate­ :i.Jl for all of the good work the staff is doing.

Most staff problems are attitude problems, and attitudes can change . You need to keep a positive atti­ LUd e about you and your coworkers . This will go a long way toward making your day more pleasant and enjoyable. If you see your attitude slipping, then talk about this with your supervisor. Check your own life.

How are you doing? Many times, a negative attitude flags personal problems that need to be addressed ou tside of the treatment center. Remember that if you do not take good care of yourself you are not going :o be very helpful to others. If you are suffering, your staff and clients will suffer. Do not hesitate to get help ~o m your supervisor or an outside counselor. Most treatment centers have an employment assistant pro­ =ess ional (EAP) who will see you a few times and, if you need it, will help you get a referral to the right pro fessional. Staff-Client Problems The staff and the clients will constantly have problems with each other. It is the nature of transference and co untertransference that there will be conflict. As the clients' maladaptive attitudes and behaviors come into pl ay, the staff can teach new methods of dealing with problems.

Never agree that a client has been treated unfairly by a staff member until you first talk with the staff m embe r. Clients will attempt to use you in a manipulative way against someone else. Remember the staff co mes first. You must not subgroup with clients against staff. This decreases the effectiveness of the entire fac ility. You must prevent clients from using their old manipulative skills. If a client is having a problem with a staff member, then arrange for the staff member and the client to meet to see whether they can resolve me issue together. You are teaching the client how to resolve interpersonal problems. If the client has a p ro blem with someone , then he or she has to go to that person to resolve the issue . Certain clients will try to pit the staff members against each other. This is common for borderline and an tisocial clients. This must be resolved by the staff as a whole. A client usually attempts this by telling differ­ ent staff members different things. The only way of making this manipulation stop is to call everyone together 3t the same time. This way, the client cannot continue to manipulate. Any other means of trying to solve this pro blem will not work because the lies will continue to operate . Once everyone gets together with the client 3t the same time, you will have a more accurate picture of what the problem is and how to resolve it. What to Do When a Client Does Not Like a Counselor Someti mes a client will want to change counselors. This client needs to share how he or she feels with the curre nt counselor often with a supervisor present. Something might be going wrong with the therapeutic alliance. This matter needs to be discussed with the counselor and the client who are having the problem. 232 CHEMICAL DEPENDENCY COUNSELING Source: ©iStockphoto.com /s lo bo. It should be rare for a client to change primary counselors while in treatment. Most of these problems revolve around lack of trust , and this is a common problem for chemically dependent persons.

Many staff-client problems result from miscommunication. It is common for two people to misinterpret each other's behavior. Only by bringing the parties together and having them check out their interpretations will the problems be resolved. Each person needs to ask for-and listen to-the other person 's thoughts and feelings. Sometimes clients will want the counselor to do too much. It is as though the clients want the counselor to do all of the work for them. When the counselor balks at this, the clients feel resentful. These clients need to accept the responsibility for their own behavior. They cannot count on someone else to work the program for them . They must work it for themselves .

A client who is having a problem with a staff member might need more time in individual sessions. The client needs to get his or her thinking accurate. Trust issues are of paramount importance in recovery. Trust is essential for the development of a good therapeutic alliance. If a client is having trust problems with the staff, you can bet that the client has this same problem outside of the treatment setting. The client might need to track his or her lack of trust to earlier situations, perhaps during childhood. Things that happened early can convince a client to trust no one . Keep asking the client if he or she ever felt these feelings at an earlier time. These situations will have to be explored in depth and worked through. The client needs to see that the situation has changed. The client is not in the original situation anymore. He or she is in a new situ­ ation that demands a new level of trust. What about the new situation makes the client feel that he or she cannot trust someone? What is the most rational decision for the client to make? Trust issues must be resolved for the client to move forward in treatment . The client will remain stuck until he or she can trust someone. Once the client trusts one person , the client can transfer the trust to someone else, the group , and then the Higher Power. What to Do When a Client Complains About a Rule Many staff-client problems revolve around rule violations. Clients will say that they did not break the rule, and they may have a very good story to tell about the situation. You must support other staff members in -..:.pt er 14 The Clinical Staff 233 :.e things they direct the clients to do. Support their consequences. They were there, and you were not --ere. Talk about how to do it next time if you need to but do not change the consequence . If you do this, ur staff members will be unable to discipline the clients. If the clients learn that the rules can be manipu­ -ed, then all of the rules become meaningless. Bring all members involved in the situation together, and -the issue through. In very rare instances, the person who leveled the consequence may remove the _ eq uence or change it to something more appropriate . This should be done only by the person who -elect the consequence. ~o chemically dependent persons want to obey the rules, but the rules exist to protect them from harm. :1c e they understand that the rules are for them rather than against them, they will be more likely to obey :. e ru les. Clients who are breaking the rules need to see how this tendency feeds into their addiction. If they .earn how to follow the rules-particularly the rule of the 12-step program-then this is recovery. The Work Environment _-~.tr eatment center should be a fun place to work. People who come into recovery at their worst are at their .xs t in a few short weeks. This is an extremely rewarding environment. It is a place full of great joy Real Ye abounds in a good treatment center. Clients and staff alike enjoy their days. If you do not genuinely enjo y y our work , then you are at the wrong place or you are in the wrong business. Chemically dependent pe rsons are a lot of fun to work with. They laugh and have a good time. They have been the life of the party :h e staff can learn how to have fun at work. If the staff members work together and love each other, then Lhey can grow from each work day Good treatment must be done in an atmosphere of love and trust. Staff members must support each oth er through the good times as well as the bad times. The old saying applies: "When the going gets tough, Lhe tough get going." Even during periods of stress, the well-functioning staff pulls together and works things ou t. Humor often saves the day, and a genuine caring for each other smoothes the rough spots for staff :n embers. Remember that you are in this field not only for your clients but also for yourse lf. You are active ly im -olved in your own individual growth.