Drug Abuse

COUNSELLING *3

Counselling is a direct, personalised, and client-centred intervention designed to help initiate behaviour change, e.g. to keep people off drugs, avoid infections or, if already infected, to prevent transmission to other inmates or partners, and to obtain referral to additional medical care, preventive, psychosocial and other valuable services that are necessary in order to remain healthy. Counselling can consist of giving short advice and information, it can be referral, it can be the core of longer and more intensive assistance and, finally - of course - of prevention. In this manual, we concentrate on counselling as a useful method of risk reduction, although the information that follows might also be useful for other tasks.
Consequently, the following issues will be discussed here:
u    How to raise the subject of safer behaviour;
u    How to discuss the subject of safer behaviour.
Either instead of, or in addition to individual counselling, you also might consider running group meetings to discuss safer behaviour. However, discussing touchy issues such as using drugs and having sex (especially true in prisons) requires mutual trust. You should make sure that people feel safe enough to do so in a group.
6.1 How to raise the subject of safer behaviour
Getting into contact with drug users is one thing, starting a conversation about things like injecting behaviour, hepatitis or HIV/AIDS, another. Those who work in a prison and are responsible for risk reduction work often realise that accidental contacts and talks can be quite fruitful, though this often means working without a clear agenda and without a well defined structure. Nevertheless it is worthwhile to set an agenda for yourself. This can result in a guideline offering some structure for the work:
Nonetheless, talking to prisoners in an unstructured setting has a lot of advantages:
u    It can be very effective because one is acting in close
proximity to the target group’s own environment. One can react directly to real life, spontaneous situations, to ques tions people have, etc. (trust building);
u    Operating in the daily surroundings of the target groups
generally facilitates an atmosphere of trust;
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*3
Based on Trautmann / Barendregt ‘European Peer Support Manual’ (see References)
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u    One is getting valuable information about the actual living
situation, the actual needs of the target groups;
If people know what one is doing, they will sometimes start talk-
ing about AIDS or other health-related subjects by themselves.
Besides this, there are various other ways to raise the issue:
u One strategy is to look for openings in the contacts - whether casual or planned - in order to raise the issue. One can give a short reminder about safer use when confronted by a drug user with an abscess. Other opportunities arise if someone has been kicked off the substitution program, if someone suffered an overdose, etc. Thus, making use of unexpected chances is very important.
u    Exclusively focusing on HIV/AIDS, or only discussing safer
use and safer sex will soon be boring. It is not attractive to drug users. Thus, it is advisable to incorporate the risk reduction message in a broader framework of drug users subculture, e.g. focusing on health in general or hygiene conditions in the prison.
u    If you meet people you know but have not seen for a while,
the questions `How are you’, `How are things going’, might be enough to get a conversation started in which health may be one subject.
u Here, too, some of the methods mentioned above that can be useful:
w A leaflet
w A newsletter/magazine
w An inquiry on what the needs and/or problems of the target group(s) are
w Giving out condoms, bleach or syringes
Handing out things and asking questions, addressing and acknowledging the expertise and knowledge of inmates can help to start a talk about the issue of risk reduction (see 9). It is vital to have a broad repertoire of means to raise the issue, especially because it is evidently not enough to just raise or discuss the issue once. Short reminders, repeating the message from a different angle or by a different approach can be very effective.
6.2 How to discuss the subject of safer behaviour
Whereas most papers on counselling refer to a structured, therapeutic setting, counselling in prison often lacks this clear structure of well-defined roles and setting. One has to create a setting for a confidential talk (finding rooms, etc.) and is therefore highly dependent on spontaneous opportunities. However, there are some rules for discussing the subject of safer behaviour.
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ude and behaviour
u    Do not be judgmental, e.g. simply judging or condemn
ing risk behaviour as stupid, incredible, will not change someone’s behaviour.
u    As a result of this principle, it is important, not to
ask`why’. The question `why’ often simply shows that you don’t understand `why’ and are therefore judging. Open questions inviting people to tell their story brings about more important information.
u    Do not patronise, and so avoid giving advice regard
ing personal business like whether or not someone should get tested for HIV or how they should behave. (`If I were you I would ...’). Instead, try to offer relevant, complete information and discuss alternatives. Making one’s own decision is more effective than adopting some one else’s view. However, in impersonal or objective mat ters advice can be very useful (`In this case you need a lawyer. You can refer to ...;’ ‘For getting an HIV test you can refer for further information to .... You first have to make an appointment by phone’; ‘You should boil a syringe for 15 minutes and not just flush it with boiling water’; etc.).
u    Do not take responsibility for someone’s problems, try
to motivate and support people to solve their problems by themselves.
u    Listen carefully. This means do not talk too much, do
not interpret, but make sure that you understood well by recapitulating briefly what you believe someone has said and asking if this is what they meant.
u    Stick preferably to the `here and now’, what do
people feel or think now, what do things/emotions mean to people now, what do they see as perspective, etc. This generally gives more relevant information to realising safe behaviour than discussing the past.
u    Pay attention to emotions. How and what do people
feel? What do certain events mean to them, etc.? This can give insight into why people behave as they do.
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u    Show that you understand and care, show interest.
Ask people how they are, how things are going, where they were (if you have not seen them for a while).If you have not seen someone for a while, ask their mates where they are, what has happened to them, or if you know, you can visit the person in their cell, in the hospital wing, etc.
u    Treat people with respect. For example, thank people
for their information and assistance, apologise when you are bothering someone, invite them for a cup of coffee, etc.
u    Do not play therapist or `shrink’. Although carefully
listening and paying attention are important one has to avoid playing the role of an uninvolved therapist. Questions like ‘Tell me, how does it feel?’, ‘What does this mean to you?’ can raise feelings of aversion, especially when given as a reply to questions for advice or help. Drug users might know this way of counselling by their attempts to kick the habit. These experiences with therapeutic treatment are frequently quite negative.
Most of these rules are closely linked to one’s personality, and to one’s attitude towards the target group. It is evident that one genuinely has to care, understand, etc. Simply pretending is not enough, nor is just adopting these rules. It is obviously nonsense to use the jargon or codes of the target group if you don’t feel familiar or comfortable doing so. One has to integrate these rules and codes into your own, personal style of behaviour.
To get a picture of how one is developing a personal style of working, regular feedback is necessary. This can be done by supervision through a colleague or - preferably - an external expert. As supervision is not based on direct observation of how someone is working, immediate feedback is not possible.
Practical rules
u    Try to find a quiet place to talk where you have an
undisturbed conversation, e.g. a quiet room, where you can sit down.
u    Make sure that somebody has the time and feels like
talking. Generally you can see at first sight if somebody
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is in a hurry, feels restless, etc. If you are aiming at a longer conversation you can ask explicitly if someone has time. You also can invite someone to have a cup of coffee.
u    Use appropriate language, i.e. language that is read
ily understood and accepted. It is important to know or learn the jargon, the subcultural codes of the target groups.
u    Provide consistent, complete and neutral information,
offering the chance for a well-considered decision. Informing people is not just telling but also listening. Particularly when asking personal questions, state clearly that people don’t have to answer, that you don’t want to be offensive. Explain the reason why you are asking this question, e.g. to get a picture what information some one needs.
u    Provide relevant information, i.e. information people
need. This can be done by a formal risk assessment
w Using a form to collect relevant information on level of knowledge (what do people know about
routes of transmission of HIV/AIDS, hepatitis etc.), attitude (e.g. how do people view condom use) and risk behaviour of the target group members (do they share their injecting equipment, etc.).
w Explaining the basics about the relevant infectious diseases (transmission of the virus, different forms (and levels) of risk behaviour, etc.)
w Asking and answering questions
w Discussing the possibilities for reducing risks, etc.
A formal risk assessment enables both prevention worker and drug user to set risk reduction goals and structure outreach prevention. However, it generally will be not possible to reach all outreach contacts with this formal instrument. For people who cannot be reached by this instrument you have to have a less formal, appropriate variant. This means one has to be able to improvise.
u    Besides explicitly talking about HIV/AIDS and hepatitis
related issues, a drug worker can also touch on or present safer behaviour information to be ‘read between the lines’. One can talk about other health subjects as how to stay healthy in prison, about drug user’s life-style (not just the misery, but also having fun, how to enjoy life).
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This approach can be effective in preventing people from getting tired of being confronted with yet another talk about HIV/AIDS, hepatitis and drug-related health risks.
u    Do not stick exclusively to AIDS prevention. Harm reduc-
tion work in prisons takes place in the environment of people. Therefore it will be impossible and inadequate to confine yourself to AIDS prevention. If you have people’s confidence they will regularly contact you for matters other than AIDS prevention. Their first priority will probably not be getting information about safer use and safe sex. They might be more in need of other services. If you do insist on AIDS-prevention topics, you might lose your credibility. Therefore it is important to have knowledge of and contacts with other potentially relevant services.
u    Support (positive) changes in behaviour and attitude to
reinforce these changes, even if they seem to be quite small. This support for changes towards safer behaviour is important to foster self-esteem and self-efficacy and thus is the basis for ongoing change.
u    Do not judge or reject a person for failure to change their
behaviour
u    Encourage and support snowballing
w By simply asking drug users to pass on the information to their peers,
w By discussing how this can be done,
w By involving drug users in the making and handing out of information material, etc.
u    Stop a talk in good time. Do not force people to go on,
either implicitly -- by ignoring the unspoken signals that someone wants to stop, and thus maybe forcing some one to continue, or explicitly (‘Wait a minute, I want to ask you one other question.’). Indicators that suggest stopping (or not beginning) a conversation can be:
w If the conversation is getting less intense, e.g.
if people stop asking questions, stop talking by
themselves and only react briefly to your questions w If people are getting restless
w If people’s attention gets diverted often, e.g. if they start talking with somebody else or change the subject
w If people start looking around.
If you want to talk with people again, you can try to make an appointment or just tell them that you will come around again to continue where you left off.