Client Workbook - BrainLine
ClientWorkbook
SUBI Project TeamCommunity Head Injury Resource Services of TorontoCarolyn Lemsky, PhD, CPsych, ABPP/ABCN, Clinical DirectorIrene Sullivan, Hon BA, Dip CS, Project CoordinatorPam Kaufman, SSW, Substance Use Community FacilitatorKristen Caballaro, Hon BA, Service CoordinatorCenter for Addiction and Mental HealthDennis James, MSc, Deputy Clinical Director, Addictions ProgramJerry Schwlab, RSSW, Manager, Addiction Assessment and Day/Residential Treatment ServicesTim Godden, MSW, RSW, Advanced Practice ClinicianToronto Acquired Brain Injury NetworkCharissa Levy, MHSc, BScOT, Executive DirectorJudy Moir, MPA, BA Psych (Hons), Assistant Executive DirectorHeather Brien, MBA, BScOT, Executive DirectorWriting Heather Chisvin, heather@chisvin.comDesign David Wyman, www.wymandesign.caIllustration Kathryn Adams, www.kathrynadams.comAcknowledgementsWe would like to thank the staff at CHIRS and the CAMH, Brentcliffe Site, who provided trainingfor project personnel, and shared their program materials and expertise freely. A special thanksgoes out to Kelly Greer, who generously provided content for the staying healthy chapter and toMegan Cowley, Trish Dekker, Ann Hilliard, Matthias Kaay, David Law and Helen Vilenski whoreviewed drafts of workbook chapters. Without their support, this workbook could not havebeen developed. We would also like to thank John Corrigan for his generous support andconsultation.Funding for the Substance Use and Brain Injury project (Grant #G03-05465) provided throughthe Ontario Ministry of Health and Long-Term Care from Health Canada’s Primary Health CareTransition Fund.CHIRSThe Substance Use / Brain Injury (SUBI) Bridging Projectis a joint effort of the above organizations to provideeducation and treatment information on substance usefollowing a brain injury.This material is owned by the SUBI project and may be reproduced with proper citation andwithout alteration for clinical use only. Expressed permission is required for any other use.
ContentsIntroductionHow to use this workbookIntroduction to substance use and acquired brain injury457Section 1 Understanding the addiction cycle111317213135394347Chapter 1Chapter 2Chapter 3Chapter 4Chapter 5Chapter 6Chapter 7Chapter 8Getting ready for changeMy top 5 reasons for changeThe effects of drugs and alcoholThe ABCs of substance useThoughts, feelings and substance useFirst things first. Ideas to get startedSaying no to alcohol and drugsCoping with cravingsSection 2 Tools to use during recoveryChapter 9Chapter 10Chapter 11JournalingBeing in groupsSetting realistic goalsSection 3 Understanding yourself and your relationshipsChapter 12Chapter 13Chapter 14Chapter 15Being your own best friendBuilding self esteemBuilding healthy relationshipsBuilding a support networkSection 4 Coping strategies for lifeChapter 16Chapter 17Chapter 18Chapter 19Chapter 20Chapter 21AssertivenessDealing with boredomCoping with strong feelingsRelaxationProblem-solvingStaying healthySection 5 Pulling it all togetherChapter 22Chapter 23Appendix AAppendix B515359697375798387919397101105109115Goal setting for recoveryLearning from lapses121123129For more informationForms for reproduction135137
IntroductionThis workbook was created for people who are living with the effects of a braininjury and are also having some problems due to drug or alcohol use.The workbook was designed by a partnership of people at Community HeadInjury Resource Services of Toronto (CHIRS) and the Centre for Addiction andMental Health (CAMH).The materials presented are based upon the programming provided at CAMH,Brentcliffe Site.To get the most out of this workbook we strongly recommend that clients reviewit with a counsellor who is familiar with addictions and/or is helping people afterbrain injury.Acquired Brain Injury counsellors using this workbook are encouraged to seekconsultation from professionals with experience in the treatment of substanceabuse.Counsellors in addictions and substance abuse are encouraged to seekconsultation from professionals with experience in the management of theeffects of acquired brain injury.4
How to use this workbookThis workbook was put together for three groups of people: People living with the effects of brain injury who are having some problemsdue to drug or alcohol use Counsellors in substance use Counsellors in acquired brain injury (ABI)It can be used as an aid in structuring individual counseling sessions with a clientor as handouts for use in group settings. Each chapter is organized into thefollowing sections to make the workbook easy to follow: GoalsInformationSelf-assessmentWorksheetPlanWe recommend that each individual session or group work follow the structuresuggested by the format of the workbook. Sessions should begin with a reviewof the goals, followed by the presentation of information, self assessment andpersonal goal-setting. In most chapters, information is brief enough that it canbe reviewed with the client in a single session. However, there are some topicareas that are more complex and may take several sessions to review.A recovery checklist is included in the Forms for reproduction section.Completing this form, or a similar plan at the end of each session, will help tokeep clients focused on their particular goals. Getting in the habit of reviewingthese each week will assist clients in organizing their thoughts, problem-solving,and follow-through.A structured self-assessment is provided in most chapters. Worksheets and plansare provided to assist the client in applying the new information to their ownplan of action.The order of the chapters provides a logical sequence for the introduction ofinformation. However, this order can be altered to fit the needs of a particularclient or the structure of the program in which it is being used.Please note that not all chapters contain all sections. Worksheets can be takenout of the workbook and used as handouts for groups.5
This workbook is designed to be a resource forthe following user groups: Counsellors with little experience in substance use should find enoughinformation and examples in each chapter to have meaningful conversationswith their clients about substance use and its effects. However, the workbookis not intended to be a replacement for consultation with counsellors insubstance abuse. Counsellors with little experience in acquired brain injury should find that thestructured, written presentation and concrete examples will help clients tocompensate for memory impairments and other cognitive difficulties.However, consultation with an acquired brain injury professional is stronglyrecommended. The multiple choice and checklist format of self-assessments is designed tofacilitate self-assessment for persons whose cognitive difficulties makeanswering open-ended questions difficult.6
Introduction tosubstance use andacquired brain injuryIs my substance use really a problem?This is a very difficult question to answer, particularly for a person who has had abrain injury. After reviewing the available information about the effects ofalcohol and brain injury we have concluded that it is not safe to use alcohol inany amount after brain injury. Having said that, the usual recommended limitsfor safe use of alcohol for those under the age of 65 are two drinks in a day formen and one drink per day for women. The difference between men andwoman is based on size and the ability of the body to process the alcohol.There are many reasons why it is generally considered unsafe to use illegal drugs.There is a risk of getting arrested — people who sell drugs are not regulated bylaw, so people who buy them are at risk for being the victims of crime. Someillegal drugs pose a great risk of causing further brain injury as well. Taking moreof your prescription drugs than your doctor prescribes is also dangerous. Medicalcomplications, including further brain injury, can result.If you have had a brain injury, it is not safe to drink alcohol in any amount, it isnot safe to use illegal drugs, and it is not safe to take more than the prescribeddose of your medications.Here are some signs that it might be time to ask for help —do any of these signs apply to you? You have tried to cut back or stop using substances on your own butsomehow you keep on using Someone around you is very worried about your use of alcohol or drugs You worry about your use of alcohol or drugs You have had legal, financial or relationship problems that are related toyour use of alcohol or drugsThere are a lot of good reasons for avoiding the use of drugs and alcohol after a braininjury. A helpful resource is: User’s manual for faster, more reliable operation of abrain after injury (Ohio Valley Center, 1994; www.ohiovalley.org)7
Eight reasons not to useHere are the eight reasons that the Ohio Valley Center givesfor not using drugs or alcohol after a brain injury:1People who use alcohol or other drugs after their injury do notrecover as well as those who do not. After brain injury some brain cells(neurons) are killed. Sometimes connections between neurons are disrupted aswell. Recovery is the process of rebuilding connections between brain cells.Unfortunately, the body cannot make new brain cells. Most often beingintoxicated (drunk) means that the functioning of your brain cells has beendisrupted. This makes it more difficult to recover from your injury.2Problems with balance, walking and talking are made worse byalcohol and drugs. Alcohol and drugs can cause falls and/or difficulty inspeaking, even in those without brain injury. After a brain injury, problems withbalance and speech caused by the injury itself can make these problems worse.3People who have had a brain injury sometimes say and do thingswithout thinking them through. This problem is made worse by drugsand alcohol. One of the functions of your brain is to stop you from acting onbad ideas. That function is turned off when you are using. This can result indoing and saying things that you regret later.4 Brain injuries can make it more difficult to pay attention, remembernew information and think things through clearly. Drugs and alcoholinterfere with all of these mental abilities. Many people find that after theirbrain injury they have to relearn some of the skills they once had. It is commonto have problems finding the right word, concentrating, solving problems andmaking use of other thinking skills. Adding alcohol and drugs to these problemsmakes it even harder to get things done.5 After a person has had a brain injury, they generally find that alcoholand other drugs have a more powerful effect. After a brain injury, the brainis more sensitive to alcohol and drugs. No matter what a person’s ability tohandle alcohol and drugs was before their injury, it is reduced after injury. Also,alcohol and drugs can interfere with any prescribed medications.8
6After a brain injury it is common to have times when a person feelsdown or depressed. Drinking and using drugs can make depressionworse. After a brain injury there are a lot of changes and challenges that makelife more difficult. That can be a cause for feeling down. Also, the effects of abrain injury itself can cause a depressed mood. That may be one reason whysome people turn to alcohol or drugs to feel relaxed and happier. That may betrue in the short run. In the long run, though, things usually get worse. Alcoholacts as a depressant in the brain. That will make you more depressed.7Drinking and using drugs can increase the likelihood of having aseizure. About 5% of people with a brain injury go on to have trouble withseizures. Seizures are serious and can cause further brain damage or injury. Thatis why doctors take great care to help their patients prevent having seizures.Many people are prescribed drugs to prevent seizures after they have had a braininjury. It is very dangerous to mix alcohol and other drugs with thesemedications. Taking yourself off prescribed drugs so that you can drink is alsovery dangerous. Talk to your doctor and get the facts.8Using drugs or alcohol after a brain injury increases your risk ofhaving another brain injury. After you’ve had one injury, your chances ofhaving another brain injury are three times greater. Brain injuries can causepeople to have more accidents because of changes in their balance, coordinationand judgment. Alcohol and drugs only make these difficulties worse.Congratulations on having made the decision to seek moreinformation on the effect of substance use on acquired brain injury.By going through the information in this workbook you will learn to understandmore about your substance use. You will also find coping strategies to help youmanage the difficulties that may arise during your recovery and you will findinformation about how to pursue a healthy lifestyle. Remember that one bookwill not give you all the answers — it is very important to find people whom youtrust to help you.9
Section 1Understandingthe addiction cycle11
Chapter 1Getting ready for changeGoals To learn that the good thingsassociated with substanceuse may come quick andeasy, but they don’t last long To learn that the problems that comefrom using drugs or alcohol last a long timeInformationThe first step in your recovery is to understand why you use drugs or alcohol and your reasons forwanting to make a changeSelf-assessmentCheck any or all of these short-term benefits of drinking or drug use that apply to you: Instant gratification (feeling good right away)Helps me get to sleepHelps me deal with painHelps me deal with stressPuts off having to deal with something that I don’t want to think aboutMakes me numb (helps me to stop having feelings)Gives me something to do when I feel lonelyHelps me to socializeHelps me to relaxGives me a sense of courageHelps me to have fun and lifts my spiritsHelps me feel normal, like one of the groupGives me something to do when I feel boredHelps me feel less depressedHelps me loosen up and be more excitingOther short-term benefits:13
Lasting effects of drug useHere are some problems that come from drinking or drug use. Notice that the effects tend to lasta long time. Check any or all of these long-term effects you might have experienced: Forgot what happenedFell or got in an accidentDid something unsafe or illegalLost moneyArgued with my familyArgued with my friendsHad problems with my healthHad problems with the lawLost my house/apartmentHurt someone I care aboutDid something that was against my own valuesLost control of my temperDamaged my reputationGot kicked out of a rehabilitation programHad trouble keeping doctor or therapy appointmentsWas not getting the most out of my rehabFelt badly about myself (damaged my self-esteem)Found that my problems were still there when I sobered upOther long-term effects:14
Worksheet, Chapter 1Getting ready for changeNow that you’ve had a chance to examine some of the pros and cons of your drinking or druguse, you might find it helpful to complete this chart. You may want to come back to it from timeto time as you learn more about yourself.Drinking or drug useWhat’s good about itWhat’s not good about it15
Chapter 2My top 5 reasons for changeGoals To understand how important motivationis to making a change To define your motivation for wantingto make a change To have your motivations handy duringthe tough timesInformationMaking changes in your life is a real challengeand it helps to have a clear idea of why youwant to make a change and what might helpkeep you motivated during the rough times.Some reasons for making a change might include: Relationships that are important to youGoals you want to reachWays your health might improveActivities you want to pursue17
Worksheet, Chapter 2My top 5 reasons for changeI want to make a change for the following reasons:12345PlanThere are a lot of ways that you can put your list to use.Check any or all of these ideas that you think might work for you: Write your list on a card and keep it with you Share your list with a supportive person so that they can encourage you Write a poem or a jingle you can say or sing to yourself Keep a journal with pictures to keep you inspired (see Chapter 9, page 53) Make a poster and hang it in a place that you will see each day If your list involves people who are important to you, use their pictures or something they havegiven you to remind yourself of what you are working for Plan to call or talk to five people to tell them about your reasons for making a changeAdd these things to your Coping Card (see Chapter 8, page 47).19
Chapter 3The effects of drugs and alcoholGoals To learn about how drugs and alcohol changethe normal functioning of the brain and body To understand the health effects of usingsubstancesInformationWhy it feels like you can’t live without drugs or alcoholOur brains are wired so that when we do something that gives us pleasure, we tend to want todo it again. That’s what drives us to do things that help us survive — eating, for example.Almost all drugs that are used to get high change how the natural chemicals work in the brain’spleasure centre. This change tricks you into thinking that the drug is something you need forsurvival. Often, the changes in brain chemistry that drugs cause last longer than the high. Thatcan cause serious long-term problems, including withdrawal symptoms and brain damage.REWARD CIRCUITThis is a picture of the reward circuit in thebrain. The most important thing to noticePre-frontalcortexis that the reward circuit has strongreasoningconnections to the part of your brain thatand planningis responsible for basic emotions (thenucleus accumbens) and the part of yourNucleusVentralaccumbensbrain that regulates basic body functionstegmentalbasicarea(the ventral tegmental area). One of theemotionsbasic bodyreasons that addictive drugs have such afunctionsstrong effect is that they act on the part ofthe brain that is in charge of very basicsurvival instincts. When the urge to use thedrug is strong enough, this part of thebrain can override the part of the brain in charge of reasoning and planning (pre-frontal cortex).This is one reason why most drugs make the problem of being impulsive — acting withoutthinking — worse. This is also why people spend a lot of time and energy getting the drug theyabuse for a short-term high, even though it causes a lot of problems in the long run.21
What drugs and alcohol do to your bodyStimulants speed up bodily functions. Depressants slow the body down. Some drugs cause you tosee and feel things that are not really there — but the effects of drugs don’t stop there. As youread through the information on the following chart, you will see that although drugs may haveone or two effects that make you feel good, they also cause many problems. Because of the waydrugs work on the brain, you may focus on the one or two positive effects, without stopping tothink about all of the problems. Sometimes the problems last much longer than the effect of thesubstance itself. This causes damage to the body and brain that may be permanent. Many drugs,and alcohol, have been shown to have long-term health effects that include liver damage, anincreased risk for getting cancer, heart disease and brain damage.This table show the effects of some common drugs. It is important to notice that all drugs listedmake some of the problems that come with brain injury even worse.CannabinoidsNameCommon namesWhat they doProblems they mitates a pleasurechemical in the brainSlow thinkingApathy(loss of motivation)Poor balancePoor coordinationPoor memoryPoor learningAnxietyPanic attacksFast heart rateCoughActive Ingredient:Tetrahydrocannabinol(THC)Increased risk forpsychotic episode22
DepressantsNameCommon namesWhat they doProblems they causeBarbiturates(e.g., Amytal,Phenobarbital
or as handouts for use in group settings. Each chapter is organized into the following sections to make the workbook easy to follow: Goals Information Self-assessment Worksheet Plan We recommend that each individual session or group work follow the structure suggested by the format of the workbook. Sessions should begin with .
Jul 25, 2019 · Where: Client List Client Profile. Note: Please search for each client before creating a new record. See “ Search for a Client” for more information. To add a new client to the system, follow the steps below. 1. On the left menu, click . Client List. 2. On the Client List screen, click . Add Client. Figure 2-2: Client List screen, Add .
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The Intake Process 3 Engagement Letters 4 Managing Clients 5 Handling a Difficult Client 5 The Finish Line 8 Conclusion 9 Client Fees and Billing 10 14 Timely Tips for Client Relations 12 30 Training Topics 13 SAMPLE FORMS Prospective Client Questionnaire 14 Office Intake: New Client Form A 16 Office Intake: New Client Form B 17
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