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David Stuart


Focus always on 4 things

· The kind, firmly-boundaried relationship you can offer

· Goal setting/goal accomplishment skills

· Harm reduction information /equipment

· Craving management skills, relapse prevention

Welcome, introduction, boundaries.

Kindness, skill and firm boundaries will be at the core of all consultations going forward; it's good to establish these up front.

- Explain how your 'service' works (this particular consultation, and subsequent consultations).

- Explain the time limitations, and how that time can best be spent. Explain where you might need to stop a particular dialogue that is straying into areas you aren't qualified to help with (for example, a complex discussion about traumatic past experiences can destabilise a client's mental health, trigger a more dangerous relapse. If a client is currently using drugs, these discussions might better be left until the person's drug use is more stable, or left to a qualified addiction therapist/psychologist.)

- Explain the limits of your skill-set and remit. if you aren't a psychologist/counsellor/psychiatrist/doctor/sexual health expert, explain this; do not get lost in dialogue outside of your skill set, or that you are not qualified to practice. It can be tempting to indulge and explore underlying issues, and it IS helpful to understand these; but those discussions must be managed very cautiously, they ought never to distract from your skill-set and your remit to help affect their choices & behaviour moving forward.

- Do not diagnose.

- Explain the safety of the space you are providing; that it is a firmly-boundaried space; what confidentiality means in that environment, what should or should not happen if you accidentally see each other outside of this space (that includes real space and online).

- Sexual/flirtation boundaries; in the contexts of chemsex, be mindful that sexuality and sexiness might have been experienced as transactional or exploitable by the person; assure them that this is a safe space in regard to their sexuality. Assure them that you value that boundary. Be mindful that people who have been victims of transactional/exploitative sex, sexual harassment/assault, people who have been ensconced in highly sexualised environments, or exposed to normalised non-consensual environments can often be overtly flirtatious or sexually available within support settings and with support workers. What might be perceived as fun flirtatiousness might actually be a complex coping mechanism, or a very vulnerable person testing the safety of the relationship you are offering. Be sure to be firmly-boundaried, and to assure the person that you are providing a safe, non sexual space for them.

- Create a relationship. Being mindful of the time limitations you may have (and your boundaries), help develop trust. Listen to their story, don't guide it too much during introductions. Be affirming, be kind, be non-judgmental, be safe, and let the person get a sense of these things they can trust from you. If you need to interrupt this for the sake of time, do so gently, apologising for the time restraints, and assuring them you want them to get the very best out of the time together, and that you might need to focus or guide the dialogue moving forward. Be sure that's well understood, and that you're both in agreement about that.

Focus on your job; set a goal, work toward it; impart craving management skills, relapse prevention skills, harm reduction information. A drugs-worker's main job is to help a person with the choices they will make (re their drug use) in the comings days/week. Do not be distracted from this important focus.

Begin session with a (very) recent history

If time is available, it can be helpful to hear about the first time and age they first tried alcohol or drugs; the contexts of that, and how their use developed over time. Pay note to any patterns you see; periods of dependent use, a preference for sedatives over stimulants (or vice versa), use associated with periods of trauma, shame, embarrassment, lone use versus social use, use that increased during certain periods. It can be helpful to know if they have accessed support of any kind in regard to their drug use, and if so, how they experienced that support, if it brought about any changes in behaviour.

What activities is your use mostly associated with (eg, clubbing, socialising, home alone, sex one-on-one, group sex, lone masturbation, Juzt before bed, when playing on apps

If it is a 1st visit;

If it is a follow-up visit, begin with a summary of goal accomplishment (or otherwise) in last week(s). "What was your goal for the last week? Did you accomplish it?"

- Affirm accomplishments & successes. They did something right; what was that?

- Explore non-accomplishments; what wasn’t done right? What can be improved upon? Lessons learned.

- What cravings were experienced? At what times? What triggered them? How were they managed? What worked what didn't? What can be done differently next time?

- Prepare for coming week. Does patient understand their personal triggers? Is patient’s mastery of craving management improving?

- Always always discuss harm reduction.

If someone isn’t motivated…

- or if they are highly ambivalent

- or presenting in crisis

- or only there because someone else told them to come

- or if they are unwilling to commit to any goal or change

- if they are not ready to make any changes

- or not wanting to commit to any suggestion you might make...

That's OK.

Change (in this regard) is frightening. Don't hurry anybody.

Don't pressure them into committing to changes they don't want to make. It's ok to let them go without a plan for Change. It is an opportunity to check if they have good awareness of harm reduction practices; it's a good opportunity to see if they have some boundaries that keep their use from accelerating or becoming problematic.

Always seek their permission to discuss these things; don't force it upon them.

If they aren't ready to set a goal, that's always ok; invite them to reflect and return when they are more certain of what they want to achieve.

Sometimes when fear or ambivalence or reluctance are steering the conversation, you might find yourself going around in circles. When you find that happening, you can always come back to these core questions;

- “What brought you here today?”

- “Why have you come?”

- “How can I help you today?”

- "What do you want to achieve here?”

- "How can we best make use of this time”?

And if they can't answer these questions - that's ok. Don't let the valuable time be wasted. Just be kind. Explore the pros & cons of their chemsex experiences. Help them establish boundaries to keep them safe.

And let them know they are welcome to come back at another time.

Always let them know you are kind and boundaried

Guidance for Handovers, client notes

Reason for presentation:

History/contexts of recent use

Goal identified?

Motivation to achieve goals?

Plan (for coming weeks. Returning?)

Any urgent risks?

Follow up email? Referral made? Info sent?