Developing the Reflective Practitioner : Supervision in Harm Reduction Programs

Developing the Reflective Practitioner: Supervision in Harm Reduction Programs A Training for Housing Works 10.29.07 57 Willoughby Street, Brooklyn Prepared and Delivered by Richard Elovich, MPH www.richardelovich.com

Training Contents: • Introduction (slides 2-5) • The team and group dynamics (slide 6-29) • Supervision, program philosophy, review of harm reduction, concepts and skills, trainings into practice (30-71) • A supervisory framework for staff-client interactions (72-81) • Supervision as developing reflective practice (82-90) • Monitoring and evaluation (91-104) • Cites and resource material for this training (105-6) www.richardelovich.com

Ground Rules • Elicit the reasons for having ground rules from participants. • Why might it be important for us to have ground rules? • Elicit from group members their ideas about ground rules • Let’s try to make a list of “ground rules” for the group that will help each of you individually to get the most out of our time together.

Training Contract • Stay focused today. Be on task. • Listening is a key to this training. Reflective listening. Listening to directions so they don’t have to be repeated and so you get the task or exercise right. • Listen to new ideas. Listen to what’s coming up inside you in relation to what’s being presented. Try to put your thoughts and feelings into words instead of “shutting down.” • Acknowledge and respect differences. You can “agree to disagree” on a contentious point and move on. • Participate in role plays. Go (forward) and grow. • Everyone has permission to pass. Offer feedback constructively not personally. Try to receive feedback as a gift. • Learning environment. Try to be okay with taking some learning risks. Stretch past your edge of what you know and what you are comfortable with. • Confidentiality. Hold the container. Don’t be leaky. • Turn off phones and beepers. • No cross talk. Allow one person to speak at a time. Equal time over time. • Start and end on time, including breaks. Be alert to tendency to fudge this. • Use “I” statements. • Can everybody agree? Is there anything you absolutely cannot live with? • Now we are off. www.richardelovich.com

LEARNING PROCESS: KNOWLEDGE • Acquisition of content • Retention (store in memory) • Application (retrieve and use) • Proficiency (integrate and synthesize)

What do you see? Working together as a group: (1) What makes an effective group? (2) Accountability: what does it mean?

GROUPS • Before we pursue groups as tool. We need to think about what they are. • We are social animals. We live and die in groups. We get our sense of ourselves socially. Most of what we do is social.

WHAT IS A GROUP? • List everything you do in a typical day from the moment you wake up in the morning up to the moment you fall asleep. • Delete from your list all the activities you perform with groups of people and see what is left. • Let’s discuss.

WHAT IS A GROUP? • Commuters (regular hour)? • Motorists (regular hour)? • Pedestrians on the street (regular hour)? • Employees in a department of a hospital or social service setting? • Sidewalk book venders and place holders? • Neighbors during blizzard?

WHERE DID YOU FIND GROUPS? • Work environment • Family and kinship • Civic associations (church, PTA, Senegalese Association) • Informal friendship clusters • Street demonstration • Student organizing

WHAT GROUPS MEAN TO PARTICIPANTS • Someone learns he does not have a disease and this means he loses group affiliation • Doctor on television show ER cannot perform surgery any longer and loses his “master” identity. • Someone attempting to stop drinking as to confront consequences of separating from peer group

QUESTIONS YOU RAISED • How do people use groups? • What happens to a group when someone is absent? How does group experience absence of one, two, three members?

What Makes a Group Effective? • Goals • Interdependence • Interpersonal interaction • Structured Relationships • Mutual Influence • Motivation

Goals • Groups exist for a reason. People join groups in order to achieve goals they are unable to achieve by themselves. A group may be defined as a number of individuals who join together to achieve a goal. It is questionable whether a group could exist unless there was a mutual goal that its members were trying to achieve.

Interdependence. • A group may be defined as a collection of individuals who are interdependent in some way. According to this definition, the individuals are not a group unless an event that affects one of them affects them all. Conceiving of a group as a dynamic whole in the sense that an event or action that affects one member is likely to affect all.

You are a member of a team where each individual has a specific role and specific responsibilities • Who are you accountable to?

Interpersonal Interaction. • A group may be defined as a number of individuals who are interacting with one another. According to this definition, a group does not exist unless interaction occurs. It is this interaction process that distinguishes the group from an aggregate.

Structured Relationships. • A group may be defined as a collection of individuals whose interactions are structured by a set of roles and norms. According to this definition, the individuals are not a group unless their interactions are so structured. A social-psychological group is an organized system of two ore more individuals who are interrelated so that the system performs some function, has a standard set of role relationships among its members, and has a set of norms that regulate the function of the group and each of its members.

Mutual Influence. • A group may be defined as a collection of individuals who influence each other. Individuals are not a group unless they are affecting and being affected by each other; therefore, the primary defining characteristic of a group is interpersonal influence. A group is two or more persons who are interacting with one another in such a manner that each person influences and is influenced by each other person.

Motivation. • A group may be defined as a collection of individuals who are trying to satisfy some personal need through their joint association. According to this definition, the individuals are not a group unless they are motivated by some personal reason to be part of a group. Individuals belong to the group in order to obtain rewards or to satisfy personal needs. It is questionable that a group could exist unless its members’ needs are satisfied by their membership.

GROUP DYNAMICS • Emphasis on process of group rather than group as an object. Thinking thorough this a bit will help us use groups not just rotely as received tools but as creative health practitioners who work with group process. • What a group needs to be. • Roles, expectations, norms, and procedures within group process. • Understanding the development and life of a group process.

CREATING PRODUCTIVE GROUPS • A pseudogroup • A traditional work group • An effective group • A high-performance group

Group Dynamics • Robert Bales (1965) three themes: dependence on the leader; pairing among members for emotional support; fight-flight reactions to a threat to the group. • Shultz (1958) three issues: affection; inclusion; and control. • Tuckman (1965) five stages: forming; storming; norming; performing; and adjourning.

Forming: uncertainty in which members try to determine their place in the group and the procedures and rules of the group.

Storming: conflicts begin to arise as members resist the influence of the group and rebel against accomplishing the task. Members often confront their various differences and conflict management is the focus of the group.

Norming: group establishes some consensus regarding a role structure and a set of group norms for appropriate behavior. Cohesion and commitment increase.

Performing: group members become proficient in working together to achieve the group’s goals and become more flexible in developing its patterns of working together.

Adjourning: the group disbands.

Stages to Group Development* • Defining and Structuring Procedures • Conforming to Procedures and Getting Acquainted • Recognizing Mutuality and Building Trust • Rebelling and Differentiating • Committing and taking ownership of the goals, procedures, and other members • Functioning maturely and productively • Terminating * Johnson and Johnson

What is supervision? www.richardelovich.com

Supervision • Managing the program • Monitoring the effectiveness of the individual worker, the team, the service delivery, and the effectiveness of standards, codes of ethics and conduct • Developing reflective practice in harm reduction oriented service programs • Assisting individual workers and the team to apply and adapt concepts, approaches, and skills from a training to their practice www.richardelovich.com

Are Concepts and Skills in Trainings applied and integrated into the work people do? www.richardelovich.com

On a Scale of 1 to 10 1 = not evident in the work… 10 = very evident in the work • Harm Reduction • Stages of Change • Motivational Interviewing • A Strengths Based Approach • How is each reflected in the work? www.richardelovich.com

Why articulate program philosophy Assumptions about drug users Harm reduction among drug users Intravention and intervention Implications of harm reduction in all domains Program PhilosopHy

Program Philosophy • An evidence basedprogram philosophythat: examines and clarifies underlying assumptions—about drug use, about the people who use drugs, about opioid dependence and people who are opioid dependent, • Examines and clarifies the principles, goals, processes, technologies and acceptable outcomes of harm reduction.

Why have a Program Philosophy • The program philosophy should be consistently reflected in program policies and practices. • In order to be evaluated, a program’s specific policies and procedures—like any health or medical program—need to be logically consistent with its overall philosophy. • Moreover, programs need to inform and, if needed, clarify philosophy, policies, and procedures to each and every member of the service delivery team and to clients/patients, their relatives, as well as members of the local community.

Exercise • In smaller groups, divide a flip chart sheet into three components of harm reduction program philosophy: • examine and clarify underlying assumptions—about drug use, about the people who use drugs, about patterns of opioid dependence and people who are opioid dependent • Identify and discuss the principles, goals, processes, technologies, and outcomes of harm reduction. • How should the program philosophy be consistently reflected in program policies and practices.

Each group presents:

Putting Harm Reduction Trainings Into Action Understanding the Harm Reduction Model to apply it consistently in service delivery to injection drug users www.richardelovich.com

Managing a Harm Reduction Oriented Service Program • Management of Staff • Team Meetings • Supervision • Clear Policies and Procedures • The Learning Environment • Reducing Burn-out www.richardelovich.com

Where should we focus? • Each supervisor presents a thumbnail sketch of a client. Getting to the bottom line? • Why now? • What are themes that emerge? • Selecting a case to examine that helps identify a problem or problem solving, engages the group in thinking about practice, and is an opportunity to learn together www.richardelovich.com

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Trainings • Harm Reduction • Stages of Change • Motivational Interviewing • A Strengths Based Approach • Reflective Practice www.richardelovich.com

Two Salient Features of Harm Reduction • the harm reduction model is clearly predicated upon the recognition that some “behavioral outcomes” have greater situational importance than others. Specifically, the harm reduction model prioritizes the prevention of HIV transmission. • As a strategy by which to achieve reduction in the transmission of HIV, harm reduction is based on the recognition that particularly behavioral goals must be tailored to the specific needs and real-life capacities of the individuals to whom they are directed. www.richardelovich.com

Research consistently shows that (1) attunement to drug user readiness, interest, or capacity to change, i.e., attunement to individual drug users expectations of his encounter with help(ers), and (2) the quality of the helping relationship (respect, credibility, trust, rapport) are directly associated with positive results. www.richardelovich.com

Developing the Reflective Practitioner : Supervision in Harm Reduction Programs