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The First Interview – Addictions Counseling

1.  Goals in a first interview

a.  Allow the client to tell you her/his story in her/his own words

b.  Let the client know that you understand what she/he believes, even when it includes that she/he does not need to be there.

c.   This is not the moment to express that you may disagree with client.

2.  The first interview with the self-referred adult

a.  The client feels the need to explore the possibility of getting therapy.

3.  Prepare yourself  in advance

a.  Has the client been in the therapy before?

b.  Review documentation

    • Medical history
    • Psychiatric evaluation
    • Biopsychosocial assessment
    • Previous clinician’s notes

c.    Ask yourself

    • What don’t I know that I need to know?
    • Write down notes and questions you want to ask before calling the client to set up an appointment
    • Add a healthy dose of skepticism to everything you find out

4.  What to ask your supervisor before the first interview

a.  Any questions you have after reading documents provided on the client

b.  Whom to include in the interview

c.   How long the session should last

d.  How often should you see the client

e.  How to introduce your self

f.    When and how to record sessions

5.  When calling the client, remember that

a.  Your relationship with the client starts right there

b.  How should you introduce yourself to the client

c.   Be professional and concerned

d.  Remember that this is NOT a therapy session

e.  Maintain confidentiality from this moment on

    • Find out if, and under what circumstances, you are required by law not to maintain confidentiality.
    • Except in those circumstances (above), always get written consent from the client to share identifying information to other agencies
    • Telephone calls: remember that even the fact that the individual is a client is confidential information.
    • When necessary use fictious names and situations

6.  The room set up is important

a.  Keep it comfortable and simple

b.  How would YOU feel coming here?

7.  Before you start the interview

a.  Select an assessment instrument, based on

    • Your agency
    • The age of the client
    • Reliable
    • Valid

b.  Explain the assessment process to the client

8.  Ask your supervisor how you should gather information during the session

a.  Taking notes?

b.  Just listening?

c.   Audiotaping?

d.  Videotaping?

e.  Using a computer?

9.  During the interview/session

a.  Start where the client is

b.  Your concern is the client’s feelings

c.   Keep self-disclosure to the minimum

d.  The focus is on the client, not on you

e.  Practice active listening

f.    Do not put words or feelings into your client’s mouth

g.  Ask who, what, when, where, and how

h.  Don’t ask WHY

    • It assumes client knows the answer to his/her problem
    • Client might feel attacked and therefore act defensive
    • They might tell you more than they are ready to share
    • If client tells you more than they meant to, they might never come back

10. Presenting problem

a.  Why is the client here now?

    • Basic data

11. At the end of the session

a.  Leave enough time to ask your client if there are any questions

b.  Ask client if she/he would like to come back

c.   Give the client a card with information about her/his next appointment

d.  Walk your client to the door

e.  Be aware of the door-knob syndrome

    • Client waits to tell you something very important until there is not time left to discuss it
    • You can end the session by saying “That sounds like something we should talk about. Let’s begin with that next week.
    • You NEVER let a client leave your office if you have a sense that she/he might hurt her/himself or others.

Reference: Where to Start and What to Ask – Susan Lukas 

Addiction Counseling Tools: The MSE – Mental Status Exam

The Mental Status Exam (MSE)

The Mental Status Exam is part of the assessment process. Skillful counselors and therapists are able to identify clients with co-occurring disorders. Well-trained substance abuse counselors and therapists can provide a more competent service when they possess the basic knowledge in mental disorders that co-occurred with substance abuse problems. The following is a brief outline of the MSE.
1. The Mental Status Exam (MSE)

  •  It is the process of noting the observable in some systematic way
  • It is different from the biopsychosocial assessment
    • Based mostly on facts about the client’s life
    • Description of the problem provided by the client
  • The MSE is basically our observations
  • It’s a very useful tool for assessing a client over time

2. Helpful questions for the MSE

  • What has changed?
  • When did it change?
  • Has it change for the better or the worse?
3. Two things to keep in mind
  •  Ask for further explanation when you don’t understand something the client has told you
  • Document what is worth noting
 4. Where to begin
  •  Start by describing those things that anyone looking at the client would notice
  • It does not matter when the MSE is completed
  • Remember that a good clinician is a good observer
 5. Avoid two real temptations
  • To infer meaning from what you are actually seeing
  • To see things that are in reality just your assumptions
 6.  Areas to address in the MSE
  •  Appearance
    • How does the client look and behave?
  • Speech
    • How does the client speak?
  • Emotions
    • What is the client’s mood/affect?
    • How does the client feel most of the time?
    • How does the client appear to be feeling during the interview with you?
  • Thought process and content
    • How does the client think?
      • Circumstantiality – takes a while to get to the point
      • Perseveration – repeating phrase or returning to same subject
      • Association – how does the client get from one idea to the next?
  • What does the client think about?
    • Delusions?
    • Compulsions?
  • Sensory perception
    • Illusions?
    • Hallucinations?
  • Mental Capacities
    • Is the client oriented in time, place, and person?
    • What is your estimate of the client’s intellingence?
    • Can the client remember and concentrate?
    • How are the client’s judgment and insight?
  • Attitude toward the interviewer
    • Client’s attitude towards you
    • Does it change over time?
    • Does he/she respond to empathy?
    • Does he/she appear to be capable of empathy?

Reference: Where to Start and What to Ask – Susan Lukas. (This is by far one of my favorite books. I highly recommend it) 
 Dual Disorders – David O’Connell

Drug Addiction and Co-occurring Disorders

Dual disorders is a term used in the past to refer to clients who deal with substance abuse problems and mental disorders. Nowadays we use terms such as co-occurring or comorbid disorders. All it means is that there is one or more problems in addition to the original problem. Clients with substance abuse problems usually deal with poly-substance abuse and one or more mental disorders. Then, it is much more complex than just thinking of a client with cocaine addiction and bipolar disorder. In reality, we encounter clients abusing more than one substance and presenting symptoms for one or more mental disorders. Therefore, it is important for substance abuse counselors and therapists to be well-trained in both substance abuse assessment and mental disorders assessment. Clients are often misdiagnosed with mental disorders as the main problem, when the real case is that the client’s symptoms could be the product of the substance(s) being abused. Since several symptoms of substance abuse and mental disorders overlap, counselors and therapists need to have the skills to identify the main problem and the co-occurring problem.This is a brief outline about dual/co-occurring/comorbid disorders

  1. Co-Occurring Disorders
    • Substance abuse problems combined with mental disorders
    • Counselors/therapists can treat clients with co-occurring disorders by mastering basic approaches
  2. Models of Training
    • Scientific Professional Model
      1. Training of psychologists and psychiatrists
      2. Classroom teaching of “facts”
  • Craft Model
  1. Traditional addictions counseling training
  2. Based on personal experience and on-the-job apprentice-style training and supervision

There advantages and disadvantages of both, but can be overcome by combining them.

  • First Steps
    • Learn about the disorder
  1. Read available literature on the topic
  2. DSM-IV
  • Assess the client carefully
  1. Avoid misdiagnosing clients due to overlapping of symptoms between the effects of a drug and a mental disorder
  2. Is there a mental disorder, regardless of the substance abuse problem?
  3. Is the substance causing the symptoms? (e.g. schizophrenia, paranoia, depression due to substance use)
  • Learn what to avoid in treatment
  1. Do no harm
  • Learn appropriate treatment strategies
Other Considerations
  • Continuing Care
  1. Help the client maintain sobriety and the mental disorder under control by providing good after-care.
  • Role of Medication
  1. Become familiar with the client’s medication
  2. Medication should be monitored closely

Psychiatric and Psychological reports

  • Impulse control
    • Client’s tendency to act on feelings, thoughts, or impulses
  • Level of functioning
    • How well clients manage their impulses
  • Affective expression
    • Client’s style of emotional expression
  • Cognitive functioning
    • Client’s level of intelligence
  • Perceptual functioning
    • Nature and frequency of client’s perceptual disturbances
  • Reevaluation
Discussing the diagnosis with the client
  • Avoid undermining treatment
  • Encourage AA or NA involvement
  • Supervision
Other Considerations
  • Well-trained addictions therapists/counselors can skillfully treat the psychiatric disorder and the substance abuse disorder
  • Competence in the brief therapies is needed
  • Cognitive Behavioral Therapy (CBT) is one of the most effective ones.

Reference: Dual Disorders – David F. O’Connel 

8 Practice Domains of Substance Abuse Counselors

8 Practice Domains – 137 Questions on the IC&RC ADC Exam

Domain 1: Clinical Evaluation – 24 questions

• Demonstrate effective verbal and non-verbal communication to establish rapport.
• Discuss with the client the rationale, purpose, and procedures associated with the screening and assessment process to facilitate client understanding and cooperation.
• Assess client’s current situation, including signs and symptoms of intoxication and withdrawal, by evaluating observed behavior and other available information to determine client’s immediate needs.
• Administer the appropriate screening and assessment instruments specific to the client’s age, developmental level, culture, and gender in order to obtain objective data to further assess client’s current problems and needs.
• Obtain relevant history and related information from the client and other pertinent sources in order to establish eligibility and appropriateness to facilitate the assessment process.
• Screen and assess for physical, medical, and co-occurring disorders that might require additional assessment and referral.
• Interpret results of data in order to integrate all available information, formulate diagnostic impressions, and determine an appropriate course of action.
• Develop a written summary of the results of the assessment in order to document and support the diagnostic impressions and treatment recommendations.

Domain 2: Treatment Planning – 20 questions

• Discuss diagnostic assessment and recommendations with the client and concerned others to initiate an individualized treatment plan that incorporates client’s strengths, needs, abilities, and preferences.
• Formulate and prioritize mutually agreed upon problems, immediate and long-term goals, measurable objectives, and treatment methods based upon assessment findings for the purpose of facilitating a course of treatment.
• Use ongoing assessment and collaboration with the client to review and modify the treatment plan to address treatment needs.

Domain 3: Referral – 10 questions

• Identify client needs which cannot be met in the current treatment setting.
• Match client needs with community resources considering client’s abilities, gender, sexual orientation, developmental level, culture, ethnicity, age, and health status to remove barriers and facilitate positive client outcomes.
• Identify referral needs differentiating between client self-referral and direct counselor referral.
• Explain to the client the rationale for the referral to facilitate the client’s participation with community resources.
• Continually evaluate referral sources to determine effectiveness and outcome of the referral.

Domain 4: Service Coordination – 10 questions

• Identify and maintain information about current community resources in order to meet identified client needs.
• Communicate with community resources concerning relevant client information to meet the identified needs of the client.
• Advocate for the client in areas of identified needs to facilitate continuity of care.
• Evaluate the effectiveness of case management activities through collaboration with the client, treatment team members, and community resources to ensure quality service coordination.
• Consult with the client, family, and concerned others to make appropriate changes to the treatment plan ensuring progress toward treatment goals.
• Prepare accurate and concise screening, intake, and assessment documents.

Domain 5: Counseling – 33 questions

• Develop a therapeutic relationship with clients, families, and concerned others in order to facilitate self-exploration, disclosure, and problem solving.
• Educate the client regarding the structure, expectations, and limitations of the counseling process.
• Utilize individual and group counseling strategies and modalities to match the interventions with the client’s level of readiness.
• Continually evaluate the client’s level of risk regarding personal safety and relapse potential in order to anticipate and respond to crisis situations.
• Apply selected counseling strategies in order to enhance treatment effectiveness and facilitate progress towards completion of treatment objectives.
• Adapt counseling strategies to match the client’s needs including abilities, gender, sexual orientation, developmental level, culture, ethnicity, age, and health status.
• Evaluate the effectiveness of counseling strategies based on the client’s progress in order to determine the need to modify treatment strategies and treatment objectives.
• Develop an effective continuum of recovery plan with the client in order to strengthen ongoing recovery outside of primary treatment.
• Assist families and concerned others in understanding substance use disorders and utilizing strategies that sustain recovery and maintain healthy relationships.
• Document counseling activity to record all relevant aspects of treatment

Domain 6: Client, Family, and Community Education – 15 questions

• Provide culturally relevant formal and informal education that raises awareness of substance use, prevention, and recovery.
• Provide education on issues of cultural identity, ethnic background, age, sexual orientation, and gender in prevention, treatment, and recovery.
• Provide education on health and high-risk behaviors associated with substance use, including transmission and prevention of HIV/AIDS, tuberculosis, sexually transmitted infections, hepatitis, and other infectious diseases.
• Provide education on life skills, including but not limited to, stress management, relaxation, communication, assertiveness, and refusal skills.
Provide education on the biological, medical, and physical aspects of substance use to develop an understanding of the effects of chemical substances on the body.
• Provide education on the emotional, cognitive, and behavioral aspects of substance use to develop an understanding of the psychological aspects of substance use, abuse, and addiction.
• Provide education on the sociological and environmental effect of substance use to develop an understanding of the impact of substance use on the affected family systems.
• Provide education on the continuum of care and resources available to develop an understanding of prevention, intervention, treatment, and recovery.

Domain 7: Documentation – 17 questions

• Protect client’s rights to privacy and confidentiality according to best practices in preparation and handling of records, especially regarding the communication of client information with third parties.
• Obtain written consent to release information from the client and/or legal guardian, according to best practices and administrative rules, to exchange relevant client information with other service providers.
• Document treatment and continuing care plans that are consistent with best practices and applicable administrative rules.
• Document client’s progress in relation to treatment goals and objectives.
• Prepare accurate and concise reports and records including recommendations, referrals, case consultations, legal reports, family sessions, and discharge summaries.
• Document all relevant aspects of case management activities to assure continuity of care.
• Document process, progress, and outcome measurements.

Domain 8: Professional and Ethical Responsibilities – 21 questions

• Adhere to established professional codes of ethics and standards of practice in order to promote the best interests of the client and the profession.
• Adhere to jurisdictionally-specific rules and regulations regarding best practices in substance use disorder treatment in order to protect and promote client rights.
• Recognize individual differences of the counselor and the client by gaining knowledge about personality, cultures, lifestyles, gender, sexual orientation, special needs, and other factors influencing client behavior to provide services that are sensitive to the
uniqueness of the individual.
• Continue professional development through education, self-evaluation, clinical supervision, and consultation in order to maintain competence and enhance professional effectiveness.
• Identify and evaluate client issues that are outside of the counselor’s scope of practice and refer to other professionals as indicated.
• Advocate for populations affected by substance use and addiction by initiating and maintaining effective relations with professionals, government entities, and communities to promote availability of quality services.
• Apply current counseling and psychoactive substance use research literature to improve client care and enhance professional growth.

Reference: IC&RC Candidate Guide
Re-blogged from LCDC Exam Review (WordPress)

8. Professional and Ethical Responsibilities

Professional and ethical responsibilities are the obligations of an addiction counselor to adopt ethical and behavioral standards of conduct and continuing professional development. Our competencies in this area, are:

1. To adhere to established professional codes of ethics that define the professional context within which the counselor works to maintain professional standards and protect the client.

Knowledge, skills, and attitudes:

  • Federal, State, agency, and professional codes of ethics.
  • Clients’ rights and responsibilities.
  • Professional standards and scope of practice.
  • Boundary issues between client and counselor.
  • Difference between the role of the professional counselor and that of a peer
  • counselor or sponsor.
  • Consequences of violating codes of ethics.
  • Means for addressing alleged ethical violations.
  • Nondiscriminatory practices.
  • Mandatory reporting requirements.
  • Openness to changing personal behaviors and attitudes that may conflict with ethical guidelines.
  • Willingness to participate in self, peer, and supervisory assessment of clinical skills and practice.
  • Respect for professional standards.

2. To adhere to Federal and State laws and agency regulations regarding the treatment of substance use disorders.

Knowledge, skills, and attitudes:

  • Federal, State, and agency regulations that apply to addiction counseling.
  • Confidentiality rules and regulations.
  • Clients’ rights and responsibilities.
  • Legal ramifications of noncompliance with confidentiality rules and regulations.
  • Legal ramifications of violating clients’ rights.
  • Grievance processes.

3. To interpret and apply information from current counseling and psychoactive substance use research literature to improve client care and enhance professional growth.

Knowledge, skills, and attitudes:

  • Professional literature on substance use disorders.
  • Information on current trends in addiction and related fields.
  • Professional associations.
  • Resources to promote professional growth and competency.
  • Read and interpret current professional and research-based literature.
  • Apply professional knowledge to client-specific situations.
  • Apply research findings to clinical practice.
  • Apply new skills in clinically appropriate ways.
  • Commitment to life-long learning and professional growth and development.
  • Willingness to adjust clinical practice to reflect advances in the field.

4. To recognize the importance of individual differences that influence client behavior, and apply this understanding to clinical practice.

Knowledge, skills, and attitudes:

  • Differences found in diverse populations.
  • How individual differences affect assessment and response to treatment.
  • Personality, culture, lifestyle, and other factors influencing client behavior.
  • Culturally sensitive counseling methods.
  • Dynamics of family systems in diverse cultures and lifestyles.
  • Client advocacy needs specific to diverse cultures and lifestyles.
  • Signs, symptoms, and patterns of violence against persons.
  • Risk factors that relate to potential harm to self or others.
  • Hierarchy of needs and motivation.
  • Assess and interpret culturally specific client behaviors and lifestyles.
  • Convey respect for cultural and lifestyle diversity in the therapeutic process.
  • Adapt therapeutic strategies to client needs.
  • Willingness to appreciate the life experiences of individuals.
  • Appreciation for diverse populations and lifestyles.
  • Recognition of one’s biases toward other cultures and lifestyles.

5. To use a range of supervisory options to process personal feelings and concerns about clients.

Knowledge, skills, and attitudes:

  • The role of supervision.
  • Models of supervision.
  • Potential barriers in the counselor–client relationship.
  • Transference and countertransference.
  • Resources for exploration of professional concerns.
  • Problem-solving methods.
  • Conflict resolution.
  • The process and effect of client reassignment.
  • The process and effect of termination of the counseling relationship.
  • Phases of treatment and client responses.
  • Willingness to accept feedback.
  • Acceptance of responsibility for personal and professional growth.
  • Awareness that one’s personal recovery issues have an effect on job performance and interactions with clients.

6. To conduct self-evaluations of professional performance applying ethical, legal, and professional standards to enhance self-awareness and performance.

Knowledge, skills, and attitudes:

  • Personal and professional strengths and limitations.
  • Legal, ethical, and professional standards affecting addiction counseling.
  • Consequences of failure to comply with professional standards.
  • Self-evaluation methods.
  • Regulatory guidelines and restrictions.

7. To develop and use strategies to maintain one’s physical and mental health.

Knowledge, skills, and attitudes;

  • Rationale for periodic self-assessment regarding physical health, mental health, and recovery from substance use disorders.
  • Available resources for maintaining physical health, mental health, and recovery from substance use disorders.
  • Consequences of failing to maintain physical health, mental health, and recovery from substance use disorders.
  • Relationship between physical health and mental health.
  • Health promotion strategies.
  • Carry out regular self-assessment with regard to physical health, mental health, and recovery from substance use disorders.
  • Use prevention measures to guard against burnout.
  • Employ stress-reduction strategies.
  • Locate and access resources to achieve physical health, mental health, and recovery from substance use disorders.
  • Model self-care as an effective treatment tool.
  • Recognition that counselors serve as role models.
  • Appreciation that maintaining a healthy lifestyle enhances the counselor’s effectiveness.

TAP 21

7. Documentation

Documentation involves the recording of the screening and intake process, assessment, treatment plan, clinical reports, clinical progress notes, discharge summaries, and other client-related data.

The competencies in this area, are:

1. Demonstrate knowledge of accepted principles of client record management. 

  • Regulations pertaining to client records.
  • The essential components of client records, including release forms, assessments, treatment plans, progress notes, and discharge summaries and plans.
  •  Composing timely, clear, complete, and concise records that comply with regulations.
  • Documenting information in an objective manner.
  • Writing legibly.
  • Using new technologies in the production of client records.

2. Protect client rights to privacy and confidentiality in the preparation and handling of records, especially in relation to the communication of client information with third parties. Our knowledge and skills in this area, are:

  • Federal, State, and program confidentiality rules and regulations.
  • The application of confidentiality rules and regulations.
  • Confidentiality rules and regulations regarding infectious diseases.
  • Apply infectious disease regulations as they relate to addictions treatment.
  • The legal nature of records.
  • Request, prepare, and complete release of information when appropriate.
  • Protect and communicate clients’ rights.
  • Explain regulations to clients and third parties.
  • Provide security for clinical records.
  • Willingness to seek and accept supervision regarding confidentiality rules and regulations.
  • Respect for clients’ rights to privacy and confidentiality.
  • Commitment to professionalism.
  • Recognition of the absolute necessity of safeguarding records.

3. Prepare accurate and concise screening, intake, and assessment reports. Essential elements of screening, intake, and assessment reports, include:

  • psychoactive substance use and abuse history
  • physical health
  • psychological information
  • social information
  • history of criminality
  • spiritual information
  • recreational information
  • nutritional information
  • educational or vocational information
  • sexual information
  • legal information

4. Record treatment and continuing care plans that are consistent with agency standards and comply with applicable administrative rules.

  • Current Federal, State, local, and program regulations.
  • Regulations regarding informed consent.

5. Record progress of client in relation to treatment goals and objectives.

  • Appropriate clinical terminology used to describe client’s response to intervention and progress made toward completing treatment goals and objectives.
  • How to review and update records:
  1. Prepare clear and legible documents.
  2. Document changes in the treatment plan, client status, client response to and outcome of interventions, level of care provided, and discharge status.
  3. Use appropriate clinical terminology and standardized abbreviations.
  4. Note client’s strengths and limitations in achieving treatment goals.
  5. Record client’s response to and outcome of interventions.
  6. Record changes in client’s status, behavior, and level of functioning.
  1. Note limitations of treatment provided to client.

6. Prepare accurate and concise discharge summaries.  The components of a discharge summary, include:

  • client profile and demographics
  • presenting symptoms
  • diagnoses
  • selected interventions
  • critical incidents
  • progress toward treatment goals
  • outcome
  • continuing care plan
  • prognosis
  • recommendations

TAP 21

6. Client, Family, and Community Education

Addiction counselors play an important role in providing clients, families, significant others, and community groups with information about the risks involved with alcohol, tobacco, and other drugs use, as well as available prevention, treatment and recovery resources.

Our competencies in this area are:

  1.  To provide education both formal and informal about substance abuse prevention and treatment programs, and the recovery process. In order to help people from multicultural backgrounds, we need to keep in mind:
    • Cultural differences among diverse communities.
    • Cultural differences in substance use behaviors.
    • Delivery of educational programs that are culturally relevant.
    • Research and theory on prevention of substance abuse problems.
    • Learning styles and teaching methods that we can adapt to our clients.
    • How to facilitate discussions in a safe and respectful environment.
    • How to preparing outlines and handout materials.
    • How to make public presentations to deliver the information effectively.
    • Cultural issues in planning prevention and treatment programs.
    • Age and gender differences in substance use patterns.
    • Culture, gender, and age-appropriate prevention, treatment, and recovery resources.
    • Awareness of our own cultural biases.
  2. To describe the risk and protective factors that increase and decrease the likelihood for an individual, community, or group to develop a substance use disorder. Our knowledge in this area includes:
    • Risk and protective factors for the onset of substance use disorders.
    • How to present the issues from a non-judgmental perspective.
  3. To describe the warning signs, symptoms, and the course of substance use disorders. We must be familiar with:
    • The continuum of use and abuse, including the warning signs and symptoms of a developing substance use disorder.
    • The current Diagnostic and Statistical Manual of Mental Disorders (DSM) categories or other diagnostic standards associated with psychoactive substance use.
  4. To describe how substance use disorders affect families and significant others. We need to educate our client about:
    • How psychoactive substance use by one family member affects other family members or significant others.
    • The family’s influence on the development and continuation of a substance use disorder.
    • The role of the family, couple, or significant others in treatment and recovery.
  5. To describe the continuum of care and resources available to the family and significant others. Our goals are:
    • To present available treatment options, including local health, allied health, and behavioral health resources.
    • To motivate both family members and the client to seek out resources and services from the full continuum of care.
    • To describe different treatment modalities.
    • To identify and make referrals to local health, allied health, and behavioral health resources.
    1. Although this may sounds easy to do, we need to keep in mind the difficulties families and significant others go through when seeking help. We must work from a strengths-based principle, which emphasizes client autonomy.
  • To describe principles and philosophy of prevention, treatment, and recovery.
    • We must be familiar with the models for substance abuse prevention and treatment, and recovery from substance use disorders.
  • To understand and describe the health and behavior problems related to substance use, including transmission and prevention of HIV/AIDS, tuberculosis, sexually transmitted diseases, hepatitis C, and other infectious diseases.
    • Awareness of our own biases when presenting the information.
  • To teach life skills, including but not limited to stress management, relaxation, communication, assertiveness, and refusal skills.
    • Delivering educational sessions.
  • TAP 21

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