24 July 2020

Reflections on a Counseling Relationship

 

Considering the significance of relationships in any interpersonal interaction is not exactly blog-worthy news; the importance of the relationship between a counselor and a client is no exception. Actually, there is quite a substantial literature on the subject, with numerous references to the role that the relationship plays in what is called the "common factors" related to effective psychotherapy. Going as far back as 1936, Saul Rosenzweig posited that there are "common factors" inherent in all psychotherapies. 

 

An interesting review of the "common factors" phenomenon is included in the 1995 article by Miller, Hubble, & Duncan entitled, "No More Bells and Whistles" (Miller, S. , Hubble, M. , & Duncan, B. [1995]. The Family Therapy Networker, 19, 52-63). In this article the authors suggest that the outcome of all therapy is influenced by 4 factors common to all effective psychotherapy: 1) Therapeutic Technique, e.g., CBT, Person-centered, etc. (accounts for 15% of outcome), 2) Expectancy and Placebo, e.g., client beliefs re the effectiveness of counseling, etc. (15%), 3) Therapeutic relationship of which "bedside manner" is a euphemistic way of referring to the practitioner's influence on the relationship (30%), and 4) Client Factors, e.g., access to treatment/means to pay for treatment, supportive family, social contacts, etc. (40%).

 


Although one can argue that practitioners have control over which therapeutic technique will be

employed, clearly, he or she has no control over 55% of the factors that affect therapy outcome - according to Miller, Hibble, & Duncan, "expectations/placebo" (15%) and "client factors" (40%) - meaning that the single biggest factor that affects the outcome of counseling/therapy over which the practitioner has significant if not complete control is the therapeutic relationship (30%). Although this may seem a minor factor (30%) affecting the outcome of services, it is nonetheless almost a full third of the outcome and, when considering that the relationship is a significant part of whether a client engages in services or not, it can definitely impact client expectations about therapy not to mention "client factors" like enhancing support networks and/or client willingness to establish/utilize such.

 

An unrelated but nonetheless tangential issue to the significance of the relationship in the outcome of therapy is the fact that the health care professional--of any type--least likely type of being sued is the practitioner who clients/patients report "liking," the corollary being, the most likely to be sued is the practitioner whom the client/patient does not like or sees as condescending, arrogant, patronizing, aloof, "cold, etc. See EXAMPLE 1, EXAMPLE 2

 

When discussing these points with students I would point out that establishing a warm, caring and empathic relationship with a client does not preclude addressing issues a client may not want to hear. As a matter of fact, a strong, positive relationship can enable the delivery of such feedback/information more

likely to be considered. I conducted an activity with my behavioral health counseling students to demonstrate: I would ask students to think of someone they hold in high regard...someone they trusted, respected, and recognized as a "good human being" and tell them this could be anyone living or deceased provided they had had a personal relationship. I would then ask, "Did this person always tell you what you wanted to hear?" - As I paused before my next question, I would see most head gesture negatively. Then I would ask, "did this person ever say or do something that upset you or made you angry? - This time when pausing I would see most students positively nodding their heads. Then, "did this person ever upset you so much that you did not talk to him or her for an hour or a day or a week or longer? Again, positive head nods. I would then ask, "why, then, was the first person that popped into your head when I asked you to think of someone you hold in high regard, trust, respect, and recognize as a good human being someone who did not always tell you what you wanted to hear, sometimes said or did things that upset you, and perhaps even to a point where you did not speak for an hour or day or longer?" I would then answer the question for them..."because this person was always truthful, honest, and treated you with respect, always letting you know that you were important and he or she would never do anything to hurt you purposefully. 

 

As important as a positive relationship with clients may be, it is also important for students to not mistakenly think that this means they must "be friends" with clients. They need to understand that developing a positive relationship is of paramount importance but that it does not equate with only telling clients what they will appreciate hearing.

 

What do you think?


Dr. Robert

____________________

1Thomas, M. L. (2006). The Contributing Factors of Change in a Therapeutic Process. Contemporary Family Therapy: An International Journal, 28(2), 201–210

18 June 2020

Thoughts on Recovery: There’s No GPS to Map the Way


 Long-term recovery from a substance use disorder (SUD) is difficult to define. Some suggest that although recovery begins with the decision to change one’s use behavior, others suggest that it cannot commence until and unless one’s “change in use behavior” includes total abstinence. Still, others argue that one never recovers from a SUD and one remains in a perpetual state of “recovering,” although even with this, only if abstinence is maintained.

In other words, recovery would seem to mean different things to different people. What is imperative, however, at least for a behavioral health practitioner to remember is that how others define recovery is not the issue of primacy when working with someone having a SUD or mental health disorder (MHD). What matters is how that client understands recovery and therefore defines it and is motivated to pursue it. Supporting a client’s efforts to recover from a SUD or MHD necessitates acknowledging and working to support the client’s autonomy, that is, the client’s right to determine what he or she will or will not do; what he or she wants to accomplish with the practitioner’s help. Now if one’s client wants assistance using heroin without overdosing, this may be something the practitioner is unable or unwilling to help the client pursue. That said, this practitioner might refer the individual to a user room such as they have in the Netherlands or other jurisdictions outside the U.S.

Behavioral health practitioners need to avoid dogmatic definitions of recovery for their clients. Preconceived notions about recovery tend to result in inadvertently directing clients to pursue the practitioner’s view of recovery, which may or may not be what the client wants or needs. Practitioners that pursue their understanding of what constitutes recovery is problematic in that it violates a basic ethical principle of counseling – autonomy…more on this in a bit.

“Recovery” by its very nature implies change…movement from where one is to where one wants to be. It implies movement from a problem to a solution. The challenge for practitioners, however, is to help clients identify what the best solution may be for each individual client rather than be quick to impose a one-size-fits-all recovery objective and expect the client to follow.
Before recovery can begin, one must recognize the need for this change. We see this in the 1st step of A.A. or N.A.; we see this in the individual who seeks treatment to address a mental health disorder, and we see this whenever someone conducts a cost – benefit analysis in one’s life and realizes that the price paid for continuing to do what has always been done is greater than that associated with making a change. The point remains, however, what this change looks like is not something imposed on the client but rather something the practitioner helps a client explore.

Recovery is a simple process that is incredibly difficult to complete. Behavioral health practitioners can assist clients in considering questions designed to increase the likelihood that the pursuit of recovery becomes a desired option. The “specifics” of what the client wishes to change must be specific and operationally definable and include specific steps that “set one up” to succeed…many little steps accomplished one-at-a-time. Clients need to understand the personal reasons for making this change…for taking these many and gradual steps and to understand why it is important to do all this lest quickly becoming bored, overwhelmed, or frustrated and quit.

Although these questions are intended for clients to consider, I suggest that practitioners respond to them personally. For example, consider something you have decided to change: Why would you want to make this change? How might you go about making the change if you wished to increase the likelihood of success? What are several reasons why making the change is a good idea? How important is it that you accomplish this change? These questions are adapted from questions Miller suggests are important when employing Motivational Interviewing to help clients consider engage in “change talk.”

Ask ten people to define recovery and you will get at least a variety of answers. Those whose recovery from a SUD necessitates abstinence will include abstinence as a prerequisite of recovery…those whose recovery involves involvement with a mutual aid or self-help group will include involvement with such groups in their definition. Practitioners who define recovery as successfully completing treatment and aftercare plans will view this as a prerequisite of recovery…and blame the client if such is not realized. In short, recovery is what recovering people do.

There is an African adage that says, “When elephants fight, it is the grass that suffers.” Is abstinence required for SUD recovery? Is spontaneous recovery real? Can you be in SUD recovery if you are taking meds? Does medication-assisted treatment clear a path to recovery? Can one ever be truly recovered or is one simply in a perpetual state of recovering?

These are all very real questions, some of which are quite controversial. Although they are interesting to consider as they unfold at a professional conference, debating their usefulness with a client can quickly sabotage efforts to assist an individual with a SUD or MHD who is seeking treatment.

The American Counseling Association defines autonomy as the principle that addresses the concept of independence. The essence of this principle is allowing an individual the freedom of choice and action. It addresses the responsibility of the counselor to encourage clients, when appropriate, to make their own decisions and to act on their own values. Clients who are told they must do “whatever” if they wish to recover have had their autonomy hi-jacked. It can be argued that to define recovery for a client is to violate the ethical principle of autonomy or the right a client’s right to choose a course of action to pursue in treatment.

If recovery involves the movement from “problem” to “solution,” who should define what is a problem and what is its solution? If recovery is possible, then is it a process with a finite point denoting completion or a continual progression toward an ever-improving state of recovery?
How can you, as a practitioner, guide a client on this journey of recovery without imposing your understanding of what recovery is? Are you, as a practitioner, in a state of recovery from your preconceived ideas and notions regarding treatment and recovery? These are all important questions, and ones difficult to answer without having someone or ones with whom to discuss them.

It is when the person who happens to be a behavioral health practitioner connects with the person who happens to be his or her client, the “person connecting with another person” dynamic, that is the point when the magic happens in counseling. So, clients, when presented with the opportunity to consider all the options that are available to them, can choose their own course of action, this is when the path to recovery becomes obvious. Effective counselors can present their clients with probing questions designed to provoke objective thought about the pros and cons of each option being considered, but they will never direct a client to choose a particular option, directly or indirectly, especially if that option suggests a “one-size-fits-all” course of action.

Remember:
Control leads to compliance; autonomy leads to engagement.
― Daniel H. Pink

Unsolicited advice is the junk-mail of life.
-- Bernard Williams

What do you think?

18 May 2020

Personifying Addiction: Can Viewing One’s SUD as a Toxic Relationship Aid Treatment?


Who does this sound like?

·       Has a sense of entitlement and require constant, excessive admiration
·       Exaggerates achievements and talents
·       Is preoccupied with fantasies about success, power, brilliance, beauty or the perfect mate
·       Expects special favors and unquestioning compliance with their expectations
·       Never takes responsibility, blaming others for mistakes, oversights, or poor judgment
·       Has an inability or unwillingness to recognize the needs and feelings of others
·       Behaves in an arrogant or haughty manner, coming across as conceited, boastful and pretentious[1]
No, I am not referring to a contemporary politician—that is grist for another discussion mill. I refer to Al K. Hall, to Mary Juanna, to C.O. Cain, to Ox E. Contin, to Herr O’Wynn, to P.K. O’Cette…you get my drift. A personification of a substance use disorder, A.K.A. “addiction,” as some malevolent other that possesses an individual is not new. Robert Louis Stevenson’s famous The Strange Case of Dr. Jekyll and Mr. Hyde is semi-autobiographical in which the transformation of Dr. Jekyll when consuming the potion made of a “fine white power” to the murderous Mr. Hyde has become a familiar euphemism for addiction[2].
Although my personifications of a substance use disorder (SUD) may seem silly when compared with Stevenson’s more literary heavy, an important point remains: when characterizing addiction as a malevolent being, doing battle with that anthropomorphized image of an identifiable villain becomes more plausible than attempting to challenge some nebulous disorder. To view addiction as simply a social construction of inappropriate or otherwise described deviant behavior leaves the individual with that disorder little choice but to view the self as at best somehow defective if not a failure as a human being. Likewise, not only do those with an SUD tend to then label themselves as addicted with all that pejorative term implies, historically those who have attempted to provide treatment have tended to treat the addiction rather than the individual with the disorder.
Although interventions with the personification of an SUD may seem logical—who wouldn’t seek to confront the villain in any drama—when the addiction and the individual who has that disorder are indistinguishable in the eyes of the practitioner, such interventions become confrontational with the individual the focus of the practitioner’s assault. As William Miller suggests, this is when practitioners wrestle with their clients rather than attempt to dance with them. When confronted most individuals with an SUD will react instinctively, defensively recoiling from the practitioner whose treatment is perceived as a threat.
Interestingly, there may be two strategies that when employed in tandem may help avoid such
confrontations. The first is a given and has become quite well known over the last 30-years and for that reason not discussed in detail here; motivational enhancement therapy where empathy, collaboration, an appreciation of client autonomy, and evoking change talk are the hallmarks of effective treatment. The second is as yet unknown and argued in this essay as the personification of an SUD as an entity with which the addicted individual has a toxic relationship.
This “entity” manifests many if not all the characteristics of narcissism as outlined in the introduction above. As difficult as treating SUDs may be, inviting individuals to understand their dependency as a conflict with a self-absorbed parasitic nemesis can free one’s client to begin viewing change as a battle that can be won as opposed to a disorder that must be endured. Likewise, framing treatment as a struggle between the individual with the disorder and the personified disorder enables the practitioner to assume the role of mentor, guide, strategist, or counselor but definitely not the client’s adversary.
When seeing clients with SUDs I would often ask them to imaging their disorder as a gremlin sitting on their shoulder, constantly whispering in their ears, saying whatever was necessary to justify taking the next drink or pill or “hit.” I would then ask that they write a letter to their gremlin and tell it everything they ever wanted to say to get it to “shut up.” Once written, I would ask that the letter be read in group and for the group to comment and provide feedback, the point being that the personification of substance use dependence was a bully and that bullies can be silenced but only when confronted and when the one doing the confronting is supported by peers who understand how difficult the bully is to overcome.

What do you think?
To read how Dracula is an allegory for alcoholism/addiction, consider my essay Al K. Hall as Dracula: Film as a Clinical/Pedagogical Device[3]



[2] See Wright, Daniel. “The Prisonhouse of My Disposition’: A Study of the Psychology of Addiction in Dr. Jekyll and Mr. Hyde.” Studies in the Novel. 26.3 (1994): 254–267.

[3] If the link fails, the essay’s URL is https://robertchapman.blogspot.com/2012/07/alk.html

29 March 2020

Bloom Where You're Planted

"Bloom where you're planted"
Taken by Josh Chapman
For those of us 75 or younger, this time of pandemic may well be the most challenging time in our country that we have ever had to face. True, we have all experienced tragedy and heartache and rare is it when any have yet to experience doubt and fear in our lives. But even in those dark and challenging personal times, it was likely that there was always someone close or at least available to listen, to comfort, and to understand what we were going through and as a result, proffer the support needed to take that proverbial “deep breath” emotionally needed to calm ourselves and, as the old saying goes, “keep on keeping on.”

Unfortunately, when everyone is experiencing the same tragedy and heartache, is feeling the same cold, clammy fingers of doubt and fear encircle their very being, that “someone” close who is available to listen, to comfort, to understand is hard to find. It is as if the fictional Dementors so familiar to Harry Potter fans have somehow materialized and descended upon us, ready to suck the goodness and happiness and confidence from each of us…where is that Patronus charm when it is really needed.

Although there are no real Dementors nor Patronus charm for that matter, there may be something that can help quiet some of the doubt and fear that many…dare I say “all”…of us are experiencing, something in addition to prayer and faith in a Higher Power…music and its lyrics. Winston Churchill said during the Second World War that when going through Hell…keep on going. A contemporary singer-songwriter, David Wilcox, has committed that sentiment to a song. You can listen by clicking the title and the lyrics are below should you wish to follow along...and share a link to your songs of hope in the comments section.

You say you see no hope
You say you see no reason we should dream
That the world would ever change
You’re saying love is foolish to believe
And they'll always be some crazy
With an army or a knife
To wake you from your daydream
Put the fear back in your life

Look
If someone wrote a play
To just to glorify what's stronger than hate
Would they not arrange the stage
To look as if the hero came too late?
He's almost in defeat
It's looking like the evil side will win
So on the edge of every seat
From the moment that the whole thing begins
It is love who mixed the mortar
And it's love who stacked these stones
And it's love who made the stage here
Although it looks like we're alone
In this scene, set in shadows,
Like the night is here to stay
There is evil cast around us
But it's love that wrote the play
For in this darkness love can show the way

Now the stage is set
You feel your own heart beating in your chest
This life's not over yet
So we get up on our feet and do our best
We play against the fear
We play against the reasons not to try
We're playing for the tears
Burning in the happy angel's eyes

For it's love who mixed the mortar
And it's love who stacked these stones
And it's love who made the stage here
Though it looks like we're alone
In this scene, set in shadows,
Like the night is here to stay
There is evil cast around us
But it's love that wrote the play
For in this darkness love will show the way
Show the way
Show the way

Source: LyricFind
Songwriters: David Patrick Wilcox
Show the Way lyrics © Universal Music Publishing Group

30 January 2020

Reframing the Abstinence Violation Effect


Long-term recovery from a substance use disorder (SUD) is difficult to define. Some suggest that although recovery begins with the decision to change one’s use behavior, others suggest that it cannot commence until and unless one’s “change in use behavior” includes total abstinence. Still others argue that one never recovers from a SUD and remains in a perpetual stage of “recovering,” but only if abstinence is maintained.

Be that as it may, a perennial threat to recovering, especially if abstinence is perceived as the prerequisite of changing one’s substance using behavior, is to use, even once. This use, however, small or infrequent, is viewed as having “botched” one’s efforts to change and is referred to in many ways—a relapse, a slip, falling-off-the-wagon, etc.—but no matter the nomenclature it is all but certainly accompanied by a personal sense of having failed. In formal treatment circles, this sense of failure is referred to as the abstinence violation effect or AVE and is perhaps the single greatest contributor to a return to active involvement in one’s SUD. 

Faced with working with individuals trying to change who tend to see use as tantamount to having “F-ed up,” practitioners who treat SUDs routinely are charged with helping them reframe such use as something other than “failure” lest they return to active use. Practitioners accomplish this in various ways, however, all necessitate helping these individuals to view their use as something other than personal failure and indicative of the absence of willpower, moral turpitude, or somehow evidence that recovery is beyond one’s grasp.

Reframing use as something other than failure requires a change in perspective. Just as a patient would rather hear a surgeon discuss a 90% chance of success in a procedure rather than a 10% chance of failure, those treating individuals with a SUD who use can discuss the opportunity the “lapse” presents to recognize previously hidden risks and high-risk triggers that can sabotage recovery. Referring to use following a period of abstinence as a “lapse” rather than having “F-ed up” presents individuals with the opportunity to “act on” their use rather than “react to” it. In addition to reframing, it is also helpful to invite individuals to appreciate the temporal nature of such experiences.

Substance dependent individuals and practitioners alike recognize the risk that urges to use and the triggers associated with them can play in sabotaging a treatment plan. What is often overlooked, however, is the time that elapses between these triggers and urges and the action taken or reaction that one has in response to them. It is this time between the onset of the urge to use and the decision one makes to use or not use that presents the opportunity for the substance-dependent individual to “do something,” the result of which is to move closer to or farther away from use.

The space separating the “urges” and “triggers” from the decision to “use” or “not use” is representative of the “time” that exists between these two phenomena. Depending upon individual circumstances, the precise amount of time separating these as two poles can be minutes or days but irrespective of the specific amount of time, the fact that this separation can be measured in time presents the individual with the realization of an opportunity to do something…if you will, to act rather than react. As a matter of fact, one cannot not do something during this time as to do nothing is in itself to do something.

The individual who grasps the temporal nature of a lapse is presented with an opportunity to take the steps necessary to prevent it. Just as one can learn about how personal actions when using set oneself up for use, following this model, so can this individual appreciate the significance of having a plan in place to deal with urges and triggers should they occur…and most any recovering individual will tell you that it is not “if” these urges and triggers will occur but “when” they will. NOTE: The list of things that can be done during this time is essentially limitless. Exploring “proactive” steps to avoid use and/or cope with urges to use becomes an important topic for discussion with one’s treatment specialist or sponsor.

Alcoholics Anonymous has a slogan that speaks to the importance of being prepared; change people, places, and things. Preparing to avoid the expected triggers that can initiate an urge to drink will increase the likelihood of avoiding lapses. In addition, should use occur, viewing it as a lapse rather than a failure—not to mention an opportunity to learn something new about preventing potential future risks to recovery—increases the likelihood of maintaining sobriety.

Wayne Dyer once wrote that the only difference between a flower and a weed is a judgment. Now, apply this reasoning to one’s use after a period of abstinence: the only difference between a lapse and a failure is _____.

What do you think?
Dr. Robert

Thank you to Jessica Williams of IRETA whose blog post "Combatting the Abstinence Violation Effect" prompted the thinking that resulted in this essay.

30 November 2019

Motivation – finding a reason for change



Whether you think you can or think you can’t, you are right.
Henry Ford

It does not matter how slow you go as long as you do not stop
Confucius

We are all familiar with the adage, you can lead a horse to water, but can’t make it drink. Although the first phrase in this proverb may be true, the second only applies because it presumes that change is something motivated by an intervention attempted by an outside force. If, however, we abandon that premise and consider change an “inside job” resulting from internal motivation, then a 21st Century version of this adage may well be, You can lead a horse to water but can’t make it drink...but you can salt the oats.
https://tinyurl.com/y5odkn6q
This “salting of oats,” although accomplished by an “outside force” is nonetheless intended to evoke—although sometimes provoke—an internal shift in perspective. It is this shift that enables those being interviewed to evaluate their situation differently, to view the facts in their life through a “new set of lenses” so to speak. Like the teacher who asks a class if two-minutes is a short or long period of time and then responds, smiling, to a pupil who blurts out Short, Okay…then hold your breath for two-minutes, a shift in perspective can affect one’s interpretation of the facts, which becomes a precursor to a change in behavior. A humorous allegory to illustrate:

Lipstick in school


According to a news report, a certain private school in Washington was recently faced with a unique problem.
A number of 12-year-old girls were beginning to use lipstick and would put it on in the bathroom. That was fine, but after they put on their lipstick, they would press their lips to the mirror leaving dozens of little lip prints.
Every night the maintenance man would remove the lip prints, and the next day the girls would put them back.
Finally, the principal decided that something had to be done. She called all the girls to the bathroom and met them there with the maintenance man. She explained that all these lip prints were causing a major problem for the custodian who had to clean the mirrors every night (you can just imagine the yawns from the little princesses).
To demonstrate how difficult it had been to clean the mirrors, she asked the maintenance man to show the girls how much effort was required.
He took out a long-handled squeegee, dipped it in the toilet, and cleaned the mirror with it. Since then, there have been no lip prints on the mirror.
There are teachers...and then there are educators.

Reflecting on this, one might argue, there are interrogators…and then there are interviewers.

The less ready one is to change, the less motivation there is to make a change. Effective interviewers know this and resist the temptation to engage in what William Miller (2013) refers to as the “righting reflex” (p10) or an attempt to provoke change in the belief that doing so prevents additional untoward consequences resulting from the maladaptive behavior. However, as the old saying goes, right church…wrong pew. Instead, a more efficient approach to accessing an interviewee’s internal motivation is to assess where she or he may be on the continuum of readiness to change and then engaging the individual in such a way as to facilitate movement along that continuum toward change.
It may seem counterintuitive to delay interceding in one’s high-risk behavior, especially if that behavior presents the real potential for physical harm to the individual or those with whom she or he interacts. In fact, many who resist this approach to interviewing argue that a delay in confronting one’s reticence to change is tantamount to enabling the continuation of maladaptive behaviors. But consider this question: Which is the shorter total amount of time, the time between when someone is confronted prematurely about making a change and terminates treatment before returning a year later in a crisis, ready to consider that very change, or the three—or two or four—months it may take for a practitioner who recognizes the importance of moving through the stages of readiness until the point is reached where the individual chooses, of her or his own accord, to change? In short, as William Miller (2013) asks, is it more productive to wrestle with one’s interviewee or to dance?
Economists refer to something similar conducted by business executives and their chief financial officers as a “cost-benefit analysis.” When considering the costs involved in realizing a benefit, one can assess if the ratio between the costs associated with realizing the benefit(s) are such that they warrant continued “payment.” If the costs are deemed too high, exploring change becomes logical if not obvious. Facilitating this consideration of “costs vs. benefits” constitutes the “salt” added to the oats our interviewee is fed, thereby evoking a “thirst” for change.

What do you think?



[1] For a worksheet related to this essay, visit https://tinyurl.com/yxapk8ou
Miller, W. & Rollnick, S. (2013). Motivational Interviewing: Helping people change. Guilford Press: NY, NY