Does Confrontation Work?

Confrontation, especially confrontation in the process of counseling, is a topic I ask my students to consider in my Intro to Addictive Disorders class – click to review the class assignment associated with this request.  Invariably, students who argue that confrontation does not work point out that

aggressive, in-your-face confrontations are too direct and actually deter meaningful engagement…what Miller refers to as Attack Therapy.  However, those students who do believe confrontation has a place in effective counseling--or in the treatment of individuals with a SUD more specifically--are influenced by Miller & Rollnick’s first chapter in the 3rd edition of their book, Motivational Interviewing (link included in the linked assignment).  They come to see one’s definition of confrontation and, more importantly, he means of delivering a confrontation, as the issue of primacy when considering the utility of this aspect of counseling.

Confrontation—effective confrontation—is, if nothing else, the ability to "hold one’s feet to the fire" without causing injury.  Effective counselors do this by employing what I refer to as the Three Ps of counseling: (1) Patience, (2) persistence, and (3) perseverance.  As Rollnick suggests in a clip from his video on MI (see http://bit.ly/1C9SW66), change can happen quite rapidly when facilitated by a trained and experienced practitioner.  He suggests, and I paraphrase, If you act like you have all day, it (change) can happen in 15-minutes, but if you act like you only have 15-minutes, it can take all day; I can  attest to this, as I imagine many clinicians can. As a matter of fact, one of the nicest compliments a client ever paid me was after a particularly confrontational session, one where I employed the “3-Ps,” as we shook hand at the end and he was leaving the office, he turned, looked me in the eye and said, “You know, Dr. Robert, you could kick someone in the ass and he would turn around and thank you.”

There is a difference between confronting someone when the interaction is viewed as a contest where someone wins at the expense of the other person losing, and one that is approached as an attempt to address an issue of concern, but without the delivery of unsolicited advice or directives steeped in judgmental recommendations.  Remember the quote by Bern Williams: Unsolicited advice is the junk mail of life.

Confrontation a la Wesley Snipes, Bruce Willis, or Keanu Reeves does not work; Wm Miller of Motivational Interviewing fame calls this Attack Therapy.  Confrontation, however, employed by a skillful practitioner who is respectful, understanding, but nonetheless persistent, does.

What do you think?

Dr. Robert

Conflict of Interest or Good Marketing?

VOCATIV posted a controversial article recently on its website—see http://www.vocativ.com/culture/society/college-jello-shots/#!bO7SmR—suggesting, Colleges Profit by Getting Students Drunk off Jell-O Shots.  If you read the article, you get the impression that the institutions involved intentionally licensed their logos intending their use as “Jell-o shot cups”; the good news is that this was not the case.  Indeed, Kraft did secure permission to use school logos and create individualized Jell-O molds, likely for a licensing fee, but not with the intent of producing Jell-O shots

for tailgating.  Their intent in licensing the use of their logo was much the same as the reasoning behind T-shirts, hats, sports bottles, stadium blankets, and various sundry other items.

That said, the VOCATIV article does raise an interesting question: does a conflict of interest exist, however inadvertently, when institutions with serious and stringent alcohol policies, especially policies that are consistently enforced, license merchandise that directly or indirectly is associated with drinking in general and high-risk drinking specifically? What does it say to a prospective high school student touring campus who makes the obligatory stop at the campus bookstore and sees an array of shot glasses, beer mugs/scooners…and Jell-O molds?  And although Jell-O molds with the school logo at the bottom are apparently similar "innocent novelties," few are the students of any age who do not know of Jell-O shots and the recipes to make them – see http://www.kegworks.com/company/jello-shot-recipes for one of 2,670,000 Google hits when searching “Jell-O, shots, recipes.” 

So the original question remains, do such innocent novelties represent a conflict of interest for the institution with strict alcohol policies?  Should such “paraphernalia” be relegated to the online catalogue for the campus bookstore or is the display of such novelties innocent enough to avoid consideration as a “conflict of interest” and scrutiny of AOD prevention advocates?  Is the decision by some to divert the use of what many prevention specialists advocate, the use of a shot glass to measure a serving of alcohol when pouring drinks, sufficient cause to question the sale of such “paraphernalia” in the campus bookstore?

As we all know from our life experiences to date, rarely are things “just” what they seem to be on the surface or at first glance; what do you think?

Dr. Robert

The futility of brief interventions for illicit and prescription drug addiction—or is it?

An interesting article in the online journal, Medscape (see http://www.medscape.com/viewarticle/829612) suggests that brief interventions with those addicted to illicit substances and prescription pain medications may be futile.  I found this interesting, especially in light of my long history providing “brief interventions” with college students regarding all manner of high-risk behavior, not the least of which was drinking and other drug use. 

As disheartening, at first glance, as the cited research studies may be, I am not too concerned about these results.  First, although both cite the use of Motivational Interviewing (MI), neither seems to have truly applied MI as designed and it is questionable how Screening-Brief Intervention, Referral to Treatment (S-BIRT)…or what is now being referred to as SBI, Screening and Brief Intervention…was employed.  There is a literature that suggests the role of the interviewer as opposed to the use of MI as a technique alone affects the likelihood of movement as the result of a sessions(s); no matter how adroit the practitioner in the application of MI technique, if the individual using MI is “stiff,” distant, or otherwise “unavailable” to the individual being counseled, that individual is not likely to engage in “change talk."  As there is little indication of the skill level of those conducting the single session MI interviews in the cited research articles—and admittedly I have yet to read either study in its original form—that could affect the reported (lack of) results as well.

Returning to my opening comment regarding a question about a true (accurate?) use of MI, it is clear in Miller and Rollnick’s newer 3rd Edition of their text, Motivational interviewing: Helping people change (2013, Guilford Press), MI is more about arranging conversations so individuals talk themselves into change than about actually motivating the desired change.  This suggests that a “single session” on MI, even if done correctly and by a practitioner who is both knowledgeable and effective, may not be sufficient to actually result in immediate reductions in use or arrests, etc.  MI is not an “action stage of readiness to change” (see http://www.uri.edu/research/cprc/TTM/StagesOfChange.htm) intervention so much as a means by which practitioners can increase the likelihood that “pre-contemplative” and “contemplative” changers move in the direction of readiness to change, AKA, towards taking “action.”  Assessing the stages of readiness to change of randomly selected individuals and then exposing them to MI and reassessing their readiness to change might produce a more meaningful measure of MI’s efficacy.

Miller & Rollnick acknowledge that MI does not change behavior so much as facilitate change talk in the individual being engaged.  They actually argue that practitioner do not change behavior, in that all change is internal and many individuals will actually change their behavior, w/o treatment, once having come to a point where the tipping point in their ambivalence is reached and continuing old behavior becomes more of a hassle than instigating new.  MI is about hastening the advent of this “tipping point” rather than getting folks to change their substance using behavior.

In short, these research studies are interesting, to me, but not because they disparage MI so much as underscore the importance of understanding the difference between the “spirit” of MI and its practice as well as recognizing that MI is not so much a “velvet club” by which a “motivate” resistant changers as a “shoe horn” that can facilitate the potential changer’s “easing into” change by recognizing that it is a personal choice resulting from a simple cost-benefit analysis of the facts regarding current patterns of behavior.

What do you think?

Dr. Robert

Questions that Motivate a Consideration of Change

Conducting a conversation around the subject of change is a challenging task, especially if directing the conversation toward a less than willing individual.  Historically such conversations are structured, task oriented, and designed to “get the individual” to “see and admit to having a problem.”  Consequently, these conversations typically take on the rhythm and pace of an interrogation; have you ever done ‘this’; how often have you done ‘that.’  Such interviews are reminiscent of the old adage; Never teach a pig to sing; it wastes your time and annoys the pig.

The principles of Motivational Interviewing outline a very different way to engage individuals in what it calls, change talk (Miller & Rollnick, 2012).  What follows is a series of 5 questions from Miller & Rollnick's 3rd edition of their text that increase the likelihood that, as Miller suggests, one can dance rather than wrestle with the individual being interviewed regarding change.

1.     Why would you want to make this change?

a.     The abbreviated version: Why change?

                                               i.     Benefits/Pros of change

                                             ii.     Risks/costs/cons of not changing

2.    How might you go about it in order to change?

a.     The abbreviated version: How to succeed

                                               i.     Identify personal strengths – protective factors

                                             ii.     Cope with challenges – resiliency skills

3.   What are several of the best reasons to make this change?

a.     Selfish reasons

b.     All around good reasons?

4.   How important is it for you to make this change?

a.     Mentally

                                               i.     Peace of mind

b.     Physically

                                               i.     Wellness

c.     Spiritually

                                               i.     Connectedness; feeling “part of” something rather than “apart from” everything

5.  So, what do you think you will do now?

a.     What half-step can you make to begin moving towards change?

Miller, W. & Rollnick, S., 2012. Motivational Interviewing: Preparing people for change, 3rd Edition.  Guilford press

Addiction, Imbalance, and the Family

One of the benefits of living and writing during the digital age is the easy access that exists to information from various and sundry media outlets. This tends to make education--not to mention psycho-education used in clinical treatment--more engaging.  Such is the case regarding the short video, “Balance.” (https://www.youtube.com/watch?v=7wJj58aLvdQ). 

I use this video to facilitate discussions related to addiction in the family, homeostasis, etc. Notice how

as the film begins, the “family” works together to maintain balance whenever one its member “moves.” In class, we discuss this in the context of altruism being the primary motivating factor among the various members as regards their motivation for acting. As the video progresses, however—and the film is only 7-minutes long, so the progression is rather obvious—altruism gives way to self-interest, egoism, and ultimately, selfishness.The discussion really becomes interesting when considering the “trunk” as addiction with its “contents” being the curious, alluring “something” that becomes so beguiling. I find the video an interesting “visual metaphor” in its usefulness as an icebreaker.

At the end of the class in which I use this videos—entitled, Addiction and the Family: The Anatomy of an Imbalance and Chaotic System—I show the 2-part video (about 17-min total), Man on the Back (https://www.youtube.com/watch?v=T0m9iu6O3dg). I process the first video before showing the second part (about 7-min) and then we process the entire video in the context of the lecture following its conclusion - you may access the second part of the video by clicking its link to the right on the screen of Part I. This is always a crowd pleaser and generates no end of comments…even though the entire video is in Icelandic with English subtitles! All sorts of interesting discussion results from this screening...enabling, “co-dependence,” addiction, etc. NOTE: Both videos linked here can produce equally spirited discussion regarding other disorders and stressors besides SUDs; it is all in the “lead in comments" the facilitator makes and the discussion that follows. 

A third “series” of videos (10, 10-min videos) that is useful in “understanding addiction,” especially alcohol dependence, is entitled, “Rain in my heart” (https://www.youtube.com/watch?v=NP0InrPZpjg)  This is a BBC documentary that is quite graphic and extremely realistic in its depiction of the impact of alcohol dependence, on both the drinker and the drinker’s significant others. This video is not a “metaphor” for anything and certainly is not “entertaining” as the previously cited videos may be viewed by some. This is a frank, “hard-hitting” look at the impact of chronic alcoholism, and a “must-see” for professional counselors and those going into the medical professions.

Should you "screen" one or more of these videos, please feel free to leave your comments on them and their use.

Dr. Robert

The Buzz about Fermentation is as Silent as the "P" in Alcohol

Have you ever eaten a hotdog…a char-broiled, foot-long with diced onions and catsup or perhaps smothered in sauerkraut with mustard…or however you “like your dogs”…and enjoyed it? Ever heard someone say, “If you knew how they were made, you would never eat another one”? Yet, chances are many reading this not only have eaten those dogs, but truly enjoy…if not love…them. Well, what if we were to take a look at alcohol in much the same way. Is it possible that one could say, “If you knew how alcohol was made, you would never take another drink”?

Alcohol is a naturally occurring compound composed of oxygen, carbon, and hydrogen. The chemical formula for the alcoholic beverages most consumers drink--ethanol--is C2 H5 OH. In a proverbial

“nutshell,” alcohol is created via a process called fermentation when naturally existing organisms called yeast act upon the sugars in organic compounds as they are broken down in the natural process of decomposition. When left to their own devices, yeast continue to live and produce alcohol until the concentration of alcohol in the mixture reaches a point of approximately 12%, at which point the alcohol content causes the mixture to become toxic, killing the yeast. Beverages with an alcohol content in excess of 12% (24 proof) are created by distilling the naturally produced "mash" or "wort" to its desired strength.

After ingesting organic matter, yeast digest the sugar and produce alcohol, which is the byproduct of this digestive process. In essence, yeast ingest the sugars in organic compounds and excrete alcohol as a waste product. Yes, you read correctly, alcohol is essentially “yeast piss.” So the next time a friend asks if you want to stop by the One-Eyed Jack for a couple drinks after work, remember the process on which John Barleycorn relies to produce your favorite wine or beer or spirits.

Whether you are a connoisseur of top shelf fare or restricted to the dregs from the bottom of the barrel, do not forget to tip your hat as a sign of gratitude to the lowly yeast, for as we have all heard before, "one man’s trash is another man's treasure."

Tips for Collegiate Drinkers

That some collegians choose to drink is not news. That some of these drinkers actually choose to, or unintentionally, become intoxicated when drinking alcohol and experience an array of possible untoward consequences is likewise no secret. What may be a revelation for some is learning that most publications regarding collegiate drinking focus exclusively on these untoward consequences and covertly, if not overtly, imply that they are proof that all collegiate drinking is problematic.

If “the problem” is all collegiate drinking, then there can be but one possible objective of prevention…abstinence. However, such a goal suggests two questions: First, just as there has never been a time when alcohol was not used by some college students, can there ever be a time when no collegians drink (although it is likely that current percentages of students reporting use can be lessened and the frequency of that use and quantity consumed can be reduced)? Second, has the focus of research and prevention programming been too a posteriori and should that focus be directed instead to a priori considerations of drinking? Put more succinctly, we have been more concerned about the untoward consequences after students drink than in pursuing a better understanding of the meaning students ascribe to alcohol and drinking before consumption that influence their decision to drink in the first place. One argument in this essay is that such a priori considerations of collegiate drinking are likely to shed light on factors that affect individual decisions to drink…not to mention influencing student decisions when to drink, how to drink, or determine what circumstances warrant drinking, etc.

So if collegiate drinking is not “the” problem, but rather the drinking “some” collegians do is, here are a couple suggestions to minimize the likelihood of untoward consequences should you choose to drink:

1.  Water is a frequently cited nonalcoholic beverage many students report consuming. Remember that when drinking, the more nonalcoholic beverages that are consumed, the longer the time between alcoholic drinks and the slower the absorption rate of the alcohol already consumed. In addition, alcohol is a diuretic drug meaning that it absorbs water out of body tissue. Drinking water re-hydrates and may lessen some hangover symptoms. Ideally, those drinking alcohol should consume 1 8-oz serving of water for each standard alcoholic beverage.

2.  Students are creatures of habit. A routine of consuming “X” drinks at a sitting can yield the perception that “X” is moderate consumption, especially if friends are also drinking “X” or “X+1, 2, etc.” Consider your “routine” consumption. Multiply your “usual” amount by the number of days a week you drink. Multiply that by the number of calories per drink—90 for lite beer, 130 regular beer or  “per shot” in a mixed drink (do not forget to add calories for any mixer). The total is the number of calories consumed in a week/month/year. To get exact calorie readings for 100 different beers, visit http://www.beer100.com/beercalories.htm (remember that 12-oz of beer = 350 ml).

3.  Track your drinking over a couple typical weeks. Once you have a baseline, divide the number of drinks by the hours spent consuming them. This is your “drinks per hour” ratio. Once the pace has been determined, for example, “4/hr,” consider if you were to have a drink every 20 minutes instead of every 15. By simply adding 5 minutes between drinks you affect a 25% reduction in drinks consumed for the evening - from 4 per hour to 3. What happens if you add 15 minutes between drinks...50% reduction in alcohol consumed.

4.  Next, explore creative ways to add those 5 - 15 minutes between drinks...drink a nonalcoholic beverage like bottled water between alcoholic beverages, don't stand next to the keg, etc. Lastly, consider the pros and cons for pursuing such a change...fewer hangovers, better class attendance, clearer memory, fewer calories consumed, more money saved, etc. All this by simply adding 5 – 15-min between drinks...go figure!

5.    Ask yourself, when you have a headache, how many aspirin or Tylenol or Advil do you take? Chances are you take 2, perhaps three. If they work so well, why don’t you take 6 or 10 or 15? Before you shake your head in disbelief at this apparently idiotic question remember that most individuals that report drinking alcohol get the benefit of alcohol from just a few—and no more than 5—standard drinks (12-oz domestic beer, 10-oz malt liquor, 5-oz table wine, 1.5-oz 80 proof spirits) over an outing, but go on to drink 6 or 10 or 15+ and then find themselves dealing with the frequent consequences of heavy drinking. Remember, what causes a problem is a problem when it causes problems. Again, is it the drinking or the amount consumed that is the issue? NOTE: This tip is not suggested for those with a bona fide alcohol use disorder.

6.  Drinking on an empty stomach? What time do you generally eat dinner. If you live on campus, most dining halls are open from 4:30 PM – 7 PM, with many students eating between 5:30 and 6:30, “just like home.” What time do you generally go out when you socialize. Chances are pretty good not until 10 PM or later. Now, if the time between dinner and socializing, that is, "imbibing," is 3+ hours, you are essentially drinking on an empty stomach. Eat dinner later on nights you intend to go out and “snack” before leaving (and through your time out).

7. "Add your harm reduction suggestion as a comment."

Dr. Robert