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

6 Ways to Moderate Consumption if Choosing to Drink in College[RC1] 

By Dr. Robert Chapman, Associate Clinical Professor, Behavioral Health Counseling Department 

 

[RC2]  It’s no secret that some college students choose to drink alcohol. Nor is it surprising that some of these drinkers either intentionally or accidentally become intoxicated and face various consequences. What might be new to some is that most articles about college drinking focus almost entirely on these consequences and suggest that they prove that all college drinking is problematic.

If “the problem” is solely collegiate drinking, then the only reasonable prevention goal is abstinence. However, this goal raises questions. Is there ever a time when students do not drink? We have focused more on the consequences after students drink than on understanding the meaning they assign to alcohol and drinking before they consume it. This understanding influences their decisions to drink—when to drink, how to drink, and what circumstances justify drinking.

So, if college drinking isn't the problem, but rather the drinking some students do is, here are a few suggestions to reduce the risk of adverse consequences if you decide to drink.

1.     Water is a commonly mentioned nonalcoholic beverage that many students report drinking. Remember that when drinking, the more nonalcoholic beverages you consume, the longer it takes between alcoholic drinks and the more time there is for the alcohol already consumed to be absorbed. Additionally, alcohol is a diuretic that draws water from body tissues. Drinking water rehydrates the body and may help reduce some hangover symptoms. Ideally, those who drink alcohol should consume an 8-ounce serving of water for each standard alcoholic beverage.

 

2.     Students tend to develop habits. Drinking a certain amount of "X” drinks in one sitting can create the illusion that “X” is moderate intake, especially if friends are also drinking “X” or “X+1, 2, etc.” Think about your usual drinking habits. Multiply your typical amount by the number of days you drink each week. Then, multiply that total by the calories per drink: 90 for light beer, 130 for regular beer, or "per shot" in a mixed drink (don't forget to include calories from mixers). The result is your total calorie intake per week, month, or year. For accurate calorie counts for 100 beers, visit http://www.beer100.com/beercalories.htm (keep in mind that 12 ounces of beer equals 350 ml).

 

3.     Track your drinking over a couple of typical weeks. Once you have a baseline, divide the number of drinks by the hours spent consuming them. The resulting number 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 adding 5 minutes between drinks, you realize a 25% reduction in drinks consumed in the evening—from 4 per hour to 3. What happens if you add 15 minutes between drinks? A 50% reduction in drinking. 

 

4.     Next, explore creative ways to add those 5 to 15 minutes between drinks. Drink a nonalcoholic beverage like bottled water, or avoid standing directly next to the keg. Finally, consider the benefits of this simple change, such as fewer hangovers, improved class attendance, fewer regrets the next day, fewer calories consumed, more money saved, and more. All of this can be achieved just by adding 5 to 15 minutes between drinks.

 

5. When you have a headache, consider how much aspirin, Tylenol, or Advil you actually take. Chances are, you take two, perhaps three. So why not take 6, 10, or 15 if they work so well? Before you dismiss this as an foolish question, keep in mind that most people who drink alcohol find the effects from 1 to 3—and no more than 5—standard drinks (12-oz beer, 10-oz malt liquor, 5-oz wine, 1.5-oz spirits) during an outing. Yet they often go on to drink 6, 10, or even 15+ drinks and face the common consequences of heavy drinking. 

 

6.     I like to ask students what time they usually eat dinner. If they live on campus, most dining halls are open from 4:30 PM to 7 PM, with many students eating between 5:30 and 6:30, "just like home." Then I ask what time they usually go out when they socialize. Chances are high that most students go out after 9 PM, with many not until 10 PM or later. If there is a gap of over three hours between dinner and socializing, the student may drink on an empty stomach. Students could eat dinner later if they plan to go out and then snack before leaving and throughout the outing. 

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

 

Although no tips can prevent someone determined to get drunk from reaching that goal, those who choose to drink but want to reduce the chance of adverse outcomes may find one or more of these tips helpful.

  

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 [RC1]I am uncomfortable with this title as it places the emphasis on drinking—wrong message. How about something like: 6 Ways to Moderate Consumption if Choosing to Drink

Thank you. Good suggestion, and the title is changed.

 [RC2]I suggest a different “less negative” picture. I believe a tipped “dead soldier” (empty bottle of alcohol) is inconsistent with the emphasis of the essay.

Thank you. Good suggestion and the graphic is changed.

Dr. Robert

Preventing Relapse: A Look at Marlatt's Cognitive-Behavioral Model

Relapse prevention is an important topic in the training of any counselor, irrespective of her or his ultimate specialty. That said, any consideration of relapse need at least consider Marlatt's cognitive-behavioral therapy approach – see Larimer, Palmer, & Marlatt’s 1999 article in Alcohol Research & Health, “Relapse Prevention: An Overview of Marlatt’s Cognitive-Behavioral Model.” As for a text for a relapse prevention course, I recommend Marlatt and Donovan’s edited text, Relapse Prevention, Second Edition: Maintenance Strategies in the Treatment of Addictive Behaviors  (link to book on Amazon). Be sure to review the table of contents as you will quickly see this text truly considers the subject of relapse across ALL addictive disorders.

As an aside, an important aspects of Marlatt’s consideration of relapse is the role the “abstinence

violation effect” (AVE) plays in the onset of a true relapse. The AVE is essentially the guilt that is associated with having used after a period of abstinence. It is this guilt that plays a major role in turning the “slip” into a “fall off the wagon.” Marlatt argued that before one can relapse, the recovering individual must first “lapse.” The distinction between a “lapse” and a “relapse” being that a lapse is a temporary return to use whereas the relapse is a return to the lifestyle of the active user. It is important for counselor-ed students to recognize this difference as this concept—“lapse” precedes “relapse”—coupled with CBT enables the practitioner to “act on” the lapse rather than “react to” the relapse.

I have had individuals with whom I addressed a SUD (substance use disorder) contact me in a panic the day after a lapse, filled with guilt and shame about their use. I always begin the conversation by asking what they have done with the remainder of the alcohol, weed, cigarettes or “whatever.” Frequently, they tell me that they felt so bad about the use that they flushed the weed, dumped the alcohol down the drain, or discarded the remainder of “whatever.” I then suggest that while we can discuss the use later, “right now” what I am really interested in is the fact that they appear so committed to change that they threw away $X of product. I then suggest this shows how far they have come in their recovery and that their experience is what is called a lapse rather than a relapse. Obviously there is more to this approach than a simple 3-min conversation with a client. The point is, the practitioner follows a true “solution-focused” path; by concentrating on what the client has done well, we can move further away from the AVE and its associated guilt and shame. This guilt and shame then all but ensures the lapse progresses into the proverbial “full blown relapse.” This blending of harm reduction with CBT is a very effective strategy in “true” relapse prevention.

To put some closure on these comments, there is no distinct line of demarkation between recovery and relapse. Just as the 21-year-old at 12:01 AM on her 21st b-day has not magically become better able to drink safely than at 11:59 PM, neither does someone with a substance use disorder relapse upon taking the first sip/toke/drag. Now, do not misunderstand my comments to mean that it is “okay” to use “just a little” or we should not be concerned about that sip/toke/drag etc. Clearly, we need to be sensitive to any early indicators of someone who is skating on the proverbial thin ice as regards recovery; risk is risk and those who ignore this fact will fall through that ice. That said, Miller’s admonishment that we “dance” with clients rather than “wrestle” with them suggests that we teach our students the difference between a “lapse” and a "relapse” so that as practitioners they can proffer the guidance and support necessary to get the “train back on the tracks.”

What do you think?

Dr. Robert