Alcohol, Other Drugs, and Counseling: 2018

12 November 2018

Applying Social Psychology & Behavioral Economics in AOD Prevention

This is the first in a series on using principles from social psychology and behavioral economics as tools in AOD prevention; the first being the "FOOT IN THE DOOR" principle. The material I cite comes directly from the blog.enhancv.com blog, however, the specific examples related to addressing higher-risk collegiate drinking...and/or other risky behaviors...are original:

Principle: The foot in the door principle means that prior to asking for a big favor, you should ask for a smaller one. By first asking for something small, you’re making the individual “committed” to helping you, and the larger request acts as a continuation of something technically already agreed upon (2018, https://blog.enhancv.com).

Real-life Application:

A tourist asks you for directions. As a follow-up, they say they might get lost and ask you to walk them there. You’re more likely to agree to that, than if they straight-off asked the second question.
You missed a class and asked your classmate for their notes. Subsequently, you admit to having been a tad irresponsible this semester and ask for the notes for the entire semester. By first asking for the small favor, you increase your chances of getting the big one – namely, a free-ride on your classmate’s notes.
You just failed an important midterm and the professor doesn’t offer retakes. You decide to ask for feedback on your work and why you failed, followed by a request for a retake. You’re more likely to succeed in such a scenario, as opposed to directly asking for a retake (2018, https://blog.enhancv.com).

Case Study:

In the year 1966, two Stanford researchers – Jonathan Freedman and Scott Fraser – decided to test the effectiveness of FITD as a persuasion technique. They divided 156 women into four groups. They called the first three groups, asking a few simple questions about their household kitchen products.

Three days later, they asked to personally go through their kitchen cabinet and catalog their products. The other group was only approached with the second request. The first three groups had a 52.8% compliance rate, while the last group had only 22.2% (2018, https://blog.enhancv.com)

01 November 2018

Regarding the “Opioid Crisis”: A Word of Caution

Hardly a week will pass, especially in this election season, when concern regarding the rising number of deaths associated with overdoses on opioid medications and their illicit counterparts like heroin. This concern is warranted.

That said, with the spotlight of concern focused squarely on opioids it is easy, especially for the lay public, to lose sight of the larger issue of the impact “all” substance use in general and substance use disorders (SUD) specifically have on contemporary society. Consider tobacco & alcohol, two popular and legal psychoactive and potentially addictive substances.

Most purchases of these substances are by those who have developed a psychological if not physical dependency, A.K.A., a SUD - 10% of drinkers consume 50% of the alcohol sold in this country[1]. Add to this my personal guestimate, based on years of experience, that 80%+ of tobacco users are

dependent on tobacco and you begin to realize that the most frequent consumers of these legal substances are those whose use is more a function of need than choice, dependence rather than volition. If all those dependent on alcohol or tobacco were to miraculously quit tomorrow, there would be a major and devastating impact on our economy bot to mention the fiduciary responsibilities of local, state, and the federal governments.

A key difference when considering the concern regarding opioids is the rate of deaths associated with

their use. These are most often reported as the result of overdose (OD) whereas users of alcohol and tobacco suffer more chronic illnesses resulting in death years if not decades into their consumption. Not surprisingly, opioid overdoses, especially when due to illegal opioid use following the termination of extended legal prescription use captures more headlines.

Relatively few users OD on alcohol and I suspect none on tobacco (although nicotine is a potent poison when administered directly and in higher doses as in insecticides). Consequently, opioids garner more attention and concern than do alcohol and tobacco although the concern is focused on consumer use rather than on the availability of these prescription drugs. A side note...as we have seen with the legal production and marketing of any psychoactive substance, it is the “wet moral model” that drives public opinion regarding addiction and other problems associated with consumption. This model argues that it is a lack of consumer willpower to use these substances correctly and/or the consumer's moral turpitude that results in any problems associated with use...not the substance itself. Put more succinctly, those subscribing to the WET MORAL MODEL argue: I drink/use tobacco/take pain medication and do not have a problem so it is obviously the personal issues "of those people" that give rise to "their" problems, not the drugs themselves.

But I digress…In a society where the proverbial squeaky wheel gets all the grease, until and unless the public raises the issue of overproducing opioids to a tipping point, nothing is going to change. That said, I personally do not believe that the availability of legally prescribed opioid medication is “the problem”; it is the unbridled production of that medication and the unrelated but nonetheless confounding factor of under-informed physicians who overprescribe that is. It is the confluence of these issues—the unbridled production of opioid medications by big pharma coupled with over prescription by the medical professional—that give rise to the “opioid crisis.” NOTE: Opioids have been used since time immemorial to assuage pain and facilitate healing…all fans of Game of Thrones are aware of the role that the “milk of the poppy” play in Martin’s books. “Pain” was added as a “vital sign” by the medical profession in the late 20^th century, although that decision has not been called into question. The management of pain, however, is an important adjunct of the healing process following some surgeries and in mitigating the symptoms of specific diseases. For these reasons, opioid medications are important and productive. That said, the production of as much of these medications as the market will consume and/or their prescription in quantities that surpass the likely need only invites the type of problems we associated with opioids that currently exists.

In 1983 I had major surgery to address the loss of the use of my left hand. Upon discharge, I was given a script for Tylenol-3, which is Tylenol with codeine, a relatively minor opioid medication by today's standards but a script nonetheless that was both appropriate and appreciated. When taking the script to the pharmacy I asked the pharmacist if he would just give me 10 pills to carry me through the first couple days of my recovery rather than fill the entire script which was for considerably more, if I recall about a month's supply. I was told that by law pharmacists had to fill the scripts exactly as written but I would come to really appreciate how well they worked on headaches! Now, I realize that 1983 was a long time ago...perhaps before some readers of this missive were born, but the point remains: This combination of physician overprescribing and pharmacist response to a request for less medication may have something to do with why we have the problem we do today. Fortunately, Tylenol-3 did not induce, for me anyway, euphoria and only managed the pain associated with recovery...and I discovered that Tylenol with caffeine rather than codeine did a much better job managing my headaches...and yes, I am aware of the irony here as caffeine is a drug, just not an opioid J

By way of closing, I applaud those who have raised the issue of opioid use to its current level of awareness as we do need to address this important issue. However, I suggest that the rest of us whose awareness of opioid use disorders has become acute do not overlook the fact that the costs—economic, emotional, legal, and social—pale to almost insignificance when compared with those of alcohol and tobacco and their impact on public health, quality of life, and the economy in general.

What do you think?

Dr. Robert

[1] Cook, Philip J. (2007). Paying the tab: The cost and benefits of alcohol control, Princeton University Press. NOTE: see https://tinyurl.com/10drink50 and scroll to page 57 for details including rates of consumption for others portions of the population.

Capturing the Spirit of M.I.

As we are about to begin the 2^nd quintile of the 21^st Century, there are likely few readers unaware of Motivational Interviewing (MI). That said, acronyms like OARS, FRAMES, and other similar pneumonic tools from MI are also likely familiar terms. This familiarity, however, may…and I emphasize may…give rise to a problem when practitioners employ these strategies and techniques of MI in their work. This potential problem results from being proficient in their use but lacking when it comes to purveying the spirit of MI.

Although the use of MI strategies and techniques without necessarily conveying the spirit of MI is better than the traditional “attack therapy” approach used when “confronting” substance use disorders (SUD) years ago, when its strategies and techniques are couched in the spirit of MI, that is when the magic truly happens in brief motivational interactions. As an adage in AA goes, people do not care what you know until they know that you care. This sense of “being cared for” does not automatically result from the use of “technique.” Rather, it results from that more intangible “something else” or “extra” that may best be described as the “aura” that surrounds the use of MI’s techniques and strategies.

This brief essay is an attempt to outline what that “aura” might look like:

· The spirit of MI finds the practitioner less interested with doing something “to” individuals and more focused on doing something “with” them. When a practitioner understands that she or he is a practitioner 2^nd and another human being 1^st, that is when it becomes possible to truly embrace the individual being interviewed as the expert on her- or himself;

· Related to this, MI is not concerned with “putting in” or “filling up” the individual with what she or he lacks or “needs to know/understand/accept” to change. Rather, the practitioner is interested in “drawing out” what’s what from the individual. To call upon an old counseling 101 reference, Johair’s Window, the practitioner embracing the spirit of MI seeks to help individuals see and then understand those things hidden in the “blind spot” or “unknown-by-the-individual-but-known-by-everyone-else” quadrant;

· When a practitioner creates an environment where these previous two aspects of MI’s spiritual nature are conveyed, “change talk” becomes possible. Remember: Change is an inside job. As Sandra Anise Barnes writes in her book of poetry, Life is the Way It Is, “It’s so hard when I have to, and easy when I want to.” MI is about helping individuals discover that “they want to change” not that they “need to change.” Like in the adage about leading horses to water but not being able to make them drink, remember…we can always salt the oats.

· Practitioner’s embracing the spirit of MI conduct interviews that have more in common with an intercession than an intervention. An intervention is when I confront you to stop—or attempt to stop you—doing what I believe is the wrong thing for you to do. An intercession is when I attempt to present a different perspective from which to look at what you believe are the facts for which you have only one possible interpretation. Borrowing from cognitive behavior therapy, an intercession attempts to help you realize that “thoughts are not facts.” When interceding, I neither stop you nor prevent you from deciding what you will or will not do but I do present you with ways of looking at “your facts” from a different perspective, often employing OARS and FRAMES and other such MI techniques and strategies;

A last thought, for this essay anyway—but by no means the end of all that is involved in capturing the spirit of MI—is remembering to use what is called “person-first” language. This means that practitioners conveying the spirit of MI view and respect the individual with whom they are working as an individual. I work with John Jones who is an individual with an alcohol use disorder, not an “alcoholic”; Mary Brown who has a substance use disorder, is not “an addict.” The language we use conveys messages and meaning to not only the individuals with whom we work but also shapes the way we view those individuals and, consequently, interact with them. Even terms like “client” and “patient,” while professional and respectful, nonetheless establish something of an “us/them” relationship. Remember: MI views the individual being interviewed as the expert on her- or himself and when the individual who is an effective practitioner connects with that individual who is the expert on her- or himself, that is when the magic in counseling truly happens, magic being a euphemism for the spirit of MI.

What do you think?

02 July 2018

Cognitive Dissonance: The Parable of the College Drinker

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There once was a student who entered college a somewhat experienced drinker, having begun in high school. Upon arrival, absent a curfew and any parental supervision, his periodic drinking expanded in both frequency and consumption. This pattern soon brought him to the attention of residence life officials when following one outing he returned to the residence hall, intoxicated, and mistaking the elevator for a restroom, was written up after relieving himself between the 1^st and 4^th floors of the hall where he resided. As this was the first documented violation of university policy, he was given the option of choosing between a $300 fine and parental notification of the exact nature of his violation or to complete an alcohol assessment led by a practitioner familiar with the principles of Motivational Interviewing and trained in the use of BASICS, Brief Alcohol Screening and Intervention for College Students.

The brief two-session assessment was far more attractive than parental notification and a significant fine so he opted for the screening. Although expecting the sessions to be akin to a mandated “dad-talk” type lecture, he was pleasantly surprised when upon arriving for the first session, the practitioner seemed less concerned with his violation and more interested in initiating an open conversation about the role alcohol and drinking play in his social life. As a result, a decision he made to avoid parental repercussions and to save money presented him with an opportunity to step back from his drinking and consider if the price he was paying for a good time was worth what he was consistently having to pay to realize it. Following the two-mandated sessions, the student agreed to extend his contacts with the practitioner to learn more about how he could moderate his use to avoid further violations and other consequences associated with high-risk drinking yet continuing to socialize with friends and enjoy his college experience.

This parable is far from unique and certainly is not fictional. Such collegiate experiences are realized on campuses across the country on a regular basis. In my own career this very scenario—although the alcohol-related violations resulting in a referral for an assessment would vary tremendously—would occur regularly with outcomes that were frequently the same.

Motivational Interviewing (MI) and its use in BASICS interviews have a long and well-documented history of effectiveness. However, this essay is not intended to champion either MI or BASICS as clinical strategies for addressing high-risk collegiate drinking. Rather, the focus of this essay is the consideration of one possible explanation for why these intercessions with students seem to work so well.

Cognitive Dissonance is a psychological state of emotional discomfort resulting from the presence of opposing beliefs, ideas, or values. A classic example used to illustrate this point in intro psych courses references a hypothetical child told by its parents that all blue-eyed people are bad and not to be trusted yet when the child meets blue-eyed children and finds them fun to be with and enjoys their company, the beliefs instilled by the child’s parents conflict with the experience the child has in the real world resulting in a state of cognitive dissonance. When experiencing such, there are two primary ways one can assuage this dissonance: (1) change one’s behavior and/or (2) change one’s attitude.

The practitioner utilizing the principles of MI and conducting BASICS interviews is tantamount to the blue-eyed child our student meets who presents an opportunity to consider established beliefs about alcohol as a substance and drinking as a behavior, creating dissonance for the student. One of the primary ways the BASICS practitioner accomplishes this is with a series of very simple open-ended questions, asking, what are the good things about drinking and then following this with, what are the less good things about drinking? Then by presenting an opportunity to overlay the student’s alcohol use history atop this continuum of “good things to less good things” consequences—the good things representing the positive consequences of drinking for the student and the less good things representing the more negative consequences—the student is able to discern that there is a negative correlation between the number of drinks consumed and the cited good things happening (fewer drinks consumed is associated with more of the good things happening) while there is a positive correlation between less good things happening and the number of drinks consumed (as the number of drinks goes up so does the frequency of experiencing the less good things).

Remember that the two primary ways to assuage such dissonance are to change behavior and/or change attitude. In this case, the practitioner, because he or she employed the principles of MI thereby gaining the respect and trust of the student can, therefore, invite the student to continue with additional sessions where they can explore how to moderate consumption and thereby change behavior. There is a saying in A.A., bring the body and the mind will follow or its behaviorist corollary, it is easier to act your way into a new way of thinking than it is to think your way into a new way of acting.

Be that as it may, cognitive dissonance, instilled by the practitioner appreciative of the principles of MI and practicing BASICS, likely explains, in part, why so many students respond to motivational, brief interviews. Avoiding the “dad/mom-talk,” becoming engaged in a nonjudgmental conversation designed to explore one’s drinking history, and presented with the opportunity to conduct a personal cost-benefit analysis of one’s use of alcohol can and does result in changed student behavior, which in turn can result in changed attitudes and beliefs regarding alcohol as a substance and drinking as a behavior.

What do you think?

Dr. Robert

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