challenging client situations. Frequently, such challenges manifest themselves in an assortment of client comments, three examples of which are: (1) “how can you help me if you’re not an addict”; (2) “when I have to come to this group all of the time and hear about drugs it makes me want to use” and (3) “how does anyone expect me to get ahead when coming here takes time away from my job and my family.”
Let me address these one at a time:
1. “how can you help me if you’re not an addict”
I found that reminding myself that someone in a pre-contemplative stage of readiness to change will use any obvious difference between us to rationalize a lack of willingness to engage. Whether the client truly believes this difference matters or is just using it to resist engagement, in that client's eyes the absence of a counselor’s dependence on the client’s drug of choice casts practitioners as incapable of understanding their situation...a true "us and them" situation in the client's eyes.
Knowing this and understanding that such statements are not so much resistance born of hostility but rather an effort to maintain some degree of control in what to this point feels like manipulation by “the system,” allows us to “act on” a client’s objection to our ability to make a difference rather than “react to it,” or to use Miller's terminology, “dance with the client” rather than wrestle. It is important to mention here that this could just as easily be a client who questions our ability to help because of the difference in our ages, genders, sexual orientation, race, etcetera. Our clients often feel “trapped” and as a result, resort to any means available to maintain some degree of control over their situation, even if that is to control the counseling agenda by pointing out how “we are different.”
To argue with clients about why we can help only places them in the position of control as they direct the focus of the session. The more we argue or attempt to convince them that they are wrong, the more they retain the high ground in this exchange.
What I did when faced with a situation like this, not being in recovery -- or being male, too old, straight, white, or whatever -- was to agree with my client: You are right. I am not addicted (or male or white or whatever) and there are parts of being addicted (a woman, black, gay, or whatever) I probably cannot understand or relate to. But, I have attended “X" AA/NA meetings and listened to the stories of countless addicts and have worked with substance dependent individuals for "Y" years and listened to their stories too and have come to an understanding of addition that I think can help me to be of help to you. NOTE: Practitioners need to translate this type of response into their own words :)
If the client came back and said something like, That's bullshit. I don't care how many of those meetings you went to, those people are not like me and you can't possibly know anything about me that can help! I would again, respond by agreeing with the client: Perhaps you are right and maybe hearing hundreds of stories by people addicted to alcohol or other drugs doesn't prepare me to know exactly what you have been through but if you have ever been angry, felt betrayed, were insulted, disrespected, paralyzed by fear or anxiety, or taken advantage of or ignored, I have experienced all those things, personally. I may not know what it is like to go through a withdrawal from (client's drug of choice) but I do know what it is like to deal with the crap (depending on the client and my read of that client I might use expletives) that life can throw at us. NOTE: Employ a matter-of-fact voice and NOT one that sounds angry or aggressive.
I would then change the subject since continuing the discussion risks it starting to feel like an argument.
Changing the subject to something non-threatening but nonetheless appropriate for a counseling session allows us to regain control of the session. This “something” to which we shift the focus can be almost anything, just not anything that suggests “a problem.” Examples include:
· Tell me something about what you expected these sessions would be like before coming.
· I know from the paperwork that came with you why the folks that referred you want you to be here, but why do you think you are here?
· Even though you doubt that I can understand your situation seeing that I am not an addict, what could result in you leaving this session today thinking that, “that wasn’t as bad as I thought it was going to be”?
· Assuming for a minute that something useful could come out of coming here, what might that be?
NOTE: Make sure your question is open-ended otherwise you will likely just get “yes” or “not” answers at best.
2. “when I have to come to this group all of the time and hear about drugs it makes me want to use.”
This is another common point raised by clients, although more often by someone in a contemplative stage of readiness to change.
As in the previous situation, statements like this may come from clients who try to rationalize their belief that “coming here” is not helpful and therefore a waste of time. It is also possible that a statement like this can come from clients who believe they have “dealt with their drug issue” and now just need to fix everything else in their life without the constant reminder of “back then.”
Again, starting a reply by agreeing with the client is likely to signal understanding and a willingness to listen while at the same time earning the opportunity to challenge this rationalization without appearing to argue: (This assumes that facilitators do not allow the group to focus on the joys of drug use) I can appreciate that talking about drug and drug use in the group does place your use front and center, but how does discussing the costs and consequences of using drugs result in your “wanting to use?”
A client might reply with something like, Well, all I can think about when all we do is talk about drugs and using them is that that has been such a big part of my life for so long that it’s all I know. Even when others are talking about their problems all I think about is, “I’m not like them. I’m different and I can control this.” I know dealing with this is hard but coming here and sitting in those drug groups makes it harder. Notice how such a reply to your question allows more of the client’s story to come out, which provides additional “grist for the counseling mill.”
Now, I have no idea how an individual client would respond to a counselor’s reply of, “group makes me want to do drugs.” I suspect that in the scenario I outline here, the counselor could come back with reflective listening…not a retort or follow-up question: Hearing others discuss their drug use in a group makes you wonder if your drug use will ever change. NOTE: This is a statement and NOT a question.
I could extend this hypothetical dialogue on for several exchanges but my point here is that whether the client is trying to rationalize leaving or is genuinely concerned about how the group threatens his making any type of progress, the issue is not so much “the group” as it is the what the client is telling himself about the group…it’s a waste of time/bullshit…or it is a threat to me. Keeping the client, not the group, as the focus is one way to address such client challenges.
3. “how does anyone expect me to get ahead when coming here takes time away from my job and my family.”
Traditionally, addictions counselors would see such a statement as resistance to treatment if not indicative of denial and respond with, …and how much time did you spend with your family when using and how did that use affect your attendance and job performance? Such a reply is confrontational and draws a line in the sand and sets up an adversarial relationship between the client and counselor.
Another approach, one more in line with M.I. in general and the spirit of M.I. specifically, is to respond to such a statement with reflective listening to elicit more of the client’s story and what is the real hidden meaning in this statement. For example:
· Coming here is frustrating because it is a waste of your time. NOTE: There is no question mark at the end, meaning that this is NOT a question but a statement…a reflection.
o Although clients may reply, “Yes, that’s right,” compliant clients might say something like, “it’s not so much a waste of time as it’s time I could be using to fix things at home/on the job.”
o If they respond, “yes that’s right” a counselor could respond, A waste of time? And then process however the client responds, keeping the focus on the client and not the ‘time in group.’
o If they respond, “it’s not so much a waste of time, it’s that they were mad when I using and now they are mad because I am going to group and those meetings”[1] a counselor could respond:
§ (Reflection) It’s not that the group is a waste of time as much as your family and job don’t understand the need for all this counseling. OR
§ (Summery) O.K., let me see if I understand: if you did not have to attend group you would have “X” hours more time each week with your family and to focus on your job. What would you do with those “X” hours that could improve things at home and on the job? OR
§ (Reflection) You’re caught between the rock and a hard place and feel trapped…by what your family wants on the one hand and what we here in the program are recommending on the other.
These client situations are typical of what counselors treating SUDs face routinely. That said, no matter how a counselor responds to such client comments, different clients will react differently. My point is that there are 2 simultaneous objectives for the counselor who faces such situations:
· Such client comments come more from individuals who feel trapped or at least somewhat impotent and have lost control over their lives, and
· A counselor who realizes this is better prepared to “act on” rather than “react to” these types of client situations.
If I view my work with an individual with a SUD as not so much a contest to win but a relationship to forge, I increase the likelihood of engaging my client in an eventual consideration of making a change, especially if viewing that client as a person first and the client second. Try as I will, however, on my best day I can only help the individuals with whom I work I cannot save them…I may be able to influence their behavior, but I cannot control it.
What do you think?
Robert
[1] Notice how such a client response to the counselor’s reflective comment elicits more of the client’s story…and what is really going on in the client’s original statement
