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 1^st 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?

The Science of Persuasion and Prevention Messages

Persuading others to “try something new” or alter their behavior in a significant way can be a

daunting task; ask anyone who has raised a child, especially an adolescent child. But there is a science to persuading individuals to alter their behavior, their routines and “habits” if you will. Researched by Robert Cialdini, Ph.D., emeritus professor of psychology at Arizona State University, he pioneered the “science of persuasion,”[1] identifying six (6) specific principles of persuasion that individually and in concert may be useful in affecting student behavior – consistency, reciprocity, scarcity, authority, liking, and consensus. 

I will address these principles in a series of essays that reflect on how each might be applied by health educators and clinicians working with contemporary collegians, specifically, considering the decisions students make and their personal behavior related to the use of alcohol or other drugs. These essays will reflect on how these principles may inform efforts to persuade abstinence when use is contraindicated and moderation should a decision to use be made. Although collegians will be the focus in these essays, Chialdini’s principles and my thoughts on applying each can be repurposed or modified for work with any population.

Consistency

Humans are creatures of habit. From where we sit in church or a classroom to our morning routines, we stick to established patterns. Perhaps this is simply because we avoid change but more likely it is a function of wanting to “feel comfortable.”

How often does the plot of a thriller involve a character who falls victim to a predator simply because of consistency in following an established routine with which the predator has become familiar? Although most of us, fortunately, avoid being victimized by predators familiar with our routines, such consistency may nonetheless set us up to repeat high-risk and dangerous substance use behaviors, that is to say, our “patterned” substance use decisions regarding when and where and what to use.

Historically, preventionists have attempted to persuade behavior change by educating students about the consequences associated with high-risk and dangerous use. The argument was that intelligent students will make responsible choices if provided with the facts about risky consumption. This approach succeeded in its educational mission but failed with regards to its behavioral objective.

Subsequent efforts have focused on helping students to become personally aware of the cost-benefit ratio associated with personal consumption. Although successful, unfortunately approaches like Brief Alcohol Screening and Intervention for College Students (BASICS) reach a relatively small percentage of all students and generally only after they have been identified as high-risk users following alcohol or other drug-related incidents. Such students are viewed as belonging to a small “selective” or at-risk population if not an even smaller “indicated” population that already displays signs of a substance use problem.

What is needed is an effective prevention strategy that targets the more “universal” population of college students. This is where Chaldini’s “science of persuasion” may present an opportunity, one principle of which is “consistency.”

Related to the foot-in-the-door technique addressed earlier on this blog, “consistency” builds on the fact that we humans are more likely to commit to embracing a suggestion that follows our having made a small initial commitment. For example, if asked if I believe that efforts to reduce our carbon footprint on the environment are justified and I agree, I am more likely to commit to donating to an effort that furthers that work. When asked if I support “X” and indicate that I do, I am more likely to volunteer my time or sign a petition that furthers that work. The need for consistency between what I say and what I do may well result in my being persuaded to act in a particular way.

This is a strategy employed by fundraisers and marketers alike to encourage contributions, volunteering, purchases, or otherwise responding favorably to their overtures. Eliciting a small personal commitment to an idea or principle and coupling that with our propensity to seek consistency in our lives influences our beliefs, values, and, in the case of marketers, our purchasing decisions. Such strategies are ethical not to mention simple and extremely cost-effective and I doubt any reader has avoided their influence.

So how might a preventionist apply the principle of consistency in the work she or he is doing with collegians? What if…

• …when students present at the health center, for whatever reason, they were asked if they
  
  favored campus efforts to reduce alcohol-related hospital admission…or late-night noise in the residence halls, or sexual assaults? Chances are that all would agree. Once doing so, then asking if them if they would agree to count the number of standard drinks they have on any occasion when they choose to drink.
• …when student-athletes meet with the trainer they were asked to critique a poster intended to deter the use of smokeless tobacco and upon doing so then asked if they would be willing to post one in the residence hall or common area of their apartment complex?
• …what a Greek-letter organization applies to host a party on campus and the social chair is asked by the student life representative reviewing the application if the organization would be interested in receiving “X” cases of soft drinks/water at no charge for distribution at the party. When the social chair agrees, asking if she/he would allow a student life rep to make a 10-min risk-reduction presentation at a general meeting prior to the party. (NOTE: If a campus has an exclusive distribution agreement with a soft drink vendor, e.g., Coke or Pepsi, the proffered free soft drinks can likely be negotiated as part of the agreement, especially if the vendor knows how they will be used).

The impact of consistency as a principle of persuasion is enhanced when one’s commitment is made public. This can be in writing such as in a letter to the editor of the campus newspaper or a picture or statement published electronically on social media; perhaps with a publicly displayed poster endorsed by a campus group/organization or free T-shirts with a prevention message and/or logo. Again, the specifics of “how” the public commitment is made and to what degree is left to the creativity of the preventionist.

What is important to consider here is how might our human need to experience consistency in our lives be employed to increase the likelihood of commitment to a harm-reduction, health-promoting prevention message.

What do you think?

 Dr. Robert

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[1] When visiting this site, take the time (11:50 min) to watch the included video explaining the 6 scientific principles of persuasion.