Understanding Addiction or,

Things are not Always What They Appear to Be

Addiction is nothing if not a contemporary of humans since the dawn of recorded history. During this time, there have been many attempts to explain addiction with most having relied on the behavior exhibited by those identified as addicted in order to explain addiction. This is something like explaining the common cold as congestion, runny-nose, sneezing, and a scratchy throat. Although some or all of these realities may be indicative of the common cold and even descriptive of one who has that condition, they are not, individually or collectively, “the common cold.” If we introduce the construct of viruses—and the rhinovirus in particular—we come closer to operationally defining the common cold. However, even then, the “cold” itself is but a condition where the virus is an organism with the ability to affect its host in a particular way, the result of which is to bring about a condition we call the common cold…and then it is but one of dozens of viruses that result in conditions with “cold-like symptoms.”

Such is the case with addiction. Historically we have looked at the actions and choices of individuals who behave in a particular way and have labeled them as “addicted.” Most frequently, the interpretation of these behaviors has had a decidedly moral bent resulting in describing those “with addiction” as being morally bankrupt or of weak personal character if not the personification of moral turpitude. All of this, based upon the behaviors of an individual whose comportment falls outside the constraints of socially constructed boundaries.

With the advent of contemporary science—and more to the point, the technology that has enabled these scientific advancements—we now know that addiction is more than the behavioral indicators that suggest its presence. In fact, not only is addiction not the result from moral turpitude or a defect of personality, it is more than likely the result of distinct functions of the human brain that make some individuals particularly susceptible to this disorder. Although this susceptibility to addiction is beyond the scope of this brief essay, it is, nonetheless, a “scientific nut” that remains to “be cracked,” and likely sooner on a technological timeline than later.

Explaining addiction requires more than the simple blaming of one’s moral shortcomings and/or personality defects for the continued use of a substance or pursuit of a maladaptive behavior. Recognizing that the characteristic euphoria or “rush” associated with use and the craving that eventually follows both result from normal functions of the brain more than suggests that we revisit our understanding of addictive disorders and our historic approaches to their treatment. That particular regions of the brain associated with the “rush” and “craving” associated with the advent of this disorder suggest its etiology may be more elegant than pejorative.

We know that particular drugs like alcohol and cocaine activate what is referred to as the “reward pathway” in the brain, specifically, the ventral tegmental area (VTA) – nucleus acumbens – prefrontal cortex. Were it not for this unique function of the brain that has evolved so as to ensure that securing food, water, and the desire to continue the species are rewarded, we would literally “not be here.” That drugs like alcohol, cocaine, and behaviors like gambling can activate this pathway by mimicking or compromising the naturally occurring neurotransmitters designed to ensure survival begins to explain the “high” that occurs when engaging in these behaviors; the more one consumes, the greater the high and the greater the desire to repeat the experience. The intensity of the “high” or “rush” is what, in turn, sets the stage for the craving. As one recalls the intense pleasure associated with the addicted behavior, the rush to repeat the experience can preoccupy the individual’s mind to a point that consumption becomes an irresistible urge.

Historically, addiction, or more specifically, the repeated use noted in those with addictions, was thought to be motivated by the negative reinforcement realized when one would seek to assuage the withdrawal symptoms associated by separation from the object of one’s addiction. New research, however, suggests that it is the desire to re-experience the high that is hinge on which the door of addiction swings. The irony is, the very physical system that creates this cascade of events that results in addiction seeks to correct the imbalance created by the flood of neurotransmitters associated with the pleasure pathway by reducing the production of endogenous neurotransmitters. This reduction in neurotransmitters results in a tolerance to an established quantity of use thereby necessitating an increase in drug used or behavior required to ensure satiation. The entire cycle of behavior we have come to refer to as “addiction,” is essentially one’s attempt to recapture the euphoria associated with intoxication. One is not so much addicted to “cocaine” or “alcohol” or “gambling” as he or she is addicted to being intoxicated.

Simply stated, drugs like cocaine and alcohol block the ability to reabsorb the neurotransmitters naturally produced in the brain. As new neurotransmitters are produced to ensure the normal functioning of the brain, a flood of neurotransmitters, for example dopamine, results in continued and over stimulation of the reward pathways. As the body detects this malfunction in the normal flow of neurotransmitters, it reduces the amount of dopamine naturally created. This results in a reduced “high,” which we know as tolerance. Tolerance is met by the consumption of greater quantities of the addictive substance resulting in a spiral so frequently observed in addicted individuals.

If individuals who have an addiction do not have a crisis of character or a dysfunctional personality then to judge them as individuals based on behavior resulting from a discernable physiologic process ceases to make sense. To be blunt, people with an addiction are not bad people who need to learn how to become good; they are individuals with a behavioral health problem who need to get well. Just as there are treatments for individuals with “physical” health problems, so are there treatments for individuals with “behavioral” health problems and in both cases, those treatments work.

What do you think?

Dr. Robert

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Brief Screening for High-Risk Drinking 

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Motivating anyone to rethink an established behavior let along a personal opinion on a controversial topic is a daunting task to say the least. As a matter of fact, when one's drinking (or other drug use) is the object of a motivational intervention, this is often an even greater task. This is nowhere more the case then when a medical professional seeks to engage a patient in a conversation about his or her alcohol (or other drug) use.

For many, both medical professional and patient alike, there seems to be a vicious circle when it comes to considering motivating change where alcohol consumption is involved. This cycle, some might call it the futility cycle, is represented in this graphic courtesy of Dispair, Inc:

Ultimately, the medical professional will simply "stop asking" about use beyond the ubiquitous "do you drink" and if learning, "yes, a couple," leave it at that. Unfortunately, with substance use disorders representing one of the major medical challenges in the 21st century, at least in Western countries, this effectively nullifies early intervention by someone who may, interestingly, have the greatest likelihood of being listened to by a substance using individual...his or her medical professional.

To quickly screen for alcohol-related problems, consider using the four questions that follow (see http://bit.ly/NTuITs for source material).  The first has been suggested as a “single question” capable of determining if further screening, if not a formal assessment, is warranted and is argued in the cited article to be, in and of itself, sufficient to discern if a problem exists or not.

1.      How often do you have eight (or for women, six) or more standard drinks[1] on one occasion?[2]

      

• Monthly or more often suggests a positive screen, indicating that the respondent might benefit from an intervention to help him or her cut back.
• How often in the last 6-months have you been unable to recall some or all of what happened during the previous night’s drinking?
• How often in the past 6-months have you be unable to follow through with normal responsibilities following drinking?
•  How often in the last 6-months have you experienced concern about your drinking expressed by a family member, relative, or friend?

If the answer to the first question is no, and the interviewer believes the response is genuine, consider your screening complete.  If, however, you question the veracity of the response to question #1 or that answer is positive, then questions 2 – 4 make sense to ask.

NOTE #1: You may want to consider “working these in” over the History & Physical rather than risk appearing to conduct an interrogation.

Note #2: Most individuals, especially those who have a substance use disorder (SUD), know how to answer such questions so as to appear “lower, if not a low risk.”  It is therefore recommended to familiarize yourself with these questions so you can “work them into” a conversation with someone being screened.  A secondary approach to conducing this screening, if time permits, is to invite the interviewee to “tell his story” and then answer each question for the interviewee in your mind based on the facts in the reported story.

If the individual does not volunteer needed information necessary to answer each question, use open ended questions to access such.  For example, if the individual’s story does not allow you to answer the question, “How often in the last 6-months have you been unable to recall what happened during the previous night’s drinking?”, try asking, Tell me something about how drinking affects your memory.  If the individual is hesitant or allusive, try something a bit more direct, for example, when drinking, rate your ability to consistently and accurately recall events the next day.

Remember that effective screening necessitates never attacking or simply interrogating an individual.  If the person does not have a problem, such techniques will only serve to alienate the individual while if a problem does exist, it will only alert the individual to your perceived intent…to label and likely show condescension based on that label.

If the results of this brief screening suggest the likely problem with alcohol, ask the individual’s permission to share proactive suggestions about how he or she can pursue the issue further.  If the permission is not forthcoming, then share your concerns for the individual’s health and wellbeing based on the suggested results of the brief screening.

A simple set of follow-up questions include:

1.      What are the good things—and phrase it this way—about drinking?  Note: This is a “throw away question” because everyone will answer it according to personal preferences.  The benefit of this question is that it established your interest in the person and his or her opinion.

2.      The second question is, What are the less good things—and again, state it exactly this way—about drinking.

You will notice that the answer to the second question, which is the important question, will often (always?) mimic the problems that patient associates with drinking.  If, however, the interviewer were to ask, “Tell me about your problem with alcohol” or “What problems do you experience when you drink,” you will likely get something like, “Well, I don’t really have any problems when I drink” or “I don’t have a drinking problem.”

The purpose of this brief intervention is not to get people with alcohol problems to admit that their drinking is a problem.  The purpose is to increase the likelihood that individuals will step outside their comfort zone and look at their drinking from a different perspective.  Just as the answer to the question, “is 2 minutes a long time or a short time” is dependent on the individual’s perspective regarding time.  If, for example, the individual said this is a short amount of time, ask him or her to hold his or her breath for 2-minutes and watch for the reaction.

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[1] A standard drink = 1.5 oz 80 proof spirits, 12-oz domestic beer, 10-oz malt liquor, 5-oz table wine.

[2] Most descriptions of high-risk or what some call binge drinking suggest 5 or more standard drinks for males, 4 or more for females, but this is a controversial bench mark

Collegiate Drinking and the New Academic Year: 

Let the Games Begin...

…no, not the Hunger Games, although at times our work in higher ed may seem like we are perennially selected as competitors for the latest games.

At the start of the new academic year…for those on semesters…it is appropriate to pause and remember that humor can be a useful tool in our efforts to convey information as we seek to move individuals, students in particular, through the stages of readiness to change. For those who have yet to consider that change is a pursuit worth consideration—AKA the Pre-contemplators—humor can serve to capture their attention and invite a further consideration of a message related to revisiting personal behaviors and, hopefully, moving to a contemplative stage of readiness to change.

As with any advertising, it is important to engage the consumer before attempting to sell the  product. As Simon Sinek suggests in his TED lecture on “How great leaders inspire” (see http://bit.ly/PAzvuf), most purveyors of information begin at the outside or more superficial level of explaining “what” a thing is and move on to “how” it works and perhaps, lastly, explain “why” the listener should be interested. “Great leaders” he argues, start with the “why” and move towards the “what,” realizing that once one has been engaged, the issue becomes not motivating them to buy my idea as much as pursue their own values. He repeatedly suggests in this brief clip, “people do not buy what you do; they buy why you do it.” Consequently, “suggesting that collegians revisit their perceptions of alcohol as a substance and drinking as a behavior is a tough sell. As Prochaska pointed out over 30 years ago, pre-contemplators do not think their behavior is the result of a problem; they believe their behavior is the pursuit of a solution.

One of the best ways to invite a pre-contemplator to revisit his or her behavior and increase the likelihood of moving towards becoming a contemplator is consciousness raising activities or helping individuals to look at “the facts” from a different perspective. Challenging individuals to revisit these “facts” as they manifest themselves in their lives will rarely work if our focus is on “their” problem. As my grandfather used to say, “You don’t remove a hornets’ nest from the porch eves by beating it with a stick.” Two strategies that work particularly well regarding consciousness raising are: (1) humor and (2) sensational if not seemingly ludicrous metaphors or examples to illustrate points that force individuals to re-examine assumptions they have made regarding particular behaviors to which they have habituated.

We are all likely familiar with exercises where smoking is translated from cigarettes consumed per day to dollars spent in a year or beers consumed on a Friday night are converted to calories consumed one’s freshman year. These are "classic" examples of consciousness raising activities or strategies designed to get people to look at "the usual" from a different perspective in order to more objectively evaluate its utility. Humor can also serve to get someone’s attention and invite him or her to pause, smile, and rethink—if just for a moment—a behavior or practice that has been repeated so often as to become invisible. Psychologists refer to this as “habituation” and no one changes a behavior that has become so ritualized as to have become invisible in the grand scheme of things in one’s daily life. Take for example this student answer on a physics exam when the required answer was unknown:

Although “funnies” like these make their way around the Internet with regularity, when incorporated into work with students, they can serve to bring poignant issues to the surface for discussion in a non-threatening manner and often open the door to a meaningful discussion about realities without students necessarily  perceiving receipt of the “dad/mom” talk from the practitioner. For example, with the “joke” included above, the practitioner could ask an audience of students what they thought was going through the mind of the test taker. This can easily lead to a discussion about the link between collegiate drinking and its “perceived” consequences, then onto social norms, what factors differentiate between low- and high-risk when drinking, etc. Simalarly, programs can be done using clips from films like Animal House, which are readily available on YouTube. With a little investigating, several clips can be identified, shown, and then discussed regarding what makes them so funny…and then when their humor is exposed refocusing on the risks likely associated with the clip if it were to actually occur on campus.

The examples of humor an "silly" metaphors or examples are endless and only limited by the resourcefulness and creativity of the practitioner who emplys them. My point in this post is to suggst that humor and “creative metaphors” and stories can go a long way to opening the door to conversations with pre-contemplative students about their high-risk behaviors without having the necessarily employ the proverbial “2X4 to get their attention."

Again, and to sum up, citing my grandfather, who used to remind me that, “Whether you rush in the front door or sneak in the back, it is just as warm by the fire." Moral: Pay attention to how you plan to get from where you are to where you want to be.

what do you think?

Dr. Robert

The Solution to High-risk Collegiate Drinking: Amethyst Goblets

While researching the mythical connection between the gemstone amethyst and the consumption of alcohol, I discovered the following:

Amethyst, the most valuable crystal of the quartz family, comes in

many colors ranging from pale delicate lilac to rich deep purple. It

derives its name from a Greek word meaning "not intoxicated" and has

been known historically for its supposed power to help one maintain

that condition!

According to ancient myth, Bacchus, the god of wine, was so enraged

over a slight by the goddess Artemis that he vowed that the first person

to enter his forest would be devoured by his tigers. This hapless

mortal turned out to be the beautiful virgin Amethyst, who was on her

way to worship at the shrine of Artemis. As the ferocious beasts sprang

on her, she called on Artemis for help and was turned into pure white

stone. In repentance for his cruelty, Bacchus poured the juice of

grapes over the stone and gave it its purplish-violet color.

In memory of the transformed nymph, the stone that bears her name was endowed with the ability to protect the wearer from the evils of

intoxicating drink. The custom of drinking wine from cups of amethyst

evolved in the belief that the gems would ensure one remained sober.

Based on, http://bit.ly/LKK62Z, last accessed 24 July 2012.

In light of this, it occurs to me that a solution to the high-risk collegiate drinking may be, as is often the case, recorded in history and available for our use if we would but open our eyes.  To be specific, what if we in higher education, dedicated to educating young minds and affecting student behavior, lobbied our institutions to issue individualized drinking cups, to each student as she or he begins school on the first day--goblets carved from genuine amethyst at elite private schools and amethyst colored crystal on public campuses? 

            These mugs can be personalized with a particular institution’s logo or Greek organization’s letters, perhaps even both if done as a joint (more about joints and gemstones appropriate for preventing intoxication via marijuana later) venture.  This will ensure school/organization spirit while at the same time documenting the concerted effort to control the abuse of alcohol by the sponsoring institution/group.  To increase the likelihood that these cups, and these cups alone, will be used in the pursuit of that apparently universal collegiate rite of passage, drinking, institutions of higher education should strongly encourage its Greek organizations and other campus student groups which sponsor "mixers" to offer "free refills" to any student presenting an GENUINE amethyst drinking mug.

            It occurs to me that this could be a rather expensive proposition initially.  However, when considering the sources suggesting that chief administrators in higher education estimate that 21% of all attrition is directly attributable to alcohol related problems/issues (see http://1.usa.gov/PEtsaj, last visited 24 July 2012), amethyst drinking cups may not be financially prohibitive.

            Now, some may argue that this is a ridiculous suggestion and that money spent on such a venture would accomplish only one result, biting comments by some pundit on a cable news channel railing about “how your money is being spent.”   But I beg that you not throw this idea out like the proverbial baby with the bath water.  Consider first the literature on expectations and drinking behavior and our efforts to date to modify collegiate drinking: amethyst mugs may not be such a bizarre idea (provided we do an adequate job relating the story of Bacchus, Artemis, and the Amethyst to each student as s/he receives her/his goblet).

            I trust this brings the hint of a smile to your face; clearly its writing reflects the satirical muse that resides in my office this morning.   To pursue more serious discussion on this most important topic of alcohol and collegiate life, I suggest that you subscribe to DRUGHIED, an Google Groups discussion group dedicated to issues of alcohol, other drugs, and higher education.

To subscribe to DRUGHIED, email me at chapman.phd@gmail.com or leave a comment here.

What do you think 

Dr. Robert

Al K. Hall as Dracula:

Film as a Clinical/Pedagogical Device

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It occurs to me after recently re-watching Coppola's Bram Stoker's DRACULA and then rereading the novel that one can make an interesting argument for considering vampire legends as metaphor for alcoholism. Is there reason in or history to this thought, or is this just the result of  something like Ebenezer Scrooge's "bit of undigested beef or a blot of mustard" explanation of the ghost of Jacob Marley in the Dickens's classic A Christmas Carol ?

The idea of reading more into Stoker's classic tale of demons, lust, and the eternal battle between the forces of good and evil is far from original. However, most previous attempts to read between the lines of this tome have suggested that there was something more akin to libidinal urges and Victorian mores afoot than a consideration of the etiology of addiction and alcoholism in this gothic tale.

However, let's consider the "Dracula legend" with an eye more towards the characteristics of alcoholism. First, often introduced as a seductive, virile, and powerful purveyor of eternal life, the Dracula character is no stranger to anyone in Western culture.  Our introduction is to a mercurial, dashing, sophisticated and almost regal individual, who is apparently both wealthy and powerful, and in many respects, the envy of many whom he encounters.  This is not very different from the description of alcohol provided in the Big Book of Alcoholics Anonymous, where we read of the drug being "cunning, baffling, and powerful."

We witness Dracula's powers in a number of different ways. Whether as devotees of comics or student's of Native American myth would call him, a shape-shifter, or in his ability to command the loyalty of those under his spell, we meet an entity with the potential to control all whom it encounters. "It" promises to change the life of all that consume it, and its attractiveness results from its appearance in many forms. Hmmm...sounds like alcohol or other drugs doesn't it?[i]

Like the individual with alcoholism experiences the Siren’s call to drink, the heroine of the film, Mina, and original novel that inspired it, experiences Dracula’s allure. She is unable to ignore/withstand his power, a power already demonstrated through his having drawn Miss Lucy, Mina's closest friend, to the “dark side of the force”...but that is another film and another essay.

Knowing that the Count represents a threat, Mina still wishes to be with him 'always' and forsakes the exhortations of family and friends who warn her to beware. She is so enamored of his powers and charm that she cannot - or will not - heed the warnings of those closest to her. We see Dracula as an entity requiring one's life-blood in order to survive in true parasitic fashion.

How often have we told our alcohol dependent clients that drinking is draining them of their humanity, robbing them of their self-respect, health, and all that is held dear. We are reminded of the Chinese proverb that admonishes, "first the man takes the drink, then the drink takes the drink, then the drink takes the man," as we watch Nosferatu slowly convert the mortal into his minion.

Dracula 'controls' souls, he promises eternal life, but delivers eternal death. He is seductive and sensuous, yet absolutely self-absorbed. We can equate the lack of reflection in the mirror with alcohol's empty promise of seeing the true self while those who witness his presence in front of the looking glass see nothing. More literally, the 'blackout' that often heralds the onset of alcoholism? The stake in the heart or severing of the vampire's head but a metaphor, a reference to the necessity of total abstinence if one hopes to redeem personal freedom.

We can continue the parallels ad nauseam but my point is to question whether this film and the novel and legend to which both pay homage can play a role in the treatment of alcohol or other substance use disorders? Does it offer a vehicle that may enable individuals with substance use disorders to understand their dependence, to "see" it, literally? Is it possible that Dracula is to alcohol in Bram Stoker’s novel as Mr. Hyde is to drugs and that Robert L. Stevenson’s Dr. Jekyl and Mr. Hyde presents us with yet another useful metaphor for addiction?

If we look beyond the 'literal' plot of some of these gothic horror tales, can we find metaphor that has use for those in treatment regarding their addiction? More importantly, can these examples from the popular culture provide the professional counselor with a vehicle by which we can invite our clients to consider addictive disorders and their possible need for treatment?

Film is a power vehicle for capturing client interest, illustrating points made in therapy, and presenting a type of Bandurian "vicarious learning" experience. Enjoy this film, again, but this time; watch it with a counselor or therapist’s eye.

What do you think?
Dr.Robert

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[i] A Native American allegory

Author unknown

I Am Alcohol and Great Are My Powers

I was born between the Earth and Spirit worlds, between life and death, between substance and decay.

I was once a part of the essence of life, sleeping in the pulp of corn, grain, and fruit.

My existence there was harmless‑ I slept waiting for the death and decay of the plant life, when I would awaken for a fleeting instant to mark the final decomposition of life.  Animals who have eaten of the decaying fruit know the circle of my powers.

At first sensation is my power to bring pleasure and warm feelings to the host I invade.

My warmth and cheer have caused pain and death for countless thousands.  For my circle of power begins with pleasure but runs toward pain with each drink of my essence.  The powers are progressively stronger, so that each step entices the host to consume more and more.

When gripped within my powers, the host becomes confused‑ he thinks that pursuing my powers will give him power, but it makes him powerless.

He confuses increasing pain with increasing pleasure.  He sees my illusion as reality.  He sees my power of death as the essence of his life.

If the drinker chases my circle of power to a full rotation, only the thought of his death will bring pleasure to his mind, for death is one of two ways for release from my power, and completes the circle

The only other way is to turn in mid‑circle to face the pull of my charms, and fight them step by step to the beginning of the circle.  This battle has been fought by many, but won by few.  Those few know of my strength and ferocity‑ they have broken the spell of a terrible foe, but have not defeated me.  For the memory of my pleasure giving will lurk within their hearts, waiting but to be seized upon in a moment of lonely despair or impulse.

Those who resist my attractiveness after having broken from my spell are holy men.  They have done battle with the evil spirits in the earth world, and their reward in the spirit world is great.

Those who partake of my juices but resist the pull of the circle tempt my powers, but they may be successful if they are aware of my terrible might and illusory nature.  But if they seek life through me, they will come to know death.

Drinking, Collegiate Life, and Attrition: Is There a Connection?

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In the article, Is Heavy Drinking Really Associated with Attrition from College?  The Alcohol-Attrition Paradox, Martinez, Sher, and Wood (Psychology of Addictive Behavior; 2008 September; 22(3): 450–456) report on heavy collegiate drinking and attrition.  Historically this connection is one that many have suspected yet until fairly recently, it has been difficult to document.  This is among the first research articles to suggest a statistical connection between heavy drinking and completing a college degree. See

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2673793/pdf/nihms-104555.pdf

This article is interesting (see the discussion section if not interested in the technical information on research methodology) in that for the first time, to my knowledge, a link between heavy drinking and attrition is documented statistically.  This is of significance as it is something to which those concerned about high-risk and dangerous collegiate drinking can refer when arguing our point about increased administrative and financial support for prevention.  More to the point, with senior administrators frequently driven by fiscal “bottom lines” and boards of trustees more concerned with business models than academic missions, linking “high-risk and dangerous drinking” to “attrition,” that is “income,” can be an important step forward for our field.

Related to this, we know that using Prochaska’s Transtheoretical Model of Counseling (see http://www.uri.edu/research/cprc/TTM/StagesOfChange.htm)—with its value rooted in recognizing the significance of approaching individuals in their existing stage of readiness to change and then mounting motivational interventions designed to enhance movement towards change based on that awareness—is effective clinically.  When this model is used to approach institutional change, the principles remain the same…change results as decision makers are guided through their successive stages of readiness to make such changes based upon effective interventions.  For those administrators at the earlier stages of readiness to change, "consciousness raising" and "awareness" oriented interventions are most effective in motivating movement to the preparation and action stages of readiness to change; Martines, Sher, and Wood's article permits this be done.

In the case of senior administrators, boards of trustees, many faculty, and various other parties with vested interests in how higher education is managed, although they are aware that “collegiate drinking is an issue,” they tend to see it as more the results of student developmental issues and/or “the rites of passage” that “have always been and will always be.”  Consequently, the fact that high-risk and dangerous drinking is among the top public health issues affecting contemporary collegians is lost on the very individuals who are the most influential in making the campus policy and fiscal decisions that ultimately determine higher education’s ability to address this issue.

To definitively link heavy drinking to attrition presents an opportunity to both argue the importance of moving collegiate drinking in general and high-risk and dangerous collegiate drinking specifically to a position of greater significance and appropriateness for funding.  In short, if a registered student represent 10s of thousands of dollars annually in an institution’s fiscal bottom line, then demonstrating the role of heavy drinking, in concert with the events that students attend, plays in reducing that revenue is likely to garner greater interest when we make our pitch for prevention and intervention.

In conclusion, irrespective of the changes that senior administrators do or do not make regarding this subject, the findings reported in the research cited above also provide valuable insight for us as prevention specialists to better target our efforts and increase the effectiveness of the evidence-based best practices we are currently employing as we address heavy collegiate drinking.  In short, it is not just “heavy drinkers” that we need to target with our prevention efforts, but heavy drinkers who attend specific types of collegiate events. 

It will be interesting to see if Martinez, Sher, and Wood’s findings are replicated and if their recommendations for additional research are heeded, but irrespective of the future, there is interesting “food for thought” in this provocative article.

What do you think?

Dr. Robert

Self-disclosing vs. Self-involving Statements in Counseling

Counselors must exercise caution when using self-disclosure as a therapeutic technique, especially early in a counseling relationship. Self-disclosure can pose a problem or even sabotage a relationship when a practitioner conveys a message that the client perceives as implying what “should/should not be done.” Premature practitioner self-disclosure can even prompt clients to entertain self-demeaning thoughts, as they believe that change is elusive yet something the counselor has mastered. 

 

An effective counselor can likely accomplish much of what is attractive about self-disclosure—the humanness of sharing oneself, engaging the client in a collaborative relationship, empowering the client, and personalizing the collaborative relationship—by employing techniques associated with reflective listening. Remember that most counselors considering self-disclosure want their client to “feel better/safer/more accepted,” yet doing this without the self-disclosure and focusing instead on supporting the client is a safer and more proactive way of accomplishing this objective. The technical term to describe this alternative is self-involving statements. In such statements, the counselor can “speak from the heart” yet stop short of sharing his or her life story.

 

For example, when a client shares about a personal trauma to which the counselor can relate, instead of sharing the details associated with this fact, the counselor might say, “I can tell how difficult it is for you to talk about this. I know the courage it takes to do so, essentially with a stranger, and I appreciate your trust. Sharing like this with me suggests the progress you are making in counseling and leads me to believe that our treatment goals and objectives continue to be appropriate,” or something like this.

 

Notice how the counselor can infuse the dialogue with a distinctly personal air without having to “self-disclose” personal information. This enables the counselor to be “in the moment” and become personal while continuing to establish and maintain appropriate boundaries with a client. Further, such statements become very important when self-disclosing “my story” could superimpose a set of “how-it-should-be-done” expectations or standards on the client.

 

A good example of this is the counselor who is in his or her recovery, perhaps from a substance use disorder, and attends 12-step meetings regularly. As much as the counselor believes that sharing their story in response to a client’s fear that “things will never change” and “I guess my father was right when he called me a loser,” what the client may hear when told the counselor’s story is, “unless you go to AA/NA and stay involved with AA/NA, nothing is going to change.”  This may not be an issue for the client who views 12-step programs as beneficial or at least a “non-issue.” Still, for the client who wants no part of such a recovery, at least right now, this self-disclosure could inadvertently alienate the client who now believes that the counselor will sooner or later suggest AA and impose “his/her way” of recovery.

 

A challenge that recovering practitioners who are active in AA or NA face is how to differentiate between “sponsoring” and “counseling.” Establishing a relationship with “a sponsor” in AA or NA is a cornerstone of recovery in 12-step programs and, for many, a key component of its success. In such relationships, sponsors intentionally focus on themselves as they share “what it was like, what happened, and what it’s like now.” In 12-step parlance, sponsors share their experience, strength, and hope, essentially their personal stories of dependence and recovery with the individual they sponsor. This is essentially the antithesis of what effective counselors learn when trained to engage someone in a clinical relationship. 

 

Consequently, the recovering practitioner must understand the difference between the relationship one establishes with another 12-step member and the relationship professional counselors and therapists develop with their clients. This is not an easy task, especially for the recovering practitioner who recognizes that their recovery is due in large part to their involvement in a 12-step program. For this reason, supervisors should consider broaching this subject with their recovering supervisees and discussing the use of self-involving statements to covey their presence with clients as a possible alternative to the self-disclosure that is the hallmark of sponsorship, at least in the earlier stages of a clinical relationship.

 

What do you think?

Dr. Robert

Getting “Unstuck” in Our Thinking about Drinking

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This is a copy of a letter I sent to the Council of Southeast Pennsylvania regarding a recent newsletter – see newsletter at http://bit.ly/H14bFw

Thank you for sending the recent SEPA Council newsletter; Binge Drinking is a Nationwide Problem.  Although the newsletter points out some obvious issues of concerns regarding drinking, I write to share some thoughts on which I would appreciate your reaction if not those of your colleagues at the Council.

First, as important as the shared information is, the newsletter’s design and format presents it in a classic “scare tactics” approach.  From the two photos—one of the young male whose head is on the bar in desperation if not passed out and the other of the dower looking EMT, complete with stethoscope around the neck, perched in front of an ambulance—to the headline itself, complete with exclamation point, the Council’s proactive message about S-BIRT and its evidence-based approach to addressing high-risk and dangerous drinkers is somewhat lost in the implied message of concern if not danger.

Next, as much as the term “binge drinking” has been accepted as part of the lexicon used to describe high-risk and dangerous drinking, it is nonetheless a term that is perceived as being ludicrous by underage and young “of age” drinkers not to mention be called into question by many clinicians who view a binge as being an extended period of excessive use rather than consuming 4+/5+ drinks in a 2-hour period of time type of drinking.  NOTE: I do NOT argue the risk associated with this type of drinking.  Rather, I am concerned about our insistence as a field on using language to share a concern that the population we try to reach rejects as nonsensical, which therefore defeats our purpose.

I suggest that the Council consider these points as it prepares future copy for PSAs and other community-based publications, but more than this, I suggest it also recognize that there is more to the issue of prevention than pointing out what is not working in our system and demonstrating that with an endless parade of reports about “the problem.”  Just as research is showing us that clinical interventions designed to meet individuals with substance use disorders (SUD) where they are ideologically rather than insist that they come to the clinician’s views of substance use and treatment, and/or how the use of “strengths-based” counseling interventions motivate greater numbers of individuals with SUDs to move towards change, so can we who are involved in prevention learn something by listening to what these “binge drinkers” have to tell us about the majority of the time when they choose to drink moderately if not abstain altogether.

In this very newsletter article on “binge drinking,” it points out that the average member of this group drinks “4 times per month” and “8 drinks per occasion.”  Again…this is very high-risk.  But the point that goes unaddressed when focusing on these factoids is that 26-days a month they do not drink and they stop at 8 on those occasions when they do drink.  The question becomes, why?  This is interesting information at the least and potentially very useful when our objective is to reduce harm for both the community in which these drinkers drink and for them as individuals.

We first need to change our thinking about “doing prevention” if we hope to change the thinking of the public at large and ultimately that position of the public that “binge drinks.”  We start this when we begin to ask, Why do those who do not drink until 21 and those who if they do drink, do so in moderation, make the choices they make?

What I propose is nothing short of a paradigm shift when it comes to looking at the issue addressed in the newsletter; I appreciate this.  I also appreciate that fact that this shift is not going to be easy as many stakeholders in prevention efforts find themselves locked into their current way of thinking, which makes any suggestions coming from outside that paradigm automatically suspect.  But let me close with a simple question I use to illustrate being “stuck” in one’s own thinking when addressing this with my students:

Answer this question: What color is a “yield sign”? 

Now, visit images.google.com and in the search box type, “yield sign,” complete with quotes. 

What is the predominate color of all the pictures that appear?

Is this what you expected?

NOTE: If you are like most people above the age of 30, you likely thought, “yellow”; I did.  But “yellow” has not been the color of traffic yield signs since 1971.  So why do most people when asked this question “get it wrong”...because we are “stuck in our thinking.”  We see what we expect to see or worse yet, only look for evidence that supports our position and ignore everything else that does not.  In social psychology this is confirmation bias.

Until and unless we change OUR thinking, we have no hope of changing the thinking of those individuals we target with our programs and PSAs.

Thanks for reading to this point and allowing me to share my position.  I hope that I will be able to converse with you or other council members further.

What do you think?

Dr. Robert