Whether Bold by the Front Door or Reticent at the Back, It is Just as Warm by the Fire

This wisdom of my grandfather has served me well through the years. In counseling, it is often the quiet, sometimes gentle, but nonetheless persistent pursuit of facts that can guide someone in counseling to insight. The funny thing about insight is that once gleaned, change soon follows. 

Sandra Anice Barns wrote, It is so hard when I have to, and so easy when I want to. I have come to look at this line as speaking to what individual dealing with addiction or compulsive behaviors often realize when realizing that the hassle of change is less than that of continuing. 

Change is many things, but first, it is an "inside job." People do not change other people, but they can influence others to change themselves. I have found that humor, metaphor, and allegory are all pretty good means by which to invite people to step back, look at themselves and their behaviors from a new perspective and answer a simple question: Is what I get by following this path worth what it costs me to continue taking it?

When the answer is yes, the journey continues along its present trajectory. If, however, the answer is no--or, and this is the precursor of change, I am ambivalent and therefore unsure--I contemplate change. When this contemplation is internal, when the tipping point in my cost-benefit analysis of my behavior is reached, I do not so much decide to change because something or someone external to me "made me," but because, as Barnes suggests, I move from feeling I have to change to deciding I want to change.

I have found many stories, cartoons films, music and other examples from the popular culture that have served to be useful in my efforts to invite individuals to evaluate the facts in their lives from a different perspective. Last week I found another and wish to share it here.

I found this video clip - see http://bit.ly/dT6d8g - humorous. It was sent as a link in one of the ubiquitous emails I receive from friends and acquaintances who share "stuff from the web," the purpose of which is to prompt a smile. Although I smiled when I watched, the potential the video held to stimulate a serious conversation about drinking to excess, particularly in a collegiate population, struck me.

If you have a moment--the video is only 3-min long--watch it and enjoy. If you have a thought regarding the video in general or, more specifically, if use in stimulating serious discussion with a group regarding prompting change, I will look forward to your comments here...or you can write directly to chapman.phd@gmail.com


Dr. Robert

Educating Family and Close Friends of Individuals with 
Substance Use Disorders: 

Blooming Where You are Planted

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Generally, those who provide counseling services related to substance use disorders (SUD) do so when working with the person who uses. Another all too often overlooked but nonetheless important individual affected by SUD is the family member or close friend of the user. Finding psychoeducational materials designed to assist these individuals in understanding both the disorder and the way it affects the loved one is essentially to seek the Holy Grail of addictions literature. As with substance users involved in treatment, it is important for practitioners to meet the “individual” where he or she is on the continuum of readiness to pursue change. Frequently family and friends of substance users are at a very early stage of changing their behavior, what practitioners sometimes refer to as a pre-contemplative stage of readiness—I do not need to change, the user must make the change—or a contemplative stage—I can see how making some personal changes may help, but I am not ready to do so—at best. As such, I proffer several resources and suggestions for your consideration.

First, it might be helpful for the family member(s) or friend(s) to read some firsthand accounts of addiction and recovery. By reading first-person accounts of what it is like to be addicted, what is involved in the addicted person’s life that results in a movement towards change, and what life after change is like, family and friend glean an “insider’s perspective” on addiction. This can be quite helpful in letting go of the all too often tendency to think that all the user needs to do is “just stop”—for a humorous look at how effective this expectation is, watch this brief YouTube clip - http://www.youtube.com/watch?v=T1g3ENYxg9k

 Here is a link to some of the stories in the Big Book of AA that presents the stories of recovery from some of the early members of Alcoholics Anonymous. Granted, the drug used by the authors of these stories is alcohol, but the stories tend to give an accurate picture of the compulsion and obsession associated with addiction and, as the result, set the stage for viewing addiction as a bona fide health care problem and not a question of willpower - http://www.aa.org/bigbookonline/en_personalstoriesii.cfm

Next, it is useful to revisit the issue of “willpower” and consider it as more than an issue of perseverance or determination. According to the moral model of addiction, either “drugs are perceived as being bad and therefore so are those who use them,” this is often referred to as the “dry moral model,” or, drugs “may or may not be bad” depending on the drug (heroin/meth = bad; caffeine/alcohol = good), and strong (willed) people can use them without problems...the “wet moral model”…implying that those who experience problems are “weak willed” individuals.

An earlier essay I posted on this blog -  http://robertchapman.blogspot.com/2010/08/understanding-willpower-urban-myth-or.html may be interesting to review. Likewise, there is a collection of essays on my web page (http://www.robertchapman.net click on the essays link in the menu) that may be useful as well...be sure to check out the “counselor’s holiday message” posts. Again, you will need to scan these in order to discern which may be apropos to your interest in this topic.

Next, the film, “Rain in My Heart” may be useful. This is a documentary on alcoholism, but it allows the viewer to see the “down and dirty” reality of alcoholism/addiction and how it is not a question of will, but rather a medical disorder if not an illness or “disease.” The documentary lacks the “canned” or “preachy” feel of many professionally produced videos on addiction. It is available on YouTube in 10 installments of about 8 – 9 min each. The URL for the first being http://www.youtube.com/watch?v=NP0InrPZpjg with the next installment usually listed on the right side of each subsequent screen.

Related to this is another two-part YouTube video entitled, “The Man on the Back.” This you will need to screen carefully as it may not be useful, either in its focus or the fact that it is in Icelandic with English subtitles, but trust me that the subtitle do NOT detract from the power of this video. It has nothing “overtly” to do with addiction, but is a powerful piece on co-dependency and enabling, useful as a metaphor for addiction...the “hiker” in the film being the individual “with” an addiction and the man on the back the personification of the addiction itself. This is a bit of a reach for a lay person to get, however, without having a trained/experienced addiction professional or perhaps recovering person to “set the stage” before watching the video and then processing it at the end. The entire video, both parts, is 20 minutes, so it is brief. The URL for the first installment is: http://www.youtube.com/watch?v=T0m9iu6O3dg with the second linked from the menu on the right side of the page.

The challenge when trying to reach someone who: (1) believes he or she already knows ‘what’s what’ as regards addiction and (2) is so angry, hurt, and/or scared that hearing about let alone investing time and effort to read material that will “educate” about addiction is perceived as “fruitless” at best and a complete waste of time at worst. For this reason I suspect that “at this stage” it might be more productive to help the individual to understand addiction on an emotional level rather than try to engage him or her in a more cerebral or “intellectual” investigation of the disorder. Remember…this individual has been frustrated if not deeply wounded by the loved one’s behavior as dictated by his or her addiction.

Do not expect those who have been personally and profoundly affected by the SUD of another to accept any of these suggestions or “psychoeducational” interventions willingly or with thanks. As a matter of fact, initial overtures of help are frequently met with resentment. If, however, the information is proffered, with an emphasis on “I care” rather than “you need to know,” it is not uncommon that the individual will consider the material if not return in order to seek your counsel and support.

Dr. Robert

Understanding Aspiration: Revisiting the Term Dead Drunk

Aspirating stomach contents is most commonly experienced by individuals who are in an altered state of consciousness, e.g., head trauma, under anesthesia, under the influence of alcohol or other drugs, etc.

When in such an altered state of consciousness, bile and other stomach contents, i.e. vomit, can be aspirated or "inhaled" into the lungs if the individual is lying on his or her back and vomits while passed out.

This is a phenomenon that has been known for most of recorded history, e.g., Atilla the Hun is reported to have died on his wedding night in 467 AD as a result of aspirating vomit and/or blood while in a drunken state; aspirated vomit contributed to the deaths of Janis Joplin, John Belushi, Jimmi Hendrix

Problems associated with aspirated stomach contents fall into three broad categories - 1) obstruction of the airway and flooding of the lungs, i.e., "drowning," 2) chemical pneumonia or damage to the lining of the lungs due to acid burning - if the ph of the aspirated material is lower than 2.5, the result is chemical damage to the lining of the lungs, which precludes normal respiration, 3) bacterial pneumonia, which results from inhaling pathogens or "bacteria."

Recovery from the effects of inhaling a small quantity of aspirant is rather quick, 24 to 48 hours. Chemical or bacterial pneumonia, i.e., "aspiration pneumonia" is much more serious and treatment can take an extended period of time and require the use of antibiotic medications.

Standard training for resident life staff in most colleges and universities includes the early detection and prevention of aspirating stomach contents when intoxicated. This phenomenon, often mistakenly referred to as "alcohol poisoning, can result in "aspiration pneumonia." This training consists of knowing the signs of individuals who are at high-risk for this phenomenon and precautions when caring for the excessively intoxicated student. These include, 1) place the individual's back to a wall, pillows in front to preclude rolling onto one's back or stomach, thereby lessening the chance of aspirating vomit should the individual become sick.

True "alcohol poisoning" results from achieving a blood alcohol level so high as to anesthetize the vital reflexes associated with circulation and respiration. This is a true "alcohol overdose" with the same consequences as those associated with an overdose of any central nervous system depressant drug, barbiturates for example.

While not an uncommon phenomenon, a relatively small portion of any collegiate student body is at risk of aspiration as the majority of college students (56%) drink 4 or fewer drinks per outing and of those who drink more, many do not consume enough to suppress their gag reflex or become so intoxicated as to be unable to right themselves if they need to vomit.

To read more about the risks associated with aspirating stomach contents when excessively intoxicated, visit this webpage at Loyola Marymount University - http://www.lmu.edu/Page25064.aspx

A Counselor’s Holiday Message

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I saw an interesting quote today. It struck me as particularly apropos to the holiday season…Christmas, New Year, Kwanza, Hanukkah... Although apparently religious at first glance, albeit ecumenical, I suspect, universal nonetheless;

An important part of praying,

Is a willingness to be part of the answer.

When discussing spirituality in counseling, especially counseling individuals with substance use disorders, I tell my students that I believe there is more to spirituality than just its theological interpretation. I suggest that it may be as much a world-view that, like a Venn Diagram, includes the theological, sectarian meaning so many associate with the term, yet still leaves room for the more secular constructs of harmony and connectedness.

This understanding of connectedness is similar to the Native American concept of harmony and the belief that all things in this existence are interconnected; that all that exists is the product of the creator and as such, all imbued with a spirit that must be respected  in order for me to be respected. It is in the recognition of a thing’s spirit that we acknowledge its significance and ultimate importance to our own well being—it is acknowledgement of a “thing’s” essence and my understanding of its meaning that gives us significance. This recognition then becomes, in and of itself, a prayer when we interpret “prayer” to be an appeal, a plea, a request, a desire, a wish, or a hope—all synonyms proffered courtesy of MS Word J This prayer may be directed to a “supreme being,” but then again it can just as easily be directed to a “human being,” that is, another human in the act of becoming or secular group, like AA. This is, of course, one of the ways AA explains the spiritual aspect of the suggested program of recovery to new comers who are concerned about if not put-off by the seemingly sectarian nature of the 12-steps.

The Navajo—and I apologize if I cite the incorrect Native American tribe—have a saying:

Beauty to the right of me,

Beauty to the left of me;

Beauty before me,

Beauty behind me;

Beauty above me,

Beauty below me;

I am on the pollen path.

This is, to me, similar to what my grandfather with his 8^th grade formal education and DHW (doctor of hard work) in common sense used to tell me. “Robert,” he would say, “no matter where you go, there you are.” I now know that was not an original quote of his, but it was one of the many things pop taught me that shaped me as a boy and influenced the adult I would become; he taught me that no matter where I stand, at any given time, I am where I need to be at that time to make a difference, both in my life and in the life of another…directly, meaning today, and indirectly, meaning tomorrow and through others via their actions.

Through the years, I have come to realize that all things exist for a reason and that with the exception of us sentient human beings, that reason…that purpose…is clear and is pursued relentlessly from birth through death by all creation. We human beings also have the same purpose but, I believe, have been placed on this earth to consciously affect that purpose intentionally, namely, to assist in making this world…this place where we coexist…just a little bit better for our having been here.

To listen to the 6 O'clock news or access one’s usual source of information, however, is to get a daily dose of doubt regarding this potential to affect the world in a positive way. Yet there is “beauty to the right of me, beauty to the left of me…” if I will just look for it…more to the point, I just expect to see it.

So if praying is not just speaking with a higher power, but includes voicing an appeal or making a plea or proffering  a request or expressing a desire, or producing a wish, or cultivating a hope, then expecting a result may well necessitate being prepared to become part of the answer.

Gandhi said, We must be the change we wish to see in the world. AA says, Just do the next right thing.

Apropos to this, I share with my students another of my grandfather’s lessons, albeit updated with my own personal homage to my journey through the 60s:

Change is possible;

Change is possible for me.

Change is possible for me right now;

Change is possible for me…

… right now…

…with a little help from my friends.

At this festive holiday time of the year I wish you and all those important to you peace, good health, and faith, faith in the belief that change is possible through prayer in all its many and varied forms.

Dr. Robert

Has the new technology precluded students from learning in traditional settings and ways?

There was a time in the not too distant past when we were so unfamiliar with the new digital technology available to us that when referring someone to a web site, the entire URL would be printed or read aloud in an advertisement. Today, the bare essentials appear because "everyone knows" to enter http://www in order to visit the site--and many browser are so intuitive that all one needs to type is the essential information.

My point is that not only has the technology expanded at a pace that for many seems dizzying, but we have learned how to use that technology and, in many cases, have become dependent on it. And those who have been born in the last 20-years--the millennial generation as they have been dubbed by some--have grown up  having always known that the Internet existed, that email and text messages are as common as today as ashtrays  in restaurants and airplane seat armrests were in 1960. Times change and those who live through the change are aware of it, but those born into the change see it as just the way things are.

So what are the implications of the technological revolution of the 21st century? Will society be affected as much by it as the 19th and 20th centuries were by the industrial revolution? I suspect that this YouTube clip, may set the stage for some interesting considerations regarding this. Visit http://www.youtube.com/watch?v=SkhpmEZWuRQ

Although apparently staged, the point this clip raises is nonetheless interesting…can today’s high school students “learn” from printed textbooks if they become frustrated by their dissimilarity with where they glean most of their information…the internet? Has the disconnect between electronic media and the (in student eyes) antiquated “hardcopy” print alternative become so great as to prejudice the student and affect his or her willingness to learn? And if the answer is yes, what are the implications of this reality for us as educators, remembering that today’s high school students are tomorrow’s under grads and graduate students? More to the point, whose responsibility is it to change…the students who need to “appreciate the value of printed information” and “realize that everything on the Internet cannot be trusted” or is the problem ours to address by revisiting our pedagogy, doing much the same as educators as we have been taught to do as counselors…meet the “client” where the client is?

Just a thought…what are yours?

To consider the impact of digital technology on eduction further, watch http://www.youtube.com/watch?v=dGCJ46vyR9o

Dr. Robert

Alcoholic Energy Drink Producers to Remove Stimulants: Good News?

Although at first glance the FDA's decision today reported by CNN (http://bit.ly/buH8Ep ) may appear a victory and  “good news,” we need to realize this is also akin to what social psychologists like to call “the foot in the door” phenomenon (see http://bit.ly/cYW6Ut ). Literally, this is when I ask you to do something or give me something small in order to give me/do something larger that I was not likely to have done/granted right away. In other words, by asking for something one does not need to think much about and is likely to grant, when I ask for what I really want, the ice has already been broken and you will give me what I want. The argument goes that if you have already provided something you are more likely to provide more.

When I say that Four-Loko’s manufacturer’s offer is “akin” to the foot in the door, I mean that “we”—those who are protesting four-loco and other alcoholic energy drinks—are not likely to object to this offer and may even applaud the proffered change as we saw the added stimulants in these beverages as a major—although not the only—concern regarding these drinks. However, is the wind is then taken out of the protest movement’s sails? Is the momentum we have amassed lessened? Do sweet-tasting, high-sugar drinks equal to 4.7 standard servings/container drinks continue to be sold?

Another variation on this theme is that the producers of alcoholic energy drinks respond to our continued protests about alcohol content, calories, and potential for overdose by suggesting that we are “zealots” who are “neo-prohibitionists” because they removed the stimulants we said were so harmful yet we still are not satisfied. In short, can they spin their efforts and our response them to their advantage?

I do not have the answers to the questions I ask, but we nonetheless, as a field, need to be very careful how we proceed here. On the one hand, the removal of stimulants is a good thing; on the other, do we risk losing momentum and/or being cast as a group of “fundamentalist neo-prohibitionists”?

What do you think?

Dr. Robert

 12-Steps & Religion: Is AA Secular? 

As a professional counselor for 38-years, the last 35 of which have been spent exclusively addressing issues related to alcohol and other substance use, a frequently asked question has had something to do with the apparent religiosity of AA or other 12-step mutual aid groups. Most frequently such questions come from those being referred to AA and are based on either a limited previous exposure - "a couple" meetings "years ago" - or what had been "heard" about AA or how it was portrayed in a film or TV program. I must admit that addressing this concern was something of a challenge in the early days of my career, but as with so many things in life, it has become easier as time...and opportunities to practice...have passed. As my grandfather used to say, "We do best what we do most." Consequently, I have a couple specific thoughts to share for your consideration:

1. 1.      I have found that with individuals reluctant to consider AA or other 12-step programs--and more recently, my students who are asked to consider if they will use 12-step programs as an adjunct to their professional counseling--a bit of prep work in advance of a “first meeting" or more informal exposure, e.g., AA/NA literature, can be quite helpful. This includes accentuating the positive aspects of meetings that may be realized specifically or involvement with “the fellowship” in general. Examples of this include, the opportunity to socialize with those who do not use, the opportunity to recognize that one’s use (and the results of it) are not unique to “me,” or the simple “something to do with my time rather than use." Likewise to help him/her understand that the language used at meetings and in the literature is not necessarily as the individual interprets it. By this I mean, help the individual recognize that “language” is composed of words that are mere “auditory symbols” that only have meaning as the result of the way they are used and in the context of how they are conveyed by those who use them. Consequently, the “meaning” of words can change over time and/or the meaning of the speaker may not be the same as that of the listener who is interpreting them. I often use the example with students of the word “gay.” When AA was being formed, 1935 – 1939, “gay” meant “happy” or “joyous.” Today, of course, many people 60 or younger understand “gay” to mean being homosexual, particularly being a male homosexual. Although “gay” continues to also mean happy and joyous, it is often the context in which the word is used that enables the listener to discern the speaker’s meaning. This, unfortunately, is a bit more difficult when it comes to the perceived religious-speak used in 12-step literature and at AA and NA meetings. Consequently, the counselor has to work a bit harder to help the individual who may be agnostic if not atheist, and whom she or he wishes to refer, to be able to tolerate, let alone embrace, the program of recovery that has come to be known as AA’s/NA’s 12 suggested steps.
2. Related to the first, is to proffer a “different set of lenses” through which the agnostic or atheist can view AA's or NA's 12 suggested steps and the “language of recovery” spoken at 12-step/mutual aid meetings. One vehicle I use is B. F. Skinner’s—the famous behavioral psychologist—“humanistic alternatives” to the 12-steps. Although AA/NA is not going to alter one word or even syllable of any of its texts, we can help individuals who we believe may benefit from the program to clear the hurdle presented by the language that results in a misperception that unnecessarily precludes one from benefiting from such mutual aid groups because of a perception of their religious tone if not orientation. You can find Skinner’s “alternative steps” at http://silkworth.net/magazine_newspaper/humanist_jul_aug_1987.html
3. Another, albeit more academic resource in addressing this question is a paper I wrote on understanding (interpreting?) the 12-steps of AA. Although written for my counseling students to help them better grasp the potential12-step programs hold to provide a useful adjunct to professional counseling, this might be of use, at least as a source of “talking points” if addressing the issues of “GOD” or “Higher Power” and other things “apparently” religious in AA. Visit http://bit.ly/cI4dNh 

In closing--and to answer my opening question--"yes, I do believe that AA is secular...non-religious...focused on moving further away from the last drink or drug use rather than closer to "God." As I once heard at an open meeting of AA I attended when someone was railing about all the "god talk," "if the word bothers you as a reference to a supreme being, then use it as an acronym...Good Orderly Direction."

What do you think?

Dr. Robert

To Scare or Not To Scare: That is the Question RE Alcoholic Energy Drinks

Anyone with a passing interest in alcohol-relate issue, especially as they apply to collegians, has heard of the furor related to "Four Loco" and other caffeine infused, high-alcohol drinks. A good example of news coverage can be seen in an article in Carolyn Davis' piece in the 27 Oct edition of  Philadelphia Inquirer see http://bit.ly/bt2dJQ because of the hospitalizations, deaths, and various sundry "alcohol-related" emergencies associated with consuming such drinks, some campuses have banned these beverages and educators, political officials, parents, and others have called for action...from mandatory labeling of the number of standard doses of ethanol in a single 23.5 oz can of Four Loco (4.7) to outright banning of these products. Finding information on this issue is easy and if you are interested but having difficulty, you can post a comment or email directly and I will be pleased to share some sources.

The focus of this blog post, however, is not to participate in this debate so much as to step back from it and as two basic questions from a more global perspective: (1) Are there inherent risks associated with scare tactic approaches to "warning" individuals to not do something because it is risky and potentially harmful, and (2) have some earlier decisions made by prevention specialists and prevention researcher's diminished our credibility in the eyes of students to deliver reliable and therefore "to be listened to" information about alcohol and other drugs?

I suspect there may be a downside to efforts to emphasize the immediacy for responding to the alcoholic energy drink issue. The greater the urgency assigned to this issue, the more  likelihood that these products will appeal to a certain minority of students who are risk takers. As Linda Lederman, Dean of Social Sciences at Arizona State university, has admonished regarding the use of “high-risk drinking” as an alternative to “binge drinking” because of the potential to appeal to these students, we may want to target audiences to which we appeal with this in mind. It may result in a desired effect to raise the alarm with administrators and student affairs professionals, but cause quite a different result if that same message is delivered to students. (To risk-taking behavior and its impact on substance use further, read Tom Workman’s essay on edgework and risk takers entitled, “To the edge and back again: Edgework and Collegiate Drug Use” in my monograph, Collegiate Drug Use: A New Look at and Old Issue (http://www.rowan.edu/casa/resources/documents/chapmanfinalfinalap.pdf).  

Related to this cautionary word is the importance of considering how we wish to approach students with this information. As in so many things in our field, there is no “one size fits all” alert that will have the same impact on parents, administrators, students affairs pros and students. Remember, since we have all but acquiesced to accepting “binge drinking” as the term to describe 4+/5+ student drinking, we have lost credibility as purveyors of factual information in the eyes of some students.

In a recently published report from the Century Council—and yes, I know the CC is an arm of the distilled spirits council—students do not see this term as relevant or descriptive of their drinking – see http://bit.ly/bqZTbg Knowing this, we need to pay attention to: (1) What message about high-alcohol energy drinks do we wish to deliver to students and (2) who is it that we believe is best suited—and credible—to deliver this message? Remember the old adage, “what goes around, comes around”; it may be time to review our comfort as a field with the term “binge drinking” to describe how students drink. NOTE: Thanks Jim for not referring to 5+ drinks as “binge-drinking” in your missive J

Again, I do not attempt to “rain on the parade” and believe that social scientists, administrators in high education, and parents alike do need to address this issue as a unified entity. My caution is that we do so in such a way as to be consistent with sound prevention methodology, which has excluded "scare tactics" as a viable approach for almost 20-years..

What do you think?

Best regards,

Robert

Benign Neglect or Can Deception Ever Be Therapeutic?

The  rather brief podcast linked below suggests a novel approach for addressing the problem experienced by a German retirement home where residents suffering from dementia tended to wander off campus and become lost in the community. Irrespective of how closely the focus of this piece may parallel your professional work, there is an inherent ethical question associated with the proffered solution: Is it okay to intentionally deceive individuals, in a rather elaborate and premeditated way, when the result of the deception is a reduction in the likelihood of the demented individual experiencing harm?

Related to this is a story from my clinical experience over 30 years ago. While directing a clinical staffing in an in-patient addiction treatment program, the program’s consulting psychiatrist related the story of an elderly woman suffering from dementia who was living with her daughter. Each morning this woman would get up, happy as the proverbial clam, fix herself tea and toast, and then proceed to sit in the front-room of her daughter’s home for several hours “watching her friends as they would do their acrobatic tricks out front of the house.” Now, the friends were little people who used the telephone wires strung between the poles out-front of the house to practice their routine. As you have no doubt surmised there were no “little people” doing “acrobatic tricks” in the telephone wires in front of the house; this was the woman’s delusion.

The woman’s daughter became concerned about her mother’s hallucinations and her increasing fascination with them...in short, they because the highlight of her day and all she would talk about through the day. The psychiatrist interviewed to elderly woman, made a diagnosis, prescribed medication and in relatively short order the delusions ceased. The psychiatrist was satisfied with the result, the daughter was ecstatic with her mother’s return to sanity...and the elderly woman became severely depressed. The depression progressed to a point where the elderly woman became lethargic, inattentive to such things as eating and personal hygiene, and uncommunicative. The daughter again contacted the psychiatrist, outlined the new symptoms and her concerns for her mother after which the physician agreed to reexamine the elderly woman. He diagnosed her condition as related to the “loss of her friends” and the depression observed the result of the grieving associated with this loss.

His recommendation? Take the elderly woman off the medication and engage the daughter in supportive “talk therapy” so that she might better cope with her mother’s condition. With in a relatively short time, the elderly woman’s friends returned, she now was the one who was ecstatic and returned to her previously outlined daily routine. The daughter agreed to the therapy and as the result, was able to better cope with her embarrassment related to the stigma she perceived being associated with her mother’s “mental illness”; the case was closed.

My point in sharing this latter story is to approach the question mentioned initially above from a different perspective: Is the intentional deception of a client resulting in harm reduction or the intentional withholding of treatment that can effectively alleviate symptoms of pathology albeit with iatrogenic effect (1) justified, and if so (2) is it ethical?

What do you think?

Check out the referenced podcast on iTunes: http://ax.itunes.apple.com/us/podcast/wnycs-radiolab/id152249110  (#13, “The Bus Stop” episode)

Best regards,
Dr. Robert

Art as a Reflection on Counseling: What Does the Client See?

The attached is a quick snapshot of a piece of art I discovered when cleaning out my home office. It is somewhat difficult to tell what you are looking at unless you look closely…and perhaps with a magnifying glass…but if ever in Philly, you are invited to stop by, have some tea, and take a look, “up close and personal.” 

About 20-some-years ago I did an alcohol and other drug assessment with a young man who was mandated following a drug violation…marijuana. We did the assessment and although he was not a candidate for in-patient “drug treatment,” he was well on his way to developing a substance use disorder.


At the end of the assessment, I was looking for some way to make its results more personally meaningful for him. Because he was an artist and a huge fan of graphic novels, I asked him to prepare a review our assessment graphically: The artwork below was his rendition of the outcome of that meeting.

Essentially he storyboarded his insights regarding his drug use, projecting into the future where it might take him if he chose to ignore the results of our assessment. Although I suspect he took some artistic license in producing this piece—I did not see a violent death to be very likely in his future even if his continued use did progress to addiction—it nonetheless tells a cogent story and presents a somewhat accurate picture of the progression of a SUD, at least in Philly. More importantly, it was his interpretation of where his use might lead lest he make changes.

In any event, I thought I would share this as a way of suggesting that individuals can be invited to react to counseling in ways other than just words. What do you think?


Dr. Robert

Giving Away Beer to Attract Younger Customers: Crisis in the Making or Desperate Attempt to Counter a Shrinking Market?

AA, Spirituality, Religion, and Professional Counseling: Part II

As mentioned in my last post, AA (and other 12-step fellowships) neither advocate for nor against any issues, including whether those with symptoms of substance use disorders should become involved with AA. The issue of primacy in this discussion is how do we, practitioners of counseling, interact with AA and, more to the point, the role it plays in the care plans we negotiate with individuals involved with us in counseling.

As with many issues that surface in counseling, counselors are taught to explore all options with clients and eschew pushing a personal agenda. This does not mean that we do not have professional opinions about what works best or better than other things, but it does mean that we need to assess the client’s wishes and attempt to find a course of treatment that is appropriate in our professional opinion while at the same time consistent with the individuals wishes.

True, AA is not for everyone. That said, it seems to work well for many--and whether this means initially finding sobriety or pursuing recovery once  "dry"--this is an issue that the practitioner should consider when determining: (1) If a referral should be discussed and, more to the point, (2) when that discussion should take place in the counseling relationship. Because of the success so many recovering people attribute to 12-step programs, contemporary counselors cannot not consider such programs as a potential adjunct to professional counseling. This does not mean that “all” clients should be referred, but neither does it mean that none should be referred. It is part of what professional counselors do to determine: (1) What will work best, (2) for this individual, (3) at this particular time, (4) to best address this or her needs.


If counseling practice has changed at all over the years it is to have moved away from treating the diagnosis a client has and focus on providing service to the individual who presents seeking care for his or her needs. True, one’s diagnosis will inform the course of this treatment, but as I mentioned in my earlier post on this topic, “there are many paths to the same destination.” 


So, it seems to me that the issue is not “if” AA is appropriate, i.e., is it evidence-based treatment? Is it too religious/not religious enough, etc.? Rather the issue is how and when do I, as a professional counselor, address this issue with individuals for whom a diagnosis of a substance use disorder is appropriate. For John Jones the decision may be to not discuss this now, but perhaps later. For Mary Brown it may be to refer her immediately, and for little Johnny Middleschool, it may be to not discuss this option at all unless Johnny bring it up.

The second issue of importance in this discussion seems to be mandating individuals to attend meetings. I have to agree that mandating treatment of any sort is questionable in its effectiveness. Like the old saying goes, “Never teach a pig to sing; it annoys the pig and frustrates the teacher.” That said, there is something to be said for mandating attending “X” meetings. This is not mandated treatment as much as mandated window shopping. Any first-year psych major exposed to Bandura’s Social Learning Theory quickly can appreciate the significance of vicarious learning, which is exactly what happens when individuals attend meetings, even when mandated. For counselors to rail against the criminal justice system for its infringement on the civil rights of individuals mandated by the court to attend “X” meetings may be missing the point. 


AA and other 12-step fellowships are not treatment. First of all AA will never even discuss this as it is a violation of its tradition to remain silent on issues of politics, religion, etc. So mandating attendance to a specific number of meetings may be a hassle for the individual referred, may be perceived as having been made to “go to church,” or may simply be viewed as a waste of time, but we forget Bandura’s findings resulting from all that research in the 70s...you know what you learn and learn what you are taught...and life is a most effective teacher. And as with so many things, something new is only learned when something new is presented in such a way as to allow the observer to recognize that “the new” costs less and has fewer hassles than what was previously believed.


In my counseling career, I have told individuals, both those who voluntarily attend and those mandated to do so, to: (1) Go to a larger, open meeting, (2) arrive as the meeting is about to start, (3) sit in the back and do not say anything unless you want to, (4) leave when the meeting is over, and (5) do not just listen to the speaker but watch the other people at the meeting...what are they doing? Are they complaining or simply talking? Are they laughing or sitting sullen with their arms folded on their chest? Are they smiling or frowning? I suggest that we discuss what was seen and heard, but not just what the speaker or chair had to say, but what were the dynamics of the whole meeting they attended.


In summary, our issue as professional counselors is to determine what is best for the individuals with whom we work, but to do so in concert with their input. This means that what some may consider as controversial options, such as attending mutual aid groups as an adjunct to professional counseling, need to be considered and evaluated for appropriateness not based on their merits—they all have merits in their own right and these are clear for those who are actively involved—but based on what the individual with whom we are working wants to accomplish.

What do you think?

Dr. Robert

AA, Spirituality, Religion, and Professional Counseling: Part I

This is a topic of  importance and one that is appropriate for consideration at the start of a new academic year where the next generation of counselors—especially addiction counselors—will begin their education and training. That said, I suspect that commenting on this topic may result in a post more the length of an essay than a concise blog entry. I mention this so that readers can exercise the option to use the delete key—if you will pardon the pun—as this is why a Higher Power placed it on the keyboard…Bill Gates? Steve Job? J

A risk, I suspect, in discussing this topic is that it could be like trying to explain health care reform to your 90-year-old parents who consider Fox News and its pundits the only credible source of information on life in these United States; so be it…I love my parents dearly irrespective of their news retrieval habits and political bent.

So, concerning the question of the religiosity in 12-step recovery programs, my experience over the past 36 years as a professional counselor specializing in substance use disorders is that most of my colleagues who have voiced this concern have attended relatively few open 12-step meetings and many of those they may have attended were often the same meeting, meaning, a “particular” group on a particular day and time, attended by specific individuals where one or more indeed placed a distinctly religious spin on the “suggested steps” for recovery. As the old adage suggests, “You never get a 2^nd chance to make a 1^st impression.” If my understanding of 12-step programs had been influenced by such first-hand contact with 12-step programs or my understanding had come exclusively from what others have told me—addicted individuals who eschewed 12-step programs and/or colleagues who voiced concerns—then I too would risk engaging in what our field refers to as “confirmation bias” or the tendency to discount information inconsistent with a held belief while pointing to isolated examples of my belief as evidence of its veracity. Personally, I have been to hundreds of AA meetings in 36 years and have a larger sample on which to base my points in this post.

I do not doubt that some, both in the “addiction treatment industry” and in personal recovery, see “spirituality” and “religion” as all but synonymous, but this is neither universal in its acceptance in the counseling field nor supported in the literature of AA—I am not as familiar with the literature of NA, OA, or the other 12-step groups, so I will not make a blanket statement regarding “all” 12-step-oriented literature. I address this issue of the difference between spirituality and religion in an article I published some years ago (Chapman, R. J. [1996].  Spirituality in the treatment of alcoholism: A worldview approach.  Counseling and values, 41[411], 39-50 - see http://www.robertchapman.net/essays/spirit.pdf for a PDF of the article). Likewise, in my classes I use an unpublished essay I wrote that provides a “counselor’s perspective” on each of the 12-steps in AA when addressing 12-step programs in my Intro to Addictions course. As this is unpublished, I invite requests (Chapman.phd@gmail.com) for copies by those who may be interested.

The question regarding involving individuals in treatment for a substance use disorder in mutual aid groups such as AA needs to be based on more issues than the perceived religiosity of such programs by the counselor—either the counselor who refuses to refer or the counselor who insists on it. There are numerous reasons why a referral should be made as an adjunct to professional treatment even if the practitioner believes that there is too much God in 12-step programs—by the way, AA suggests that if the “G-word” is too upsetting, view it as an acronym – Good Orderly Direction. In an article entitled, Mutual support helps sustain treatment gains (see http://findings.org.uk/docs/nug_4_3.pdf), one study found that the irrespective of the philosophical tenets of mutual aid or self-help groups, the social support and networking alone is reason to consider such programs as an adjunct to professional treatment. In a conceptual article entitled, Self help: don't leave it to the patients (click title to read) “Keith Humphreys and colleagues report on a workgroup of US experts on substance abuse self-help organizations. Main conclusion: self-help groups are too valuable to leave to chance. They should be actively promoted and facilitated by treatment services and policymakers” (http://findings.org.uk).

My experience has been that many colleagues who have voiced concerns about the religiosity of 12-step programs have focused on this issue to the exclusion of other potential benefits that such referrals may proffer for individuals in early recovery. The concern voiced to justify avoiding such programs when developing service plans for individuals in treatment is that involvement in AA is to trade one addiction for another. Although most recovering people I have met have viewed their involvement in a 12-step program as being critical to their sustained recovery, they are quick to point out that one cannot hide in 12-step programs to the exclusion of responsibilities to family, job, or community. As a matter of facts the middle third of the 12-steps is about personal responsibility and obligation in these critical personal areas of one’s life and therefore recovery.

Another justification for avoiding 12-step program referrals espoused by some because of a concern for their perceived religiosity is the language of the 12-step and in AA literature. There is no denying that the language of 12-step literature is, by today’s standards, sexist and speaks of “most” referring to their Higher Power as “God.” This is, perhaps, one of the more legitimate arguments concerning this issue. Be that as it may, one needs to realize that this language was written in the late 1930s and 1940s and at a time when these words were the proverbial “coin of the realm.” We need to remember that “words” are but verbal symbols (when spoken), imbued with meaning by those who use them and by those who hear them. To assume a word’s meaning today when written 60+ years ago may not necessarily yield an accurate interpretation of the author(s)’ original intent. Like when my then 14-year old son took me to task for listening to the Drifters singing Under the Boardwalk in the early 90s as we rode in the car listening to the oldies station when they crooned about “making love” under the boardwalk—we had recently discussed my concern regarding the lyrics of the Heavy Metal music to which he listened—the socially constructed meaning of language can change…he heard a song about having sex when in the 1950s, “making love” meant so much more that the physical act of intercourse.

What I have found through the decades is that I can address potential concerns a “client’ may have by: (1) prepping individuals for what they will experience at 12-step meetings, (2) suggesting that “the words” they may hear/read are just that, words, and their meaning as regards change is not religious in nature, and (3) outlining how there is more to a 12-step group and its potential to aid in recovery than “the meetings” or “the steps” or the whatever. It is a package: Available 24/7…Presenting an opportunity to observe others who have learned a skill set that has served them well as regards making difficult changes…Presenting an opportunity to meet individuals who have similar social/cultural/athletic/political/’whatever” interests and yet, still do not use.

I do not agree with everything in the platform of the political party to which I am registered; I do not subscribe to all the teachings of the religion that I practice; I certainly do not agree with my parents and their views on “most things social and all things political,” but I nonetheless find all these to be critical to finding my way through the challenges of my contemporary living.

I have worked with individuals with substance use disorders for too many years to believe that there is anything like “the” way to recovery—as I learned when working on a reservation with Native Americans, “There are many paths to the same destination.” AA, NA, and the other “anonymous” fellowships have worked too well for too many for too long to be dismissed “out of hand” based on a single issue.

In closing, as I pen this post, I find myself thinking about the core ethical principles that Corey & Corey espoused in their ethics text ( Issues and Ethics in the helping professions, 7^th edition,) and that I share in my ethics course with undergraduate behavioral health counseling students: Autonomy, Nonmaleficence, Beneficence, Justice, Fidelity, and Veracity—especially Autonomy or the right for the client to make his or her own decision as to what course to follow ( p. 17 - 19). I realize that those who disagree with my arguments in this post can turn this closing point on me and suggest these are exactly the reasons they do not refer to 12-step programs, but, to paraphrase myself from above, I have seen too many individuals over the years not only get sober in AA, but find a serenity and quality of life that leads me to believe that while it may not be for everyone, it is certainly for many and who am I to decide who those “many” will be for whom AA (or other such fellowships) are a fit. I discuss 12-step programs with all clients; I mandate that all students in my addiction class attend a minimum of 2 meetings and write a critical essay on the experience; I invite members of the Cooperation with the Professional Community committee of AA to speak in my addiction class. My students will make up their own minds about the appropriateness of including 12-step programs in their approach to professional counseling, but this decision is made, hopefully, with first hand information plus my personal attempt to invite that their consideration be based on “the big picture” rather than their propensity towards “confirmation bias.”

 What do you think?

More on Willpower or, One’s ‘I Will’ is More Important than IQ.

A number of readers responded to my last post; some on the blog itself, others in a personal email. I suspect that we are fairly close in agreement, although the language we each use may differ. I agree there is a collection of behaviors labeled “willpower” in our culture. To this end, those who display these behaviors to some degree exist along a continuum of “dependence.” The point of my last post was to suggest the difference between one having mastered a set of behaviors, i.e., “skills,” and one having an inherent trait called “willpower.” Although both manifest themselves in the same way—the ability or inability to “resist temptation”—the impact of viewing willpower as a trait is that, like skin color, we humans tend to discriminate against individuals based on a socially constructed system of values.

If I view willpower as a skill or set of skills that I do not possess, then I understand my “inability to resist temptation” as a function of “knowledge” rather than a “character.” I may or may not be motivated to learn the requisite skills to change my behavior, but that is a choice I make and for which I am responsible. If, however, I view my inability to “resist temptation” as being indicative of a character defect, then I am left with no recourse but to continue on with no hope of changing behavior short of divine intervention. This is somewhat melodramatic, but change is an “inside job.” For one to first recognize and then attempt to do something about this, the individual first needs to engage in what I refer to as “possibility thinking.”

The old school view of willpower—even in AA, which suggests that willpower is not a solution for addiction—is that we individuals are capable of doing anything we put our minds to doing...the old “pull yourself up by the bootstraps” argument. Those who can do this, change, while those who cannot suffer. Interestingly, there is a cultural spin on this whole willpower thing too. The concept of willpower as a character trait is grounded in the Western belief in the primacy of individualism...a focus on “me” and “my” ability to do whatever I put “my” mind to doing, the “anyone can grow up to be president of the United States” argument. Interestingly, this cultural perspective is a relative minority as most of the world cultures relate to some extent to a collectivistic world view...the individual is NOT the building block of cultures and societies. Rather, one’s focus is on the family and community, with individual acts not so much asserting one’s inherent right to “be all that you can be” but rather, furthering the greater, common good. But I wax philosophical and this strays from the original point: willpower is a social construction and not an entity or character trait.

What I find interesting about AA—and one of its many endearing qualities—is that the steps suggest that I cannot manage change alone, but that any change made is nevertheless an inside job. This is another of the myriad paradoxes in 12-step programs/philosophy: To change, that is to say, “recover,” I must surrender to a power greater than myself, but in so doing, I find the ability to make personal changes that allow me to grow and develop. The willpower of 12-step philosophy is the power of commitment to change coupled with a realization that the change process necessitates the input and support of others, including a power greater than myself. Put another way, willpower in 12-step recovery—at least as I understand it—is better stated as “I will, power”—this is also why I believe that 12-step programs are so compatible with Cognitive-Behavioral Theory in that AA cautions against “stinkin’-thinkin’,” Beck exhorts challenging cognitive distortions, and Ellis admonished to refute irrational beliefs. These are all points along the same path to change.

Willpower only exists to the extent that one does not respond to temptation in a fashion deemed appropriate by the culture in which the individual exhibits his or her behavior. It is not like physical strength measured in “foot-pounds of torque” exerted or electrical units expended. Rather, recognition of willpower occurs after the fact and only then when an observer evaluates one’s behavior by comparing it to a predetermined, that is, social constructed hierarchy of “acceptable/unacceptable” behavior.

This is all “angels on the head of a pin” stuff except for the impact not having willpower has on one’s personal belief in an ability to change. My argument is that if I see this thing called willpower as being a set of skills, then if I do not have them, I can get them if I am willing to do what is necessary to develop said skills. On the other hand, if willpower is not a skill set, then I am fated to see myself as do others, personally “weak” and incapable affecting change.

Understanding Willpower: Urban Myth or Social Construct?

The amount of research associated with substance use disorders—a.k.a. “addiction,” “substance abuse,” “alcoholism,” etc.--is staggering; this is a good thing. Our understanding of this disorder seems to change almost monthly. From recognizing it as a biopsychosocial disorder to realizing that effective treatment necessitates a collaboration with the individual in treatment to affect change, it would seem that the 21st century will see prevention and treatment of this disorder advance at an even faster pace. Again, this is the good news...The less than good news, however, is that some remnants of the early days of the “addictions treatment industry” persistent; the advent of addiction being a function of an absence of willpower being a case in point.

“Willpower” is viewed as if its existence--or absence--is a discernable fact, something that can be measured and therefore quantified...he has no willpower, she has some willpower, etc. In other words, we act as though we can tell who “has it” and who does not simply by observing individual behavior. Those with willpower work hard in the face of adversity, overcome temptations, and remain faithful to goals and commitments while those without it are perceived as weak, unmotivated, untrustworthy, and unfortunately, lack the innate ability to see a task through to completion. But this supposed bedrock of Western character values neglects to recognize that “willpower” is not a “thing” but simply a word coined to describe a social construction we, as a culture, view as socially desirable and productive behavior. In short, one either has willpower or is devoid of it and depending on which side of that line in the dirt one stands, so is that individual’s worth as an individual determined by others.

If this were true, however, we should see this same absence of willpower when it comes to an individual following through with any behavior? For example, if I cannot seem to “stop smoking” because of my absence of willpower, I should also be incapable of remaining monogamous in my relationship with my spouse, correct? Yet there are countless example of individuals who have difficulty making certain changes in behavior attributed to a lack of willpower who are highly successful in making changes in other areas of their lives, often with relative ease...the former cigarette smoker who cannot seem to follow through with efforts to increase physical exercise or the individual who has successfully negotiated 12 challenging years of college and medical school to become a physician yet is unable to shed 15-pounds.

Willpower appears to be “situational” not because it is something tangible that one either has or does not, but rather it is a skill—or more correctly, a set of skills—that enable one to act in a particular way in a given situation. In those situations where this skill set is present...I have the requisite “willpower” to affect change; where the skills are absent, so is the “willpower." These life skills are learned, intentionally or coincidentally as I live my life, in the same way all life skills are acquired, the result of choices made and consequences realized.

All behavior is preceded by an antecedent, that is, something that comes immediately before the behavior is displayed...the “itch before the scratch.” Likewise, all behavior is followed by a consequence...the relief I feel after having scratched said itch. The consequence can be pleasant and therefore desirable or it can be unpleasant andtherefore undesirable...it must be one or the other.  is this “A – B – C” continuum that explains the acquisition of various skills, be they socially desirable or not. It is also attending to this continuum that enables one to understand behavior and, consequently, affect changes in that behavior—even changes in one’s own behavior—by understanding this simple equation and its impact on “why I do the things I do.”

This particular post does not present the time nor space to thoroughly explore this simple fact, so suffice it to say that I tend to repeat those behaviors that tend to result in a desirable consequence. An excellent book on the topic of self-directed change is, Self-Directed Behavior, 9th edition, by Watson & Tharp (Wadsworth Cengage Learning – see http://amzn.to/ajyv3L to read reviews at Amazon). The problem is that if I do not step back and look at the big picture, I may not recognize that the reinforcing consequence I am realizing are actually denying me the opportunity to perfect a skill that can change the behavior that I continue to repeat in spite of my wishes to the contrary. Allow me to explain with an example.

I want to lose 10 pounds. I know I have to eat less and exercise more to accomplish this objective. However, when I attempt to eat less I am overcome by the compulsion to eat. I tell myself that I cannot bear this discomfort, and dwell on how I will never be able to repeatedly resist this craving and tell myself this over and over until I give in and eat. When I eat, I feel better and even though I know that I caved and broke my vow, the consequence that followed my eating behavior is that I feel satiated. The “A” is the craving (or the stress or the depression or the “whatever”); the “B” is my eating, and the “C” is feeling satiated—or the passing of the craving, assuaging the stress/depression. Society looks at me and thinks, “Robert has no willpower” and it is a very short distance from that belief to being pitied or viewed as a weak an ineffectual person.

On the other hand, what if when I feel the urge to eat (or the stress, depression, “whatever”) that is the antecedent to my eating, and I was to engage in a different behavior? What if I “changed the ‘B’” and went for a walk or spoke with a friend or “did something else”? As I became distracted and the craving passed/depression/stress were assuaged, the consequence for this behavior would increase the likelihood that I would have learned a competing skill, one that would enable me to avoid eating, exercise more, and eventually drop the 10-pounds and keep it off.

So I end this post as I began...suggesting that there is no such thing as “willpower”; rather it is a social construction created to simply explain socially desirable behavior. The problem is that we have accepted that this social construction is a measurable personality trait. The problem with this is that if I buy into this belief personally and define myself as someone with little or no willpower, I unnecessarily stack the deck against myself when it comes to identifying the role I can play in making desired changes in my personal behavior. This is not to suggest that I can “do whatever I put my mind to alone” or that addicted individuals can “learn to use responsibly.” It does suggest, however, that diffiulty in making personal changes in behavior is less the function of personal weakness or a lack of so-called willpower than it has to do with an absence of a particular skill set necessary to make the desired change.

What do you think?
Dr. Robert