The Power of Presence:

Self-Involving Statements in Therapeutic Relationships

 

 

While corresponding with a former student who is in her first professional position post-bachelor's degree, the topic of using self-disclosure came up. Although discussed in classes, the issue took on greater significance for the student, given her recovery from a substance use disorder, her position in a SUD treatment program, and her recent experience with a client. I thought sharing the gist of this correspondence as a post might interest followers of this blog.

 

 

Congratulations on the offer to go full-time. Such an offer speaks to both the quality of your work as a practitioner and your value to the program as a team member; I am not surprised. My experience has always been that as individuals with substance use disorders recover, they do not just get well; they get really, REALLY well :) Over the years, as I have come to watch those individuals who find recovery in 12-step programs, some of whom seem to thrive and truly blossom, I have come to realize that people with addictive disorders tend to be among the more sensitive and, therefore empathetic people I have met—when using, that was a big part of the problem. As you know, this is not, in and of itself, sufficient to make an effective counselor. Still, when harnessed, in tandem with training and education in counseling technique and practice, these individuals can mature into, to quote folks of your generation, 'awesome' practitioners. I do not doubt that you have the potential to be one of them.

 

Your comment about the young gentleman who seems to have confided in you when learning that you have "walked the walk" is not uncommon. The challenge for you as a professional contemplating the use of this type of disclosure, however, is to be sure you know (1) why you are self-disclosing and for what purpose and (2) realize that for self-disclosure to enhance the counseling relationship and benefit the client, it is essential to ensure its use benefits the client and not the counselor. For this reason, it is generally a good idea to self-disclose "later" rather than "sooner" in the counseling relationship, perhaps as the response to a client's inquiry if you are in recovery, having watched you and come to suspect you may be by your actions rather than wearing it like a badge of honor. As the old saying goes, let your actions speak for you. When you "act like" a recovering person, people will notice, and one "acts like" a recovering person by doing what they need to do to stay clean and sober "one day at a time." As the slogan in the program suggests, "do the next right thing."

 

Remember from our classes the difference between self-involving and self-disclosing statements a counselor can make. Both can convey a personal connection and allow the client to relate more easily to the counselor. The self-disclosing statement, however, necessitates having to place the focus on you to enter the client's space and demonstrate the ability to connect. The self-involving statement, however, maintains the focus on the client and allows the counselor to meet the client personally and demonstrate the ability to empathize. A self-disclosing statement is something like, "I know what you mean because, in my early recovery, I felt alone and afraid most of the time too." Notice all the "I" statements...the focus is on the counselor, not the client. 

 

 

The self-involving statement goes, "You seem to be struggling with the fear that feeling isolated and alone tends to create - (this is an empathic reflection, as you learned in class). Your willingness to share this with me in our session and accept my suggestion to take it to the group shows the progress you have made in your recovery. 6-weeks ago, you would have just said 'screw it' and got high; today, you shared it with me and are ready to work on it; I am proud of you" - (this is the heart of the self-involving part of the statement).

 

Remember, 'you do best what you do most.' The more you do what you learned in school and continue to learn on the job and in supervision, the better you will become at doing it. You are a better counselor today, 'student's name,' than you were yesterday, and nowhere near the counselor you will become tomorrow :) Your progress is evident, and I have full confidence in your potential.

 

 

Self-disclosure is easy and seems like an effective way to help someone feel comfortable and trusting, but it can be a double-edged sword. Although you may intend it as a means of connecting with your client, they may take it as you implying how they should address their problem. It is better to engage the client by entering their experience, as a parent might do with a young child, than by expecting them to join yours.

What do you think?


Dr. Robert

1. What Causes a Problem Is a Problem if It Causes a Problem

With the publicity surrounding the recent publication of the ASAM (American Society of Addiction Medicine) update on the definition of addiction, it is likely useful to review some of the “indicators of a problem” to which non-professionals can better relate and therefore more quickly use to recognize a problem with substance use. First a quick review of the new ASAM definition:

Short Definition of Addiction: Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. To review this in more detail, visit http://www.asam.org/DefinitionofAddiction-LongVersion.html

As precise as this definition is for professionals, my experience when working with individuals in earlier stages of readiness to change their drinking and other drug use has been that such definitions present easy targets for those looking to deny their problem. Because defining addiction for professionals and for “consumers” can yield wildly different responses, this post will focus creating a “short list” of indicators that may suggest one’s use is not so much use as it is reason for concern.

In no specific order, here is a short list of indicators. Having but one of these does not necessarily suggest a problem, but as the number of indicators increases, so does the likelihood that one’s use is problematic if not indicative of addiction:

1. “What causes a problem is a problem if it causes a problem.” This ‘bumper-sticker’ wisdom comes from a well know lecturer in the alcoholism field, Fr. Joseph Martin. What it means is, if I am wondering if my substance use is becoming a problem for me or if I wonder if my significant other’s use is becoming a problem, guess what...it is becoming a problem.
2. Increasing time spent thinking about using, planning to use, or finding the economic means to support that use. For the professional this suggests “compulsion”; for the consumer it is rationalized as “preoccupation with an enjoyable activity.”
3. Similar to #2, my use has become an increasingly important determinant of how I budget my time. For example, previously enjoyed or favored past times are bypassed to make time to use. Drinks with friends rather than ball games with kids; smoking-up in the basement rather than watching TV with the family;
4. Protecting the supply. Although most people have some beer, wine and/or spirits in the house they do not have “cases” of their favorite beverage stockpiled. NOTE: The well stocked wine cellar does not necessarily mean the “oenophilist” or connoisseur of fine wines has a drinking problem. Related to this is the need to use more to gain the desired effect...which increases the importance of protecting the supply.
5. Changes in the people with whom I use. To change the people I socialize with and/or the places I socialize in in order to accommodate changes in my use pattern can foreshadow a movement towards a problem. To spend less time with John and Mary who go home after 2 in order to hang with Bill and Flo who “really know how to party,” signals a change worth noting.
6. A shift from 2 beers/sours on Fridays to 3 or 4 shots and beers “a couple nights a week” warrants consideration. Likewise, when “splitting a bowl” a couple times a month morphs into finishing a blunt a couple times a week, or Tylenol-III 2X/day for 3 days becomes Oxycodone PRN.
   

These indicators are more environmental or behavioral; personal indicators include:

1. Minimizing reported use or using secretively. Social users have too much and say, “Boy, did I over do it last night; I’m going to have to be more careful in the future.” The problem user says nothing about the overdose and deftly changes the subject if someone brings it up.
2. When considering how to budget money or time, use moves from being a “want” to becoming a “need”; from being a luxury to a necessity.
3. Changing other factors in my life in order to accommodate the use...I eat less so I can drink more (concern about weight); I switch from “good stuff I like” to “less good stuff I can afford” to consume more on the same budget; spending less on clothes or entertainment to accommodate expanded patterns of use.
4. Becoming a different person when using or the “Dr. Jekyll (the accomplished, “nice guy when sober”) / Mr. Hyde (“bestial” ghoul when using) syndrome – young kids are particularly adept at both noting this and commenting on it.
5. Sincere pledges, to self or others, regarding change are easily overturned. NOTE: The true mark of control is not saying “no” to “a” drink or drug—anyone can do this; it is saying “no” to a drink or drug I want.
6. A questionable ability to predict when I will next use and/or once starting, when I will stop.
   

There are numerous screening check lists and indicators available online (for example, see http://www.ncadd.org/). Likewise, any bookstore has numerous publications in the “self-help” section. Some are good, others, not so much. Irrespective of what you read, hear, or listen to, the bottom line regarding one’s use is, what do I tell myself? This reflects back to the first item on the first list noted above: What causes a problem is a problem if it causes a problem.

Substance use disorders are bona fide health care issues, a brain disease if you will. We have stigmatized these disorders in our culture and these stigmas have prevented individuals from recognizing that something is amiss until what was amiss becomes “a mess.” If you think something is amiss regarding your pattern of use, speak with someone who can help you step back, revisit the facts in your life, and consider an objective albeit candid new perspective from which to view these facts.

What do you think?

Dr. Robert

Can a Significant Other Provide Therapy to The Other?                                                   

Not being an ethicist I cannot speak to this question with any authority. I can, however, reflect on it as it does raise at least one intriguing clinical issue: Is it possible for a former “significant," that is to suggest intimate, "other” to be viewed objectively by either the practitioner or the client or one seeking therapy? If the answer is yes, it is feasible, does this possibility assume this objectivity is simultaneous for both parties, that is to say that both parties will be equally objective and detached from the previous relationship at the moment of their reintroduction as practitioner and client? If the answer remains yes, does this necessitate a quantifiable period of time between one’s status as significant other and becoming either practitioner or client in order for this objectivity to be realized? Assuming the answer to all these question continues to be yes and that objectivity is indeed possible, are there other implications raised by the fact that one or both parties have specific intimate knowledge regarding the other that may impact judgment as regards treatment planning and/or follow-through irrespective of objectivity? 

Just as the admiral and captain on a naval flagship dine separately from each other as well as from the crew at large—they literally dine alone so as to discourage the development of close friendships and emotional ties that could affect personal judgment regarding command decisions that necessitate the sending of one's subordinates into harm’s way—can a practitioner every truly detach him or herself from “what once was” in order to thoroughly engage in the pursuit of “what might become”?

Please know that I do not doubt the sincerity of my colleagues who suggest seeing former significant other's professionally is possible and I recognize that the vast majority of us would never intentionally jeopardize the clinical outcome of work with a client if thinking that previous knowledge of said client could result in providing subjective treatment, but we all know what we have learned and learned what we were taught, be it in the classroom, home, or previous intimate relationships. AA has a saying that is somewhat apropos here: You can always turn a cucumber into a pickle, but you can never change a pickle back into a cucumber. Albeit a bit folksy, it is nonetheless a poignant statement that speaks to the clinical issues raised in my initial ethical question: If I had been your lover, could you ever see me as other than that former lover? I am not sure I could see you as otherwise.


What do you think?
Dr.Robert

Towards an Eclectic Theory of Counseling

Counselor Educators have discussed and debated the role of theory in professional counseling since, "forever." Generally the discussion includes references to the importance of being grounded in theory so that the practitioner is "doing counseling" instead of "chatting up" an acquaintance. To this end, understanding theory and using it to center oneself as a counseling professional is productive. However, when theory becomes the issue of primacy for the practitioner, everything else tends to follow...including the services the client/patient/individual receives from the counselor. Hence, the importance of identifying a theory of eclecticism or and integrated approach to counseling that recognizes the importance of theory-drive practice, but is nonetheless sensitive to the needs of the individual with whom the counselor is working.


I have found Prochaska’s Transtheoretical Model of Counseling (sometimes referred to as the "stages of readiness to change" model - see http://www.aafp.org/afp/20000301/1409.html) to be the closest thing I have yet found to a bona fide “eclectic theory” of counseling. Its refocusing of the practitioner’s attention on the client by attending to his or her stage of readiness to change rather than presuming the primacy of the practitioner’s theoretical orientation is both refreshing as well as productive.

I agree that it is important to teach counseling theory as a “walk through the museum,” but the benefit of such a course is not that it shows student “how” to do counseling effectively so much as proffer an understanding of from “where” it originated. Personally, I have discovered that I need to have three things in order to “do” counseling effectively: (1) an understanding of why humans think and act the way we do – Personality Theory, (2) an understanding of the options available to me to do counseling – Counseling Theory, and (3) a personal “bag of tricks” born of training, experience, mentoring, etc. Whether one’s personal approach to counseling is a more fundamentalist’s adherence to “X” theory or integrated and eclectic personal approach, my argument is, one’s personal theory of counseling is essentially an amalgam of these three elements.

Prochaska’s model, for me, is a nice way to both honor the contributions of “theorists of yester year” while providing me the opportunity to practice “person-first” approaches that focus on meeting the client/patient/consumer where he or she is in the counseling process. If counseling is more about what we do with the individuals with whom we work than what we do to them, it seems that theory may well be an important component in the design of an effective vehicle to move folks from where they are to where they want to be, but it likely should not be “driving the bus.”


What do you think?


Dr. Robert

Inviting Organizational Change: Lessons from Counseling Individuals

As challenging as it may be to motivate an individual to consider changing a personal behavior, inviting an organization to move towards change can be even more daunting. To motivate a clinical staff steeped in traditional addictions counseling techniques or what William Miller refers to as attack therapy can cause any supervising counselor or clinical director to age prematurely.


First, the literature seems to suggest that the process of change for an organization is similar to that followed by an individual. This means that the organization will need to pass through the stages or readiness just as an individual does. What is a bit more complex when contemplating change in an organization made up of individuals, however, is that different individuals in the organization will likely be at different stages of readiness to change. You will therefore need to target these different segments or "changers" of your organization separately. Depending on the size of the organization with which you are working, this may already have been done for you. If so, this enables you to move directly to designing interventions based on the mean stage of readiness to change in your target group or the segment of the organization with which you will be doing the training--more on this in a moment.

If, however, you are not sure of the stage of readiness to change in your target group, you may want to do a bit of assessment first, preferably prior to engaging your audience in any particular activities. You may find one of the SORtC (stages of readiness to change) tools to be useful, for example, see the SOCRATES or Stages of Change Readiness and Treatment Eagerness Scale (see http://casaa.unm.edu/inst/SOCRATESv8.pdf). Once you have a sense of which segments of the organization are at what stage of readiness to change, you can then tailor your interventions based on the SOCtC. To get a sense of “which” interventions work best with “what” stage of RTC, visit http://bit.ly/mIQ6mL

Matching the “process of change” to the “stage of readiness” is very important given the task of facilitating change, be that when working with an individual or a group. If your target audience is in an earlier stages of RTC, then you are going to want to focus on consciousness raising, increasing awareness, social support, and related activities to move the audience toward an “ah ha” moment or epiphany. This can be done in a relatively short amount of time, but senior management or administration will need to understand your objective and more to the point, “why” you are doing it. Remember, managers tend to be more interested in “pushing” subordinates towards the change they believe needs to be made than “leading” employees towards personal growth and corporate development. 

When attempting to motivate individuals to change remember a few simply--although not necessarily easy to implement--steps:

1. Although you may be able to lead a horse to water, but you cannot make it drink...you CAN salt the oats
2. It is easier to motivate employees to move toward what they discover they want than away from what management no longer wish them to do
3. Change happens in stages. The objective of change is to move from their current stage to the next stage on the continuum, not the last stage
4. As William Miller suggests, when considering motivating individuals to change you have two choices of how to proceed: you can wrestle with them or you can dance with them...Dancing with the Stars is always more productive than WW Smack Down
5. Remember Sandra Anice Barnes' line from Life is the Way It Is, "It is so hard when I have to, and so easy when I want to." Our task as agents of change is to invite individuals to "want to."

What do you think?

Dr. Robert

Collegiate Policies on Drugs Other than Alcohol

Is it important that policies in higher ed that address "alcohol" and "other drugs" like marijuana be consistent and equitable?  Although controversial in some ways, this is essentially an issue related to equity, consistent enforcement of policies, and—perhaps most of all—money.

A bit of history: A point I have advocated for 40+ years is that alcohol is indeed a drug and should be treated as such.  The problem is that this is a position, however, that the alcohol industry has invested hundreds of millions of dollars in successfully discouraging—watch any super bowl beer advertisement.  Because alcohol “is legal” (for those 21+) it has been relegated to a different position in the panoply of drugs than most others and this is no better exemplified than by its absence (along with nicotine and caffeine, which make up the “unholy trinity” of most abused drugs that constitute the most costly in terms of untoward consequences—health costs, domestic violence, litigation, etc.) from the federal government’s schedule of drugs – see http://www.justice.gov/dea/pubs/scheduling.html

With all the models that explain drug use and addiction, public policy in this country—and this trickles down to the state, local and even campus policy makers—continues to be driven by the Moral Model of addiction postulated since time immemorial.  Interestingly, there are two versions of this model, the “dry” moral model and the “wet” (this goes back to the later 19^th and early 20^th centuries and prohibition).  The “dry” moral model suggests that the drug itself is evil/bad and therefore those who use it are, by association, “bad” as well and should be punished for their transgression of use.  This is the model that prevails to this day as regard “real drugs,” that is to say, the illicit substances.  The “wet” moral model is the model that suggests the drug is not in and of itself bad, but when not used correctly—this by the way is a social construction, but I will refer to this in a moment—problems result.  This model advocates that substance use disorders are the result of weak willed individuals whose moral fiber is lacking.  In essence the substance is ok, but those who cannot manage it are not.  These unfortunates should be pitied and, marginally, better tolerated than those who use illicit substances, but they remain social if not moral outcasts.  This model is still well ensconced in our society as regards alcohol.

A second factor tends to affects public policy and treat alcohol-related violations/behavior differently from “real drug” use; litigation and public opinion.  Higher education, if nothing else, is a business.  As such, consideration of the bottom line is always a factor in decisions regarding policy and procedures and this is nowhere better seen than as regards drug use.  As regards the issue of drugs, that is “real drugs,” whether it is federal student loan policies that penalize applicants with drug arrests, federal guidelines regards receipt and administration of grants, pressure from parents and alumni, or simply the personal attitudes, values, and beliefs of benefactors who decide where and to whom to bequeath huge donations, the pressure is on senior administrators to take a hard line on drugs, to “play to the audience” if you will.

My comments so far shed just a bit of light on why things are the way they are…there is much more history here, but such is not necessary to make my point.  What is of more pressing concern is “what can be done” in the face of this history to affect public policy on campus and do so in such a way as to (1) not leave a trail of damaged student reputations that can jeopardize future opportunities, licenses, or careers in its wake and/or (2) appear to be pandering to “druggies” or those who “advocate for the complete legalization of all drugs.” NOTE: Decriminalization is one way that many municipalities have taken to extricate themselves from this issue.  In the City of Philadelphia, the DA has essentially said that marijuana changes involving less than 30 grams of weed will be treated as a summary offense with a $300 fine; no criminal record.  Although do to reduce the burden on the courts rather than for more altruistic reasons, “6 of one, a half dozen of the other.”

AFFECTING PUBLIC POLICY IN HIGHER ED

First, I would recommend NOT lecturing on what addiction is or how it should be treated.  To begin with, this is not the issue as most students are not addicted or even “diagnosable” as having a substance use disorder—the vast majority of cases involving alcohol or marijuana cases on a college campus have less to do with addiction than they have to do with poor judgment or a socially constructed understanding of alcohol/other drugs as substances or their use as a behavior—see my 3-part monograph on this topic entitled, When they drink, available at http://robertchapman.net/essays.htm.  Second, senior administrators are not going to read a long treatise attached to a memo advocating more equitable public policy regarding drug use.

Second, the bottom line is a factor affecting the formation of public policy in higher ed.  Consequently, use the bottom line as a factor in advocating for more equitable policies that are less draconian and more proactive.  Case in point: If students found holding “X” amount of marijuana suspended for 2 terms are not paying tuition this represents a loss of roughly $25K to the institution…not to mention that I believe there are data that show a significant portion of these students do not return to the school that suspended them.

Third, argue that punishment has never been an effective deterrent to perceived/actual errant behavior whereas education is.  Just as there are effective strategies to engage high-risk and dangerous collegiate drinking in such a way as to invite drinker consideration of change (Brief Alcohol Screening and Intervention for College Students, AKA BASICS), so can these approaches be applied to other drug use, such as marijuana.  NOTE: There is a difference between the student found holding several grams of weed and a half kilo.

Fourth, leave existing policies in place but present students found in violation of said policy with a choice as regards the consequences that result from that violation.  For example, students found with less than “X” marijuana will automatically get “X,” “Y,” and “Z” sanctions, but instead of a 2 term suspension from the institution they get a choice between that 2-term suspension or the opportunity to participate in a specially designed psychoeducational program steeped in evidence-based approaches to changing student behavior.  NOTE: First question you get when raising this issue with senior administrators is, “How are we going to pay for this?!?” ANSWER: With the $25K (or some portion of it) you would have lost by suspending the student.

Obviously, there is far more to this discussion that what I have written here, but suffice it to say that this sets out a couple arguable points.

In closing, keep in mind a couple “cultural” issues that have a HUGE impact on this discussion and debate:

1. Academics and Student Affairs professionals are as different from each other culturally as are Americans and Russians.  We may both be predominantly Caucasians, but our world views are very different.

2. Higher education is NOT just about education at the upper levels of administration; it is about business too…perhaps predominantly.  Yes, everyone talks about education and we are steeped in the traditions of such, but remember that higher ed is first and foremost a business.  Therefore this discussion needs to be conducted in the language of business.

3. Perception is everything.  21^st century America is a myopic culture.  We do not see the big picture; we are all about quick fixes and the “do-not-upset-my-standard-of-living” perspectives…look at global warming, social security, federal deficit, etc.  Parents, alums, benefactors are emotional creatures, not rational ones.  They “see” a reasoned response to “drug use” and they “think” the institution is “soft on drugs.”  

The outcome of this debate is NOT going to swing on a hinge of logic; it will pivot on one of reason as vetted by those in the positions of power.  Best to educate those in that position with the logic and reason translated into the language they speak.

What do you think?

Dr. Robert

Spontaneous Remission or Quantum Change in Addictive Behavior

Although most of the literature on addiction and recovery from substance use disorders (SUD) is focused on various paths to change, we invariably hear about "spontaneous remission" or individuals who "just woke up one morning and lived their lives differently." 

Anyone working in the filed of addictions will frequently encounter stories of such change. Although some are likely due to individuals who had not progressed beyond what the DSM IV refers to as "abuse" status, meaning that the individual had yet to become dependent or "addicted," some clearly had.

To learn more on this topic I recommend Miller & C’de Baca, Quantum Change: When Epiphanies and Sudden Insights Transform Ordinary Lives, Guilford Publications, 2001, 205 pp. For an excellent summary with considerable insight given this discussion, read George Valliant’s review at http://ajp.psychiatryonline.org/cgi/content/full/159/9/1620

To whet your appetite and possible pique your curiosity about exploring further, here is one interesting quote from Valliant’s review:

Each of their book’s case histories, chosen from several dozen quantum change experiences, share many but not all of the following characteristics: ineffability, revelation, transience of the original experience (although the effects last for decades), passivity, unity with the cosmos, transcendence, awe, joy-love-peace, and distinctiveness. Such epiphanies and spiritual insights, of course, are common after mind-altering drugs, evangelical religious conversion, and temporal lobe seizures.

If I have learned anything during 40-years working with individuals with SUDs, especially alcoholism, it is that one can never doubt the power to change or the unlikely source of assistance that can facilitate such.

What do you think?

Dr. Robert

College student binge drinking and the "prevention paradox": Implications for prevention and harm reduction Weitzman ER, Nelson TF  Journal of Drug Education. 2004;34(3):247-266. Abstract (quoted from Harvard's College Alcohol Study page)

Considerable attention has been paid to heavy episodic or "binge" drinking among college youth in the United States. Despite widespread use, the binge measure is perceived by some as a low intervention threshold. We use data from the Harvard School of Public Health College Alcohol Study (n = 49,163) to describe patterns of consumption and harms along a continuum including the binge measure to demonstrate the validity of the binge threshold and prevention paradox in college. While the heaviest drinkers are at greatest risk for harm, they are relatively few and generate proportionately small amounts of all drinking-harms. The risk of harms is not zero among lower level drinkers in college. Because they are numerous, they account for the majority of harms. This paradoxical pattern suggests we moderate consumption among the majority using environmental approaches, the efficacy of which are described using case study data from a national prevention demonstration. Implications for prevention policy, programming, and media advocacy are discussed.

Click article to read entire study

This article, although somewhat dated, is (tangentially) related to my recent position (see last 2 posts) regarding the next frontier on which prevention professionals may wish to focus their attention; the moderate drinker. Although I have been arguing this point from a more qualitative position, namely, lets attempt to access the perspectives of contemporary "moderately drinking collegians" to learn what impacts their decisions regarding use, this information can inform prevention efforts to moderate student drinking and reduce the untoward incidents associated with episodic high-risk consumption.

Consider a “pincer movement” of sorts as regards attempts to change the campus culture regarding alcohol and drinking. Each front in such a movement approaches the objective of change from a different perspective. First, investigation of student perspectives regarding alcohol use, in particular the perspectives of those students who are moderate in their consumption or abstain altogether--see my previous two posts for more on this. Doing so will enable prevention specialists to learn more about those variable/factors that affect moderate consumption and do so by interviewing and observing those students already doing what preventionists advocate. At the same these perspectives are being obtained, activate the second prong of the pincer; pursue the reduction of episodic high-risk consumption via the use of environmental management strategies.

Such an approach would not "move away from" addressing the needs or behaviors of the frequent "binge drinker," but it would acknowledge that there is more to be learned about collegiate drinking than can be learned from only those who constitute the minority of contemporary collegians. To exclusively focus on the frequently "binge drinking" student when considering prevention is to react to the problem rather than act on the pursuit of a solution. 

What do you think?

Dr. Robert

Despite Efforts Over the Years, Heavy Drinking Among Students Remains Steady

The Chronicle of Higher Education, March 29

Campus efforts to raise students' understanding of the hazards of alcohol abuse ramped up through the 1980s and have since tapered off. Nonetheless, the incidence of heavy drinking among students has remained relatively steady—and a cause for concern—for the past three decades, said a speaker at the annual conference of ACPA—College Student Educators International.

Link to story

This is a continuation of thoughts noted in my previous post

Collegiate drinking is nothing if not a perennial problem and has been since Harvard opened “Butteries” in the 18^th century J Interestingly, the reason that collegiate drinking rates wax and wane, often in sync with available funding to address “problem collegiate drinking” is because we focus on the problem primarily and to a much lesser degree, on the solution.

Interestingly, when we do look at the “solution” it is the solution to the collegiate drinking problem—and we have made substantial headway in this area over the past 20 years…environmental management, social norms, social marketing, BASICS, etc. The issue is that these strategies continue to focus on the minority of students associated directly with the problems cause by collegiate drinkers, that is the “binge drinkers.” What we to this point have never addressed is a consideration of the solution as to how to motivate the majority of college students who are moderate in their drinking if not abstainers to become more proactive in their interactions with peers. In short, how do we learn why moderate drinkers and abstainers approach alcohol and drinking as they do so as to support and/or advance those student characteristics…to move towards what we want rather than always try and avoid/stop if not flee what we do not want. Instead of talking about collegiate drinking in the positive/proactive way, that is, why is moderation the norm for drinkers and/or why do abstainers abstain, all our attention goes to the “problem.” It is like asking someone, continually, for decades, to “not think about pink elephants with purple spots!....guess what they are thinking about?

The classic example of what I am suggesting is the shift in social norms regarding cigarette smoking. EVERYWHERE you went in the early 60s had ash trays and often matches. Good hosts and hostesses even offered guests cigarettes—you can even see the armrest ashtrays on older planes! 50 years later—and this is the key to this change 50 year—not only is this not the case, people cannot smoke in most public spaces and must stand a minimum distance from the main entrances to such buildings if they do choose to smoke.

Such changes take time as do any time we set out to change the culture in a demonstrable way. To change the way alcohol and drinking are viewed in higher ed is no small task and will take years if not decades, but we are not a patient field and lose interest and motivation to “do something” soon after the soft state or federal money disappears.

I can go on and on about this…you can read “a little more” about this in my previous post or you can read “a lot more” in the 2^nd and 3^rd volumes of my monograph series, “When They Drink” – see http://robertchapman.net/essays.htm

Dr. robert

Activities Key to Cutting College Binge Drinking

Drops in binge and “problem” drinking among college students are being attributed to more late-night and alcohol-free activities being offered regularly. Although some argue that these activities will only attract non-drinkers or light drinkers, higher-education officials believe that it is important to support that crowd as well, because in the absence of those activities, they will likely become drinkers, too. http://bit.ly/gRFlwq

This item, which comes from the latest edition of The Network's newsletter, News from the Front (March 2011 - http://thenetwork.ws/?page_id=305), is interesting in and of itself, but particularly provocative is its last statement referring to the need for colleges and universities to address the needs of their non-drinking or moderate drinking students in their alcohol-related programming. I take this statement one step farther and suggest that these students may be an untapped resource that can be helpful in addressing the quest to change campus culture as regards the role that alcohol as a substance and drinking as a behavior play in contemporary collegiate life.

It seems that whenever we hear about collegiate drinking it is either a report on the latest travesty resulting from some student’s drunken comportment—invariably courtesy of the popular media--or research article and clinical report related to high-risk collegiate drinking. Yet we know from study after study that most collegians are moderate in their consumption of alcohol if they drink at all--about 20% of college students nationally chose not to drink last year. Access to information about collegiate drinking tends to set up what social psychologists call “confirmation bias” or the tendency to look for evidence that supports a belief one already holds while overlooking or discounting evidence to the contrary.

With better than half of all college students either moderate in their drinking or abstaining all together and better than another quarter reporting high-risk drinking (defined as having 5 or more drinks in a 2-hr period) no more than once in the previous 2-weeks, these media reports have suggested a problem that is exaggerated and therefore unnecessarily pessimistic .

This does not, of course, suggest that the high-risk and dangerous drinking of a quarter of contemporary collegians should be overlooked or is of little concern; it is indeed a problem and is among the most significant public health issues facing contemporary college students. It does suggest, however, that most students are moderate in their behavior and exercise more than a modicum of restraint when it comes to making personal choices about alcohol and drinking.

This would seem to suggest that an important resource in the quest to change the campus drinking culture has gone untapped or at the least, under utilized, namely, the moderate drinker and the abstainer. What is it that affects the choices these students make? Why are they moderate when they drink or what factors influence their decision to abstain altogether? And even if John Jones or Mary Brown does decide to “drink a belly full of beer” on a Friday night but that may be one of a few times that is done in a semester, what factors affect his or her decision to remain moderate if not abstain on other occasions when alcohol is available and drinking is the perceived norm for the immediate group with which he/she is socializing?

The next chapter in an already significant text on collegiate drinking is about to be written. In a series of monographs on the topic of collegiate drinking entitled When They Drink, I explore the issues of why students who do drink, drink in the way they do (see Monograph at http://robertchapman.net/essays.htm). Now we need to look at what we can learn from “the rest of the students,” namely those who are moderate in their consumption or abstain altogether. I suggest that we ask these students to tell us their stories and that we then learn from them what affects the choice they make to abstain or remain moderate in their consumption when they choose to drink.

Like the story of the Good Samaritan who stopped to help a older gentleman looking for his car keys under a street light, when asked where he lost his car keys the gentleman pointed down a dark alley to his right and said, “Down there.” The Good Samaritan, looking puzzled, ask, “Then why are you looking here if you lost them way over there?” The older gentleman, glancing up with a perplexed look on his face said, “Because the light is better here!”

Perhaps we need to look at the stories of those students who are already doing what we would like to see their high-risk peers doing…decreasing the frequency of drinking episodes and reducing the quantity of alcohol consumed per occasion when choosing to drink. The light shining on the moderate drinkers and abstainers is nowhere as bright as that shining on the "binge drinkers," but perhaps we need to look where the answers are for the burning questions we ask.

What do you think?

Dr. Robert

Matching Psychotherapy to the Patient/Client

(Copied verbatim from the Effectiveness Bank alerts from Drug and Alcohol Findings).

This bulletin is devoted to reports from a high-level task force convened by the American Psychological Association to identify effective psychotherapy relationships and ways to adapt therapy to characteristics of patients other than their diagnosis, such as their personalities or cultural backgrounds. The task force commissioned reviews synthesising research on promising ways to match therapeutic approaches to different types of patients, which were published in a special issue (2011, volume 67, issue 2) of the Journal of Clinical Psychology. These reviews and the introductory article are listed below. While not specific to drug or alcohol problems, many of the studies included in the reviews concern these problems and a high proportion of drug or alcohol patients suffer from the mental health problems addressed by the other studies. The reviews offer comprehensive, evidence-based recommendations on how to maximise the benefits of psychosocial therapy.

To view entries click on a link or paste it in to your web browser address box, being sure to enter the whole address. This link:

http://findings.org.uk/count/downloads/download.php?file=bulletins/CAB_11_03_11.php

takes you to the bulletin as a whole. Links below take you to your chosen entry.

**************************************

WHAT WORKS FOR WHOM: TAILORING PSYCHOTHERAPY TO THE PERSON

Introduces the special issue of the Journal of Clinical Psychology and summarises the conclusions reached by the task force. Prime amongst these was that outcomes demonstrably improved when therapists appropriately adapted their approaches to the reactance/resistance, preferences, culture, and religion/spirituality of their clients.

http://findings.org.uk/count/downloads/download.php?file=Norcross_JC_5.cab

ADAPTING PSYCHOTHERAPY TO THE INDIVIDUAL PATIENT: STAGES OF CHANGE

Review concludes that the stages of change developed by Prochaska and DiClemente reliably predict how well psychotherapy patients will do, but no adequate studies have tested whether matching therapy to initial stage of change actually improves outcomes.

http://findings.org.uk/count/downloads/download.php?file=Norcross_JC_4.cab

ADAPTING PSYCHOTHERAPY TO THE INDIVIDUAL PATIENT: PREFERENCES

Review concludes that patients stay longer and do better if they get the type of therapy, type of therapist and type of therapeutic style they prefer.

http://findings.org.uk/count/downloads/download.php?file=Swift_JK_2.cab

ADAPTING PSYCHOTHERAPY TO THE INDIVIDUAL PATIENT: CULTURE

Review concludes that mental health services targeted to a specific cultural group were several times more effective than those for clients from a variety of backgrounds, and that more effective treatments had more cultural adaptations.

http://findings.org.uk/count/downloads/download.php?file=Smith_TB_2.cab

ADAPTING PSYCHOTHERAPY TO THE INDIVIDUAL PATIENT: COPING STYLE

Review concludes that externalising patients are best matched to psychotherapies focused on skill-building and symptom change, while those characterised by self-criticism and emotional avoidance benefit most from interpersonally focused and insight-oriented approaches.

http://findings.org.uk/count/downloads/download.php?file=Beutler_LE_3.cab

ADAPTING PSYCHOTHERAPY TO THE INDIVIDUAL PATIENT: EXPECTATIONS

Review concludes that patients who enter psychotherapy with positive expectations about outcomes tend actually to have better outcomes, suggesting that therapists should regularly assess expectations and take steps to enhance them if appropriate.

http://findings.org.uk/count/downloads/download.php?file=Constantino_M_1.cab

ADAPTING PSYCHOTHERAPY TO THE INDIVIDUAL PATIENT: ATTACHMENT STYLE

Review concludes that psychotherapy patients who feel secure in and easily form close and trusting intimate relationships have better outcomes, while the reverse is the case for those anxious about close relationships.

http://findings.org.uk/count/downloads/download.php?file=Levy_KN_1.cab

ADAPTING PSYCHOTHERAPY TO THE INDIVIDUAL PATIENT: RESISTANCE/REACTANCE LEVEL

Review concludes that patients who characteristically exhibit low levels of resistance to being led by others respond better to directive types of treatment, while patients prone to resist direction respond best to non-directive approaches.

http://findings.org.uk/count/downloads/download.php?file=Beutler_LE_2.cab

ADAPTING PSYCHOTHERAPY TO THE INDIVIDUAL PATIENT: RELIGION AND SPIRITUALITY

Review concludes that psychotherapy patients who identify with the religious or spiritual orientation of a therapy improve more than if untreated. Generally they also improve more than if treated with secular therapies, but not if these are equivalent in every other way to the religious/spiritual therapy.

http://findings.org.uk/count/downloads/download.php?file=Worthington_EL_1.cab

The Role of Technology in Training the Next Generation of Counselors

There are certainly “issues” associated with using avatars and virtual reality in the training of counselors, but the technology is both here to stay and likely to be applied to many professions, ours more than likely being on the short list.

Visit http://bit.ly/fSa5jb and watch this video on the next generation of Microsoft’s X-Box 360 Kinnect. Not only does Kinnect allow one to operate the controller through body motion; it is about to read and mimic facial expressions. This enables the avatar on screen to communicate with facial expressions much as we do in the ‘real world.” The potential to apply this technology to training counselors if not permitting individuals to be effective treated with counseling in virtual reality are provocative to say the least.

Although I have had serious concerns about “online counseling services” and online graduate programs in counseling including little or no residency requirement etc., the point remains that the technology is going to be applied to both the delivery of service and the preparation of and CEUs (continuing education units) for professional counselors. If this is to happen in a controlled fashion with the primacy of ethics and effectiveness clearly established, it is going to likely come as the result of the old guard (those currently delivering counseling services) working with the newbies (the next generation) who are tech savvy in order to bring about a judicious and efficacious blending of skill and technology. What is true today will remain true in the future as regards counseling...“it’s all about the client.”

Just as Rogers was criticized for bringing audio equipment into the counseling sanctuary in the 1950, video equipment was introduced in the late 60s and 70s, practicum students and interns were mandated to provide video tapes of sessions to be autopsied in class in the 80s, and all manner of computer software becoming not only ubiquitous in the counselor profession, but one standard by which effective practice standards are measured, this technological tide is flooding and as John Kennedy once quipped, “The rising tide lifts all the ships.”

I agree that the avatars in the Kinnect video are crude when compared to sitting in an actual session with a student, client, or group, but this is the next step in the development of this technology, not the last stop on the line. Avatars that can accurately replicate facial expressions represent nothing if not a quantum step forward in virtual reality. I agree that we need to be cautious and not rush to employ the technology simply because we can. By the same token, however, I suggest that those of us who know how to do what we do so well “with old technology” might be wise to consult with those who are ringing the bell technologically while still naïve regarding all the subtle nuances of the truly skilled counselor.

From bringing counseling services and/or education to individuals in rural areas miles from either opportunity to supplementing existing service menus in order to increase access to services for individuals with various obstacles that preclude “mainstream” counseling and/or training, I believe it appropriate for educators and clinicians alike to be cognizant of the future and what the technology holds in store for us lest we find ourselves being criticized in the not too distant future for being resistant to change in the same way we criticize some of our colleagues today who resist evidence-based treatment strategies, new medications, Motivational Interviewing, and Harm reduction, simply because “they are not the way we did it.”

I am not the spokesperson or advocate for the use of avatars and virtual reality as the primary vehicle for training counselors because I am not. I would, however, like to point out that there are issues here that we (the counseling field as a whole and not INCASE as an organization) best address lest they sneak up on us. Just as there has been a successful marriage between the “art” of counseling and the “science” of counseling, resulting in many of the best practices we presently incorporate into our academic programs and clinical practices, so should there be a collaboration between the “practice” of counseling and the “application” of technology as we look to the next generation of counselor education and service delivery.

A secondary issue worthy of consideration in this discussion is the role the “delivery system” plays in engaging the student in training or the client in practice. To refuse to consider adapting a technology that has been embraced by the likely next generation of counselors and their clients simply because we find it alien and representative of our fears that the miasma of virtual reality is restricting the development of essential interpersonal social skills is to ignore an essential point...the next generation of counselors and their likely client are in the process of if not already having embraced it.

Again, we should neither dismiss this technology out of hand as ineffective if not dangerous nor ignore it as inconsequential. Rather, we should be informing those who create and promote these technological advances in virtual reality to do so in such a way as to consistently ask the following questions:

1.      Because something can be done (technologically) should it be done? Some of us have already answered this question with a clear no; others, including myself, answer saying, “probably not, but that does not mean that something beneficial cannot come from exploring this issue.” NOTE: I am not proposing something akin to Neville Chamberlain’s attempt to appease German aggression in the late 30s—or as Churchill said, “feeding others to the alligator hoping to be the last one eaten” (pardon the paraphrasing)—but rather, a more evocative collaboration that more closely resembles brainstorming.

2.     Are there risks associated with making the synth world so attractive that it risks, directly or indirectly, prompt individuals to “drop out, tune in, and turn on.”? Until and unless human service professionals in general and counseling professionals specifically educate the tech development folks about the risks associated with making the synth world so seductive that it cannot be resisted, such developments will simply be seen as the next cool, neat advance. If, however, we work with the tech folks, outlining our concerns by proffering advice as to how to “use” the technology to accomplish our goals—training and clinical—rather than chastise them for developing a reality we believe to be harmful or dangerous or more succinctly,  “wrong,” we are likely to facilitate a “win-win” scenario. 

The metaphor of counseling an adolescent is not all that out of line when considering this discussion. If we are the experienced human service professional, the “sage adult” if you will, concerned about the high-risk behavior of our adolescent client, would we not engage that adolescent in a way that was uniquely suited to meet the client where he or she was in order to engage that adolescent in conversation rather than demand that he or she simple “stop” doing the high-risk behavior or simply refusing to consider what was being proffered? 

Allow me to close as I began...I neither wish to be nor see myself qualified as a champion for the use of technology in general and virtual reality more specifically as where counselor education should advance. I have as many concerns as do many of my colleagues on this list. There are countless examples of substances and practices that are essentially harmful and toxic in and of themselves but this does not preclude considering their use to further our quest to employ them in advancing the quality of life of individuals or advancement of the human condition. I simply suggest that we not throw out the baby of technology with the bath water of avatars as we reflect on the possible nexus of “counseling” and “virtual reality.”

As an aside, the original link to the video I posted that started this discussion was sent to the CESNET (Counselor Education & Supervision Network) listserv by Dr. Russell Sabbella of Florida Gulf Coast University (http://www.schoolcounselor.com/about-sabella.htm). He is one of the foremost researchers and advocates for incorporating technology in the training of counselor educators. Should you visit the link provided, look at the links to online article on the use of technology in counseling as well as the “Schoolcounselor.net “newsletter.”

As always, thank you for the opportunity to share my ideas and taking the time to consider them.