A Possible Reason High-risk Drinking is So Intractable in College?

Students Who Limit Their Drinking, as Recommended by National Guidelines, Are Stigmatized, Ostracized, or the Subject of Peer Pressure: Limiting Consumption Is All But Prohibited in a Culture of Intoxication - https://journals.sagepub.com/doi/full/10.1177/1178221818792414

First, I realize that this is a study conducted 3+ years ago and in New Zealand no less, however, its points seemed to resonate with me given my experience working with collegians in a small, private, urban university.

The gist of the argument presented is that the cost in social capital for students to identify, by declaration and/or behavior, as moderate drinkers or abstainers is high. In addition, "the labels" proffered by students when asked about their peers who drink, seem positive when a peer reports what we preventionist would classify as high-risk and derogatory regarding moderate or abstaining peers. There is more to the article than this but it got me thinking.

We know that student misperceptions about collegiate drinking are significant. We also have learned that when designed and conducted correctly, social norms marketing can be quite effective. We also know, however, that there is a stubborn core of high-risk drinkers that does not seem to budge no matter what preventive steps we take or programming efforts we mount. I am wondering if there is a "social capital" concern in this high-risk core regarding these negative if not derogatory labels affixed to moderate drinkers and abstainers...someone looking for a topic for a master’s thesis or doctoral dissertation? :)

Related to this stubborn core that appears immune to our prevention efforts to date, I was reading an article recently that suggested that social norms marketing can actually backfire if messages convy a social norm that is perceived by peers to be vastly out of their reach, as learning about this norm can actually discourage pursuing change. This got me thinking again...it would not surprise me to learn that the proportion of collegiate drinkers who meet the criteria for a diagnosis of an alcohol use disorder is higher in the persistent 22-23% of students reporting frequent "binge drinking" than in the general student population. If this is the case, especially if those AUD students have tried to change and were unsuccessful, might the traditional social norms marketing message that reports something like "X% of students report drinking 4 or fewer drinks when they drink" trigger a 'why bother' or what is called a "what-the-heck" reaction to our social norms messages?

The article I was reading suggested that if a target behavior is growing in popularity -- in our case, 

the number of moderate drinkers and abstainers is increasing -- especially if by modest amounts, instead of reporting actual percentages, simply report the upward trend, sans the details. So, instead of reporting that "X% of State Univ students report consuming 4 or fewer drinks if they choose to drink," reporting "for the Xth month/semester/year in a row, an increased number of State Univ students report moderating their drinking if they choose to drink." Where the 1st message could alienate high-risk drinking if construed as indicative of a peer group w/which I cannot or do not wish to identify, the 2nd is inclusive and uses positive peer pressure to affect change. True, someone who is drinking 10 drinks per outing 2X/wk and decides to "moderate use" by having 7 drinks 1X/wk is still engaging in high-risk behavior, but, hey..."any port in a storm."

Just a couple thought...what do you think?

What if Mary Poppins was a Collegiate Preventionist?

 

Imagine, if you will, that as we emerge from 17+ months of pandemic with its related lockdowns, social distancing, and virtual meetings it is a beauteous September day much like that date in the opening scenes of the 1964 Disney film, Mary Poppins. As you walk across campus after your meeting to discuss concerns about collegiate drinking and how best to prepare for the return of partying students to campus, you notice drifting down from an azure blue sky; why it is none other than Mary Poppins herself.

 

As she stands before you, quite prim and proper with her umbrella in one hand and satchel in the other, Mary Poppins announces that she is aware of the advertisement in The Chronicle of Higher Education for

an alcohol & other drug (AOD) preventionist and was on campus to apply. She adds that she is aware that your students, much like the adorable yet incorrigible Banks children, Michael and Jane for whom she had been a Nanny, have presented your Student Affairs establishment with quite the conundrum, a “can’t seem to live with them but cannot live without them” dilemma. She suggests that she just may be able to proffer some assistance in bringing resolution to the concerns you have just addressed in your meeting.

 

Your face betrays your wonderment as to just how does she know about your recent meeting let alone its focus on high-risk and dangerous collegiate drinking, but she is just assertive enough—and you are just concerned enough as the V.P. of Student Affairs has charged YOU with the responsibility to address the collegiate drinking problem—that you agree to hear her out and you invite her to your office hear her out…and for some tea.

 

I could continue this scenario and detail a hypothetical dialogue with Mary in some detail but I choose this introduction to proffer a thought not frequently considered when entertaining ideas about how best to prevent high-risk student behavior, AOD use in particular…the gamification of AOD programming.

 

Historically, prevention has focused on, as the profession’s name implies, preventing high-risk and dangerous behavior. To accomplish this objective, its efforts almost exclusively fixated on “the problem.” Such problem-focused approaches unwittingly suggested that high-risk AOD use was an all but insurmountable collegiate problem. Like a closeup photo of an object devoid of any reference in the frame for comparison, determining the extent of “collegiate drinking” as a problem becomes somewhat subjective, left to the interpretation of the observer. This, coupled with a decades-long history of preventionists almost exclusively addressing “the problem” of high-risk and dangerous drinking, has left some wondering if collegiate drinking is actually the problem we have been led to believe it is.

But back to Mary Poppins…gamification is exactly what Mary does when she assumes the responsibility of Nanny for the Banks children. To re-establish order through the introduction of routine and the instituting of basic procedures for the children to follow, she “gamifies” said routines and procedures, rules if you will, to entice compliance and, as a result, behavior change. It is, as one of the more memorable songs from the film goes, a “spoonful of sugar” that “make the medicine go down.” In that same song, Mary sings, In every job that must be done, there is an element of fun. You find the fun, and  snap! The job’s a game.[1]

 

Now I am not so naïve as to suggest that moderating student behavior is a simple matter of making low-risk decision making fun. Is there, however, a way—or are there ways—to increase the likelihood that students buy into some of our existing approaches to prevention? Can we “gamify” any of our prevention efforts?

 

To modify their behavior, students must conduct a cost-benefit analysis of any proposed change, realizing that if made, it will yield access to what they perceive as having a greater value than what they must give up to obtain it. Unfortunately, risk avoidance has not historically proven effective as such a motivator.

 

A major barrier to change is impulsivity or what Katy Milkman[2] calls present bias or the tendency to opt for the short-term reward over a longer-term benefit. For students this is avoiding the short-term reward of an “instant party”…just add alcohol…with all its social promises for the long-term benefit of better grades at the end of term. As the WWI song queried, How ya gonna keep ‘em down on the farm, after they’ve seen Parie?

 

“So,” as an effective parent says to a complaining child, “what do you propose we do?” What might the gamification of AOD prevention look like…or at least what might be a straw man to pull apart as we kick-about this idea? Again, as Katy Milkman suggests—can you tell I just read her book--

 

Gamification is another way to make goal pursuit instantly gratifying. It involves making something that isn’t a game feel more engaging and less monotonous by adding gamelike (sic) features such as symbolic rewards, a sense of competition, and leaderboards (59).

 

 

Perhaps it could involve offering “symbolic rewards” as a student “advances through successive levels” in an online alcohol awareness program. Perhaps it could involve incorporating geocaching into a social norms campaign to make it “more engaging.” Perhaps it could use a “leaderboard” to introduces a “sense of competition” between first-year resident halls for completion of a required online alcohol program. Perhaps voluntary referrals to B.A.S.I.C.S. would increase if B.A.S.I.C.S. was one stop on a term-long “campus services scavenger hunt” with an appropriately enticing prize for those who complete the hunt where a clue/direction to “the next” service came as each service is completed/visited.

 

Limits to the possibilities for the gamification of collegiate prevention efforts know no end. The creativity and resourcefulness of those who choose to incorporate the concept into a campus prevention program represents the only boundaries.

The purpose of this essay, however, is not to suggest HOW to gamify prevention—let alone suggest that any of the ideas just mentioned above are good or even likely to meet with student acceptance—but to simply ask WHAT IF we were to consider gamification as another arrow in the preventionist’s quiver? Perhaps if we were, we just might see Mary open her umbrella and drift off into the evening sky, barely audible as she hums, a spoonful of sugar…

 

What do you think?

__________

1 Milkman, Katy (2021). How to change: The science of getting from where you are to where you want to be. Penguin Random House, N.Y., N.Y.

2 Milkman, Katy (2021). How to change: The science of getting from where you are to where you want to be. Penguin Random House, N.Y., N.Y.

Harm Reduction and Substance Use Disorders

Harm reduction (HR) is an important tool for the behavioral health professional’s use when considering how best to address the issue of substance use. It is a fact, however, disturbing it may be, that we human beings have used, continue to use, and will likely always use licit and illicit substances. Although most users do so without experiencing a substance use disorder (SUD), their use, as well as the use of those who do develop a SUD too often, involves health-related risks and problems, some of which result in death.

 

HR. is essentially a collection of principles[1] that acknowledge that although substance use is and will likely continue to remain a fact of life, it is imperative for society in general and healthcare professionals specifically to champion adherence to these principles and strive to reduce the likelihood of untoward consequences resulting from the use of any psychoactive substances, licit or illicit.

 

Substance use, licit or illicit, is neither a moral nor legal issue, it is a healthcare issue. As such, efforts to interceded in the use of such substances should seek to minimize the likelihood of harm for those who use and advocate for the treatment of those whose use has resulting in a SUD. Unfortunately, the use of illicit substances in general and “addiction” specifically carry the stigma of problems realized by those morally weak and/or criminally disposed members of society.

 

Addiction is, in many ways a social construction - A social construct is something that exists not in objective reality, but as a result of human interaction. It exists because humans agree that it exists[2]. In other words, addiction is a collection of behaviors that society has deemed outside the bounds of its vie of normal and therefore aberrant. Because those with addictions do not behave in accordance with what society deems acceptable and appropriate behavior, these individuals must, therefore, suffer from some degree of moral turpitude or be criminally inclined. This “moral model” view of addiction explains our societal reaction to those who use illicit substances or display the symptoms of what we call a substance use disorder. It also justifies our proclivity as a society to arrest and punish rather than diagnose and treat those who use illicit substances.

 

To pursue the specifics of the moral model and its impact on the history of the treatment of SUDs is

beyond the scope of this essay. It is the prevention of harm to those who use substances, licit or illicit, irrespective of their reasons for use…physical dependence or hedonistic reward…that is the reason for this piece.

 

The pursuit of harm reduction can lead a healthcare professional in one or two general directions. The first, regarding treatment, results in the practitioner’s efforts to engage individuals in a way that increases the likelihood of motivating users to reconsider their use, thereby increasing the likelihood of reducing the frequency and/or quantity of that use. The second regards simply reducing the risk of untoward consequences resulting from use. Treatment is not the primary objective, just the reduction of harm associated with the use, both to the user and to the society in which that user resides.

Interestingly, HR. efforts in pursuit of the second objective can and often do result in the opportunity to pursue the first, treatment. An example of this is the evidence that comes from harm reduction efforts like “user room.” In the Netherlands, Amsterdam specifically, user rooms are places where individuals can go to consume their substances…drugs…safely. Trained staff supervise these locations, often with EMT experience and access to Naloxone. At such facilities, users can shower, wash their clothes, get something to eat, and have their basic human needs addressed. While visiting a “user room,” individuals would often establish a rapport with staff and over a period of visits, begin to talk about their use with staff. The staff, often trained in Motivational Interviewing techniques, then engage users in a discussion about the benefits and costs of their use, helping users to take a critical look at the “return on investment” related to their substance use, a more than occasional result being the user’s entering treatment.

 

Harm reduction efforts related to substance use are more concerned with the user and those with whom the user has contact than with the legality of use or the socially constructed barriers that distinguish between the “appropriate use of licit substance,” like alcohol, or its “inappropriate use” or the use of any illicit substance. It is an approach rooted in the belief that the prevention of harm is rooted in the promotion of health and therefore a quintessential exemplar of health care.

 

And before rejecting this argument by citing concerns about needle exchange programs, the encouragement of use  by user rooms, or state-supported addiction in methadone maintenance programs, notice how dependent we all are on harm reduction in our lives already: seat belts, airbags, antilock brakes, fire retardant clothing, smoke detectors, CO2 detectors, hand railings, antiskid strips on steps, sunscreen, etcetera, etcetera, etcetera.

What do you think?

Dr. Robert

 

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[1] See Principles of Harm Reduction at https://harmreduction.org/about-us/principles-of-harm-reduction/ for a summary of these principles.

[2] Bainbridge, Carol (2020). CF - https://www.verywellmind.com/definition-of-social-construct-1448922

What We Need to Understand About Willpower

Willpower is arguably a social construction that we humans have conjured up to explain why some are successful in controlling their behavior while others are not -- For those who do, we say they “have willpower” while those who do not, don’t. 

What is willpower but a means by which we choose to measure our ability to control ourselves and/or our

environment. This preoccupation with control, especially when measured regarding our ability to regulate our personal behavior, lends itself to a binomial consideration of success…we either succeed or fail in exercising that control. However, it is just this point…viewing willpower as an ability one either possesses or not…that results in self-defeating beliefs when struggling with efforts to self-direct behavior change. But what if willpower is not so much an ability one either has or does not have, like a biological trait genetically passed along by birth parents, but a skill capable of development like any other?

The first step in developing this skill of self-regulation is identifying the specific details associated with the behavior I am trying to regulate. If, for example, I “drink too much” and have come to the realization that I have a “drinking problem,” then the behavior I am trying to regulate is my drinking and my objective is to drink less if not quit altogether. Although “not drinking” may seem the obvious objective, until and unless I understand the details associated with my issue, I am likely to think that the only option available to meet my quit-objective is to “will myself” to “not do it,” the white-knuckle approach to change if you will. With willpower as my perceived only approach to change, I assign the responsibility for my success to a supposed character trait, one that I may or may not have. In short, viewing willpower as a trait relegates my ability to change to the genes I inherited from my biological parents, which makes the likelihood of my success little more than a crapshoot. But is this an accurate assessment of how people change? Are only “some of us” destined to change our behavior should we wish to do so?

And what if “willpower” is a skill rather than a trait? A skill, like any other, capable of development over time through practice. By attending to the details of my behavior, for example, my drinking, I can identify important clues that affect my ability to change it…or change my gambling habit, or failure to take my medication, or “whatever” it is I seek to change. If what-causes-a-problem-is-a-problem-when-it-causes-a-problem, then the more I know about “it,” the better prepared I am to make appropriate behavioral changes that support my ultimate change objective. When I do “it,” where I do “it,” with whom I do “it,” etc. This is consistent with viewing willpower as a skill that I develop. Like the old joke about the visitor to N. Y. City when asking the maestro, “How do I get to Carnegie Hall” gets the reply, “Practice, practice, practice,” the will to change is as much a skill that one develops as it is a personal desire to alter one’s behavior.

The more I know about “my habit” or the pattern of behavior I wish to change, the better prepared I am to address it. And when I do decide to address it, I am choosing to act on that behavior rather than react to it. This means my success in changing my behavior has more to do with the steps I take that support that change than the amount of willpower I may or may not have been born with. In short, as a skill, willpower is something developed, strengthened, controlled, and then, directed.

Reflections on a Counseling Relationship

 

Considering the significance of relationships in any interpersonal interaction is not exactly blog-worthy news; the importance of the relationship between a counselor and a client is no exception. Actually, there is quite a substantial literature on the subject, with numerous references to the role that the relationship plays in what is called the "common factors" related to effective psychotherapy. Going as far back as 1936, Saul Rosenzweig posited that there are "common factors" inherent in all psychotherapies. 

 

An interesting review of the "common factors" phenomenon is included in the 1995 article by Miller, Hubble, & Duncan entitled, "No More Bells and Whistles" (Miller, S. , Hubble, M. , & Duncan, B. [1995]. The Family Therapy Networker, 19, 52-63). In this article the authors suggest that the outcome of all therapy is influenced by 4 factors common to all effective psychotherapy: 1) Therapeutic Technique, e.g., CBT, Person-centered, etc. (accounts for 15% of outcome), 2) Expectancy and Placebo, e.g., client beliefs re the effectiveness of counseling, etc. (15%), 3) Therapeutic relationship of which "bedside manner" is a euphemistic way of referring to the practitioner's influence on the relationship (30%), and 4) Client Factors, e.g., access to treatment/means to pay for treatment, supportive family, social contacts, etc. (40%).

 

Although one can argue that practitioners have control over which therapeutic technique will be

employed, clearly, he or she has no control over 55% of the factors that affect therapy outcome - according to Miller, Hibble, & Duncan, "expectations/placebo" (15%) and "client factors" (40%) - meaning that the single biggest factor that affects the outcome of counseling/therapy over which the practitioner has significant if not complete control is the therapeutic relationship (30%). Although this may seem a minor factor (30%) affecting the outcome of services, it is nonetheless almost a full third of the outcome and, when considering that the relationship is a significant part of whether a client engages in services or not, it can definitely impact client expectations about therapy not to mention "client factors" like enhancing support networks and/or client willingness to establish/utilize such.

 

An unrelated but nonetheless tangential issue to the significance of the relationship in the outcome of therapy is the fact that the health care professional--of any type--least likely type of being sued is the practitioner who clients/patients report "liking," the corollary being, the most likely to be sued is the practitioner whom the client/patient does not like or sees as condescending, arrogant, patronizing, aloof, "cold, etc. See EXAMPLE 1, EXAMPLE 2. 

 

When discussing these points with students I would point out that establishing a warm, caring and empathic relationship with a client does not preclude addressing issues a client may not want to hear. As a matter of fact, a strong, positive relationship can enable the delivery of such feedback/information more

likely to be considered. I conducted an activity with my behavioral health counseling students to demonstrate: I would ask students to think of someone they hold in high regard...someone they trusted, respected, and recognized as a "good human being" and tell them this could be anyone living or deceased provided they had had a personal relationship. I would then ask, "Did this person always tell you what you wanted to hear?" - As I paused before my next question, I would see most head gesture negatively. Then I would ask, "did this person ever say or do something that upset you or made you angry? - This time when pausing I would see most students positively nodding their heads. Then, "did this person ever upset you so much that you did not talk to him or her for an hour or a day or a week or longer? Again, positive head nods. I would then ask, "why, then, was the first person that popped into your head when I asked you to think of someone you hold in high regard, trust, respect, and recognize as a good human being someone who did not always tell you what you wanted to hear, sometimes said or did things that upset you, and perhaps even to a point where you did not speak for an hour or day or longer?" I would then answer the question for them..."because this person was always truthful, honest, and treated you with respect, always letting you know that you were important and he or she would never do anything to hurt you purposefully. 

 

As important as a positive relationship with clients may be, it is also important for students to not mistakenly think that this means they must "be friends" with clients. They need to understand that developing a positive relationship is of paramount importance but that it does not equate with only telling clients what they will appreciate hearing.

 

What do you think?

Dr. Robert

____________________

1Thomas, M. L. (2006). The Contributing Factors of Change in a Therapeutic Process. Contemporary Family Therapy: An International Journal, 28(2), 201–210

Thoughts on Recovery: There’s No GPS to Map the Way

 Long-term recovery from a substance use disorder (SUD) is difficult to define. Some suggest that although recovery begins with the decision to change one’s use behavior, others suggest that it cannot commence until and unless one’s “change in use behavior” includes total abstinence. Still, others argue that one never recovers from a SUD and one remains in a perpetual state of “recovering,” although even with this, only if abstinence is maintained.

In other words, recovery would seem to mean different things to different people. What is imperative, however, at least for a behavioral health practitioner to remember is that how others define recovery is not the issue of primacy when working with someone having a SUD or mental health disorder (MHD). What matters is how that client understands recovery and therefore defines it and is motivated to pursue it. Supporting a client’s efforts to recover from a SUD or MHD necessitates acknowledging and working to support the client’s autonomy, that is, the client’s right to determine what he or she will or will not do; what he or she wants to accomplish with the practitioner’s help. Now if one’s client wants assistance using heroin without overdosing, this may be something the practitioner is unable or unwilling to help the client pursue. That said, this practitioner might refer the individual to a user room such as they have in the Netherlands or other jurisdictions outside the U.S.

Behavioral health practitioners need to avoid dogmatic definitions of recovery for their clients. Preconceived notions about recovery tend to result in inadvertently directing clients to pursue the practitioner’s view of recovery, which may or may not be what the client wants or needs. Practitioners that pursue their understanding of what constitutes recovery is problematic in that it violates a basic ethical principle of counseling – autonomy…more on this in a bit.

“Recovery” by its very nature implies change…movement from where one is to where one wants to be. It implies movement from a problem to a solution. The challenge for practitioners, however, is to help clients identify what the best solution may be for each individual client rather than be quick to impose a one-size-fits-all recovery objective and expect the client to follow.

Before recovery can begin, one must recognize the need for this change. We see this in the 1^st step of A.A. or N.A.; we see this in the individual who seeks treatment to address a mental health disorder, and we see this whenever someone conducts a cost – benefit analysis in one’s life and realizes that the price paid for continuing to do what has always been done is greater than that associated with making a change. The point remains, however, what this change looks like is not something imposed on the client but rather something the practitioner helps a client explore.

Recovery is a simple process that is incredibly difficult to complete. Behavioral health practitioners can assist clients in considering questions designed to increase the likelihood that the pursuit of recovery becomes a desired option. The “specifics” of what the client wishes to change must be specific and operationally definable and include specific steps that “set one up” to succeed…many little steps accomplished one-at-a-time. Clients need to understand the personal reasons for making this change…for taking these many and gradual steps and to understand why it is important to do all this lest quickly becoming bored, overwhelmed, or frustrated and quit.

Although these questions are intended for clients to consider, I suggest that practitioners respond to them personally. For example, consider something you have decided to change: Why would you want to make this change? How might you go about making the change if you wished to increase the likelihood of success? What are several reasons why making the change is a good idea? How important is it that you accomplish this change? These questions are adapted from questions Miller suggests are important when employing Motivational Interviewing to help clients consider engage in “change talk.”

Ask ten people to define recovery and you will get at least a variety of answers. Those whose recovery from a SUD necessitates abstinence will include abstinence as a prerequisite of recovery…those whose recovery involves involvement with a mutual aid or self-help group will include involvement with such groups in their definition. Practitioners who define recovery as successfully completing treatment and aftercare plans will view this as a prerequisite of recovery…and blame the client if such is not realized. In short, recovery is what recovering people do.

There is an African adage that says, “When elephants fight, it is the grass that suffers.” Is abstinence required for SUD recovery? Is spontaneous recovery real? Can you be in SUD recovery if you are taking meds? Does medication-assisted treatment clear a path to recovery? Can one ever be truly recovered or is one simply in a perpetual state of recovering?

These are all very real questions, some of which are quite controversial. Although they are interesting to consider as they unfold at a professional conference, debating their usefulness with a client can quickly sabotage efforts to assist an individual with a SUD or MHD who is seeking treatment.

The American Counseling Association defines autonomy as the principle that addresses the concept of independence. The essence of this principle is allowing an individual the freedom of choice and action. It addresses the responsibility of the counselor to encourage clients, when appropriate, to make their own decisions and to act on their own values. Clients who are told they must do “whatever” if they wish to recover have had their autonomy hi-jacked. It can be argued that to define recovery for a client is to violate the ethical principle of autonomy or the right a client’s right to choose a course of action to pursue in treatment.

If recovery involves the movement from “problem” to “solution,” who should define what is a problem and what is its solution? If recovery is possible, then is it a process with a finite point denoting completion or a continual progression toward an ever-improving state of recovery?

How can you, as a practitioner, guide a client on this journey of recovery without imposing your understanding of what recovery is? Are you, as a practitioner, in a state of recovery from your preconceived ideas and notions regarding treatment and recovery? These are all important questions, and ones difficult to answer without having someone or ones with whom to discuss them.

It is when the person who happens to be a behavioral health practitioner connects with the person who happens to be his or her client, the “person connecting with another person” dynamic, that is the point when the magic happens in counseling. So, clients, when presented with the opportunity to consider all the options that are available to them, can choose their own course of action, this is when the path to recovery becomes obvious. Effective counselors can present their clients with probing questions designed to provoke objective thought about the pros and cons of each option being considered, but they will never direct a client to choose a particular option, directly or indirectly, especially if that option suggests a “one-size-fits-all” course of action.

Remember:

Control leads to compliance; autonomy leads to engagement.
― Daniel H. Pink

Unsolicited advice is the junk-mail of life.

-- Bernard Williams

What do you think?

Personifying Addiction: Can Viewing One’s SUD as a Toxic Relationship Aid Treatment?

Who does this sound like?

·       Has a sense of entitlement and require constant, excessive admiration

·       Exaggerates achievements and talents

·       Is preoccupied with fantasies about success, power, brilliance, beauty or the perfect mate

·       Expects special favors and unquestioning compliance with their expectations

·       Never takes responsibility, blaming others for mistakes, oversights, or poor judgment

·       Has an inability or unwillingness to recognize the needs and feelings of others

·       Behaves in an arrogant or haughty manner, coming across as conceited, boastful and pretentious[1]

No, I am not referring to a contemporary politician—that is grist for another discussion mill. I refer to Al K. Hall, to Mary Juanna, to C.O. Cain, to Ox E. Contin, to Herr O’Wynn, to P.K. O’Cette…you get my drift. A personification of a substance use disorder, A.K.A. “addiction,” as some malevolent other that possesses an individual is not new. Robert Louis Stevenson’s famous The Strange Case of Dr. Jekyll and Mr. Hyde is semi-autobiographical in which the transformation of Dr. Jekyll when consuming the potion made of a “fine white power” to the murderous Mr. Hyde has become a familiar euphemism for addiction[2].

Although my personifications of a substance use disorder (SUD) may seem silly when compared with Stevenson’s more literary heavy, an important point remains: when characterizing addiction as a malevolent being, doing battle with that anthropomorphized image of an identifiable villain becomes more plausible than attempting to challenge some nebulous disorder. To view addiction as simply a social construction of inappropriate or otherwise described deviant behavior leaves the individual with that disorder little choice but to view the self as at best somehow defective if not a failure as a human being. Likewise, not only do those with an SUD tend to then label themselves as addicted with all that pejorative term implies, historically those who have attempted to provide treatment have tended to treat the addiction rather than the individual with the disorder.

Although interventions with the personification of an SUD may seem logical—who wouldn’t seek to confront the villain in any drama—when the addiction and the individual who has that disorder are indistinguishable in the eyes of the practitioner, such interventions become confrontational with the individual the focus of the practitioner’s assault. As William Miller suggests, this is when practitioners wrestle with their clients rather than attempt to dance with them. When confronted most individuals with an SUD will react instinctively, defensively recoiling from the practitioner whose treatment is perceived as a threat.

Interestingly, there may be two strategies that when employed in tandem may help avoid such

confrontations. The first is a given and has become quite well known over the last 30-years and for that reason not discussed in detail here; motivational enhancement therapy where empathy, collaboration, an appreciation of client autonomy, and evoking change talk are the hallmarks of effective treatment. The second is as yet unknown and argued in this essay as the personification of an SUD as an entity with which the addicted individual has a toxic relationship.

This “entity” manifests many if not all the characteristics of narcissism as outlined in the introduction above. As difficult as treating SUDs may be, inviting individuals to understand their dependency as a conflict with a self-absorbed parasitic nemesis can free one’s client to begin viewing change as a battle that can be won as opposed to a disorder that must be endured. Likewise, framing treatment as a struggle between the individual with the disorder and the personified disorder enables the practitioner to assume the role of mentor, guide, strategist, or counselor but definitely not the client’s adversary.

When seeing clients with SUDs I would often ask them to imaging their disorder as a gremlin sitting on their shoulder, constantly whispering in their ears, saying whatever was necessary to justify taking the next drink or pill or “hit.” I would then ask that they write a letter to their gremlin and tell it everything they ever wanted to say to get it to “shut up.” Once written, I would ask that the letter be read in group and for the group to comment and provide feedback, the point being that the personification of substance use dependence was a bully and that bullies can be silenced but only when confronted and when the one doing the confronting is supported by peers who understand how difficult the bully is to overcome.

What do you think?

To read how Dracula is an allegory for alcoholism/addiction, consider my essay Al K. Hall as Dracula: Film as a Clinical/Pedagogical Device[3]

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[1] Based on Mayo Clinic’s website’s “signs and symptoms” of Narcissistic Personality Disorder

[2] See Wright, Daniel. “The Prisonhouse of My Disposition’: A Study of the Psychology of Addiction in Dr. Jekyll and Mr. Hyde.” Studies in the Novel. 26.3 (1994): 254–267.

[3] If the link fails, the essay’s URL is https://robertchapman.blogspot.com/2012/07/alk.html

Bloom Where You're Planted

"Bloom where you're planted"
Taken by Josh Chapman

For those of us 75 or younger, this time of pandemic may well be the most challenging time in our country that we have ever had to face. True, we have all experienced tragedy and heartache and rare is it when any have yet to experience doubt and fear in our lives. But even in those dark and challenging personal times, it was likely that there was always someone close or at least available to listen, to comfort, and to understand what we were going through and as a result, proffer the support needed to take that proverbial “deep breath” emotionally needed to calm ourselves and, as the old saying goes, “keep on keeping on.”

Unfortunately, when everyone is experiencing the same tragedy and heartache, is feeling the same cold, clammy fingers of doubt and fear encircle their very being, that “someone” close who is available to listen, to comfort, to understand is hard to find. It is as if the fictional Dementors so familiar to Harry Potter fans have somehow materialized and descended upon us, ready to suck the goodness and happiness and confidence from each of us…where is that Patronus charm when it is really needed.

Although there are no real Dementors nor Patronus charm for that matter, there may be something that can help quiet some of the doubt and fear that many…dare I say “all”…of us are experiencing, something in addition to prayer and faith in a Higher Power…music and its lyrics. Winston Churchill said during the Second World War that when going through Hell…keep on going. A contemporary singer-songwriter, David Wilcox, has committed that sentiment to a song. You can listen by clicking the title and the lyrics are below should you wish to follow along...and share a link to your songs of hope in the comments section.

Show the Way 

(https://www.youtube.com/watch?v=SBmIIDiN57E) 

David Wilcox

You say you see no hope
You say you see no reason we should dream
That the world would ever change
You’re saying love is foolish to believe
And they'll always be some crazy
With an army or a knife
To wake you from your daydream
Put the fear back in your life

Look
If someone wrote a play
To just to glorify what's stronger than hate
Would they not arrange the stage
To look as if the hero came too late?
He's almost in defeat
It's looking like the evil side will win
So on the edge of every seat
From the moment that the whole thing begins

It is love who mixed the mortar
And it's love who stacked these stones
And it's love who made the stage here
Although it looks like we're alone
In this scene, set in shadows,
Like the night is here to stay
There is evil cast around us

But it's love that wrote the play
For in this darkness love can show the way

Now the stage is set
You feel your own heart beating in your chest
This life's not over yet
So we get up on our feet and do our best
We play against the fear
We play against the reasons not to try
We're playing for the tears
Burning in the happy angel's eyes

For it's love who mixed the mortar
And it's love who stacked these stones
And it's love who made the stage here
Though it looks like we're alone
In this scene, set in shadows,
Like the night is here to stay
There is evil cast around us
But it's love that wrote the play
For in this darkness love will show the way

Show the way

Show the way

Source: LyricFind

Songwriters: David Patrick Wilcox

Show the Way lyrics © Universal Music Publishing Group

Reframing the Abstinence Violation Effect

Long-term recovery from a substance use disorder (SUD) is difficult to define. Some suggest that although recovery begins with the decision to change one’s use behavior, others suggest that it cannot commence until and unless one’s “change in use behavior” includes total abstinence. Still others argue that one never recovers from a SUD and remains in a perpetual stage of “recovering,” but only if abstinence is maintained.

Be that as it may, a perennial threat to recovering, especially if abstinence is perceived as the prerequisite of changing one’s substance using behavior, is to use, even once. This use, however, small or infrequent, is viewed as having “botched” one’s efforts to change and is referred to in many ways—a relapse, a slip, falling-off-the-wagon, etc.—but no matter the nomenclature it is all but certainly accompanied by a personal sense of having failed. In formal treatment circles, this sense of failure is referred to as the abstinence violation effect or AVE and is perhaps the single greatest contributor to a return to active involvement in one’s SUD. 

Faced with working with individuals trying to change who tend to see use as tantamount to having “F-ed up,” practitioners who treat SUDs routinely are charged with helping them reframe such use as something other than “failure” lest they return to active use. Practitioners accomplish this in various ways, however, all necessitate helping these individuals to view their use as something other than personal failure and indicative of the absence of willpower, moral turpitude, or somehow evidence that recovery is beyond one’s grasp.

Reframing use as something other than failure requires a change in perspective. Just as a patient would rather hear a surgeon discuss a 90% chance of success in a procedure rather than a 10% chance of failure, those treating individuals with a SUD who use can discuss the opportunity the “lapse” presents to recognize previously hidden risks and high-risk triggers that can sabotage recovery. Referring to use following a period of abstinence as a “lapse” rather than having “F-ed up” presents individuals with the opportunity to “act on” their use rather than “react to” it. In addition to reframing, it is also helpful to invite individuals to appreciate the temporal nature of such experiences.

Substance dependent individuals and practitioners alike recognize the risk that urges to use and the triggers associated with them can play in sabotaging a treatment plan. What is often overlooked, however, is the time that elapses between these triggers and urges and the action taken or reaction that one has in response to them. It is this time between the onset of the urge to use and the decision one makes to use or not use that presents the opportunity for the substance-dependent individual to “do something,” the result of which is to move closer to or farther away from use.

The space separating the “urges” and “triggers” from the decision to “use” or “not use” is representative of the “time” that exists between these two phenomena. Depending upon individual circumstances, the precise amount of time separating these as two poles can be minutes or days but irrespective of the specific amount of time, the fact that this separation can be measured in time presents the individual with the realization of an opportunity to do something…if you will, to act rather than react. As a matter of fact, one cannot not do something during this time as to do nothing is in itself to do something.

The individual who grasps the temporal nature of a lapse is presented with an opportunity to take the steps necessary to prevent it. Just as one can learn about how personal actions when using set oneself up for use, following this model, so can this individual appreciate the significance of having a plan in place to deal with urges and triggers should they occur…and most any recovering individual will tell you that it is not “if” these urges and triggers will occur but “when” they will. NOTE: The list of things that can be done during this time is essentially limitless. Exploring “proactive” steps to avoid use and/or cope with urges to use becomes an important topic for discussion with one’s treatment specialist or sponsor.

Alcoholics Anonymous has a slogan that speaks to the importance of being prepared; change people, places, and things. Preparing to avoid the expected triggers that can initiate an urge to drink will increase the likelihood of avoiding lapses. In addition, should use occur, viewing it as a lapse rather than a failure—not to mention an opportunity to learn something new about preventing potential future risks to recovery—increases the likelihood of maintaining sobriety.

Wayne Dyer once wrote that the only difference between a flower and a weed is a judgment. Now, apply this reasoning to one’s use after a period of abstinence: the only difference between a lapse and a failure is _____.

What do you think?

Dr. Robert

Thank you to Jessica Williams of IRETA whose blog post "Combatting the Abstinence Violation Effect" prompted the thinking that resulted in this essay.