As a student therapist, I am spending about 20+ hours a week at a substance abuse treatment center. The biggest lessons I’ve learned thus far, pertains to the nature of resistant as it appears within addiction. Since understanding this concept is critical to my effectiveness, I’m stopping to reflect upon what I’ve learned thus far….
From The Client’s Perspective…..
Last week at my internship site I was leading a therapy group for individuals struggling with addiction. At one point, during the session, someone asked me “what do you think of all of us?” This followed an exercise on awareness that required participants talked a bit about the consequences of their addiction. With the spotlight faced squarely upon me, everyone awaited silently for my response. I knew what I wanted to say, but was nervous in my ability to communicate it effectively. Starting off with a desire to put myself in the client’s shoes, this is what I hoped to convey…
I wanted to acknowledge their overwhelming sense of shame about what they had done, & how this made forward motion difficult.
I tried to let them know I understood they were struggling without their coping tools. I was aware of the full-on rush of thoughts & feelings came with this…
I hoped to convey empathy for their traumatic histories as well as the daily struggles that made quitting so difficult…
A perplexing mix of empathy and gratitude filled my mind. While my heart went out to them, a need for radical acceptance, opposite action, and responsibility lay before them. My mind floated toward my own pathway of recovery & healing. I was grateful for the long road to toward this present moment. I’ve really come a long way.
Paradoxical Dualism – Subjectivity & Objectivity
As I see it, a perplexing dualism exists within the counselor’s mind while providing therapy. On the one hand, you have a Rogerian unconditional positive regard as an essential element in the therapeutic relationship. On the other hand, you have the sort of confrontational style found with addiction counseling’s history. Where is there a middle ground between these extremes? In today’s medically-based climate, objective analysis of presenting symptoms is emphasized. Adding to this is is the attitude of individualism prevalent in Westernized medicine. As an INFP, I gravitate toward empathy, understanding, & validation. As a biracial individual, multicultural sensitivity is a priority. Is the pendulum swinging away from these things as it pertains to the practice of therapy?
From clinical perspective resistance to recovery is as infuriating as it is perplexing. Effective solutions to escape the miseries of addiction are available What is preventing them from utilizing these tools?!?!
Not surprisingly, this question is reminiscent of the “Why don’t you just leave?” response I got from my family during the “it years”. Its so hard to understand what it is to “live the problem”, when you’re outside it from a safe and objective distance. Unresolved baggage from childhood traumas, produced a shame-filled reality wherein I was worthless – unimaginable to outsiders. The “I need him” mentality brought about by prolonged ostracism was difficult to understand. Emotionally, I felt lost with nobody in my corner. I needed someone – ANYONE – to love me…..
…So how can one begin to step outside the empathist’s hat, and begin to develop a discerning clinical judgment on the matter of this perplexing resistance, that allows you to prolong & magnify misery when healing solutions exist within one’s reach? My first answer to this question came in the form of insights from the “SASSI-3”
Measuring Resistance – SASSI3
“SASSI” stands for “Substance Abuse Subtle Screening Inventory”. It is utilized in intake evaluations at the inpatient substance abuse facility I’m interning at currently. This brief self-reporting instrument helps identify those who are likely to have a substance abuse problem (sassi.com, n.d.). Of relevance to this post, are a few “subtle scales” which don’t have a direct bearing on substance abuse behaviors, but are useful for making”inferences” (sassi.com, n.d). I describe a few interesting subtle scales below:
“OAT” Obvious Attributes
“OAT Scale scores measure the extent to which an individual endorses statements of personal limitation…low scorerers are likely to be reluctant to acknowledge personal shortcomings. (Miller, Renn & Lawzowski, 2001, p. 3)”. As I understand it, this score reflects characteristics of our temperament that can either function as strengths or areas of growth. Low scorers are more prone to deny their shortcomings. Miller, Renn, & Lazowski, (2001) suggest that “it is not useful to agree or disagree with clients’ self-appraisals” (p. 3).. When encountering individual’s with low OAT scores, it is important to avoid being too critical since this can cause clients to become defensive. Instead motivational interviewing is useful to build discrepancy and reduce resistance.
“SAT” Subtle Attributes
The SAT score is useful in identifying “characteristics of substance misuse that are not easily recognized as such (Miller, Renn & Lawzowski, 2001, p. 3).” The utility of this measure, is in its ability to help reveal information clients deny to themselves or become deluded about. In other words, it is a measure of an individual’s degree of self-deceptiveness regarding the consequences of one’s behavior. Miller, Renn, & Lazowski, (2001) note the “sincerely deluded” (p. 3) nature of an addict’s tendency to avoid acknowledging the consequences of continued use. So how does one begin discussing such subjects?
“There is no point in giving people messages that are too strong and too discrepant from their points of view. On the other hand, there is also no point giving a message unless it promotes positive change. Successful feedback depends on starting from a point that clients can accept and then increasing the breadth of their understanding.(Miller, Renn & Lawzowski, 2001, p. 4).”
“The primary purpose of the DEF scale is to identify defensive clients who are trying to conceal evidence of personal problems and limitations (Miller, Renn & Lawzowski, 2001, p. 3).” In other words, it assesses an individuals tendency to conceal of an personal or situational problems in their lives. This is ego-driven activity, reveals how they feel about themselves in relation to others. For example, low DEF scores indicate low self esteem & feelings of hopelessness about one’s situation. In contrast, elevated DEF scores indicate individuals are concealing their problems in order to “fake good” (Miller, Renn, Lazowski, 2001, p.4). Concealing problems in this way serves to protect people from something painful they wish to avoid dealing with.
So to conclude, the SASSI-3 characterizes resistance as a: (1) a refusal to acknowledge personal shortcomings, (2) a tendency to remain deluded about the consequences of one’s actions and (3) a general desire to conceal personal problems from oneself.
So How Do You Address this Resistance????
Earlier this week, in a supervisory meeting, the interns sat down to discuss the cases they were assigned. As the “newbie” of the group, I stepped back and listen throughout most of the session. At one point, an intriguing debate ensued between the supervisory therapist and an experienced intern who is close to graduation. From their discussion, I noted two divergent attitudes on the utility of confrontation and direction. Underying these divergent attitudes were two very different approaches to therapy. What follows are two different therapeutic approaches that appear as opposite ends on a continuum. What follows is a description of the two extremes along this continuum of variance in therapy approaches:
A Rogerian Nondirective Stance
Non-directive therapy, considers the client to be his/her own expert. In other words, the direction that therapy takes depends on a client’s own personal judgment and not the therapist’s. Rogers describes non-directive therapy as client-centered in the sense that they have a capacity for self-understanding and self-direction. It is a mirror opposite of authoritarian confrontation common in addiction counseling. This empathetic approach involves the establishment of “a collaborative partnership that respects the client’s capacity for and right to self-determination (Policin, 2003, p. 20)”
From this perspective a therapist’s job is unconditional positive regard and an acceptance of their feelings. It excludes a need to explain, challenge, or direct (Raskin, 1948). The client’s subjective stance, takes presidence over the therapist’s clinical judgment:
“the nondirective point-of-view on this issue is that to the extent that some other frame of reference than the client’s is introduced into the therapeutic situation, the therapy is not client-centered” (Raskin, 1948, p. 106).
Confrontation in Counseling…
Defined as “process by which a therapist provides direct, reality-oriented feedback to a client regarding the client’s own thoughts, feelings or behavior” (White & Miller, 2007, p. 2), therapeutic confrontation has a long history in the field of addiction counseling. Historically, this counseling style was utilized in chemical dependency treatment to overcome denial & resistance (Policin, 2003). Aggressive confrontational styles like “Synanon’s attack therapy” Pokin, (2003), were utilized to break down the defense mechanisms underlying an addict’s utilized to deny their problems. White & MIller (2007) described this confrontation as a highly varied form of confrontation ranging from “frank feedback to profanity-laden indictments, screamed denunciations of character, challenges and ultimatums. (p. 2)”. This description resonates with a story my own therapist told me of her own internship experience at a substance abuse treatment facility in the 70’s.
A Comparison of Non-direction & Confrontation
Understanding of the client?
According to White & Miller (2007) the prevalent view of addicts changed somewhere between the 1920’s – 1950’s from an individual who was struggling with side effects of medications to a “‘vicious’ addict who sought narcotics as a source of pleasure” (p. 4). Implicit in this confrontational perspective is a view of the client the cause of these problems. This perspective focuses on an addict’s “defective, psychopathic personality (White & Miller, 2007, p. 4)”. In contrast, a Rogerian non-directed approach, focuses on the client not as a cause of the problems, but as the solution to them. Finally, modern perspectives point toward alterations in brain function.
A Confrontational Perspective holds the client as the cause of his/her problems and attributes their issues to a personal defect of some sort (White & Miller, 2007; Policin, 2003). In contrast, a modern view of addiction holds a medically based-perspective which dictates that addiction is a disease. The cause of addictive behavior are neurological alterations in the brains reward system. These alterations in the reward and control circuits of the brain (Inaba & Chen, 2014) are associated with addiction since they are responsible for encouraging us to engage in those behaviors that are beneficial for our survival. Our textbook calls this reward pathway the “go switch” (Inaba & Chen, 2014, p. 2.13), since it is the brain’s motivator and reinforces beneficial behaviors. In an addict’s brain, alterations can be found in this area. Personally, I believe an epigenetic & biopsychosocial perspective best describes the complex causal factors underlying addiction.
Understanding the solutions?
Underlying the confrontational stance common in counseling’s history, is the fact that – if left to their own devices – addicts would continue to engage in self-destructive behavior. “…addicts avoid dysphoric affective states, anxiety, and genuine intimacy by using substances and engaging in antisocial behaviors, such as manipulation of others for their own needs” (White & Miller, 2007, p. 5).” This observation, appears to underlie the extreme forms of confrontation described earlier.
In contrast, modern treatment approaches involve symptom management during detox alongside some form of therapy (inpatient,outpatient, group and/or individual). Motivational interviewing is useful in helping the client attain self-awareness. This can involve helping clients gain insight into their addiction while uncovering behavior patterns and attitudes underlying their habit. Personally, I haven’t seen a pure non-directive stance in the addiction counseling field. However, I believe an empathetic stance and collaborative approach are critical factors of successful counseling.
In the next section, I’d like to return to that internship supervisory meeting I mentioned earlier. Here’s an overview of the two sides of the debate I listened to on that day….
Can There Be a Middle Ground Between Extremes???
Side one – Sugar Coating Truth.
The intern in this conversation made a comment on the pointlessness of sugar-coating the truth & asked the supervisor what the point was if we never confronted them on anything. “Isn’t there a case in therapy when it is warranted to give our opinion on matters pertaining to the client’s well-being?” After all, “to sugarcoat the truth is to do a disservice for the person who is on the receiving end. You don’t do anyone favors by avoiding blunt truth (Nguyen, 2015).”
Side Two – Raising Concerns on Confrontation & Coercion….
“It is time to accept that the harsh confrontational practices of the past are generally ineffective, potentially harmful, and professionally inappropriate. (White & Miller, 2007).”
“Confrontation continues to play a strong role in many treatment programs (White & Miller, 2007, p. 176).” Obviously, it isn’t utilize in the extreme forms common in counseling’s history. However, despite its continued research has shown this method as often less effective than supportive approaches (White & Miller, 2007). Additionally Policin (2003) notes that confrontational styles, are shown to produce “harmful effects including increased drop-out, elevated and more rapid relapse, and higher DWI recidivism (p. 20).” My own impression of this approach is it has the potential to be harmful, shame-inducing. It focuses on change through emotional coercion over insight or conscious choice.
My thoughts thus far? Somewhere between these extremes lies a healthy balance.
Miller, F.G, Renn, W.R. & Lawzowski, L.E. (2001). Sassi Scales: Clinical Feedback. Springville, IN: The Sassi Institute.
Polcin, D. L. (2003). Rethinking Confrontation in Alcohol and Drug Treatment: Consideration of the Clinical Context. SUBSTANCE USE & MISUSE, 38(2), 165-184.
Raskin, N. J. (1948). The development of nondirective therapy. Journal of Consulting Psychology, 12(2), 92.
Nguyen Vincent (2015, February, 23). How to Deliver Cold Hart Truth and Stop Sugar Coating Reality. Retrieved from: http://www.selfstairway.com/cold-truth/
sassi.com (n.d.) Sassi Institute – “Early Intervention Saves Lives”. Retrieved from: https://www.sassi.com/
White, W. & Miller, W. (2007). The use of confrontation in addiction treatment: History, science and time for change. Counselor, 8(4), 12-30.