This post continues with a ‘train of thought’ I left off at with my last post titled ‘Understanding & Handling Resistance’
Confrontation & Addiction Counseling…
Recently, in the ensuing stress associated with a 70+ work week, I decided to meet up with my long-time therapist (even therapists need therapists). As I began describing my internship experiences, she gave me a cursory overview of addiction counseling’s history. In my last post, (link above) I make the following comment:
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)”.
Honestly, as described above, I’m really troubled by an approach like this. Rather than encouraging change through personal growth and increased insight, it sounds very shame-inducing. Admittedly, there are many aspects of addiction that are infuriating for addiction counselors. After all, Substance use disorders encompass a complexity of physiological, behavioral, and psychological symptoms. Physiological dependence is a byproduct of alterations in brain function due to prolonged exposure to an addictive substance, which produce strong cravings and withdrawal symptoms. Psychological components can include self-destructive patterns of behavior, poor self-control and ineffective coping skills. Treatment is rather complex as a result. In addition to addressing any long-term health issues, it is also essential to manage physiological symptoms of withdrawal. Addressing a client’s ambivalence to addiction treatment is complicated in light of these multifactorial issues and any lingering cognitive deficits.
So what is Coercion?
“The crux of coercion is to motivate the patient to comply with addiction treatment by enforcing consequences” (Sullivan, et al, 2008, p. 36). In examining the ethical nature of such practices, it is useful to consider the instances in which coercion is used throughout treatment. An obvious example of coercive treatment includes situations in which drug users are given a choice between treatment and penal sanctions for crimes committed (Stevens, 2012). Less obvious instances include staged interventions, contingency contracts, and pharmacological coercion via Antabuse (Sullivan, et al, 2008).
There appears to be much controversy surrounding the issue of coercion in substance abuse treatments. Those who oppose coercive treatment techniques state that these interventions are a violation of an individual’s personal liberties, and right to informed consent (Sullivan, et al, 2008; Stevens, 2012). Advocates, however point out that “few chronic addicts will enter or remain in treatment without some external motivation, or legal coercion” (Sullivan, et al, 2008, p. 42). At first glance, I find legitimacy in both perspectives.
Proponents of Coercive Interventions
On the one hand, it is clear that long-term use of addictive substances can produce cognitive deficits that interfere with one’s ability to participate in the treatment planning process. This fact alone seems to support the notion that some coercive efforts may be called for, (including the less obvious forms discussed earlier). Some proponents stress that it is a duty to act on behalf of those who are impaired to make treatment decisions (Marlowe, et al, 1996). From this perspective it is presumed that “once treated the individual will be grateful in retrospect for the intervention” (Marlowe, et al, 1996, p. 77).
Critics of Coercive Techniques
In addition to violating an individual rights, critics counter by stressing the fact that treatment is often ineffective if the individual is unmotivated to change. The Transtheoretical Stages of Change Model, is in fact a great illustration of this and provides a useful perspective that allows us to assess a client’s level of ambivalence to change. Instead, helping the client increase their level of motivation to change is preferred (Sullivan, 2008).
One resource provided an interesting discussion of cultural considerations pertaining to the use of coercive techniques that is also relevant. Collectivism and individualism each provide different perspectives of one’s “self” in relation to others, that is likely to determine effectiveness of such techniques. Individualistic societies promote the idea of self-responsibility, independence, and autonomy (Sullivan, 2008). As a result, from this perspective the individual is perceived to be responsible for their addiction, and coercive techniques are often less effective. On the other hand, collectivist societies provide a different view of the “self” as part of something greater. Individual well-being is a societal concern and coercive techniques are often much more effective. However, “collectivist families can also impede recovery if the group perceives drinking or drugging behavior as normal or an indication of weak character” (Sullivan, 2008, p. 44).
Regarding the utility of coercive techniques, Marlowe, et al, (1996) notes that many of the less obvious forms of coercion, often involve forms of negative reinforcement. In fact throughout the treatment process are coercive influences that involve an “escape or avoidance reinforcement schedule…[in which] the aversive stimulus precedes the target event” (Marlowe, et al, 1996). With this in mind, Marlowe, et al, (1996) suggest that a comprehensive assessment of coercive influences may assist treatment planning. In fact, when reading this resource I’m reminded very much of behavioral therapy. The use of naturally occurring contingencies that influence one’s behaviors and decisions is common throughout treatment. If utilized in this way, I’m not against the coercive influence of a contingency contract, or staged intervention, as described by Sullivan, et al. (2008). However, I’m very “wet behind the ears”, and my thoughts on the matter are likely to change as time progresses….
Marlowe, D. B., Kirby, K. C., Bonieskie, L. M., Glass, D. J., Dodds, L. D., Husband, S. D., & Festinger, D. S. (1996). Assessment of coercive and noncoercive pressures to enter drug abuse treatment. Drug and Alcohol Dependence, 42(2), 77-84.
Polcin, D. L. (2003). Rethinking Confrontation in Alcohol and Drug Treatment: Consideration of the Clinical Context. SUBSTANCE USE & MISUSE, 38(2), 165-184.
Stevens, A. (2012). The ethics and effectiveness of coerced treatment of people who usedrugs. Human rights and drugs, 2(1) 7-16.
Sullivan, M. A., Birkmayer, F., Boyarsky, B. K., Frances, R. J., Fromson, J. A., Galanter, M., & Tamerin, J. S. (2008). Uses of coercion in addiction treatment: clinical aspects. American Journal on Addictions, 17(1), 36-47.
White, W. & Miller, W. (2007). The use of confrontation in addiction treatment: History, science and time for change. Counselor, 8(4), 12-30.