Counseling Those With Substance Abuse Disorders Assignment | Top Essay Writing

Your manager asks you to see a client who appears to be decompensating. He has stopped coming to the center and his wife asks you for assistance. She says he is not eating, sleeps all day and rarely gets out of the house. He is talking gibberish to himself and mumbles profanities. She is afraid that he may harm her or their 3-year-old child. She further tells you she thinks he may be doing drugs but does not know which ones. She says the last time he was like this he attempted suicide through overdosing on his psych meds. He takes Ritalin for adult ADHD. What is your first priority in this case? Why? What type of treatment would you suggest? Why? What types of therapy might help this client stay on track? Why?

 

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Meaning, Uncovering the Next Layer We don’t see things as they are; we see things as we are. Anaïs Nin Understanding the content of the client’s story gives us an outline or picture in our minds about what has happened. The emotions add color to the story and help us imagine the sometimes overwhelming feelings that he or she is experiencing. On the other hand, when we understand a person’s meaning system, we begin to grasp how the person views the world. Meanings are built from a person’s past experiences, which are “alloyed with firm beliefs, fuzzy ideas, and unconscious schemes and prejudices” (Leontiev, 2007, p. 244). Thus, reflection of meaning is a significant step beyond reflection of content and emotion, because it helps us understand the client’s unique background and perspective. It also allows clients to become aware of the lens through which they are seeing themselves and others. Consider the case of Joan, who had been having problems at work for 2 years. Her co-workers had split into two factions that everyone on the job called “the redbirds” and “the bluebirds.” There was considerable animosity because of a power struggle between the leaders of the two groups. Joan found herself allied with the bluebirds. During one of their after-work gripe sessions, she revealed that she knew one of the redbirds, Bob, had sought treatment for alcoholism. Bob had told her this several years ago when they were on good terms. Somehow this information leaked to the administration; Bob’s boss called him “on the carpet” because the company was working on several government contracts, and Bob was investigated as a security risk. A couple of weeks later, Joan went to the company’s employee assistance program and asked for counseling. During the interview, she and the helper (Lynn) had the following exchange. Joan: “There is just so much turmoil. It used to be a good place to work. Now it’s ‘dog eat dog.’” Lynn: “You are sad because things have changed and now there is so much competition.” (reflection of feeling and paraphrase) Joan: “Yes, that among other things.” Lynn: “Okay, say more.” (door opener) Joan: “Well, Bob told me about his treatment for alcoholism one night when we were working late, sort of offhandedly. I even thought of him as a friend.” Lynn: “You’re afraid of his reaction when he finds out that you leaked the information.” (reflection of feeling and paraphrase) Joan: “Not really. It just seems a nasty thing to do to someone who was trying to be friendly.” Lynn: “In other words, you are disappointed in yourself for having betrayed a confidence.” (reflection of feeling and meaning) Joan: “Yeah, that’s the thing. I think I did it just to be part of the club. I don’t like that about myself. I wish I were secure enough to have my own opinions about people.” Lynn: “It sounds like it has always been very important for you to be approved of, and sometimes, to be part of the group, you find yourself doing something you don’t even agree with.” (reflection of meaning) If Lynn had merely paraphrased the story of Joan’s problems at work, her thoughts, and her underlying feelings, it would have been a productive session. However, Lynn chose to dig more deeply, not only paraphrasing Joan’s feelings about recent events but also looking at the underlying meaning—the perceptions and values her client attributed Figure 6.1  Levels of Disclosure to the self, the office situation, and the other workers involved. Notice how Lynn understands Joan’s disappointment in herself and how this leads to a deeper response by Joan. Previous paraphrases and reflections of feeling were not nearly as effective as when the helper keyed in on what was really bothering Joan. Figure 6.1shows that every client’s story, like Joan’s, has several layers. As if peeling an onion, a client is likely to give us first the content of the story, then the feelings it evokes, and finally, its personal meaning. The figure also illustrates the fact that as the client’s story becomes deeper over time, there are occasional returns to more superficial material. Increasing depth is due to the development of trust, but at the same time, more threatening material emerges, such as feelings and meanings that evoke embarrassment and shame. Therefore, depth varies as the client discloses. If the helper can keep the client focused on deeper issues and provide a safe environment, the full meaning of the story starts to emerge and the session trends deeper. Why Reflect Meaning? The story of Joan and Lynn demonstrates that unless we understand meaning, we are missing a crucial aspect of the message. In the section that follows, some of the reasons for reflecting feelings are described using Joan and Lynn’s conversation as an example. To Understand the Client at a Deeper Level Some investigations into the transcripts of Carl Rogers have found that 70% of his responses were reflections of meaning, not feelings (Elliott, Bohart, Watson, & Greenberg, 2011). You might notice that he sometimes speaks for the client, starting his sentences with “I,” such as “I just don’t trust myselfto be a good partner.” Rogers used this method of pretending to be the client as a way of getting in touch with the meaning the client assigns to events, thereby understanding him or her at a deeper level. Thus, one of the benefits is that the helper gets a feel for the client’s worldview.

To Lead to Deeper Self-Understanding in the Client

Thinking back about the conversation between Joan and Lynn, recall that the events in Joan’s story clearly have a deeper significance than Joan herself is able to identify at first. Why is it important for the helper to bring this deeper level of meaning to the surface? One reason is that the client takes these backdrop issues for granted. When the helper highlights them, the client begins to realize their significance and begins to understand that these meanings are part of the unique way he or she constructs the world.

To Emphasize that the Story is the Client’s Version

Besides increasing the client’s insight and the helper’s understanding of the client, reflection of meaning allows the client to recognize that the story he or she is telling is not the facts but is, instead, a perspective. The helper holds up a mirror to the client, “reflecting” rather than agreeing with what the client says. The helper lets the client get a good look at his or her own values and viewpoint about the self, others, and the world. When a client sees himself or herself through the eyes of another, he or she begins to envision how to make constructive changes. In Joan’s case, by opening up to the meaning of the story, she begins to see that her actions were due, in part, to her long-felt need for approval. When she makes this connection, it paves the way to set a goal for becoming more self-directing. Here are some leads a helper might use to emphasize the point that this is the client’s distinctive story and to avoid agreeing with the client that his or her perception is reality:

“In your mind, you were snubbed.”

“For you, this was another piece of evidence that trusting people is dangerous.”

“From your perspective, if only you had had better parenting, you wouldn’t be so down on yourself.”

To Push the Client to Go Deeper

Reflecting meaning inevitably has the effect of getting the client to discuss even deeper issues than those brought out in the first version of the story. Take a look at the end of the dialogue between Joan and Lynn. Can you see how Joan’s next statements in her dialogue with Lynn might progress? Perhaps she will discuss how she was raised, where her values came from, and how she is going to interact with her colleagues in the future. Whereas reflecting meaning leads to more disclosure and exploration of a topic, a helper’s inability to tap meaning results in more superficial conversations.

To Examine The Concept of Depth

Beginning helpers are often confused when the client’s story seems to have run its course. They feel that once the basic facts are known, where else can the conversation go? This is because the helper has not gone deeper into the meaning of the story. Figure 6.1shows the concept of depth in a client’s story over time. According to this model, superficiality is the result of traveling too rapidly through the story in a horizontal direction, rather than going deeper, or vertically. The depth that a client is willing to reveal depends on a number of factors. Among these are helper responses, client readiness and willingness, and whether or not the client feels safe in the therapeutic relationship.

Encouragers like “Uh-huh” and “Go on” do not necessarily nudge the client to go deeper. They tend to keep the client at whatever level the discussion has reached. If the helper does not invite the client to reach deeper levels by reflecting feelings and meanings, the client will normally remain at level 1 (Figure 6.1). Of course, some clients are very psychologically minded and will quickly discuss the deeper aspects of a problem with little prompting, but even insightful clients frequently miss the importance of meaning because they take their meanings for granted.

On the other hand, some clients are not very talkative and are uncomfortable with expressing feelings and uncovering personal issues. In that case, going deeper takes a much longer time, even if the helper is very inviting and uses reflecting skills. Such clients may have trouble getting to the feelings and meaning levels, and when they do, they only visit briefly. Clients are more likely to disclose deeply if the helper is perceived as competent, trustworthy, and nurturing.

Obviously, the only factors that the helper can control are his or her own actions. The helper cannot always break through a client’s reluctance to open up. To increase the likelihood of greater depth in the client’s explorations, the helper must not only avoid the overuse of closed questions and an interrogating attitude but also rely on reflecting skills to enhance empathy in order to deepen the client’s story whenever possible.

Challenging the Client to Go Deeper: The Inner Circle Strategy

In Joan’s case, the helper used questions and reflections of meaning to get at the deeper levels of the story. Sometimes clients have difficulty recognizing that their stories have these deeper layers, and it is useful to challenge them to move from a superficial recounting to the area of personal meanings, secrets, and core beliefs (see Shaughnessy, 1987). Arnold Lazarus, the founder of multimodal therapy, used what he called an “inner circle strategy” for getting clients to identify deeper, more personal issues (1981, p. 55). Using the inner circle strategy, the helper draws a series of concentric circles labeled A, B, C, D, and E (see Figure 6.2). At ring E are issues that are essentially public and might be discussed with almost anyone on first meeting, including one’s appearance and occupation. Issues at ring A are very personal such as sexual problems, anger and resentment toward people, negative views of the self, and secrets that the client feels are immoral or dishonest. Most relationships start at D and move toward A as the relationship grows. However, some relationships remain very close to D, and deeper topics are never broached. To understand a client’s willingness to disclose, the helper may ask the client to write in the names of individuals, including the helper, who have access to the various rings from A to D. Lazarus advocated using the diagram to confront the client when therapy has become too superficial. For example, the helper might say, “It seems to me that we are discussing issues that fall in the D or C category. The most effective work occurs at level A or B. I am wondering whether you do not feel comfortable talking about these deeper levels yet.”

Figure 6.2

The Inner Circle Strategy

Stop and Reflect Secrets

“You are only as sick as your darkest secret.” In Alcoholics Anonymous, this aphorism is used to remind those in recovery that being truthful and open about themselves is much healthier than putting on a false front. The positive consequences of disclosing to others include the following:

  1. We may see a reduction in psychological and physical problems.
  2. We may be better able to quit smoking or other addictions because we are affected by the opinions of others.
  3. The secret does not have to be suppressed and therefore it loses its power to dominate one’s life.
  4. When we reveal secrets, we may gain insight and see the issue in a different light. (Kelly & McKillop, 1996)

Although being honest within a professional relationship has these benefits, more than 50% of therapy clients report that they have kept secrets from their helpers (Hill, Thompson, Cogar, &­Denman, 1993Kelly & Yuan, 2009Robey, 2011). When a client comes to a helper for help, how important is it that he or she be completely honest? Is it permissible for a client to retain some privacy and under what circumstances? How can we invite clients to share but show respect for their refusal to examine every nook and cranny of their private lives (Kottler& Carlson, 2011)? Many ethical guidelines of professional organizations deal with the issue of secrets because their members are expected to maintain their clients’ confidences. It is a paradox that we are to keep our client’s secrets, yet we cannot force them to be completely honest with us. Consider the following scenarios and think about how you might handle them. If possible, discuss them with a small group of fellow learners.

  • Your client is a 43-year-old married man who has just returned from an alcohol treatment center. He does not want to attend Alcoholics Anonymous (AA) for aftercare but comes weekly for counseling. During his sessions, he is open about his substance abuse issues but is very quiet about his family relationships and his sources of social support. You feel that going to AA would be helpful in maintaining his sobriety and in providing a social outlet. Apparently he has no friends and confides in no one. How would you deal with this situation? How far would you go in insisting that he learn to open up?
  • You are conducting outpatient group therapy for 12 women. One of the rules of the group is that there will be no socializing outside of the group. One evening while shopping, you happen to see two of the women from the group sitting together at a restaurant in the mall. They are deep in conversation, and they do not notice you. How do you think their secret relationship might affect their interactions with each other and with the group? As the group leader, what should you do? Should group leaders have rules about keeping secrets?
  • You have been seeing a client, Isabel, for 4 weeks. At first, she discussed her dissatisfaction with her job and her concerns about parenting her teenage son. On the fifth week, Isabel admits she is having an affair with a co-worker, unbeknownst to her husband. Isabel says that her husband senses something is wrong in the relationship and wants marriage counseling. Isabel believes they could benefit by being seen as a couple and asks you to do the counseling, but not to reveal the ongoing affair. What would be the best response to Isabel? Can you agree to keep this secret if you see them as a couple?

Stop and Reflect

We have been talking about the fact that the most productive therapeutic relationships are developed when clients feel free to reveal their deepest thoughts, feelings, and perceptions. Clients who venture to this level of disclosure are, however, risking a great deal. What would a person need to know about you before you would feel that he or she were sufficiently informed to help you? How long would you have to know someone before discussing your deepest secrets? Read each topic in the following list, and identify something relevant about yourself that you would be willing to discuss with a helper during the first session and something else that you probably would not discuss. Write down brief notes under each heading. What do you fear might happen if you were to disclose the thoughts, feelings, and perceptions that you would prefer not to discuss?

Topic I Would Disclose I Would Not Disclose
·         Your family values and family history

·         Your religion or spiritual beliefs

·         Your sexual history

·         Your personal dreams and ambitions

·         Happy and unhappy childhood memories

·         Physical limitations, disabilities, and illnesses

·         Times when you were dishonest or unethical

Draw an inner circle for yourself like the one in Figure 6.2and write down the names of people who have access to the deeper issues in your life. Now think of one or two issues that you would not discuss with anyone, even a professional helper. What would stop you? Are there also issues at rings B and C that would be difficult but not impossible to discuss with a helper? What issues would you discuss only if there were safeguards of confidentiality? Share your inner circle with a small group of classmates if you feel comfortable in doing so. There is no need to discuss the issues at each of the levels. However, it might be interesting to compare the numbers of people who have access to the various levels of your life. Who are these people, and how did they gain this kind of trust?

Worldview: Meanings Are Personal

For the meaning of life differs from person to person, from day to day and from hour to hour. What matters, therefore, is not the meaning of life in general but rather the specific meaning of a person’s life at a given moment.

Viktor Frankl

One way to think about meaning is that it is a product of a person’s worldview. Worldview is a term that refers to a person’s view of self, others, and the world (Koltko-Rivera, 2004). Language, gender, ethnicity/race, religion/spirituality, age, physical abilities, socioeconomic status, and trauma all influence the development of one’s worldview. In addition to worldview, a client’s personal values (what is important in life) are sources of meaning that can be brought to the surface. Recall the discussion between Lynn and Joan. The issue boiled down to Joan’s feeling that she had betrayed herself as well as a friend’s confidence. Violations of one’s personal values are frequently background issues in client’s messages. The helper’s job is to understand both the client’s worldview and his or her values so that the client’s viewpoint—and the meaning of his or her story—can be appreciated and an appropriate solution to the client’s problems found. Without understanding Joan’s moral dilemma and disappointment in herself, do you think it would be possible to help her deal with her situation at work? The appropriate solution must be consistent with her ideas of what is right and healthy. In other words, it must take into account her worldview and values. One of the ways that helpers can understand a client’s worldview and access the meaning a client ascribes to his or her situation is to be sensitive to client disclosures.

Following are some other examples of client statements that give a window into worldview or values.

View of Self

  • “I am essentially . . . (a good person) (evil) (selfish) (okay/not okay) (smart/dull) (damaged) (unlovable).”
  • “Nothing I do seems to work out.”
  • “I always land on my feet.”
  • “I am unlucky.”
  • “I am a victim.”
  • “I am a bad parent.”

Notice that these statements express general notions about the self, rather than defining specific abilities such as being a good piano player or having a good sense of direction.

View of Others

  • “People are . . . (unreliable) (essentially good) (selfish) (trustworthy) (kind).”
  • “Men are all alike.”
  • “People will take advantage of you if they can.”
  • “White people are . . .”
  • “Asians are . . .”

Beliefs about the Environment or the World in General

  • “It’s a jungle out there.”
  • “Life is a vale of tears.”
  • “You can’t get ahead.”
  • “It’s bad luck.”
  • “God punished you.”
  • “Things always turn out for the best.”

Values

  • “People should treat each other fairly.”
  • “Men should be the head of the family.”
  • “Family secrets should be kept in the family.”
  • “Conflict is bad.”
  • “You should always try to do your best.”

CHAPTER 7

When Should we use the Challenging Skills?

During the initial stages of the relationship, the helper strives to understand the client’s unique worldview by getting the client to open up. As a client tells the story, the helper listens attentively using the nonjudgmental listening cycle (NLC). After several cycles, the helper begins to detect distortions, blind spots, and inconsistencies. He or she may then use challenging skills to help clients function with more accurate information about themselves. With heightened self-awareness, they are better able to make decisions and to operate free of illusions and “vital lies.” Challenging is consistent with the primary goal of helping: to empower clients by encouraging them to explore their thoughts, feelings, and behaviors and to take steps toward their dreams and goals.

When challenging skills are used, the aura of safety and support, so carefully constructed by the helper, is at risk. There is a fundamental shift from relationship building to a focus on the goals set by the client and helper, conveying to the client that the helping relationship is not a friendship but a business partnership during which the helper may have to hold the client’s feet to the fire in order to attain the agreed-upon outcomes. Clients need to be challenged when:

  • They are operating on misinformation about the self. For example, a client may underestimate her intelligence, feeling that she is not capable of attending college when there is evidence to the contrary.
  • They are operating with mistaken ideas and irrational beliefs. For example, the client believes she must be perfect.
  • They misinterpret the actions of others. This tendency is called mind readingand is a common problem among couples. A client may act on assumptions without confirming them, making statements such as the following: “I could tell by the way he acted that he did not want to date me anymore.”
  • They are blaming others rather than examining themselves. For example, a client may blame the boss at work but refuse to look at his own responsibility for the poor relationship or his own work performance.
  • Their behavior, thoughts, feelings, and values are inconsistent. For example, a client talks about how much she values honesty but, at the same time, discusses how she hides her financial difficulties from her husband.
  • They are not operating according to their own values.
  • They are not working on the goals that they participated in setting.

In this chapter, we will focus on two building blocks, or basic skills, used to challenge clients and help them deal with problems more consciously. The first of these is giving feedback: providing information and your honest reaction to the client. The skill of giving effective feedback is one that has wide application in helping, including group work, couples counseling, and individuaGiving Feedback

Why Is Feedback Important?

Disclosing oneself to others and receiving feedback from others are the twin processes of promoting personal growth. The invitational, reflecting, and advanced reflecting skills that you have already learned are the primary methods helpers use to encourage client self-disclosure. We have discussed how the mere act of confiding in another person seems to have many health benefits (Pennebaker, 19902004), and the ability to be “transparent” to others has also been linked with mental health (Jourard, 1971). Learning to receive feedback is the other key to self-awareness and growth. Clients need accurate feedback in order to confront inconsistencies in their own attitudes and to know how they are affecting others. Most problems that people face are “people problems.” People usually come for help when they experience pain in their interpersonal worlds. Unfortunately, we often receive conflicting messages about ourselves from other people because even family members and close friends may be afraid to give us honest feedback. Many of the terrible singers on talent shows have been encouraged by their closest friends and family members to participate. Our significant others may withhold feedback because they do not wish to jeopardize the ­relationship. Rosen and Tesser (1970) call this unwillingness to transmit bad news the “mum” effect. Thus, we are often operating with incorrect or inadequate information. On the other hand, the helper has both the opportunity and the responsibility to deliver honest feedback even if it is uncomfortable to do and for the client to receive. Irvin Yalom (2000) compares the responsibility to give accurate feedback to the job of an executioner because it is the helper’s duty to point out the holes and flaws in, and sometimes to kill, the client’s most romantic ideas. Therefore, it is critical to deliver feedback in ways that benefit the client.

How to Give Feedback

In the helping relationship, giving feedback means supplying information to a client about what you see, feel, or suspect about him or her. Feedback helps people grow when they are receiving constructive, specific information about themselves. When a professional helper gives feedback, the sole purpose is to help the client. Feedback from a professional—unlike that from family and friends—does not take into consideration the needs of the helper or concern itself with whether or not this will produce a strain on the relationship. Helpers only give feedback when clients ask for it or when clients need information to progress. They give feedback for three purposes:

  1. To indicate how the client’s behavior affects the helper

Example: “You say you want to be assertive, but I experience your behavior as passive when you look away and avoid eye contact.”

  1. To evaluate a client’s progress toward the goals

Example: “As I see it, you have now been successful in overcoming your anxiety by facing the situations you have been avoiding.”

  1. To supply a client with information based on the helper’s observation

Example: “I notice that you never seem to talk about your father.”

Feedback may be rejected by clients because “the truth hurts,” because it is incorrect in the client’s eyes, or because it is too harsh. Therefore, helpers endeavor to present feedback in ways that will make it more palatable. Here are some suggestions about how to give effective feedback in a way that others may accept. These are also good rules for trainees, who may be giving feedback to each other in group exercises.

  1. Use I-messages.

In his classic book about raising children, PET: Parent Effectiveness Training (19752000), Thomas Gordon described the process of delivering feedback as “I-messages.” Most feedback statements delivered by helpers are I-messages because using the word I conveys that the helper is expressing his or her own perspective. When a person starts a conversation by saying, in effect, “This is my viewpoint,” we are more likely to listen nondefensively. For example, consider the following pieces of feedback:

“I am uncomfortable when you talk that way about women.”

“I am hurt that you did not seem to acknowledge my birthday.”

“I notice that you don’t seem to have any friends.”

  1. Do not give people feedback on their personality traits or something they cannot change.

It is hard to see how one can change one’s character and so such general remarks are easy to reject.

Poor feedback (boss to subordinate): “You are a procrastinator.”

Good feedback: “For the past 3 months, your report has been late.”

  1. Be specific, concrete, and nonjudgmental.

Poor feedback: “You’re bugging me.”

Good feedback: “I find it annoying when you whistle during my favorite music.” (I-message with specific content)

  1. Always ask permission before giving feedback.

For example: “You say that people at work are angry about your behavior. Would you like some feedback?”

Or, “I would like to give you some feedback on something I have noticed. Is that all right?”

  1. Sometimes feedback about touchy subjects is accepted more easily if it is offered tentatively.

You do not have to dilute the feedback; rather, find an acceptable route to get the client to think about what is being reported.

Poor feedback: “You are avoiding that issue with your father.”

Good feedback: “I got the impression last time that talking about your father was difficult for you and you seemed to steer away from that topic. Maybe it is because you think you deserted him when he was ill. Am I right about this?”

  1. Give only one or two pieces of feedback at a time.

When too much feedback is given, client defenses rear up like impenetrable walls.

Poor feedback: “I think you should improve your appearance at work. You look disheveled, and you need to wear a more formal shirt. By the way, you left the copy machine on again last night, and you forgot to call Dodie back.”

Good feedback: “I think you should improve your appearance at work. For example, your pants are wrinkled, and a T-shirt really is not appropriate.”

  1. Do not forget to give feedback that emphasizes the client’s strengths.

It is easy to assume that clients are aware of their strengths and that we should focus only on their foibles. Identifying strengths is part of “positive psychology” and focusing on positive character traits engenders hope (Lopez & Kerr, 2006Ward & Reuter, 2011). We tend to give more feedback to uncover unknown weaknesses rather than to point out assets. More often, clients need to know what is going right, what is working, and what resources the client has to bring to the problem (see Wong’s [2006] strength-centered therapy and Ward & Reuter’s [2011] strength-­centered counseling). Try focusing on the positive aspects first and bringing up the negatives later.

Poor feedback: “You asked someone out for a date, but you did not work on the other part of the assignment, where you were to confront your friend about her behavior. Let’s talk about that.” (only mentioning the negative)


  1. Good feedback:
     “Based on what you’ve said today, I’m picking up that you have made real progress. Even though it was a little scary, you asked two people for a date and one of them said yes.”
  2. Use a follow-up question to determine whether the feedback was received and how it was accepted.

Helper: “A minute ago, I pointed out that you have spent the last few weeks talking only about your ex-husband. What is your reaction to that feedback?”

Stop and Reflect

There is a parallel in our own optic system that can demonstrate the existence of blind spots or holes in our view of the world, at least from a physiological viewpoint. You may know that the optic nerve attaches to the back of the eyeball. Where it connects, there is a small gap in the picture your brain sees. Because we have two eyes, the other eye takes over and corrects for this tiny blind spot and we never know that it exists. Take a look at the X and the large dot shown in Figure 7.2. Now hold this book with your right hand and stretch it out to arm’s length. Stare directly at the X on the left side of the page. Close your left eye and slowly move the book straight toward your face. At about 12 inches, the dot on the right side disappears.

Figure 7.2

Blind Spot

The physical blind spot is only an analogy of the psychological phenomenon. Still, it alerts us to the fact that our knowledge about the world and ourselves is not complete. Because we are unaware of these hidden parts of ourselves, it takes some convincing before we believe what is revealed. Consider the following questions:

  • In this experiment, you learned about your blind spot through actual experience. Suppose I had merely told you about the blind spot? Which information is the most powerful in convincing you of its existence?
  • How can we help clients have experiences of their psychological blind spots rather than merely telling them?
  • Suppose you gave the client some feedback that you were 98% sure was true and accurate, and the client’s response was to dismiss it completely. How do you think you might react? How could you get the client to consider it further without damaging the relationship?
  • Suppose that a client feels rejected in her personal relationships. In her interactions with you and with other personnel, you notice that she talks constantly, rarely allowing anyone else to control the conversation. First, write down a nonjudgmental feedback statement exactly as you would deliver it. Next, identify one or two other situations where the client might get this kind of feedback. What assignments might you give the client to make her more aware of this tendency?

Confrontation

Confrontation is the second challenging skill we will address in this chapter. Confrontations point out discrepancies in client beliefs, behaviors, words, or nonverbal messages. As a result of confrontation, client awareness of inconsistencies is stimulated, and the client is motivated to resolve them. In essence, it is an educational process that brings information to the client’s attention that has been previously unknown, disregarded, or repressed. The most powerful confrontation urges the client to resolve the inconsistencies. Confrontation creates emotional arousal and can lead clients to develop important insights and motivate them to change their behavior.

What Is a Discrepancy?

discrepancy is an inconsistency, a mixed message, or a conflict among a client’s thoughts, feelings, and behaviors. In fact, every problem contains discrepancies. For example:

  • A client says that she wants an equal, sharing relationship, but she only dates domineering men.
  • A client says that she loves her job, but she complains about it constantly.
  • A client states that he wants to improve his marriage, but he forgets to go to marriage counseling sessions.
  • A client is intelligent and tenacious but is convinced he will not do well in school.

Why Should Discrepancies Be Confronted?

Ivey and Simek-Downing (1980) say that “the resolution or synthesis of incongruities may be said to be a central goal of all theoretical orientations” (p. 177). In fact, most well-known therapeutic systems use confrontation to some degree. The Gestalt therapist Fritz Perls confronted clients about incongruities in their nonverbal and verbal behavior (which he labeled “phony”). Albert Ellis, the founder of rational emotive behavior therapy, liked showing clients the gap between their beliefs and rationality by directly exposing them to the “nuttiness” of their ideas. Albert Ellis used loud voice tones or even curse words to intensify confrontations. Some early group therapy methods for treating substance abuse (the Synanon approach, Straight Inc.) used personal attacks and abusive confrontation to create client movement in dealing with deeply ingrained behavior patterns. However, there is little evidence to support the use of such strong confrontation. In fact, it appears that, even with substance abusers, a consistent highly confrontational therapist style is not as effective as a moderately confrontational one (see Figure 7.1and Miller, Benefield, &Tonigan, 1993). This information has added support to a theoretical approach called motivational interviewing (MI), which has been successfully practiced and researched in addictions programs. In MI, helpers are careful to acknowledge the client’s point of view while pointing out the conflict. They use confrontations but qualify them as “double-sided reflections.” For example:

Client:“Everybody wants me to stop drinking. But I am not going to give up going with my friends for a beer or two. There is nothing wrong with that.”

Helper:(Referring to things the client has said in the past) “Although you often talk about the many problems that alcohol has caused in your life, you just can’t see quitting and distancing yourself from your drinking friends.”

In this double-sided reflection, the helper acknowledges the client’s statement that he wants to continue to drink for social reasons and at the same time does not pull any punches by reminding the client of the problems alcohol has caused him. The helper’s agreeing with part of the client’s statement softens the blow of the confrontation, making it moderately challenging. To use anything stronger could create a rupture in the helper/client relationship, which is the very thing that keeps the client in treatment and engaged with the helper.

In this chapter, we urge you to consider how to raise inconsistencies in a client’s mind without alienating him or her. Confrontation is an advanced reflecting skill that should be developed after the early helping building blocks of invitational and reflecting skills have been firmly established. Research confirms that highly trained (doctoral) counselors used confrontation more often than students (Tracey, Hays, Malone, & Herman, 1988). At the same time, doctoral-level counselors demonstrated less dominance and verbosity than student helpers. It appears, then, that as helpers gain experience, they use confrontation more frequently, talk less, and are less pushy as they provide support.

Cognitive Dissonance and Confrontation: Why Confrontation Works

Do you remember the concept of cognitive dissonance from your first Introduction to Psychology class? Cognitive dissonance theory states that we are motivated to keep cognitions such as values, beliefs, and attitudes consistent (Festinger, 1957). When people experience inconsistencies in their thoughts, feelings, and behaviors, this creates tension, and they are motivated to reduce the tension. As a consequence, we can either convince ourselves that the incongruity is unimportant or else change one of the incompatible elements. Let us take the example of quitting smoking. Smokers are aware of the health risks but also continue smoking. The conflict between smoking behavior and putting oneself at risk creates cognitive dissonance. Smokers may reduce the dissonance in a number of ways: to either ignore or misinterpret the facts about health risks or else tell themselves that they are “addicted” and therefore quitting is not under their control (self-handicapping strategy; Jenks, 1992). Either way, smokers are pushing the risks out of awareness. One study of college students who smoked asked them to view an online program about the effects of smoking (­Simmons, Heckman, Fink, Small, & Brandon, 2013). They were then asked to make a video recording of their own negative experiences with smoking and then they watched their recording. The researchers found that the students whose awareness of the risks had been heightened were more motivated and had higher rates of smoking cessation than those in comparable treatments. Heightening of awareness led to ­motivation.

Consider also the case of Donna, a 25-year-old woman who describes her job as good-paying but also as repetitive and boring. She needs the job to help her mother, who is struggling to survive on Social Security. Donna wants to go to college because she is not intellectually challenged in her present position, but the costs are too great. This creates dissonance. She deals with the tension caused by these conflicting thoughts by telling others and herself that education and intellectual challenge are not really important. We all use such defense mechanisms to distort reality so that we can reduce anxiety. In this case, the distortion masks the fact that Donna does really want to go to college and the lack of intellectual stimulation does bother her. For her, going to college may not be possible but pretending that her desire does not exist is creating a giant “blind spot” in her life. Many times, clients use defense mechanisms to escape dissonance, rather than making choices based on thinking and planning. When helpers confront people with these discrepancies, anxiety often resurfaces but so does awareness of choices. Donna may realize that there may be nontraditional and incremental ways of taking classes she has not considered, but first she must be confronted with her tendency to push the inconsistency out of awareness.

Kiesler and Pallak (1976) reviewed dissonance studies and found a link between dissonance and physiological arousal (Cooper, Zanna, &Taves, 1978Croyle& Cooper, 1983Pittman, 1975Zanna& Cooper, 1974). It seems that clients actually change their attitudes in order to reduce the arousal caused when the helper makes the client aware of the two incompatible elements. The confrontation causes anxiety because the client then becomes aware of this split, which is normally kept out of awareness by his or her defenses. The client’s frozen position has provided some security, but now the client is acutely aware of both sides of the conflict again and becomes motivated to change (Elliott & Devine, 1994). In the case of Donna, the helper might encourage Donna to become more aware of her need to be intellectually stimulated and ask her to talk about it, explore it, and even investigate options to use her mind. Without blind spots and defense mechanisms, it is possible to make decisions that are more reality-based and personally satisfying (Claiborn, 1982Olson &Claiborn, 1990).

Although we may use confrontation to bring buried elements into consciousness, we must remember that clients do not really like it because it produces negative emotions (Harmon-Jones, 2000Hill et al., 1988). If the helper’s confrontation is too powerful and the client’s emotional arousal is too great, the client not only will reject the message but also may be less willing to explore feelings and to trust the helper (Hill et al., 1988). Thus, therapists tend to use confrontations sparingly because doing so is strong medicine; and they should combine it with a liberal helping of support, or else they risk causing a rupture in the relationship (Barkham& Shapiro, 1986Norcross, 2011Strong &Zeman, 2010).

Types of Discrepancies and Some Examples

There are five elements of a client’s story that can come into conflict: the client’s worldview or beliefs, the client’s previous experiences, the client’s verbal messages, the client’s nonverbal messages, and the client’s behavior. It is not important to memorize each of the types of possible discrepancies. The examples that follow are simply meant to help sensitize you to the fact that discrepancies in a client’s story can take many forms.

Incongruity between Verbal and Nonverbal Messages

Client:“It’s been hell. This whole thing. It’s almost funny [laughs]. You know. Sometimes he loves me, sometimes he hates me.”

Helper:“Your laughing and smiling make me think the problem is not serious, and yet I can tell by what you’ve said that it has been very painful for you.” (confrontation)

Incongruity between Beliefs and Experiences

Client:“I do the best I can. And I am a hard worker. But I am not as smart as my classmates. They are really smart. That bothers me. I am almost finished with my degree but I didn’t sail through like they did.”

Helper:“Okay, I am confused. You say you are not smart enough and yet you are almost finished with your degree.” (confrontation)

Incongruity between Values and How the Client Behaves

Client:“My son is the most important thing in the world to me. But I just don’t have time to see him every week. I need some recreation, too. If I want to get ahead at work, I have to put in the hours.”

Helper:“If I understand you, you say that your relationship with your son means a lot to you, but somehow you’ve let other things get in the way.” (confrontation)

Incongruity between What the Client Says and How the Client Behaves

Client:“I’ve been going to Cocaine Anonymous as I said I would. But it’s not really helping. Every time I see one of my old friends, I’m back into it again.”

Helper:“I’m confused. You say that you want to give up cocaine, and yet you continue to see your old drug friends.” (confrontation)

Incongruity between Experiences and Plans

Client:“Sure, my girlfriend and I have been having a lot of problems lately. But if we moved in together, I think things would improve.”

Helper:“From what you told me before, isn’t one of the problems that whenever you spend any length of time together, you fight even more? Yet, you are thinking that being together full time will make things better.” (confrontation or “double-sided reflection”)

Incongruity between Two Verbal Messages

Client:“My wife makes twice as much money as I do. It doesn’t bother me. But I always feel that she looks down on me because of it. I should be making a lot more than I do. I often think about starting a new career.”

Helper:“Okay, on the one hand, you say that it doesn’t bother you, and yet you also say that you feel inadequate in her eyes and talk about a career change!” (confrontation)

Ethical Alert

In our discussion of confrontation, some guidelines were given for its most effective use. But a few of these issues point to ethical issues as well. The codes of ethics do not specifically identify confrontation, but there are guidelines for use of emotionally arousing techniques and the training you should receive before using them. Consider the following:

  1. It is unethical according to the codes of helping professionals to use a technique that you are unfamiliar with unless you are under the supervision of someone who is adept in its use. Strong confrontation, being a potent method, is a technique that should be discussed with a supervisor before it is applied.
  2. Most ethical codes point to considering the cultural, religious, and spiritual background of a client before applying a technique such as confrontation. Confrontation is an excellent example of a technique with important cultural and developmental implications. For example, Lazarus (1982) discusses how this technique backfired with some Native American children in a school counseling setting. Others have recommended a gentle approach in using confrontation with African American and Asian American clients (Ivey, 1994). Schectman and Yanov (2001)found that confrontation was not effective with children in groups in Israel.
  3. Using confrontation as a way to vent your frustration would not be ethical. Helpers may feel frustrated when the client is not progressing quickly enough, but the needs of the clients must take precedence over those of the helpers.
  • For more information, consult the following codes of ethics on association websites:
  • American Counseling Association’s 2014 Code of Ethics

http://www.counseling.org/knowledge-center/ethics

  • American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct

http://www.apa.org/ethics/code/index.aspx

  • National Association of Social Workers

http://www.socialworkers.org/pubs/code/default.asp

  • American Association for Marriage and Family Therapy

https://www.aamft.org/iMIS15/AAMFT/Content/Legal_Ethics/code_of_ethics.aspx

  • National Organization for Human Services (NOHS)

http://www.nationalhumanservices.org/index.php

How to Confront

The helper’s confrontational statement is a reflection that usually uses the following formula: “You (think, value, believe, say, experience, plan, behave, or show nonverbally)       but you also (think, value, believe, say, experience, plan, behave, or show nonverbally)         .”

  • “You said , but your nonverbals said      .” (verbal versus nonverbal)
  • Example: “You said you were happy, but I don’t see that in your face.”
  • “You believe , but you possess      .” (negative beliefs about oneself versus strengths)
  • Example: “You say that you believe you aren’t very strong or tough, but the tenacity I saw when you dealt with the Veterans Administration does not seem to fit with that belief.”
  • “You value , but you act      .” (values versus actions)
  • Example: “You obviously value your family, but you spend nearly 60 hours at work each week.”
  • “You said , but you acted      .” (verbal versus actions)
  • Example: “You said you were excited about coming to counseling, but you haven’t been making your appointments.”
  • “You plan to do , but your past experiences tell you      .” (plans or beliefs versus past experiences)
  • Example: “You plan to try to become more socially active, but there is a part of you that says you’ll be rejected like before.”
  • “You say , but you also say      .” (verbal versus verbal)
  • Example: “Sometimes you say you are happy with your job, and other times you threaten to quit.”

As you begin to identify discrepancies and present them to a client, you might find it helpful to memorize the following phrase: “On the one hand,      ; on the other hand,      .” This formula allows you to plug in any two discrepant elements without having to name which elements are in conflict (verbal vs. nonverbal, values vs. actions, verbal vs. actions, etc.). Although you do not wish to overuse this statement with clients, this formula will help remind you to look for the conflicting aspects of a client’s story. In Table 7.1, each of the major building blocks is described along with its purpose, when to use it, and a suggested formula. This chart may help remind you of the formulas that you have learned. It also shows how confrontation follows the relationship-building invitational, opening, reflecting, and advanced reflecting skills.

MyCounselingLab Application Exercise 7.1

Practice in Identifying Discrepancies

MyCounselingLab Video Exercise 7.1

When Worlds Collide

Steps to Confrontation

  1. Step 1First, take time to understand the issue and listen carefully, making sure the relationship is well established before confronting. Move through the NLC to fully understand the client’s message and reflect feelings and meaning. Ask yourself whether the timing is right or whether a confrontation will prematurely place stress on the relationship. In other words, have you earned the right to confront (Egan, 1977)?
  2. Step 2Present the confrontation in a way that the client will most likely accept it. In other words, make your confrontations moderately challenging. The following
  1. Table 7.1 Building Block Skills, Formulas, and Timing
Building Block What It Reflects When to Use It Formula
Paraphrase (P) Most important events and thoughts When you are trying to understand what is happening or what the client is thinking None
Reflection of Feeling (ROF) Client feelings As soon as you sense the emotions behind the content You feel     when       .
Reflection of Meaning (ROM) The meaning When you have understood the content, the feelings, and the meaning You feel      because      .
Confrontation (CON) Discrepancies in the story When the relationship is strong enough On the one hand, you (think, value, believe, say, experience, plan, behave, or show nonverbally)      but on the other hand, you (think, value, believe, say, experience, plan, behave, or show nonverbally)        .
  1. example shows a helper using open questioning and reflection of feeling to gently usher in confrontation and reduce the negative impact.
  2. Jyoti (Helper):“You say that this hasn’t been a good school year for you and you are thinking about dropping your Advanced Placement class.” (paraphrase)
  3. Olivier (Client):“Yeah, it’s not going too well.”
  4. Jyoti:“Well, if I understand it right, you’re discouraged because you are getting a ‘B.’” (reflection of feeling)
  5. Olivier:“Yeah, obviously I am not going to make it.”
  6. Jyoti:“Okay, I’m confused. On the one hand you say it’s been a terrible year but at the same time a lot of good things have happened this year. We’ve talked about the fact that you’ve become more organized and gotten along better with your teachers. You’re doing better than passing in your AP class but you don’t want to recognize that.” (confrontation of client’s negative view of self and strengths)
  7. Olivier:“I guess so. But I still have a long way to go.”
  8. Jyoti:“Sounds like it’s hard for you to pay attention to the strengths you have and the gains you’ve made this year. In a way, you seem to prefer to focus on what you’re not achieving.” (confrontation of client’s avoidance of strengths and focus on weakness)
  9. Olivier:“I’m afraid I would slack off if I patted myself on the back all the time.”
  10. Step 3Observe the client’s response to the confrontation. In this case, the client does not fully accept Jyoti’s first confrontation. The helper notes this and repeats her confrontation in a slightly different way.
  11. Step 4Follow up the confrontation by rephrasing or retreating. When the client does not accept or rejects the confrontation outright, the helper should try another tack. Because clients often respond to confrontation either by denial or by superficial agreement, the helper must be ready to follow up with additional exploration, another confrontation, or clarification. Jyoti’s second confrontation seems to be more acceptable to the client. He gains some insight into his situation.

MyCounselingLab Application Exercise 7.2

Practice Using the Helper Competency Scale (HCS) to Evaluate Confrontations

Common Problems in Confrontation and Their Antidotes

A good confrontation is one that the client responds to thoughtfully and that furthers the dialogue between helper and client (Strong &Zeman, 2010). If you want to see the effectiveness of your confrontation, examine the client’s response in a transcript. Did it push the client to examine the deeper issue? Unfortunately, many confrontations “bounce off” because the client is not ready to look at the discrepancy or because the confrontation either is worded too strongly or is too vague. In short, the aim of the confrontation is to examine both sides of the client’s view of the problem. That is what deepens the conversation. Here are three common problems in confrontation as well as some suggested ways of dealing with them (antidotes).

Responding When the Client Denies The Truth of The Confrontation or Shrugs It Off

  • Antidote: Follow up on the confrontation. For example:

Client:“When I first met my co-worker, Michele, I was excited about her because she seemed so nice but I soon caught on that she was just a fake. I guess I just can’t stand that in a person. She talks about me behind my back and although I never say anything, it makes me mad. But there are some other people in the office that agree with me and so I have support.”

Helper:“So you don’t like the fact that she talks about you behind your back but you can’t seem to be honest with her either.”

Client:“Yes, but she doesn’t listen to what anyone says and besides she has applied for a transfer and maybe that will solve the problem.”

Helper:(Following up) “What I said before was that on the one hand you can’t stand people who are not honest and I was wondering if you are little bit scared of broaching that issue.”

Responding When the Client Accepts One Part of the Confrontation While Rejecting another part

  • Antidote: Having the client disagree with some of the confrontation but accept part of it can clarify this issue and lead to further dialogue. At such times, the helper is encouraged to focus the discussion on the areas of agreement and press for a resolution of the conflict. The following is based on our previous example in which a helper confronted a client (1) who stated that he wanted to give up cocaine and (2) who continued to associate with his old, drug-using friends. The dialogue shows how the client partially accepts the confrontation, and the client and counselor then begin a deeper dialogue.

Client:“I’ve been going to Cocaine Anonymous as I said I would. But it’s not really helping. Every time I see one of my old friends, I’m back into it again.”

Helper:“I’m confused. You say that you want to give up cocaine, and yet you continue to see your old drug friends.” (confrontation)

Client:“I do want to stop using. But what am I supposed to do? Stay by myself all the time? That I am not willing to do.”

Helper:“So on the one hand you know that your friends are the greatest risk factor for using again but on the other hand the idea of being alone is scary. Do you think it’s possible to have friends and be sober?” (asking client to resolve the dilemma)

The client appears to fully accept the confrontation. Now what?

When the client accepts the confrontation, another problem can arise. What do you do next? Sometimes the helper freezes because he or she is momentarily caught off guard by the client’s acceptance.

  • Antidote: The answer to this problem is to encourage the client to engage in some activity that helps resolve the two sides of the problem: something that reinforces the acceptance the client has identified. In the following example, the helper suggests that the client get ideas from fellow support group members.

Client:“I don’t know. I guess recovering addicts have new friends that don’t use. But how you do that?”

Helper:“I’m not an expert on this. But some people who have been off cocaine for a while must be familiar with this problem. It seems like it might be fairly common. Between now and when we next meet, would you be willing to think about this? Go to your next Cocaine Anonymous meeting and ask one or two people about this. Then let me know what they have to say.”

Client:“All right. And I’ll talk to my friend Michelle. She’s been sober for a year now.”

Final Cautions about Confrontation

One writer called confrontations the “thermonuclear weapons” of helping. They are powerful, and their force can help or harm. Confrontation may arouse negative emotions and the defenses of the client or damage self-esteem, rather than increase awareness and

motivate action. Although the force of the confrontation should not be watered down with qualifiers, confrontation must be presented in a way that does not shame the client by saying “Gotcha!” We are aiming to deliver moderately confrontational statements with the client’s best interests at heart.

Earlier, we mentioned that the timing of the confrontation could be important. Timing means knowing when confrontation will do the most good. Obviously, the time for confrontation is when the client/helper relationship is well established and the client trusts the helper’s motives. In general, strong challenges should not be made until the NLC has been firmly established. It has been my experience that frequent and premature confrontations based on very little information tend to erode the credibility of the helper and thereby damage the relationship.

MyCounselingLab Video Exercise 7.2

Other Ways of Challenging

Besides pointing out discrepancies using confrontation, there are other methods for getting clients to pay attention to discrepant, irrational, or troubling issues and focusing the conversation in that direction. Among these are relationship immediacy, teaching the client self-confrontation, challenging irrational beliefs, and using humor. These are more advanced skills but we mention them here because you will likely run into them early in your training through films or reading. We hope that you will mentally note that they fall in the category of challenging skills and that supervision is necessary as you learn to use them.

Relationship Immediacy

When you meet someone for the first time, think about what issues are the most difficult to discuss. It is easier to talk about past problems and previous relationships rather than present issues and relationships. It is easier to discuss issues that are positive and uplifting rather than those that are negative or depressing. It is also easier to talk about issues that concern neither of us, such as the weather, rather than talking about what is going on between us right now. By the same token, it is sometimes difficult for the helper to bring up issues affecting the helper or the relationship between helper and client. However, the ability to give honest feedback and discuss the helper/client relationship openly gives it a special meaning that separates it from other social interactions. The relationship can be a laboratory where the client can learn about his or her effect on others. Relationship immediacy (Kiesler, 1988) is a technique that helpers use to give clients here-and-now feedback about their effect on another person—the helper.

Relationship immediacy is a comment by the helper about what is happening in the relationship right now. Immediacy statements by the helper should have three characteristics:

  1. The helper uses the word Iin the statement to indicate that this is the helper’s perspective.
  2. The helper describes the client’s behavior or the helping relationship issue in nonjudgmental terms.
  3. The helper expresses his or her feelings in a way that does not overload or burden the client.

These three characteristics are illustrated in the following helper statement: (1) “I am aware that (2) when I make a suggestion, such as the one just presented, we seem to end up in a struggle and the issue gets dropped. (3) I am a little concerned about this.”

Helpers use relationship immediacy because the client’s interactions with the helper are probably similar to the client’s interactions with significant others. For example, a client might talk incessantly, not leaving room for the helper to respond. Using an immediacy challenge, the helper might say, “You tell me that other people say you don’t listen to you. As I am sitting here, I don’t feel listened to either. Can we talk about that?” In this vein, Murray (1986) cites the example of a young woman who came to therapy because she felt she was overly dependent on her father. For example, whenever she had car trouble, she turned it over to him. After a month of therapy, she brought in her auto insurance policy, which she was having trouble deciphering, and handed it to the therapist who began reading it. After a moment, the therapist laughed and exclaimed, “Look, I’m behaving just like your father.”

Relationship immediacy is “you-me” talk. It challenges the client to focus on the helper’s impressions of the therapeutic relationship. Relationship immediacy can enhance intimacy in a relationship because it acknowledges the mutual bond and gives the client liberty to also look at his or her feelings toward the helper. It is one of the best ways of dealing with so-called resistance and transference reactions. Relationship immediacy is also an invitation to examine the client/helper relationship conflict as a microcosm of the client’s difficulties. It can be used to address or prevent ruptures by asking the client to honestly assess the quality of the therapeutic bond. It should only be used if it seems that the relationship issues between client and helper relate to the client’s goals or if the therapeutic relationship is strained and needs to be repaired. Relationship immediacy can be of the “here-and-now” variety such as, “Right now, I feel a lot of tension between us because we brought up the alcohol issue. What is your reading on that?” Alternatively, the helper can ask the client to reflect on the relationship as it has progressed up to that point. For example, “Over the past few weeks, I have found that our relationship seems to have changed. My experience is that the sessions are much more fun and productive. What do you think?”

Teaching the Client Self-Confrontation

Although it is good to have the input of others, it may be more useful to have the client learn to self-confront, a skill that could provide lasting benefit when the helping relationship is over. Self-confrontation has been studied as a complex assessment and research tool (Hermans, Fiddelaers, de Groot, &Nauta, 1990Lyddon, Yowell, &Hermans, 2006). But the method can be applied more simply as a research project that the client conducts on himself or herself with the assistance of a helper. One way to do self-confrontation is for the client to write down everything that he or she considers to be a conflict in life. For example, “I am in love with this woman, but she has made it clear I am only a friend,” or “My parents want me to get better grades, but I really don’t want to go to college.” If given as a writing assignment, the client might be asked to respond to questions such as:

  • “What is it that I don’t really want to do?”
  • “What would it say about me if I changed in the ways people want me to?”
  • “In what ways am I lying to myself?”
  • “What possibilities in my life am I not paying attention to?”
  • “What conclusions am I drawing about life that have no evidence to support them?”

The helper then guides the discussion of these issues in the past, present, and future and helps the client explore the issues collaboratively. Together client and helper try to identify key themes in the client’s life that come from this discussion. Finally, client and helper identify a plan to solve the dilemmas.

Challenging Irrational Beliefs

Some cognitive therapists challenge clients’ strongly held beliefs when these beliefs are responsible for clients’ emotional suffering. Challenging beliefs involves making the client aware of their irrational nature and teaching them to dispute these disturbing thoughts when they arise. Thus, although the helper highlights the irrational ideas in session, disputing and replacing irrational thoughts is ultimately a form of self-confrontation. The client learns to confront his or her erroneous beliefs. Following is a short list of irrational beliefs adapted from Ellis and Velten (1992). Ellis has longer lists of common irrational beliefs, but this will give you a feel for the general categories.

  1. Shoulding and musting: “I must be the best in my class.” “I should have learned this by now.”

More rational challenge: “Have you ever tried saying, ‘I would like to be the best in my class’ without laying a ‘must’ or ‘should’ on yourself? I think it is those words that cause you to feel so upset when you can’t reach perfection.”

  1. Awfulizing: “When I don’t get it right the first time, it is a tragedy, a catastrophe, and it is awful.”

More rational challenge: “Isn’t it more accurate to say that it’s unpleasant, but not the end of the world?”

  1. Low frustration tolerance (“I can’t control myself”): “I can’t stop myself from calling my ex-girlfriend.” “I can’t wait to buy things when they are on sale, and I get myself into big credit card debt.”

More rational challenge: “So, it’s uncomfortable for you to wait, right? But is it really true that waiting is impossible or is it just annoying?”

  1. Blaming: “No one even tried to help me. It’s their fault that I wasn’t able to register for classes, not mine. This is the worst school.”

More rational challenge: “I wonder about this idea that it is the responsibility of other people to get you registered and help you when you didn’t even request assistance.”

  1. Overgeneralizing—“always” or “never” attitudes: “I went to one AA meeting and all they did was drink coffee and smoke cigarettes. The organization is crazy. No one gets helped there.”

More rational challenge: “I’d like to take issue with this idea that attending one AA meeting gives you enough information to make this blanket statement. Isn’t it possible that there were some positive aspects of the meeting? Tell me why you think you must look at this in black and white. Is it really true that you get nothing from a meeting like this?”

You can probably see how confronting a person’s beliefs can feel like a very strong intervention. It takes a great deal of skill to challenge a client’s beliefs in a way that does not alienate him or her personally. The goal is for both client and helper to gang up on the irrational beliefs while maintaining a good working relationship.

Humor as Challenge

Humor can be one way of relating to clients and teaching them to view situations in a different way. It can possibly be a needless distraction. But humor can also be a way of making a confrontation, especially through exaggeration. Both stories and humor seem to bypass the client’s defenses. Clients tend to accept humorous stories because they are not seen as preachy or mean. Once, a client told me about her fears that, as a divorced woman, everyone would be looking at her and treating her differently. I responded by agreeing that although she lived in a city of one million people, that, at first, rumors would be spreading like wildfire. There would be newspaper headlines and, of course, television news. I reassured her that after the requests from talk shows were rebuffed, she would be able to resume her private life once again. She laughed with me and admitted that her fears were overblown as usual. I was able to get away with this because I knew the client well, and she did not perceive me as laughing at her. That is, of course, the primary precaution of using humor as confrontation. It could belittle the client or convey that you think his or her concerns are unimportant. Again, there is no substitute for knowing your client and having the kind of relationship where you can talk about ruptures when they occur.

Culture Check

The following is a story by Cindy Yee Fong about how she was brought up and how her family and cultural values helped her become a nonjudgmental listener and also presented a challenge when she was forced to confront her clients.

Respect is a core value in Chinese culture. “Respect your parents and do as they say.” “Respect your teachers and don’t question or challenge them.” “Respect your family and don’t discuss concerns or problems outside the family circle.” “Respect your elders and don’t talk back to them.” These were the values and expectations instilled in me by my parents, especially my mother. She was born in China and believed strongly in these rules.

When I first began working as a counselor, my job was to facilitate a group for court-ordered drunk drivers, one of the most angry and difficult client populations. You can imagine the challenges I had to face. For someone who is assertive, open, and willing to confront others, regardless of age or status, this would be a difficult job. For someone like me who was taught to listen, not interrupt, and agree with others, especially older people and those in higher positions, it was a daunting task.

Frequently, there were older clients in the group who tended to “ramble on” in their discussions. Interrupting them, in Chinese eyes, would have been very disrespectful. When doctors, lawyers, and teachers were in the group and expressed opinions contrary to my curriculum, it was nearly impossible for me, at first, to disagree with them. It has taken quite a while for me to overcome this reluctance to be what my culture would consider “disrespectful” and to develop the necessary skills as a counselor to be assertive in confronting others. This is still an area I am trying to improve. My cultural style of passive acceptance has helped me develop unconditional acceptance regardless of differences. This has facilitated my developing rapport with clients and getting to the point in a relationship where they can accept confrontation. Chinese cultural values and beliefs have been both helpful and challenging to me as an emerging helper.

  • Cindy Yee Fong indicates that respect is one of the core values in Chinese culture. Thinking back on your own upbringing, what cultural or family values would you describe as “core”?
  • What were your family’s values about contradicting others, keeping the peace, and disclosing weaknesses? Was family business to be kept within the family? Do you think any of your own core values may have an effect on your willingness either to talk with clients about their deepest issues or to confront certain individuals?
  • One of the most common difficulties for most of us is overcoming the “mum” effect, the social rule that says to keep feedback to yourself. As a helper, your contract with the client implies that you will give honest feedback despite your personal discomfort. Think about some specific situations that will create discomfort for you such as refusing an expensive gift from a client, informing a client that his or her personal hygiene is poor, dealing with tardiness, talking about sexual problems, discussing whether the client is having an affair, or asking whether the client is being honest with you. Which do you think will be the most difficult for you? How might you increase your comfort with these topics?
  • Would you find it more difficult to confront someone of a different ethnic or racial background, someone older or younger than you, someone who has a high-status profession, or someone of the same or opposite sex? How do you plan to overcome these limitations? Discuss with a small group some strategies for overcoming some of these roadblocks to feedback and confrontation.

 

 

Counseling techniques for substance abusers have traditionally fallen along the lines of being confrontational. There are still many programs that operate with an unswerving and relentless commitment to forcing the substance users into admitting their problems in a public forum. There are consequences for nonadmission of their faults. The price for not owning up is humiliation in front of the group and accusing them of being in denial even if they are telling the truth. Some of these techniques can border on emotional abuse of the client and promote relapse versus healing. In the department of corrections or prisons, there are many addicts who choose to go to prison for a year or two rather than being put through this type of program for several months. Chances are, they have had a lifetime of abuse from family and fear any further retribution or reopening old wounds in an unsafe environment. In many of these centers, pharmacology for mental illness is considered a drug use that needs to be eliminated as well.

Fortunately, the tide has changed for substance abusers and addicts. The emphasis today is on confrontation but with a large dose of empathy. People do not become substance abusers accidentally. Some may start out as experimenters, but often, people seek out drugs for deeper reasons. Some learned to handle the difficult situations in life through the use of drugs or alcohol. Some have an underlying mental illness they are medicating. Some may have a trauma they are unable to process. There are many reasons, and it is easy to understand how so many people get caught up in this vicious cycle of soothing the rage through the maladaptive use of substances. For them, it is easier to numb the feelings than have to deal with them by facing them. For some, these feelings are too terrifying to identify. It is the task of the therapist to provide a safe space to work through and pass through the underlying causes of their addictions. Other reasons for addictions may include physiological causes. A person who is constantly tired might use uppers or speed to enhance their ability to complete work. Soon, they are unable to function without them. These people are called functional addicts. They are able to hold down jobs and can be quite successful until the drugs no longer work, and they find themselves needing more just to maintain their normative level of activity. These are the most difficult to treat because they are socially adept and successful.

There are many counseling theories and variations that are utilized in treatment of substance abuse disorders. Generally, addictions counseling relates specifically to the outward behaviors; psychotherapy attempts to elicit a broader and deeper understanding. Usually, the therapist utilizes whatever combination works for a particular client. It is important to note that drug or alcohol abuse has been the coping mechanism that got the addicts this far in life. It is how they know to survive. It may very well be the foundation upon which they stand. Replacing this foundation with an adaptive one takes time, trust, and a willingness to face the issues feeding the addiction. Expressing a lifetime of issues can be painful but freeing. As always, providing a safe space for the client’s work, and building a therapeutic alliance are key issues in successfully moving the client in a positive direction.

There are various types of interventions depending on the state of the addict. If the addicts are forced into treatment by the court system, their participation might be superficially complying with court directives and not substantive. If it is the result of an intervention by family, there may be resentment by the addict toward the family members. There are still others who seek treatment as an escape from the failures of their daily lives. No matter why individuals come to treatment, determining the level of care is critical.

Dual diagnosis means that the client has a diagnosed substance abuse, dependence, or induced disorder that is comorbid (coexisting) with a diagnosed mental illness. Though there is often difficulty discerning which came first, the substance problem or the mental illness, both are treated. Many professionals believe that the substance abuser is always medicating the mental illness. However, the substance oftentimes is the root cause of the mental illness as seen in the way substance abuse is diagnosed. For example, depending on the stage of alcoholism, a client can exhibit symptoms of psychosis such as auditory or visual hallucinations. Delirium can also occur in withdrawal from alcohol abuse or dependence. Once the substance is eliminated, the psychological symptoms often dissipate.

However, use, abuse, or dependence on a substance can result in permanent or long-term psychological consequences. For example, chronic caffeine dependence can raise the risk of anxiety problems as well as sleep deprivation issues that can also result in symptoms as severe as psychosis. Sleep is critical in maintaining good mental health. Too much or too little can have a devastating effect, especially in the long term. How well a person is eating and sleeping are early indicators of underlying issues. For example, sleeping too much or too little is a symptom of depression. Sleeping 2–3 hours per night over an extending period of at least several days while feeling completely rested can be a symptom of anxiety or mania. Overeating or undereating are symptomatic of depression, anxiety, and several eating disorders.

It is important to note that these symptoms in conjunction with a group of indicators significantly raises the risk of diagnosis while none of these in and of themselves constitutes a diagnosis. Drug and alcohol abusers are also often malnourished. In the later phases of methamphetamine addiction, abusers become extremely thin with their faces drawn and aged considerably. In other words, there are multiple factors to consider when diagnosing someone with a substance abuse disorder and a corresponding mental illness.

The following list includes substance abuse disorders that are listed per the Diagnostic and Statistical Manual of Mental Disorders, and it specifies the disorders with physiological dependence/without physiological dependence (DSM-IV-TR, 2000, pp. 15–22):

Alcohol-Related Disorders

  • Alcohol-use disorders
  • Dependence
  • Abuse
  • Alcohol-induced disorder
  • Intoxication
  • Withdrawal intoxication delirium
  • Withdrawal delirium
  • Induced persisting dementia
  • Induced persisting amnestic disorder
  • Induced psychotic disorder with delusions or with hallucinations
  • Induced mood disorder
  • Induced anxiety disorder
  • Induced sexual disorder
  • Induced sleep disorder
  • Alcohol-related disorder not otherwise specified

Amphetamine (or amphetamine-like related disorder)

  • Same as alcohol
  • Caffeine-related disorders
    • Caffeine intoxication
    • Induced anxiety
    • Induced sleep disorders
    • Caffeine-related disorder not otherwise specified
  • Cannabis-related disorders
  • Dependence
  • Abuse
  • Cannabis Induced
    • Intoxication
    • Intoxication delirium
    • Induced psychotic disorder
    • Cannabis induced anxiety disorder
    • Related disorder not otherwise specified
  • Cocaine-related disorders
  • Hallucinogen-related disorders
  • Inhalant-related disorders
  • Nicotine-related disorders
  • Opoid-related disorders
  • Phencyclidine (or like) disorders
  • Sedative, hypnotic, or anxilytic disorders
  • Polysubstance-related disorders
  • Other (unknown substance ) related disorders

Reference

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (IV-TR ed.). Washington, DC: Author.

SAMHSA/CSAT Treatment Improvement Protocols

“The Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of substance abuse. CSAT’s Office of Evaluation, Scientific Analysis, and Synthesis draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country” (Substance Abuse, n.d.).

TIPs encourages the use of short-term, solution-focused therapies versus psychotherapy that would take time to deal with the client’s unconscious issues and conflicts that may be driving the addiction in the first place.

Solution-focused therapy (SFT) is a useful tool in meeting the short-term problems the addict faces as well as the financial needs of both the center and the client. The SFT focus is on repeating past positive behavior and asking the clients what their life would look like if they were drug free and to imagine this type of future for themselves. They then plan how to get there.

How to Facilitate the Development of Basic and Life Skills (in Conjunction With Group Therapy)

CBT therapists encourage the utilization of self-help groups, family therapy, couples therapy, psycho-educational groups, skills groups such as parenting classes, and any other therapeutic interventions that keep the client on track. The more focused the clients are on improving their life, the less energy is spent on planning their next drug use. Facilitation of basic life skills can also be enhanced within the context of psychotherapy groups. Here, the therapist facilitates the group, and the group serves as a microcosm of the external world in which each participant lives. Similar life issues arise, and the group assists the client in forming new ways of handling old situations. The group becomes a family that models appropriate behavior. With the guidance of the therapist, the group is able to stay focused and concentrate on the issues important to the group. The group becomes the supportive, safe entity that the family was unable to provide.

How to Promote Client Knowledge, Skills, and Attitudes That Contribute to Positive Change in Substance Abuse Behaviors

To summarize, it takes a group of therapies to assist the clients in making a positive change in substance abuse behaviors. It is essential that they have the knowledge and skills to use coping strategies when approached with the choice of whether they will use or not. Their attitude toward their drug of choice can be relearned through psychoeducational groups as well as psychotherapy group and self-help groups comprising of their peers. However, the motivation rests with the clients. Psychotherapy group can be used to model appropriate interrelationship skills through the use of a skilled therapist. Self-help groups need to be shopped until the client feels comfortable within a particular group. Not all groups are alike, especially in the self-help variety that reflects the current leader’s style.

As previously referenced, substance abuse treatment guidelines are published by the Substance Abuse Mental Health Treatment Services Administration under the division of CSTAT or the Center for Substance Abuse Treatment through the use of TIPs or Treatment Improvement Protocols. This is the most accurate, up-to-date best practices treatment site available on the Internet, and reports contain specific information on the treatment of different addictions, mental health comorbidity, adolescent treatment, and a host of other information.

References

Substance Abuse & Mental Health Services Administration. (n.d.). Retrieved November 24, 2009, from http://www.samhsa.gov/index.aspx

Addiction/Alcoholism/Substance Dependence (DSM-IV-TR)

Merriam-Webster (2010) defines the word addiction as “compulsive need for and use of a habit-forming substance…characterized by tolerance and by well-defined physiological symptoms upon withdrawal.”

The Diagnostic and Statistical Manual-IV-TR (DSM-IV-TR) defines substance dependence as the following (American Psychiatric Association, 2000):

[a] maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

  1. Tolerance, as defined by either of the following:
    1. A need for markedly increased amounts of the substance to achieve intoxication or desired effect.
    2. Markedly diminished effect with continued use of the same amount of substance.
  2. Withdrawal, as manifested by either of the following:
    1. The characteristic withdrawal syndrome for the substance.
    2. The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.
  3. The substance is often taken in larger amounts or over a longer period than was intended.
  4. There is a persistent desire or unsuccessful efforts to cut down or control substance use.
  5. A great deal of time is spent in activities to obtain the substance, use the substance, or recover from its effects.
  6. Important social, occupational or recreational activities are given up or reduced because of substance use.
  7. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

The Centers for Disease Control (CDC) explains the difference between alcoholism and alcohol abuse as the following (Frequently Asked Questions, n.d.):

Alcoholism or alcohol dependence is a diagnosable disease characterized by several factors, including a strong craving for alcohol, continued use despite harm or personal injury, the inability to limit drinking, physical illness when drinking stops, and the need to increase the amount drunk to feel the effects.

According to the Alcohol Abuse Basics (n.d.) Web site, the differentiation between alcohol abuse and alcoholism is the following:

The main difference between alcohol abuse and alcoholism is that alcohol abuse, though similar to alcoholism, does not include a strong craving for alcohol, tolerance, and physical dependence on alcohol.  Additionally, alcohol abuse, unlike alcoholism, does not necessarily include the loss of control.

Is Mr. Moore in the following example suffering from addiction/alcoholism/substance dependence? Assume the following additional facts:

When Mr. Moore started going out with his business partners 7 years ago, he would have about 2–3 drinks. As the years progressed, he began drinking more and more. His wife has talked to him repeatedly about coming home after work and not going out to drink with his partners. She has attempted to intervene, but these efforts have only been met with disappointment. Mr. Moore would consistently promise on different occasions that he would be home on a particular evening, only to not show and stumble in at 2:00 a.m. On the night of his arrest, the result of a breathalyzer administered by the police showed his blood alcohol count (BAC) at a 0.24, which is three times the legal limit of 0.08. This information would meet the first criteria of tolerance. Most individuals do not intend to become addicted to any substance. This is many times not a conscious thought. Arguably, the third criterion is met in that Mr. Moore drank more and more alcohol over a long period of time. Mr. Moore’s repeated promises to not go out with his partners and to come home failed miserably; thus, his attempts to control his drinking were unsuccessful. This meets the fourth criteria above. Mr. Moore has missed many of his children’s recitals, concerts, plays, sporting events, graduations, and so forth because of his continued drinking, thus the fifth criteria is met. Only three of the above criteria need to be met over the course of a 12-month period for one to be considered alcohol dependent. Clearly, Mr. Moore has met these criteria and could be diagnosed under the DSM-IV-TR with alcohol dependence.

References

Addiction. (2010). In Merriam-Webster’s Online Dictionary. Retrieved from http://www.merriam-webster.com/dictionary/addiction

Alcohol abuse basics. (n.d.). Retrieved from Alcohol Abuse Basics Web site:  http://www.alcohol-abuse-basics.com

American Psychiatric Association (APA). (2000). DSM-IV-TRdiagnostic and statistical manual of mental disorders-text revision (4th ed.). Arlington, VA: Author.

Frequently asked questions. (n.d.). Retrieved from the Centers for Disease Control and Prevention Web site: http://www.cdc.gov/alcohol/faqs.htm#12

Individual Therapy

There are several types of individual therapeutic approaches that can be used when treating a client with a drug or alcohol addiction. Those approaches include psychodynamic therapy, humanistic therapy, and cognitive-behavioral therapy.

Psychodynamic Therapy

Psychodynamic therapy focuses on the impact of the person’s unconscious on the behaviors demonstrated. For example, a person growing up in a home where substance abuse is the primary coping strategy may be influenced into substance abuse.

Humanistic Therapy

Humanistic therapy focuses on identifying the good within the person. It focuses on building self-esteem to help redirect negative behaviors. For example, the humanistic approach helps people process thoughts about themselves and how those thoughts influence their behaviors. A patient may believe that he or she was born to be an alcoholic because he or she has never been able to quit successfully. The goal of this type of therapy is to help build patients’ self-efficacy about their abilities and thus facilitate change in their behaviors.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy focuses on helping clients identify the correlation between their thoughts and their behaviors. Once the correlation is identified, it is important to then identify what triggers a certain thought process that lead to positive behaviors and what triggers the thoughts that lead to negative behaviors. The goal of this type of therapy is to modify behaviors to produce the desired outcome rather than the undesired outcome. Consider this example: A client identifies that he usually drinks alcohol right after he gets into an argument. He stated that he is triggered to become angry when he is told that he has done something wrong. He and the therapist then work together to identify some coping strategies to aide him with handling his frustration when he is wrong. This helps the client change his behavior of drinking when he is able to control the negative thought patterns that trigger the drinking.

Group Therapy

Group counseling is an affective form of treatment for substance abuse disorders. Group therapy helps the abuser to identify with others who are experiencing similar difficulties. The most common type of self-help group counseling is Alcoholics Anonymous (AA). The most popular model for treatment of substance abuse is the Twelve Step program pioneered by AA (Alcoholics Anonymous History, 2010). This foundation supports the belief that alcoholism is a disease and that alcoholics must acknowledge their addiction to the alcohol. The addiction itself is seen as being more powerful than the individual; therefore, the individual must look to a higher power to overcome the addiction.

The major modality of AA is group meetings. Many believe that the social support they receive helped to save their lives; however, critics feel that it fosters dependence by teaching abusers that alcoholism is a disease that cannot be controlled without a higher power and the help of other people. For those who are motivated to complete treatment and have the support of family, AA has proven to be effective; however, other treatments are needed for the large number of people who do not respond to AA’s approach.

Reference

Alcoholics Anonymous history. (2010). Retrieved from http://www.aa.org/aatimeline

 

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