October 2012

By this stage of my career (meaning I’m old), I thought I had encountered most of the attitudinal terminology debates in the addiction and mental health fields. In fact, if you are a longtime reader of Tips and Topics, you know that I have addressed -often- the attitudes behind certain words we use: “manipulative” and “compliance” versus “adherence”, “attention-seeking”, “borderline” etc.

When reading a 2012 interview of William R. Miller (Motivational Interviewing) by another giant in the addiction field William L. White (Recovery in addiction and recovery-oriented systems of care), I was surprised I had not considered the issues behind our common use of “relapse” in addiction treatment.

TIP 1
Notice your attitude and actions when you talk about “relapse”, especially when your client has just “relapsed.”

Listen to what Bill Miller says: “Well, it’s a term borrowed from medicine, but in our field, it takes on very pejorative, shaming overtones. When you’ve “relapsed,” it’s pretty clear you’ve done something bad and it’s your own fault.”

You might say: “No” I don’t shame anyone for relapsing – it’s all part of the disease of addiction. Maybe you don’t treat clients as if they’ve done something bad and blame them for a flare up of their illness, but lots of your colleagues still do. Otherwise, how come most programs still have policies like this: If a client shows up to an outpatient group with alcohol on their breath because they drank a few beers, or they shot up some heroin, or smoked some crack, what happens? Staff checks to make sure the client is not immediately unsafe. But then what? They are told to go away and come back later when they are sober.

Depressed Clients
Imagine doing that to a person suffering from Major Depression. They have a flare up of suicidal ideation, but are not so suicidal as to need hospitalization.
Would you tell them to go away and come back later when they are not suicidal?

• Another panic attack? (Panic Disorder) – come back later.
• Psychotic again? (Schizophrenic Disorder) – go away.
• Blood pressure up again? (Hypertension) – could be grounds for discharge!

Bill Miller again: “When a person with hypertension or diabetes winds up in the emergency room, we don’t typically say they have relapsed. Recurrences of symptoms are normal in chronic diseases, and managing those is what long-term care is all about.”

Clients in Residential Treatment
Sometimes while on a pass, a residential client might bring back alcohol or other drugs to the program. It is then that these attitudes and actions really show up. Almost universally, that means immediate discharge to the street, or to another level of care like detox. Neither discharge nor detox is really warranted if a person just drank a few beers or smoked marijuana or even methamphetamine.

Clients with poor impulse control
Imagine doing that to a person with impulses for cutting behavior. Say the impulses overtake the client. They start using their lunch knife to self-mutilate, not to the point of severe bleeding needing sutures. Nevertheless this is a troubling flare up. What do you do? Even if they bring in razor blades back from a pass, then thinks better of it and hands them in, what do you do? Do you discharge them OR see it as a crisis to be managed and treated?

• Isolating in their room again, hearing voices? (Paranoid Schizophrenia) – grounds for discharge.
• Pacing with pressured speech, grandiose talk and two hours of sleep? (Bipolar Disorder) – discharged.
• Blood sugar up again and eating an extra piece of pie, not at all sticking to their diabetic diet? – Definitely discharged

Before you think I am just interested in stepping on your program policy toes and blowing up your sacred cows, there are some alternative attitudes, actions and solutions in SKILLS below.

Now for the part of Bill Miller’s interview that surprised me.

TIP 2
Consider whether even the term “relapse” has no useful clinical meaning.

This is the point in the interview where I was surprised I had not even considered the term “relapse” could possibly be nebulous and clinically not useful.

Bill Miller again:
“If symptoms recur, we blame the patient for relapsing. In addition to that moralistic overtone, the very term “relapse” implies that there are only two possible states: “clean” and “dirty,” “sober” and “relapsed.” Ironically, the very concept of “relapse” implies the black-and-white thinking that “relapse prevention” is meant to undo. If you use, you have “relapsed,” are no longer in recovery and the clock starts over. Outcome data just don’t look like that. In a multisite study where we wanted to predict “relapse,” we had a hard time defining it. How bad does a “lapse” have to be before it becomes a “relapse”? How many days of drinking are required, or does any drink do it? Is there an amount threshold, and should it be indexed to body weight? How many days do people have to be “good” before their next use qualifies as a relapse? Actual outcome data show high variability in the length, spacing and severity of use and symptoms during the course of recovery. In good recovery with a chronic condition, episodes of symptoms become shorter, less severe and more widely spaced. Perfection is the exception…….. We’ve made far too much of “relapse” in this field. In writing Treating Addiction, it was a discipline to replace the idea of “relapse”-not with euphemisms, but with a different way of thinking about maintenance and recovery.”

It is that “different way of thinking” I invite you to consider. I’m still trying to get my head around the possibility of even eliminating the term “relapse” from my clinical vocabulary. It seems sacrilegious – a sacred cow too much to give up in addiction treatment. But a warning if you start thinking differently: It could mess up your attitudes, actions and policies when a person uses while in treatment.

Reference:
White, William L (2012): “The Psychology of Addiction Recovery: An Interview with William R. Miller, PhD” a feature article in Counselor Magazine Jul-Aug, 2012.

For readers who are new to Tips and Topics, the first Tip in SKILLS will point you to solutions for re-thinking how we deal with substance use while in treatment. For longtime readers who have heard me before on this topic, but are still ambivalent about changing your attitudes, actions or policies, take another look.

TIP 1
Revisit what to do about your “relapse” policies.Rather than repeat what is referenced in previous editions, start with Volume 7, No. 3 June 2009. Read SAVVY and SKILLS. In those sections you will be directed to other previous writing on this topic.  https://changecompanies.net/tipsntopics/2009/06/

TIP 2
Begin the shift to delete the term “resistance” from your clinical vocabulary.

By this point you may be wondering what I am suggesting. Not only am I questioning “relapse” as a concept and clinical issue, but now “resistance”? Actually I have written about this issue many times before. Search the Tips and Topics archives on “resistance” and you will see previous editions on this.

Like thousands of others, you can tell I have been profoundly influenced by Bill Miller’s work. I want to alert you how Bill Miller again is leading us to think outside of our usual clinical box. (At The Change Companies, Bill Miller has been a Senior Advisor for many years). His third edition of Motivational Interviewing has just come on the market. I haven’t read all 470 pages, but I did zoom in on how this third edition deals with “resistance”.

• You can cut right to the chase. Turn to the Glossary and look up “resistance” on page 412: “Resistance – A term previously used in Motivational Interviewing, now deconstructed into its components: sustain talk and discord.”
• Notice “previously used” means: “Resistance” as a term and concept will no longer be used as in previous editions- “Rolling with Resistance”; “Responding to Resistance”.
• Here’s a quote from page 197: “…our discomfort with the concept of resistance has continued to grow, particularly because it seems to place the locus and responsibility for the phenomenon within the client. It is as though one were blaming the client for “being difficult.” Even if it is not seen as intentional, but rather as arising from unconscious defenses, the concept of resistance nevertheless focuses on client pathology, under-emphasizing interpersonal determinants.”

So if you start deleting “resistance” from your clinical vocabulary and focus on “sustain talk” and “discord,” you are now in a better position to attract a person into recovery than responding to them as a resistant, non-compliant person in denial.

So what is “sustain talk”?

• It is “the client’s own motivations and verbalizations favoring the status quo.” (p. 197). The person is not interested in changing anything; I am OK with keeping things the way they are – status quo, sustain what I have already got or where I already am.
• “There is nothing inherently pathological or oppositional about sustain talk. It is simply one side of the ambivalence. Listen to an ambivalent person and you are likely to hear both change talk and sustain talk intermingled.” (p. 197). “Well maybe I have a drug problem and should do something about it if I don’t want to be arrested again.” (Change talk). “But it really isn’t as bad as they say, they’re just overacting.” (Sustain talk).

What is “discord”?

• “If we subtract sustain talk from what we previously called resistance, what is left? The remainder …more resembles disagreement, not being “on the same wavelength,” talking at cross-purposes, or a disturbance in the relationship. This phenomenon we decided to call discord.” (p. 197).
• “You can experience discord, for example, when a client is arguing with you, interrupting you, ignoring, or discounting you.” (p. 197).
• “Sustain talk is about the target behavior or change” – drinking or drugging, over-eating, gambling etc. “Discord is about you or more precisely about your relationship with the client – signals of discord in your working alliance.” – Are you on the same page as your client? Are you more interested in abstinence and recovery than they are? Are you doing more work than them about going to AA or taking medication?

Coming soon:
Motivational Interviewing authors, Miller, Moyers and Rollnick have developed a two-part DVD set. It provides descriptions and demonstrations of the new four-process method of Motivational Interviewing. DVDs won’t be available to ship out until mid-December, however you can pre-order from The Change Companies.  https://www.changecompanies.net/motivational_interviewing.php

Reference:
Miller, William R; Rollnick, Stephen (2013): “Motivational Interviewing – Helping People Change” Third Edition, New York, NY., Guilford Press.

When I reflect on all the people who have influenced my thinking, behavior, attitudes and life meaning they have many things in common. But one aspect is clear. All reached their impact by many years of dedicated, persistent, committed and often courageous work. Every age and era has its challenges; each era thinks their challenges top previous ones. However today’s high-speed technology really fuels what faces our generation.

• For years, composers and musicians had to toil for years honing their craft, recording for hours in expensive sound studios to make a record which might sell a few thousand copies. Now a teen or 20 something can churn out a sophisticated music track on their laptop computer, post it on the internet and be a hit with millions overnight.
• Time was when to be a celebrity, you had to have produced, invented, performed or created something of lasting value and skill. Now you can make a three-minute video, post it on YouTube and get 10 million hits in a few days. Or let cameras follow you around, swear a lot, fight and yell and get lots of cosmetic plastic surgery and millions worship you.

I recognize there are many positives about this high-speed technology as well. I love my iPhone. Up and coming artists don’t have to kowtow to monopolistic corporations to have their work recognized. Millions can be raised for charitable causes in hours via social media and so on.

So my point? Somehow we must help our children or our friends’ children embrace personal values, find meaning and make a contribution to the world. This integrity won’t come from immersing themselves in watching Housewives of Orange County and New York; burning hours checking Facebook; texting and Tweeting – neglecting their reading and spelling, not developing interpersonal skills, and focusing on how to get a million hits on the internet.

You can say I’m old. But think about who has influenced your life profoundly and how they got there.

Over the past few years, I have had the opportunity to do more teleconferencing group supervision, case consultation and coaching on person-centered services, individualized treatment and systems change. Agenda items don’t just include problems and difficult cases or dilemmas, but also encompass success stories.

On a recent group call, Ashleigh was sharing how she and her team are making the shift to more individualized services, away from fixed program-driven care. I asked her to share some solutions and her story (I have edited it to emphasize her points):

“Heraclitus, the Greek Philosopher, said it best when he said change is the only constant. Ironically we still resist although it is an ever-present part of our lives and especially our work as counselors. Therefore, when we embarked upon the effort to change our clinical system and application at The Bridge, I expected some resistance. Either it was my superior skills of presentation and persuasion, or the staff was ready for a change, but they walked out of the room energized to implement our ideas to make services more individualized from screening and assessment, to treatment plans, to the group therapy process.

Glad you could join us this month. See you again after Thanksgiving in November.