29. 辅导因成瘾而困扰的人

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29 Counselling those troubled by addiction

What comes into your mind when you think about addiction? We suspect that when most people are asked this question they will think firstly about addiction to alcohol, smoking and illicit drugs; however, when we spent a lew moments thinking about addiction we realised that the word can also be applied to a wide variety of behaviours. We regularly read in the newspapers of addiction to problem gambling, video games, computers, prescribed drugs, and even behaviours that are often considered normal, such as excessive exercising.

WHAT IS ADDICTION? A person who is addicted to a particular behaviour will find that it is particularly difficult to stop engaging in that behaviour. Somehow the addictive behaviour locks them in to continuing that behaviour. Any attempt to withdraw from the behaviour may lead to physical, emotional or psychological consequences. This is unfortunate, because it is clear that whenever a person becomes addicted to a particular behaviour there are almost certain to be harmful consequences with regard to their physical, emotional or psychological health. Further, there may be negative implications for relationships with others and for the person’s ability’ to lead a satisfying and fulfilling life. HELPING A PERSON WHO IS TROUBLED BY AN ADDICTION Ideally, a person troubled by addiction should receive help from an agency that specialises in treating the relevant addiction; however, this is not always possible. Another option is for an experienced counsellor to work under the supervision of a professional who has the relevant expertise. One way of addressing addiction is by using an approach called Motivational Interviewing (Kollnick et ah, 2008). I bis involves using principles and strategies discussed in earlier chapters of this book, which come from Person-Centred Counselling and Cognitive-Behavioural Therapy. THE GOALS OF MOTIVATIONAL INTERVIEWING A central goal of Motivational Interviewing is to enhance the motivation for change of the person seeking help. To achieve this it needs to be recognised that people who want to overcome an addiction are generally ambivalent. A part of them recognises the problems addiction presents for them, while another part recognises the positive effects of engaging in the addictive behaviour. For example, a person troubled by addiction to a drug such as methamphetamine may acknowledge the negative effects of continual use, while also experiencing what they perceive as positive feelings after using the drug. RECOGNISING AMBIVALENCE In Chapter 26 on facilitating action, when we considered working with those seeking help to change their behaviour, we were also mindful of their readiness to change. You might remember that we used the Gestalt awareness circle to illustrate that pushing for either choice or behaviour change results in increased emotional arousal, which is clearly unhelpful for the person (see Figure 26.1 on page 203). Ambivalence results from the presence within the person of two opposing ideas, attitudes or emotions. As a consequence, the person’s readiness to change is compromised by their confusion from trying to deal with opposing internal forces — one part of them wants to change, while another part is resistant to change. When counselling a person troubled by addiction it is helpful to recognise ambivalence as normal and understandable. Helping a person to resolve their ambivalence is one of the keys to helping them to change.

RECOGNISING MOTIVATION In order to be able to change an addictive behaviour, a person has to have a sufficient level of motivation to change. Unfortunately, the level of a person s motivation is likely to fluctuate from one time or situation to another, making it more difficult for change to occur. However, human beings are subject to the influence of other people, so a person’s motivation can be influenced, at least in the short term, by others. For example, they may be influenced by other people with the same addiction, by friends, or by workers in an agency set up to address addiction. Can you recall a situation of your own where your motivation to engage in some activity has been influenced, particularly through conversation with a companion or close friend? David can. He had no interest in playing golf and considered the game an uninteresting waste of time. However, after much persuasion from his son, Edward, his motivation increased to the level at which he agreed to try playing one round of golf. After this his motivation increased so that subsequently he became quite an enthusiastic golfer (although not particularly successful!). Although it is clearly possible to influence a person’s level of motivation, the extent to which this is possible depends on the person’s readiness to change. Prochaska et al. (1992) suggest that when trying to influence motivation it can be helpful to recognise and discriminate between six different stages of readiness to change and to use different skills and strategies at each stage.

STAGES OF READINESS TO CHANGE the six stages are: 1 Precontemplation 2 Contemplation 3 Determination 4 Action 5 Maintenance 6 Relapse. PRECONTEMPLATION At this stage the person seeking help is not ready to change their behaviour. This is where a person might say, ‘I don’t have anything to change; 1 don't have a problem,’ even though other people around them say that they do have a problem because they have been found in difficult and uncomfortable situations as a result of their behaviour. CONTEMPLATION In the contemplation stage the person may say something like, ‘Yes, 1 do have a problem. 1 have tried to stop before. 1 need to change and 1 will do something about it some day/ DETERMINATION Phis stage is where the person makes up their mind and decides to do something. They might say, ‘Yes, 1 do have a problem and 1 will do something to change now, or next week.’ They set a specific time in the very near future. ACTION It is in this stage that it can be advantageous for a counsellor to begin to work more actively than before. People in this stage say things like, ‘I am doing something to change my behaviour.’ In the action stage it is advantageous for the person to get together a package of strategies that they can use to help them change their behaviour. MAINTENANCE This stage is probably the hardest. It’s the stage where the person has found all the things they need to do to change their behaviour and has started to put these into practice. What is needed now is practice and more practice. It’s a time for making the new behaviours into a habit. At this stage a person might say things like, ‘After the party/events/outing 1 realised that 1 had not thought to indulge in my addictive behaviour/ Once this begins to occur, they are on the way to successful change. RELAPSE Relapse is the alternative to maintenance and is also a feature of the change process. This stage is very important because it is a common part of the process. If a lapse occurs it can turn into a relapse because people are hard on themselves. However, rather than seeing a lapse as failure it can be refrained as a normal part of the change process. Information discovered as a consequence of the lapse can be used to make decisions about what needs to be done in the future to minimise the possibility of other lapses occurring. In order to change addictive behaviour, the person may need to repeat all or some of the above stages a number of times.

THE PROCESS OF MOTIVATIONAL INTERVIEWING There is an important difference between Motivational Interviewing and the counselling strategies previously described in the book. The skills and strategies described in previous chapters are underpinned by an assumption that a person will, through exploring their issues, discover for themselves ways to change and be motivated to make use of these. In contrast, Motivational Interviewing places responsibility on the counsellor to purposefully promote the motivation to change (Levingston & Melrose, 2009). In order to do this, the counsellor needs to discover what stage the person has reached in the change process: are they right at the beginning of the process, are they in the pre contemplation stage, or are they further along the change process? To make an assessment of the person’s position, the counsellor might explore the following: • the person’s primary concern • the person’s current circumstances • the exact nature of the person’s addictive behaviour and the function or purpose that it serves for them • the person’s previous experiences with regard to changing the troubling behaviour • the person’s possible mental health problems • the person’s support networks, family relationships, and other social issues • the person’s expectations with regard to their behaviour. It is usually the precoiitemplation stage that brings the person to counselling and this is the stage where the counsellor discovers what stage the person has reached in the change process. During the contemplation stage it can be advantageous to help the person seriously consider two basic issues. 1 he first is how much of a problem their addictive behaviour poses for them. The second is how the problem is affecting them both positively and negatively. One way to do this is to draw a table similar to that shown in fable 29.1 and then work together with the person who is troubled by the addiction to fill in the positive and negative spaces in the table, "fable 29.1 has been designed for use by a person with an alcohol addiction. You might like to experiment by filling in fable 29.1 with responses that you think you would be likely to receive from a person seeking help with an addiction to

Table 29.1 Exploration of ambivalence chart CONTINUE DRINKING Positives when continuing to drink Negatives when continuing to drink STOP DRINKING Positives when not drinking Negatives when not drinking alcohol. After the table has been completed, we expect that you will have noticed that the problem of addiction is complex; it involves a two-sided conflict with negatives and positives connected with both continuing the addictive behaviour and giving up the addictive behaviour. Very often, too much focus on either the negatives of the addictive behaviour or the positives associated with change can lead the person who is seeking help to become defensive. This results in reinforcing the argument in favour of the addictive behaviour. As a consequence, when dealing with addictive behaviour it is usually more helpful to emphasise how much of a problem the addictive behaviour poses for the person with regard to changing. Consider fable 29.1. It is likely that the positives on the side of continuing the addictive behaviour will be the most likely triggers for relapse, and these positives might explain why attempts to change in the past have been unsuccessful, for example, someone who is troubled by an addiction to alcohol and also suffers from anxiety may find that drinking helps them to relax and have a good night’s sleep. When they stop drinking they may have trouble sleeping and consequently experience a strong desire to return to their previous levels of drinking. Therefore, consideration of the pluses on the side of use and the minuses on the side of change need to be taken into account when addressing relapse prevention. In the determination stage, a person seeking help will be determined to take action. That determination is influenced by past experiences. However, those who have made unsuccessful attempts to change their addictive behaviour in the past need encouragement to decide to go through the change cycle again. In the action and the maintenance stages it is important to recognise expectations. For example, it is unlikely that abstinence from the addictive behaviour will be achieved quickly. As mentioned earlier, when addressing issues in the relapse stage, consideration of the pluses on the side of use and the minuses on the side of change need to be taken into account.

COUNSELLOR BEHAVIOUR From the previous discussion it is clear that it is certain to be difficult for a person troubled by an addiction to change. Consequently they will benefit from the encouragement and support that a counsellor can provide. Brad Levingston and Jenny Melrose (2009) suggest that the following counsellor behaviours can be especially useful when counselling those troubled by addiction: • Express empathy: Throughout the stages of the process of change it is important for the counsellor to continue to express empathy with the person, demonstrating that they fully understand the facts and feelings being presented. Particularly when the person is ambivalent about change, it is important to focus on being empathic, instead of trying to coerce the person into changing. • Develop discrepancy: It can be useful to gently but persistently highlight discrepancies between continuing the present behaviour and achieving other important goals. The idea is not to make the person feel guilty for a failure but to encourage them to produce arguments for making a change. • Avoid arguments-. Arguments breed defensiveness and reduce rapport and are consequently counterproductive. • Roll with resistance-. As indicated in Chapter 26, it is important to deal with resistance by giving the person an opportunity to talk through those things that are blocking progress. Sometimes it can be useful to change strategies. Support self-efficacy: Self-efficacy is the belief that the person has the capacity to learn to cope and survive. Starting with small goals and working up to bigger things is a good way to go. Provide feedback: Provide feedback on the range of options the person might consider: feedback can be given in the form of a summary so that the person realises that they have been listened to and understood. As counsellors, when working with people seeking help to change addictive behaviour, we need to recognise our own limitations and refer to professionals who have specialist expertise with regard to addiction whenever appropriate and possible. Many communities have agencies that provide services for people experiencing addictive behaviours. Additionally, it may be appropriate to recommend that a person might benefit from another form of intervention, such as group counselling, belonging to a support group or family therapy. If, when counselling, you recognise that you may not be able to meet the needs of a person seeking your help, we strongly suggest that you consult with your supervisor with regard to the options available. Additionally, this will provide you with an opportunity to explore any issues of your own, which may have been triggered by your work with a person who is troubled by addiction.

Learning summary Although addictive behaviours have negative consequences, they are difficult to change. Problems in addressing addiction involve readiness and motivation to change. Motivation can be influenced by other people. The stages of readiness to change are precontemplation, contemplation, determination, action, maintenance and relapse. The Exploration of ambivalence' chart can be a useful tool in addressing addiction.

References and further reading Lovingston, B. & Melrose, J. 2009, Alcohol and young people, in K. Geldard (cd.), Practical Interventions for Young People at Risk, SAGE, London. Pita, D.D. 2004, Addictions (Counseling: A Practical and Comprehensive Guide for Counseling People with Addictions, Crossroad, New York. Prochaska, J.O., DiClemente, C.C. & Norcross, J.C. 1992, In search of how people change: applications to addictive behaviours, American Psychologist, 47(9): 1102—14. Kasmussen, S. 2000, Addiction treatment: Theory and Practice, SAGE, Thousand Oaks, CA. Rollnick, S., Miller, W.R. & Butler, C.C. 2008, Motivational Interviewing in Health (Care: Helping Patients (Change Behaviour, Guilford, New York.