29. 辅导因成瘾而困扰的人

第29章：咨询那些因成瘾而困扰的人

1. 引言

当你想到成瘾时，你会想到什么？我们怀疑大多数人被问到这个问题时，首先会想到对酒精、吸烟和非法药物的成瘾。然而，当我们花了一些时间思考成瘾时，我们意识到这个词也可以应用于多种行为。我们在报纸上经常读到对问题赌博、视频游戏、电脑、处方药甚至被认为是正常的过度锻炼等行为的成瘾。

2. 什么是成瘾？

一个对特定行为成瘾的人会发现，停止这种行为特别困难。不知为何，这种成瘾行为使他们继续这种行为。任何试图戒掉这种行为的努力都可能导致身体、情感或心理上的后果。这是不幸的，因为很明显，每当一个人对特定行为成瘾时，几乎肯定会对其身体、情感或心理健康造成有害后果。此外，这种成瘾可能会对人际关系和个体满足和充实生活的能力产生负面影响。

3. 帮助因成瘾而困扰的人

理想情况下，因成瘾而困扰的人应从专门治疗相关成瘾的机构获得帮助；然而，这并不总是可能的。另一种选择是由有经验的咨询师在具有相关专业知识的专业人士的监督下工作。

一种解决成瘾的方法是使用称为动机访谈（Motivational Interviewing）的方法（Kollnick et al., 2008）。这涉及使用本书前几章讨论的原则和策略，这些原则和策略来自以人为中心的咨询和认知行为疗法。

4. 动机访谈的目标

动机访谈的核心目标是增强寻求帮助的人改变的动机。为了实现这一点，需要认识到，想要克服成瘾的人通常是矛盾的。一方面，他们认识到成瘾给他们带来的问题，另一方面，他们也认识到参与成瘾行为的积极效果。例如，一个因甲基苯丙胺成瘾而困扰的人可能承认持续使用这种药物的负面影响，同时也会体验到使用药物后他们认为的积极感受。

5. 认识矛盾心理

在第26章关于促进行动的部分，当我们考虑帮助那些寻求改变行为的人时，我们也关注他们改变的准备程度。你可能记得，我们使用格式塔意识圈来说明，推动选择或行为改变会导致情绪激动，这对个体显然是没有帮助的（见第203页的图26.1）。

矛盾心理源于个体内部存在两种对立的想法、态度或情感。因此，个体的改变准备度因其试图应对内部对立力量的困惑而受到影响——一部分的他们想要改变，而另一部分则抵制改变。

在咨询因成瘾而困扰的人时，认识到矛盾心理是正常且可以理解的很有帮助。帮助个体解决矛盾心理是帮助他们改变的关键之一。

认识动机

1. 认识动机

为了能够改变一种成瘾行为，一个人必须有足够的动机去改变。不幸的是，一个人的动机水平可能会随着时间或情况的不同而波动，这使得改变更加困难。然而，人类受其他人的影响，因此一个人的动机至少在短期内可以受到他人的影响。例如，他们可能受到有相同成瘾的人、朋友或专门处理成瘾问题的机构工作人员的影响。你能回忆起自己的一次经历，你的动机在与同伴或亲密朋友的交谈中受到了影响吗？大卫能。他对打高尔夫球毫无兴趣，认为这个游戏是一种无聊的时间浪费。然而，在儿子爱德华的多次劝说下，他的动机增加到愿意尝试打一轮高尔夫球的程度。在这之后，他的动机进一步增加，最终他成为了一个相当热衷的高尔夫球手（尽管并不特别成功！）。虽然显然有可能影响一个人的动机水平，但这种可能性的程度取决于个人改变的准备程度。Prochaska等人（1992）建议，在尝试影响动机时，识别并区分六个不同的改变准备阶段，并在每个阶段使用不同的技能和策略是有帮助的。

2. 改变的准备阶段

六个阶段是：

预期阶段

考虑阶段

决心阶段

行动阶段

维持阶段

复发阶段

预期阶段

在这个阶段，寻求帮助的人还没有准备好改变他们的行为。这个人可能会说：“我没有需要改变的地方，我没有问题。”即使周围的人说他们有问题，因为他们因这种行为而陷入困难和不舒适的情况。

考虑阶段

在考虑阶段，这个人可能会说：“是的，我确实有问题。我以前试过停下来。我需要改变，总有一天我会采取行动。”

决心阶段

在这个阶段，这个人下定决心并决定采取行动。他们可能会说：“是的，我确实有问题，我现在或下周就会采取行动。”他们设定一个非常近的具体时间。

行动阶段

在这个阶段，咨询师开始更积极地工作是有利的。处于这个阶段的人会说：“我正在采取行动改变我的行为。”在行动阶段，对个体来说，制定一套可以帮助他们改变行为的策略是有利的。

维持阶段

1. 维持阶段

这个阶段可能是最困难的。在这个阶段，个体已经找到了他们需要做的一切来改变行为，并开始付诸实践。现在需要的是练习和更多的练习。这是一个将新行为变成习惯的时期。在这个阶段，个体可能会说：“聚会/活动/外出之后，我意识到我没有想到要去从事我的成瘾行为。”一旦这种情况开始发生，他们就走在成功的改变之路上了。

2. 复发

1. 复发

复发是维持阶段的替代，也是改变过程的一个特征。这个阶段非常重要，因为它是一个常见的过程部分。如果出现一次失误，它可能会变成复发，因为人们对自己很苛刻。然而，与其将一次失误视为失败，不如将其视为改变过程的正常部分。由于失误而发现的信息可以用来做出决定，以便在未来尽量减少其他失误的发生。为了改变成瘾行为，个体可能需要重复上述所有或某些阶段多次。

动机访谈的过程

1. 动机访谈与传统咨询的区别

动机访谈与书中先前描述的咨询策略之间有一个重要的区别。前几章描述的技能和策略基于一个假设，即个体通过探索自己的问题，会自行发现改变的方法并有动机去利用这些方法。相比之下，动机访谈要求咨询师主动促进改变的动机（Levingston & Melrose, 2009）。为了做到这一点，咨询师需要了解个体在改变过程中的阶段：他们是刚刚开始，处于预期阶段，还是已经进展到改变过程的更后期？为了评估个体的位置，咨询师可能会探讨以下方面：

主要关切：个体的主要关切是什么？

当前情况：个体目前的生活状况如何？

成瘾行为的性质：个体的成瘾行为的具体性质及其对他们有何功能或目的？

改变经验：个体在改变困扰行为方面有哪些以往经验？

心理健康问题：个体是否有心理健康问题？

支持网络：个体有哪些支持网络、家庭关系和其他社会问题？

行为期望：个体对自己的行为有哪些期望？

通常，预期阶段会促使个体寻求咨询，这也是咨询师了解个体在改变过程中所处阶段的时候。

2. 考虑阶段的策略

在考虑阶段，帮助个体认真考虑两个基本问题是有益的：

成瘾行为的影响：他们的成瘾行为对他们有多大影响？

影响的双面性：这个问题如何在积极和消极方面影响他们？

一种方法是绘制一个类似于表29.1的表格，然后与受成瘾困扰的个体一起填写表格中的积极和消极部分。表29.1是为患有酒精成瘾的人设计的。

积极影响	消极影响

你可以尝试用你认为会从寻求酒精成瘾帮助的人那里得到的回答来填写表29.1。在表格完成后，我们预计你会注意到成瘾问题的复杂性；它涉及一个双面冲突，继续成瘾行为和放弃成瘾行为都有积极和消极的方面。

表29.1 矛盾心理探索图表

继续饮酒	不饮酒
继续饮酒的积极方面	不饮酒的积极方面
继续饮酒的消极方面	不饮酒的消极方面

1. 关注矛盾心理

很多时候，过多关注成瘾行为的消极方面或改变的积极方面会使寻求帮助的人变得防御。这会导致强化支持成瘾行为的论点。因此，当处理成瘾行为时，通常更有帮助的是强调成瘾行为对个体改变构成多大的问题。

2. 考虑表29.1

考虑表29.1。很可能，继续成瘾行为的积极方面将是复发的主要触发因素，这些积极方面可能解释了为什么过去的改变尝试未能成功。例如，一个因酒精成瘾而困扰且患有焦虑症的人可能会发现，饮酒帮助他们放松并睡个好觉。当他们停止饮酒时，他们可能会有睡眠困难，因此强烈希望回到之前的饮酒水平。因此，在处理复发预防时，需要考虑使用方面的积极因素和改变方面的消极因素。

3. 决心阶段

在决心阶段，寻求帮助的人将决心采取行动。这种决心受到过去经验的影响。然而，那些在过去尝试改变成瘾行为未成功的人需要鼓励，以决定再次经历改变周期。

4. 行动和维持阶段

在行动和维持阶段，认识期望非常重要。例如，迅速戒除成瘾行为是不可能的。

5. 复发阶段

如前所述，在处理复发阶段的问题时，需要考虑使用方面的积极因素和改变方面的消极因素。

咨询师行为

1. 咨询师行为的重要性

从前面的讨论可以看出，对成瘾困扰的人来说，改变一定是困难的。因此，他们会受益于咨询师提供的鼓励和支持。Brad Levingston 和 Jenny Melrose (2009) 建议，以下咨询师行为在咨询成瘾困扰的人时尤其有用：

表达同理心：在整个改变过程中，咨询师需要继续表达对个体的同理心，展示他们完全理解个体所呈现的事实和感受。特别是当个体对改变感到矛盾时，重要的是专注于表达同理心，而不是试图强迫个体改变。

发展差异：温和但坚定地指出继续当前行为与实现其他重要目标之间的差异是有用的。目的是不是让个体因为失败而感到内疚，而是鼓励他们提出改变的理由。

避免争执：争执会引起防御性，降低亲和力，因此是反productive的。

应对抵抗：如第26章所述，重要的是通过给个体机会谈论阻碍进步的事情来应对抵抗。有时改变策略是有用的。

支持自我效能：自我效能是指个体相信自己有能力学会应对和生存。从设定小目标开始，逐步过渡到更大的目标是一个好的方法。

提供反馈：提供个体可能考虑的各种选项的反馈。反馈可以以总结的形式给出，使个体意识到他们已经被听取和理解。

2. 咨询师的自我认知

作为咨询师，当我们与寻求帮助改变成瘾行为的人合作时，需要认识到我们自己的局限性，并在适当和可能的情况下，将个体转介给具有成瘾专业知识的专业人士。许多社区有提供成瘾行为服务的机构。此外，可能适合推荐个体参加其他形式的干预，如团体咨询、加入支持小组或家庭治疗。如果在咨询过程中，你意识到你可能无法满足寻求帮助的个体的需求，我们强烈建议你与你的主管讨论可用的选项。此外，这将为你提供一个机会，探讨你自己的任何可能由与成瘾困扰的个体工作引发的问题。

学习总结

成瘾行为的挑战：虽然成瘾行为有负面后果，但它们很难改变。

处理成瘾的问题：处理成瘾问题涉及改变的准备度和动机。

动机的影响：动机可以受到他人的影响。

改变的准备阶段：改变的准备阶段包括预期阶段、考虑阶段、决心阶段、行动阶段、维持阶段和复发阶段。

矛盾心理探索图表：矛盾心理探索图表是处理成瘾的有效工具。

参考文献和进一步阅读

Lovingston, B. & Melrose, J. 2009, Alcohol and young people, in K. Geldard (ed.), Practical Interventions for Young People at Risk, SAGE, London.

Pita, D.D. 2004, Addictions: 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 Behavior, Guilford, New York.

本章知识点阐述

进一步阐述知识点

1. 成瘾的广泛性

成瘾的定义：成瘾不仅限于对酒精、烟草和非法药物的依赖，还包括对多种行为的依赖，如问题赌博、视频游戏、过度锻炼等。
社会影响：成瘾行为不仅影响个体的身体和心理健康，还会对人际关系和社会功能产生负面影响。

2. 成瘾的特点

难以戒断：成瘾者往往发现很难停止成瘾行为，即使知道其有害后果。
戒断症状：尝试戒断成瘾行为时，个体可能会出现身体、情感或心理上的不适。
负面影响：成瘾行为对个体的身心健康、人际关系和生活质量产生负面影响。

3. 咨询策略

专业机构：理想情况下，成瘾者应从专门治疗成瘾的机构获得帮助。
监督下的咨询：在缺乏专业机构的情况下，有经验的咨询师可以在专业人士的监督下提供帮助。
动机访谈：动机访谈是一种有效的咨询方法，通过增强个体的改变动机来帮助他们克服成瘾。

4. 动机访谈的目标

增强改变动机：动机访谈的核心目标是增强个体改变的动机。
矛盾心理：成瘾者通常处于矛盾心理状态，一方面认识到成瘾的负面影响，另一方面又体验到成瘾行为的积极效果。

5. 认识矛盾心理

矛盾心理的定义：矛盾心理源于个体内部存在两种对立的想法、态度或情感。
影响改变：矛盾心理会影响个体的改变准备度，使其在改变过程中感到困惑和犹豫。
咨询策略：咨询师应认识到矛盾心理是正常且可以理解的，帮助个体解决矛盾心理是帮助他们改变的关键。

总结

成瘾是一个复杂的问题，涉及多种行为和物质。咨询师在帮助成瘾者时，应认识到成瘾的广泛性和特点，了解专业的治疗方法，并掌握有效的咨询策略，如动机访谈。通过增强个体的改变动机，帮助他们解决矛盾心理，咨询师可以有效地支持成瘾者克服成瘾，改善生活质量。在实践中，咨询师应根据具体情况灵活运用这些技术和方法，以达到最佳的咨询效果。

进一步阐述知识点

1. 认识动机

动机的重要性：动机是个体改变行为的关键因素。没有足够的动机，个体很难坚持改变。

动机的波动性：个体的动机水平会随着时间或情况的变化而波动，这增加了改变的难度。

外部影响：他人的影响可以在短期内提高个体的动机水平。例如，家人、朋友或专业人士的劝说和支持可以激发个体的改变动机。

2. 改变的准备阶段

预期阶段：
- 特征：个体尚未意识到问题的存在，拒绝承认需要改变。
- 咨询策略：咨询师可以通过提供信息和反馈，帮助个体认识到问题的严重性，从而激发其改变的动机。

考虑阶段：
- 特征：个体开始意识到问题的存在，但尚未决定采取行动。
- 咨询策略：咨询师可以通过倾听和支持，帮助个体探索改变的可能性，增强其改变的决心。

决心阶段：
- 特征：个体下定决心并决定采取行动，设定具体的时间表。
- 咨询策略：咨询师可以帮助个体制定详细的行动计划，提供必要的资源和支持。

行动阶段：
- 特征：个体已经开始采取行动，实施改变计划。
- 咨询策略：咨询师可以提供持续的支持和反馈，帮助个体克服困难，保持改变的动力。

维持阶段：
- 特征：个体已经成功改变行为，并努力维持新的行为模式。
- 咨询策略：咨询师可以帮助个体建立长期的维持机制，防止复发。

复发阶段：
- 特征：个体在改变过程中出现反复，回到旧的行为模式。
- 咨询策略：咨询师可以帮助个体分析复发的原因，重新制定改变计划，提供额外的支持和资源。

总结

动机是个体改变成瘾行为的重要驱动力。咨询师在帮助成瘾者时，应认识到动机的波动性和外部影响的作用，并根据个体的改变准备阶段采取不同的咨询策略。通过识别和区分不同的改变准备阶段，咨询师可以更有效地支持个体，帮助他们逐步克服成瘾，实现行为的持久改变。在实践中，咨询师应灵活运用这些技术和方法，以达到最佳的咨询效果。

进一步阐述知识点

1. 维持阶段

阶段特点：
- 难度：维持阶段是最困难的阶段之一，因为个体需要将新行为内化为习惯。
- 实践：需要大量的练习和重复，以确保新行为成为自然的习惯。
- 自我监控：个体需要持续监控自己的行为，确保不会回到旧的行为模式。

咨询策略：
- 强化正面行为：咨询师可以通过正向反馈和奖励，增强个体的新行为。
- 预防措施：帮助个体识别高风险情境，并制定应对策略，防止旧行为的复现。
- 长期支持：提供长期的支持和跟进，帮助个体巩固新行为。

2. 复发

阶段特点：
- 常见性：复发是改变过程中的常见现象，大多数人在改变过程中都会经历多次复发。
- 自我批判：个体在复发后往往会对自己非常苛刻，这可能导致更大的挫折感。
- 正常化：将复发视为改变过程的正常部分，而不是失败，有助于个体保持积极的态度。

咨询策略：
- 认知重构：帮助个体重新评估复发的意义，将其视为学习的机会，而不是失败。
- 问题解决：利用复发过程中获得的信息，制定具体的解决方案，以减少未来复发的可能性。
- 支持网络：鼓励个体建立支持网络，如家人、朋友或专业机构，以获得持续的支持和帮助。

总结

维持阶段和复发是改变成瘾行为过程中不可或缺的两个阶段。维持阶段需要个体通过大量的练习和自我监控，将新行为内化为习惯。咨询师可以通过强化正面行为、预防措施和长期支持，帮助个体巩固新行为。复发虽然是一个常见的现象，但不应被视为失败。咨询师应帮助个体将复发视为学习的机会，利用复发过程中获得的信息，制定具体的解决方案，以减少未来复发的可能性。通过这些策略，个体可以逐步克服成瘾，实现持久的改变。

进一步阐述知识点

1. 动机访谈与传统咨询的区别

个体主动性：传统咨询强调个体通过自我探索发现改变的方法，而动机访谈则要求咨询师主动促进个体的改变动机。

咨询师的角色：在动机访谈中，咨询师承担更多责任，需要积极引导个体发现改变的动力。

2. 评估个体的改变阶段

主要关切：了解个体的主要关切有助于确定他们最关心的问题。

当前情况：了解个体的当前生活状况有助于评估他们的整体状态。

成瘾行为的性质：了解成瘾行为的具体性质及其功能，有助于制定针对性的干预措施。

改变经验：了解个体在改变方面的以往经验，可以帮助咨询师更好地理解他们的改变历程。

心理健康问题：识别个体的心理健康问题，有助于提供更全面的支持。

支持网络：了解个体的支持网络，有助于调动外部资源，提供更多的支持。

行为期望：了解个体对自己的行为期望，有助于设定合理的改变目标。

3. 考虑阶段的策略

成瘾行为的影响：帮助个体评估成瘾行为对他们的实际影响，包括积极和消极的方面。

双面性：通过填写表格，帮助个体认识到成瘾行为的复杂性，以及继续和放弃成瘾行为的双面影响。

认知重构：帮助个体重新评估成瘾行为的意义，将其视为一个需要解决的问题，而不是无法改变的事实。

总结

动机访谈与传统咨询策略有所不同，它要求咨询师主动促进个体的改变动机。为了有效地进行动机访谈，咨询师需要评估个体在改变过程中的阶段，并探讨多个方面的信息。在考虑阶段，帮助个体认真考虑成瘾行为的影响及其双面性，有助于他们更好地理解自己的问题，从而增强改变的动机。通过这些策略，咨询师可以更有效地支持个体，帮助他们克服成瘾，实现持久的改变。

进一步阐述知识点

1. 关注矛盾心理

防御性：过多关注成瘾行为的消极方面或改变的积极方面会使个体变得防御，这会强化支持成瘾行为的论点。

问题强调：在处理成瘾行为时，应更多地强调成瘾行为对个体改变构成的问题，而不是仅仅关注消极或积极方面。

2. 考虑表29.1

积极方面：继续成瘾行为的积极方面可能是复发的主要触发因素，这些积极方面可能解释了为什么过去的改变尝试未能成功。

例子：例如，一个因酒精成瘾而困扰且患有焦虑症的人可能会发现，饮酒帮助他们放松并睡个好觉。当他们停止饮酒时，他们可能会有睡眠困难，因此强烈希望回到之前的饮酒水平。

预防策略：在处理复发预防时，需要综合考虑使用方面的积极因素和改变方面的消极因素，制定全面的预防策略。

3. 决心阶段

决心：在决心阶段，个体决心采取行动，这种决心受到过去经验的影响。

鼓励：对于那些在过去尝试改变成瘾行为未成功的人，需要给予鼓励，帮助他们决定再次经历改变周期。

4. 行动和维持阶段

期望：在行动和维持阶段，认识期望非常重要。例如，迅速戒除成瘾行为是不可能的，个体需要有耐心和持续的努力。

长期支持：提供长期的支持和跟进，帮助个体巩固新行为，防止复发。

5. 复发阶段

综合考虑：在处理复发阶段的问题时，需要综合考虑使用方面的积极因素和改变方面的消极因素，制定具体的预防和应对策略。

认知重构：帮助个体重新评估复发的意义，将其视为学习的机会，而不是失败。

总结

动机访谈中的矛盾心理探索是帮助个体改变成瘾行为的重要工具。通过使用表29.1，咨询师可以帮助个体全面评估继续成瘾行为和改变行为的积极和消极方面，从而增强改变的动机。在不同阶段，咨询师需要采用不同的策略，如鼓励决心、认识期望和预防复发，以支持个体逐步克服成瘾，实现持久的改变。通过这些方法，咨询师可以更有效地帮助个体，提高改变的成功率。

进一步阐述知识点

1. 咨询师行为的重要性

表达同理心：同理心是建立信任和理解的基础。通过表达同理心，咨询师可以帮助个体感受到被理解和接纳，从而减少防御性，增强改变的动机。

发展差异：指出继续成瘾行为与实现其他重要目标之间的差异，可以帮助个体认识到改变的必要性，而不是让他们感到内疚。

避免争执：争执会引起个体的防御性，降低亲和力，从而阻碍改变。咨询师应避免争执，采用温和的方式引导个体。

应对抵抗：面对个体的抵抗，咨询师应给予个体机会表达自己的想法和感受，通过倾听和理解来缓解抵抗。

支持自我效能：自我效能是改变的重要因素。通过设定小目标，逐步过渡到更大的目标，可以帮助个体建立信心，增强自我效能。

提供反馈：提供反馈可以帮助个体认识到自己的进步和不足，增强改变的动力。

2. 咨询师的自我认知

自我局限：咨询师需要认识到自己的局限性，及时将个体转介给具有成瘾专业知识的专业人士。

转介资源：许多社区有提供成瘾行为服务的机构，咨询师可以推荐个体参加这些服务。

多种干预：除了个体咨询外，还可以推荐个体参加团体咨询、支持小组或家庭治疗，以获得多方面的支持。

自我反思：咨询师在工作中可能会遇到挑战，需要定期与主管讨论，进行自我反思和调整。

总结

成瘾行为的改变是一个复杂的过程，需要咨询师提供持续的鼓励和支持。通过表达同理心、发展差异、避免争执、应对抵抗、支持自我效能和提供反馈，咨询师可以更有效地帮助个体克服成瘾，实现持久的改变。同时，咨询师需要认识到自己的局限性，及时转介个体，并提供多种干预资源，以支持个体的全面康复。通过这些方法，咨询师可以更好地帮助成瘾困扰的个体，提高改变的成功率。

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.