Knowledge Share

Working through ambivalence with adolescent substance abusers

Matthew Snyder & Lynn Zubernis April 1, 2012

As practicing counselors, we all have clients who are “easier” than others. The easy clients are motivated toward change, take action on established goals and internalize feedback readily. The other side of that coin is that we also have clients who are more difficult. They are not motivated toward change, do not perceive the need for change and are ambivalent toward counseling. We have all encountered the person who has experienced a heart attack but continues to smoke, or the person who keeps abusing alcohol despite DUIs, failed relationships and repeated hangovers. Why do some people change, while others continue to engage in self-destructive behaviors?

In many settings and with many populations, ambivalence is more the rule than the exception. Clients who are mandated for treatment by an administrator or judge, who are “forced” into counseling by concerned parents or loved ones, or who are simply “going through the motions” may exhibit high levels of ambivalence, and this can be a major impediment to positive change. So how, as counselors, do we best help these clients?

If we look at James Prochaska and Carlo DiClemente’s “stages of change” model, many of these ambivalent clients are in the precontemplation stage. In other words, they are not at the point in the change process in which they are able to make insightful conclusions. They do not see their behaviors as problematic, or if they do, they are most likely blaming an external entity or third party for their problems. When we have clients who are at an early stage of the change process, we want to help them begin to feel or think that they are ready, willing and able to make a positive change. To achieve this, clients must recognize that their current behavior is a concern, think that they will be better off if they change and believe they are able to change.

So, how do we get them from this initial defensive stance to a place in which they are internally goal driven and actively seeking solutions? William Miller and Stephen Rollnick (1991) and Thomas Bied, William Miller and J. Scott Tonigan (1993) established that certain critical conditions must be present for change to occur. These conditions include empathy, feedback regarding personal risk associated with current behaviors, emphasis on personal responsibility for change, clear goal options and the facilitation of client self-efficacy. Following this work, Robert Stephens and Roger Roffman (1996) found that brief treatments can be effective for substance use clients and can establish these critical conditions for change.

Building on these areas of critical research, which have been continued and expanded through the past two decades, this article will briefly discuss how to work effectively with ambivalent clients and provide some useful techniques and strategies for doing so. Because most of us work within the constraints of managed care, organizational constraints or merely the financial realities of the current economy, we will focus on brief treatments that empirical studies have demonstrated to be effective. The framework and interventions we present feature eclectic ideas from a variety of theoretical approaches to counseling, including humanistic, cognitive behavior, solution-focused and motivational interviewing paradigms.

Substance abuse is a serious problem among adolescents, who face significant stressors in competition for academic and job success, a lack of support from overstressed parents and school systems, and the challenges posed by formal operational thinking and rampant social comparison (including cyberbullying). It is widely accepted that both risk taking and resistance are developmentally appropriate parts of individuation. Thus, the approach outlined here can be particularly effective in helping teens and young adults to accomplish positive change.

The initial sessions

The first counseling session is always important. Ideally, it establishes rapport and sets the groundwork for client change. With ambivalent or unmotivated clients, the initial session is even more critical.

The goals of such a session are first to express empathy, then to develop discrepancies between what the clients want and the behaviors they are engaging in and, finally, to support the belief that clients can make positive change. Rapport is critical and hinges on the counselor’s expression of real interest in clients’ views. This means not being dismissive or making assumptions based on one’s own beliefs about what is “best” for clients.

We often tell our graduate students that counseling is not like putting together a barbecue grill — there are no printed instructions or one-size-fits-all approaches. Instead, a counselor has to listen, long enough and hard enough to “get it.” But how can counselors really know that we get it? When we do, clients’ behaviors and coping strategies will make sense — not in a general way perhaps, but in the context of their specific circumstances. Their behaviors may be kicking them in the backside, but somewhere, a reinforcement contingency is present that is keeping them dependent on this behavior. Oftentimes, clients also have a realistic fear of giving up the only coping strategy they have been able to find.

One important caveat is to avoid increasing the client’s resistance, which will result in the client tuning you out — and very little actual change. Try to steer clear of taking any kind of argumentative stance. This will help you avoid power struggles, including adolescents’ typically knee-jerk response to anything that sounds as if an adult is telling them what to do. Drawing from what humanistic psychology teaches us, the counselor should listen and reflect rather than judging or telling clients what to do. From a motivational perspective, it is important for all clients — but especially for adolescent clients — to make choices for themselves and to experience that choice as being internally motivated.

During the initial session(s), it is expected that adolescents will be ambivalent regarding change. Start from this premise and try not to expect otherwise. After the counselor accepts this and listens closely enough to understand the context of the client’s behavior, the next step is to develop discrepancies. These usually involve a client’s behaviors not matching his or her verbalized goals or affective expression. No matter how ingrained the coping behavior, even the most defended clients are aware on some level that there are costs to the behaviors they have adopted.

However, it is just as critical for the counselor to remember that clients likewise perceive benefits to their behavior. If the behavior is continuing, something is reinforcing it, and the perception of the client is that the reinforcements are currently outweighing the costs. As we often emphasize to our graduate students, every behavior has a reason — you just need to keep digging to figure out what that reason is. Beginning counselors commonly fear acknowledging the “positives” that clients associate with their addictive behavior, whether it be substance abuse, an eating disorder or self-harm. But the counselor gains credibility and the client feels as though the counselor “gets it” when both costs and benefits are discussed openly.

Having acknowledged the positives, we then want to examine the negative outcomes and make concrete comparisons between the two. We follow this with a systematic exploration of the feelings associated with these behaviors and outcomes. Change does not happen in an intellectual, rational vacuum. If the emotional costs of change are perceived as too high, clients will remain where they are — this makes perfect sense, because no one wants to incur emotional suffering.

The next step is to move forward to the future, examining how these behaviors affect the client’s long-range goals. The reinforcing impact of many coping behaviors such as substance abuse are limited to short-term pain reduction, and clients avoid awareness of long-term negative impact. It is human nature to prioritize stopping immediate pain over some future deferred benefit. Change will occur only if adolescents perceive a discrepancy between where they are and where they actually want to be, while also having the emotional regulation skills and substitute coping strategies to tolerate some discomfort in getting there. In other words, it makes sense to change only when the client (not the counselor) comes to believe that the good things about the problem behavior are outweighed by its adverse consequences.

A good way to get clients to express their ambivalence, as well as their awareness of some of the potential costs of their behavior, is through reflective listening. For example, a client who talks about feeling less anxious and more sociable when using marijuana but is also motivated to do well in school and concerned about the cognitive impact of use is expressing both positive and negative aspects of using. A typical reflective statement that points out one of these discrepancies would be “So, you are saying that you really enjoy the feeling of getting high, but at the same time you are afraid of losing brain cells.” If a client says, “Maybe I should start cutting down on my marijuana use a little bit before I lose my job or get suspended from school,” the counselor could follow with “So you see a connection between your drug use and problems you are having at school and work.” In making such a statement, the counselor is acknowledging and reinforcing the client’s insight, which naturally leads into more directive goal setting.

It may sound counterintuitive, but we want clients to become more distressed about their usage. People are motivated to change something when they’re in distress, so clients need to experience that distress. By first understanding and then challenging their defense mechanisms and pointing out the discrepancies, counselors can use this distress as a motivating factor toward change.

The early sessions should also be designed both to increase client motivation to address issues of concern and to empower clients for change by educating them about cognitive behavior approaches and the triggers to their substance abuse. It is important in these initial sessions for clients to start expressing motivational statements. These statements can be in the cognitive, affective or behavioral realms. For example, a client might say, “I guess maybe this is more serious than I thought” (cognitive recognition of the problem) or “I’m really worried about what’s happening to me” (affective expression). Motivational statements also include implied or stated intention to make changes, such as “I’ve got to do something!” or “I know I can do it if I put my mind to it.”

Later sessions

After the initial session(s), in which counselors have highlighted some discrepancies and clients have been able to verbalize some motivation statements, there are many techniques you can use to help clients progress toward goal setting and positive change.

Often, young adults who are abusing substances have a limited repertoire of alternative coping skills, so they are understandably reluctant to give up the ones they do have. Skill deficits should be explored and remedied, and new behaviors should be taught and practiced. This can be achieved through role-play, scripting or cognitive restructuring.

A functional analysis can also be very helpful at this point in the process. It will help clients explore and understand that there are antecedents and consequences that influence their usage patterns, and that their responses to these environmental contingencies are entirely understandable. Change the antecedents and consequences, and the behavior changes.

An understanding of the way in which their use is influenced by external factors, in combination with an emphasis on the client’s ability to change these, can be motivating and empowering. This approach also avoids pathologizing clients. Self-efficacy is an important component to later sessions. From this point, you can help clients come up with alternative behaviors and cognitions that will in turn alter their ultimate consequences.

Once clients have gained an understanding of how their behaviors are negatively affecting multiple aspects of their lives and have gained motivation toward change, the next step is goal setting.

Warning signals and how to navigate around them

Resistance is common when working with ambivalent clients. It should be expected but not ignored. Resistance might take the form of a client contesting some factual information or something the counselor has said. It might take the form of frequent interruptions to change the subject or be of the “yes, but …” variety. These should serve as red flags for the counselor, indications that you’re pushing too hard or trying to go too fast. Clients didn’t develop this coping strategy overnight, and it’s unrealistic to think they’ll discard it quickly either.

When you sense resistance, drop back and “roll with the resistance.” Repeat clients’ statements in a neutral, nonjudgmental tone, letting them know that you’re hearing them and that you realize what they’re saying is important. Express empathy with their statements, perhaps by reframing them toward the positive. Emphasize what clients are already doing that’s helping them move toward positive change. Shift focus away from obstacles that seem immovable to barriers that these clients have already been able to surpass.

Rather than arguing with clients, it can be helpful to try a paradoxical approach, siding with the problem instead of challenging it. Exaggerating what clients have said can sometimes help them to see the downsides of their coping strategies more clearly. For example, if a client has said that alcohol makes him or her more sociable, you can take that side by expanding the statement: “You can only talk to people and get to know them if you’re drinking, and it’s really helping you get to know people better and form some close relationships.”

Other motivational interviewing techniques are also useful in minimizing resistance. Asking open-ended questions (“What do you think about your alcohol use?” instead of “Do you know what drinking does to you?”), using reflective listening and validating the client’s worldview are all good approaches to use in helping the counselor to “get it” and helping the client to feel “gotten.”

Clients are more likely to attempt change and to persevere after relapse if the counselor has taken the time to get to know them and shared positive affirmations with them. Engaging in the helping process when dependent on a coping strategy that will be challenged takes a tremendous amount of courage. Reflecting that courage back to the client can be the starting point for real change.

“Knowledge Share” articles are adapted from sessions presented at past ACA Annual Conferences.

Matthew Snyder is an assistant professor and graduate coordinator in the Department of Counselor Education at West Chester University. Contact him at msnyder@wcupa.edu.

Lynn Zubernis is an assistant professor in the Department of Counselor Education at West Chester University.

Letters to the editor: ct@counseling.org

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1 Comment

  1. Makava Holiday

    Hi, I am a recovering addict and alcoholic. I have been drug free for nearly 6 years. I work in an outpatient Methadone clinic and have been met with alot of resistance frommy patients, I just wanted to thank you for this article and let you know it has been very helpful for me.

    Reply

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