Here's the handout from my workshop at Counselor Camp 2001. I'm presenting a very similar workshop (it even has the same title!) in November at the Association for Experiential Education's 2011 International Conference. That workshop will focus more specifically on integrating narrative therapy and experiential education with this population.
Overcoming the Stuckness
Six Keys to Facilitating Change with Substance Abusing Teens
Presented by David Flack • Counselor Camp 2011
Teens are teens. They aren’t adults and they aren’t children. That seems obvious, right? Obvious or not, though, it is essential to remember when working with this age group. Adolescence is a discrete developmental stage that focuses on the tasks of developing identity, autonomy, intimacy, sexuality, and achievement. With substance abusing teens we often see distorted, funhouse mirror versions of these normal developmental tasks. With co-occurring teens, that mirror can be even more distorted.
It is normal for teens to question, rebel against, and ultimately reject the plans of authority figures, including the most well intentioned drug counselors. That means our clients are doing exactly what they should be doing, just in maladaptive, problematic ways. Yet, we often label them non-compliant, oppositional, or treatment resistant.
What Else Do We Know About Our Clients?
• Teens rarely enter treatment by choice. Since establishing autonomy is an important task of adolescence, when teens are mandated or pressured to attend treatment, there is a predictable conflict that frequently results in reactance.
• Substance-abusing teens typically exhibit rigid thinking habits. If we use confrontational or directive approaches, we’ll stop being allies and become adversaries. This won’t be useful for anyone!
• Most of our clients have complicating factors. 80% of substance-abusing teens have a mental health challenge; 70% have a history of trauma. If not addressed, these challenges can become insurmountable obstacles to change.
With these points in mind, I’ve developed Six Keys for facilitating change with substance-abusing teens. These Keys are a “mash up” of motivational interviewing, stages-of-change, narrative therapy, and existential psychotherapy. I think of them as the “C” in CBT — a way to assist adolescent clients in overcoming rigid thinking, getting unstuck, and moving forward.
First Key: Everyone is motivated by something.
When starting treatment, teens often deny any problems related to alcohol, marijuana, or other drugs. When this happens, many helpers quickly label them as resistant. This can be a self-fulfilling prophecy. In other words, if you expect resistance then you’ll probably get it.
When given an opportunity, even the most reluctant clients are likely to identify something that motivates them to engage in treatment — often legal, school, or family problems. These may not be the motivators we want for our clients, but change requires meeting clients where they’re at, not where we want them to be.
Help clients find their “hook” by using the Five R’s of Motivational Interviewing:
• Relevance. Why is change important?
• Risks. What are the risks of changing? What are the risks of not changing?
• Rewards. What will you gain from change?
• Roadblocks. What are the obstacles to change?
• Repetition. Review these at each session.
Second Key: Change requires leaving your Comfort Zone.
Our clients are stuck in seemingly endless loops of maladaptive behaviors. Our task is to assist them in getting unstuck, not behave better, fulfill external mandates, or stop using. Hopefully those things happen, but they’re side effects of getting unstuck. When we start thinking about our task this way, we’re better able to help clients discover how to leave their Comfort Zones.
In the Zone
• Comfort Zone. Most people spend most of their time in their Comfort Zone, where risks and challenges are minimal, but so is change or learning.
• Challenge Zone. When you leave your Comfort Zone, you enter your Challenge Zone. This is where learning and change occurs.
• Crisis Zone. In the Crisis Zone, stress is too high for effective learning.
Risking Change
Leaving your Comfort Zone is risky. However, it is necessary if change is going to occur. Three ways to assist clients in taking this risk are:
• Acknowledge the risk. Increased awareness is one of the first steps to changing any behavior. Spend time talking with clients about the risks involved in change and ways to move forward anyway.
• Explore good risks vs. bad risks. Their behavior might suggest otherwise, but most substance-abusing teens are risk adverse. Bad risks have become commonplace in their lives, but they actively avoid taking good ones.
• Provide opportunities to practice safe risk taking. I’ve had clients try belly dancing, glass blowing, rock climbing, snowshoeing, and more. Adventure outings and other experiential activities also provide ways to practice risk taking.
Super-stuck Teens
This is a term I use for those clients who are simply unwilling to leave their Comfort Zone. For these teens, The Known — no matter how bad — is inherently better than The Unknown. Super-stuck teens are overwhelmed by existential anxiety. This can be defined as stress or anxiety rooted in our awareness of personal freedom and the responsibilities that accompany choices.
Teens with chaotic histories, unstable environments, and past traumas are most likely to become super-stuck. Super-stuckness can also occur with “timid” teens, clients who have poor self-esteem, and youth with traits of anxiety or depression, even if sub-clinical.
In my experience, super-stuck teens will likely spend a longer-than-usual time in the Contemplation and Preparation Stages of Change (see Third Key). They require extra patience, increased empathy, and counselors focused on relationships over compliance.
Third Key: Change is a process, not an event.
Even when it seems that change was instantaneous, we’re really seeing the end result of a process. The Stages of Change is a transtheoretical model that identifies five steps:
• Pre-contemplation. I don’t have a problem.
• Contemplation. Maybe I have a problem.
• Preparation. I have a problem and am thinking about what to do.
• Action. I’m doing something about my problem
• Maintenance. My new behavior has become habit.
It is important to remember that movement through these stages isn’t always linear. The most obvious example of this is Recycling (or Relapsing). When attempting any kind of change, relapse into old behaviors can be a necessary part of the process and a valuable teachable moment.
When relapse happens, we tend to blame a lack of skills, situational factors, or client unwillingness. These may be the extenuating circumstances, but I propose that relapse happens because we push our clients into Action too quickly. Recovery isn’t a race! We need to set our abstinence agendas aside and give our clients the time they need to move through all the Stages of Change.
Fourth Key: Expect ambivalence.
Ambivalence can be defined as simultaneously believing two seemingly contradictory ideas. In the case of substance-abusing teens: I want to fix my problem and I want to keep using. As we know, teens typically enter treatment because of legal, school, and family pressures, but don’t think they have a problem with alcohol, marijuana, or other drugs. Is it any surprise they’re ambivalent?
Helping clients resolve their ambivalence requires exploring both the pros and cons of using. However, drug counselors often focus solely on the problems. Our clients know they have a problem. They don’t need us telling them over and over. If anything, doing so may be invalidating and reaffirm their apparent inability to make change.
Resolving Ambivalence
As we know, substance-abusing teens have rigid thinking habits. These habits reinforce their ambivalence by keeping them stuck in extreme thinking. Resolving ambivalence requires them to think beyond the extremes. In addition to exploring the pros and cons of using, some strategies for helping with this are:
• Engage clients in activities and discussion on balance, the Middle Path, and similar concepts.
• Explore all-or-nothing thinking.
• Whenever possible, use continuums, spectrums, and scaling questions.
• Assist clients to develop critical thinking and mindfulness skills.
Fifth Key: Changed lives require changed stories.
The stories we tell about ourselves and our experiences define how we act, think, and feel. They determine how we make sense of our past, present, and future, how we interpret the information of our lives, and how we interact with the world.
Substance-abusing teens have lives filled with problem-saturated stories. These tales of stuckness, maladaptive behavior, and treatment failures have become the defining stories for their lives. These stories are constrictive, leaving our clients trapped in an ever-shrinking Comfort Zone, with fewer and fewer options. As helpers, we need to provide opportunities to create new, more hopeful stories.
Externalizing the Problem
• Instead of having a problem or being a problem, assist clients to view problems as existing outside themselves.
• Externalizing the problem removes pressures rooted in blame, shame, and defensiveness.
• We can take this even further by encouraging clients to think of their problems as characters in their stories.
• You can assist clients to externalize their ambivalence by presenting the idea of both an Addictive Voice and a Rational Voice.
Seek Exceptions
• Clients build and sustain problem-saturated narratives by ignoring times when The Problem wasn’t in control.
• Seeking exceptions involves assisting clients to identify those ignored times.
• Explore these exceptions in great detail. Much can be learned from them.
• Identifying exceptions assists clients to discover the skills they already possess but have been ignoring because The Problem was in control.
Re-authoring
• Once exceptions have been identified, clients can start re-authoring their problem-saturated stories.
• Re-authoring involves giving clients the opportunity to create new, more empowering stories.
• Anything that involves clients successfully leaving their Comfort Zone and experiencing exceptions to their problem-saturated narratives can provide useful material for these new stories.
Sixth Key: Maintain a playful approach.
I conceptualize the challenges faced by some adolescent clients as developmental debt. Various developmental theories exist, but most have some things in common. For example, most include stages of development that are linked to age ranges. Also, most include a task that needs to be accomplished in order to move to the next stage.
Traditional perspectives on development suggest that if a task isn’t successfully completed, then the person becomes stuck at that stage. While that may have been accurate when these developmental models were created, it seems to me this is no longer true. Instead, sociocultural and biological factors keep pushing individuals forward, even if developmental tasks are unresolved or only partially completed.
With every push forward, these individuals become less likely to successfully complete the next stage, resulting in an ever-growing developmental debt. Think of it like a credit card that never gets fully paid off. Not only will you always have a balance due, but you’ll also get further and further behind each month.
Maintaining a playful approach is one way to meet our “in debt” clients where they’re at both emotionally and cognitively. Also, play and playfulness creates an environment that allows these teens to start paying off some of that debt. In other words, a playful approach provides opportunities for our clients to go backwards in order to catch up.
Activities from the Workshop
The following activities and exercises were part of the workshop: Chiji Mingle, Endless Loop, Chiji Zones, Mega Jenga, Gutter Ball, Brainstorm Posters (The Good, the Bad, and the Ugly), and Whack 'Em.
Further Reading
• The Art of Changing the Brain, by James Zull
• Changing for Good, by James Prochaska, John Norcross & Carlo DiClemente
• Elusive Alliance, edited by David Castro-Blanco & Marc Karver
• Interviewing for Solutions, by Peter de Jong & Insoo Kim Berg
• Motivational Interviewing, by William Miller & Stephen Rollnick
• Motivational Interviewing with Adolescents & Young Adults, by Sylvie Naar-King & Mariann Suarez
• Pathways to Change, by Matthew Selekman
• The Primal Teen, by Barbara Strauch
• Real Boys, by William Pollack
• Reviving Ophelia, by Mary Pipher
• What is Narrative Therapy?, by Alice Miller
Showing posts with label ambivalence. Show all posts
Showing posts with label ambivalence. Show all posts
Monday, September 19, 2011
Saturday, March 21, 2009
Puzzle Pieces
I've recently read two books, Beautiful Boy and Tweak. Beautiful Boy, by David Sheff, is about the author’s struggles with his son Nic’s addiction, as well as his own denial and codependency. David wrote, “Addicts are in denial and their families are in it with them because often the truth is too inconceivable, too painful, and too terrifying” (p. 15). One aspect of this book I found especially interesting is the way the author integrates three different threads—his son’s addiction, general information on chemical dependency, and his own growing codependency. Tweak, by son Nic, provides another perspective.
While Beautiful Boy covered Nic’s entire life, Tweak covers about two years when Nic is in his early twenties, starting with a relapse that becomes a 28 day methamphetamine and heroin binge, followed by a stint in at an inpatient facility, about a year of clean time, another relapse, and another stint at an inpatient facility. While Beautiful Boy contains much confusion and helplessness, Tweak is about anger and desperation.
Throughout Beautiful Boy, David reports on his ongoing attempts to talk Nic into treatment for one more try. Like most addicts, Nic does not believe he needs treatment and does not believe it will help. Considering at least four treatment attempts are documented in David’s book, Nic’s skepticism seems understandable. It hasn’t worked before, why will it this time? This is something I face with clients frequently.
Most of my clients have been in treatment before, some several times. In fact, I’m currently working with a client who has completed inpatient twice in the past, has been in three different outpatient programs, and has been to mental health therapists off and on for nearly five years. This client is now eighteen and court mandated. Failure to follow through with all treatment recommendations would most likely lead to jail time. So he reluctantly agreed to begin treatment one more time, but he reported, “It probably won’t do any good.” Why would he think otherwise?
There is another level to Nic’s ambivalence, though, which seems quite common. Nic wrote, “Using is suck a fucking ridiculous little circle of monotony. The more I use, the more I need to kill the pain, so the more I need to keep using. Pretty soon it seems like going back, facing all my shit, well, it’s just too goddamn overwhelming. I’d rather dies than go through it” (p. 146).
At a certain point, using is no longer about getting high or the initial positive reinforcements. Instead, it becomes about escaping—at least temporarily—from the ever-mounting number of negative outcomes of using. It seems easier to just keep using. Nic wrote, “I don’t care. Isn’t that the greatest gift in the world—just not to care? I feel so grateful for it. That’s nothing I ever knew sober” (p. 60). Why give that up? For many of my clients, that’s the biggest question that needs answering in treatment.
Getting clean is hard work. It means changing everything in your life. It also means taking huge risks. Nic wrote, “Trying is terrifying because I know I will just fail” (p. 296). Nearly all my clients know that feeling. Nearly all my clients have made very similar comments. What if they say they want to get clean, but then can’t actually do it? What if they take that risk, but then fail? If they don’t try, then there's no possibility of failure. My clients know how to use. They've never failed at using. That sounds strange, perhaps, but addicts understand. And, that “circle of monotony” may be a bit of a bore, but at least it is predictable.
Many of my clients live in highly dysfunctional families, frequently filled with the chaotic fallout of substance abusing parents, family members with mental health issues, economic pressures, and similar stressors. For these youth, the predictable circle of monotony can have a certain appear. As a client once said, "I use. I get high. No surprises."
Chaos is not Nic’s history, though. Although divorced, both parents are successful and his childhood appears reasonably healthy. He went to private schools. He was successful and popular as a child, active in sports and other extracurricular activities. He doesn’t seem like a future meth addict. So what happened? I wondered that the entire time I was reading Beautiful Boy. I wondered that through much of Tweak.
Nic has a certain level of genetic predisposition, a grandfather who was an alcoholic. However, one grandparent who died before he was even born doesn’t seem enough to me, even though Nic wrote about his first using experience, with alcohol, “I drank some and then I just had to drink more until the whole glass was drained completely. I’m not sure why. Something was driving me that I couldn’t identify and still can’t comprehend” (p. 2).
Although this sounds very disease-like, I don’t believe in the disease model all that much, especially for adolescents. There must be more. There must be a missing puzzle piece. If Nic finds that missing puzzle piece, maybe he can get and stay clean. If I can help my clients find their missing pieces, maybe they can get and stay clean, too.
Maybe recovery is really about finding missing puzzle pieces.
In Beautiful Boy, this missing piece is not addressed. David is simply too helpless to look beyond the next crisis. In Tweak, though, it seemed obvious fairly quickly that Nic might have mental health issues. At first, I wondered if I was looking for this because of my work experience. After all, my clients all have co-occurring disorders, I’ve always worked with co-occurring clients, and I feel strongly that most adolescents with significant substance abuse issues probably have challenges in this area.
Much of Nic’s writing reflects a depressive state. At other times, though, he seems almost manic, even though it usually seems related to his use of meth. Nic wrote, “I… have an incredible anxiety socializing with people. I mean, if I’m at work, or I’m high, then that’s okay. But sober, going out with people my age, I am just really uncomfortable.” (p. 161). Eventually, after all his other treatment episodes, all the therapists he’s seen in his life, past diagnoses of depression and prescriptions for antidepressants that he simply abuses, and all the time spent high, Nic is given a diagnosis of bipolar disorder.
In my opinion, bipolar disorder is the new overly diagnosed condition. However, when accurately applied, I’ve seen treatment for this condition change lives dramatically. After two weeks on medications for bipolar disorder, Nic wrote, “Something has changed. And then it hits me—maybe it’s the medication… Sure, the change isn’t very dramatic. It’s no like shooting meth or something. But there is a slight difference. Keeping my head above water suddenly doesn’t seem so tiring. The blackness doesn’t swallow me up to such a horribly suffocating depth” (p. 204).
Both Beautiful Boy and Tweak can be grueling. David seems to often be lost in his helplessness and codependency, unable to live his life or even care for his other children. Indeed, David frequently wrote that he is addicted to Nic’s addiction. This is apparent throughout his book. This is also something I see frequently in the family members of clients.
Reading the relentless passages about using, crime, prostitution, and self-inflicted trauma is almost unbearable at times. After being diagnoses with bipolar disorder, Nic wrote, “How could I have spent my whole life battling so hard, not knowing what was wrong?” The better question, I think, is how could so many therapists, treatment centers, and other counselors have missed that puzzle piece?
With some of my clients, treatment is about learning skills to resist using. That's pretty simple. For other clients, though, there's much more. They know these skills. Heck, they could lead group sessions on triggers, relapse prevention, emotion regulation, and mindfulness. But, they still use. There's something missing in their recovery. They haven't found their puzzle piece. Yet.
While Beautiful Boy covered Nic’s entire life, Tweak covers about two years when Nic is in his early twenties, starting with a relapse that becomes a 28 day methamphetamine and heroin binge, followed by a stint in at an inpatient facility, about a year of clean time, another relapse, and another stint at an inpatient facility. While Beautiful Boy contains much confusion and helplessness, Tweak is about anger and desperation.
Throughout Beautiful Boy, David reports on his ongoing attempts to talk Nic into treatment for one more try. Like most addicts, Nic does not believe he needs treatment and does not believe it will help. Considering at least four treatment attempts are documented in David’s book, Nic’s skepticism seems understandable. It hasn’t worked before, why will it this time? This is something I face with clients frequently.
Most of my clients have been in treatment before, some several times. In fact, I’m currently working with a client who has completed inpatient twice in the past, has been in three different outpatient programs, and has been to mental health therapists off and on for nearly five years. This client is now eighteen and court mandated. Failure to follow through with all treatment recommendations would most likely lead to jail time. So he reluctantly agreed to begin treatment one more time, but he reported, “It probably won’t do any good.” Why would he think otherwise?
There is another level to Nic’s ambivalence, though, which seems quite common. Nic wrote, “Using is suck a fucking ridiculous little circle of monotony. The more I use, the more I need to kill the pain, so the more I need to keep using. Pretty soon it seems like going back, facing all my shit, well, it’s just too goddamn overwhelming. I’d rather dies than go through it” (p. 146).
At a certain point, using is no longer about getting high or the initial positive reinforcements. Instead, it becomes about escaping—at least temporarily—from the ever-mounting number of negative outcomes of using. It seems easier to just keep using. Nic wrote, “I don’t care. Isn’t that the greatest gift in the world—just not to care? I feel so grateful for it. That’s nothing I ever knew sober” (p. 60). Why give that up? For many of my clients, that’s the biggest question that needs answering in treatment.
Getting clean is hard work. It means changing everything in your life. It also means taking huge risks. Nic wrote, “Trying is terrifying because I know I will just fail” (p. 296). Nearly all my clients know that feeling. Nearly all my clients have made very similar comments. What if they say they want to get clean, but then can’t actually do it? What if they take that risk, but then fail? If they don’t try, then there's no possibility of failure. My clients know how to use. They've never failed at using. That sounds strange, perhaps, but addicts understand. And, that “circle of monotony” may be a bit of a bore, but at least it is predictable.
Many of my clients live in highly dysfunctional families, frequently filled with the chaotic fallout of substance abusing parents, family members with mental health issues, economic pressures, and similar stressors. For these youth, the predictable circle of monotony can have a certain appear. As a client once said, "I use. I get high. No surprises."
Chaos is not Nic’s history, though. Although divorced, both parents are successful and his childhood appears reasonably healthy. He went to private schools. He was successful and popular as a child, active in sports and other extracurricular activities. He doesn’t seem like a future meth addict. So what happened? I wondered that the entire time I was reading Beautiful Boy. I wondered that through much of Tweak.
Nic has a certain level of genetic predisposition, a grandfather who was an alcoholic. However, one grandparent who died before he was even born doesn’t seem enough to me, even though Nic wrote about his first using experience, with alcohol, “I drank some and then I just had to drink more until the whole glass was drained completely. I’m not sure why. Something was driving me that I couldn’t identify and still can’t comprehend” (p. 2).
Although this sounds very disease-like, I don’t believe in the disease model all that much, especially for adolescents. There must be more. There must be a missing puzzle piece. If Nic finds that missing puzzle piece, maybe he can get and stay clean. If I can help my clients find their missing pieces, maybe they can get and stay clean, too.
Maybe recovery is really about finding missing puzzle pieces.
In Beautiful Boy, this missing piece is not addressed. David is simply too helpless to look beyond the next crisis. In Tweak, though, it seemed obvious fairly quickly that Nic might have mental health issues. At first, I wondered if I was looking for this because of my work experience. After all, my clients all have co-occurring disorders, I’ve always worked with co-occurring clients, and I feel strongly that most adolescents with significant substance abuse issues probably have challenges in this area.
Much of Nic’s writing reflects a depressive state. At other times, though, he seems almost manic, even though it usually seems related to his use of meth. Nic wrote, “I… have an incredible anxiety socializing with people. I mean, if I’m at work, or I’m high, then that’s okay. But sober, going out with people my age, I am just really uncomfortable.” (p. 161). Eventually, after all his other treatment episodes, all the therapists he’s seen in his life, past diagnoses of depression and prescriptions for antidepressants that he simply abuses, and all the time spent high, Nic is given a diagnosis of bipolar disorder.
In my opinion, bipolar disorder is the new overly diagnosed condition. However, when accurately applied, I’ve seen treatment for this condition change lives dramatically. After two weeks on medications for bipolar disorder, Nic wrote, “Something has changed. And then it hits me—maybe it’s the medication… Sure, the change isn’t very dramatic. It’s no like shooting meth or something. But there is a slight difference. Keeping my head above water suddenly doesn’t seem so tiring. The blackness doesn’t swallow me up to such a horribly suffocating depth” (p. 204).
Both Beautiful Boy and Tweak can be grueling. David seems to often be lost in his helplessness and codependency, unable to live his life or even care for his other children. Indeed, David frequently wrote that he is addicted to Nic’s addiction. This is apparent throughout his book. This is also something I see frequently in the family members of clients.
Reading the relentless passages about using, crime, prostitution, and self-inflicted trauma is almost unbearable at times. After being diagnoses with bipolar disorder, Nic wrote, “How could I have spent my whole life battling so hard, not knowing what was wrong?” The better question, I think, is how could so many therapists, treatment centers, and other counselors have missed that puzzle piece?
With some of my clients, treatment is about learning skills to resist using. That's pretty simple. For other clients, though, there's much more. They know these skills. Heck, they could lead group sessions on triggers, relapse prevention, emotion regulation, and mindfulness. But, they still use. There's something missing in their recovery. They haven't found their puzzle piece. Yet.
Tuesday, December 2, 2008
Readiness to Change
As I’ve previously written, I believe that making change is about resolving ambivalence. Miller and Rollnick wrote that when facilitating change in others, “It is useful in understanding a person’s ambivalence to know his or her perceptions of both importance and confidence” (p. 53). This balance between importance and confidence can be thought of as an individual’s readiness for change (Miller & Rollnick, p. 54).
Within the chemical dependency field, an individual’s readiness to change is given much important. Per standards set by the American Society of Addiction Medicine (ASAM), readiness to change has been identified as one of six areas, or dimensions, to be evaluated during an initial substance abuse assessment and to be re-evaluated during monthly updates.
As a drug/alcohol counselor, I clearly think a lot about readiness to change in others. Indeed, much of what I do as a clinician is really about helping clients to increase their readiness to change. However, it seems to me that this is presented as a vague concept within the ASAM assessment criteria. Basically, the more resistant an individual appears, the lower his readiness to change. However, if resistance truly is “an unhelpful idea that has handicapped therapists” (Selekman, p. 32), it seems unproductive to use it as a means of assessment. Worse, this pessimist mindset seems likely to keep the client stuck.
After all, if a client is resistant and therefore completely unwilling to engage in treatment, even the most skilled clinician would be left with no options. These clients sit in treatment for a while, refusing to engage, then get discharged for being non-compliant, not amiable to treatment, or unwilling to participate in their own recovery. Shame on them! Clients may not enter treatment resistant to the process, but they do sometimes leave that way. Or, as Seligman wrote, “Pessimistic prophecies are self-fulfilling” (p. 6).
Recently, I began working with “Michael.” Michael had been working with another clinician for about two months when he was referred to me. The clinician stated, “He doesn’t want to do any work and is completely unwilling to engage in treatment. I think he needs mental health services.” Michael’s attendance at group and individual sessions had been poor thus far, and the referring clinician stated that he was “adamant” about continuing to use marijuana and alcohol. The referring clinician also used that word resistant many, many times during our one conversation about this client.
The Process of Change
I believe a useful way to evaluate readiness to change is by assessing the individual’s Stage of Change. According to Stages of Change theory, lasting change is a process, with the individual moving through six distinct stages. These are pre-contemplation, contemplation, preparation, action, maintenance, and termination. Each stage “entails a series of tasks that need to be completed before progress to the next stage” (Prochaska, Norcross & DiClemente, p. 39). Sometimes, an individual returns to a prior stage in order to do more work. Within this model, that’s not a failure, just part of the process. In fact, I believe that recovery is an experiential process, and that relapse can be the most important part of that process.
Traditionally, most substance abuse programs assumed all clients entering treatment were in the action stage. To me, this is just absurd, especially when you consider that most clients—like Michael—are mandated in the first place. Perhaps resistance is really about this misfit of stages. If an individual is pre-contemplative and being treated as if he is ready to take action, wouldn’t he appear non-compliant, not amiable to treatment, and unwilling to engage? That certainly describes Michael. When I first met him, my perspective was a bit different than the referring clinician’s.
Michael was—and remains—a challenging client who tests boundaries, is likely to debate minor details, and always does the minimum required. However, he wasn’t resistant. Rather, he was stuck in pre-contemplation. Like anyone in pre-contemplation, Michael didn’t believe he had a problem. Since he didn’t have a problem, why should he change anything? And, the more people pushed him to take action, the less likely it would happen.
Miller and Rollnick wrote, “ When the idea of change or treatment is forced on an unwilling recipient it is not uncommon for the individual to engage in the problem behavior to a greater extent in an attempt to assert his or her freedom” (p. 337). According to the referring clinician, Michael’s using had increased since starting treatment. In fact, the referring clinician offered this information as proof of Michael’s resistance.
If Michael was actually stuck in pre-contemplation, my efforts shouldn't be to get him to take action. My efforts should be to help him get unstuck. Prochaska, Norcross and DiClemente have identified specific tasks for each Stage of Change. I have found these stage-specific tasks to be useful when working with clients. I've also found that the Stages of Change model and motivational interviewing have much in common. In fact, Miller and Rollnick wrote, “[M]otivational interviewing can be used to assist individuals to accomplish the various tasks required to transition form the pre-contemplation stage through the maintenance stage” (p. 202). Employing basic motivational interviewing principles when doing Stages of Change work seems a natural choice.
Miller and Rollnick identified four general principles for motivational interviewing. These are express empathy, develop discrepancy, roll with resistance, and support self-efficacy (p. 36). Especially when combined with stage-specific tasks, these principles are highly effective in helping clients move through the Stages of Change (Miller & Rollnick, p. 203). And, when the clients are successful, they are also developing the confidence to continue their change process.
The Confidence to Change
Miller and Rollnick wrote, “Readiness [to change] implies at least some degree of both importance and confidence. A person who does not see change as important is unlikely to be ready to change. Similarly, people who see change as impossible are unlikely to say they are ready to do it” (p. 54). Initially, Michael didn’t see change as important, but he also had doubts about his ability to make meaningful change.
I proposed two goals for Michael. First, address the tasks of pre-contemplation so he could start making some movement on the Stages of Change. Second, increase his sense of self-efficacy and thereby improve his optimism. When I presented this plan to Michael, his only response was, “Whatever. As long as I don’t get my probation revoked.” That lead to a third goal for Michael: do what is necessary to stay out of detention, which meant attending weekly individual sessions with me and having clear UAs.
Michael was reluctant to stop his use, but agreed to this plan because, in his words, “I’ll go to detention if I don’t.” I’ve only been working with this client for a short time, but clear progress has already occurred. Michael has been present at all his scheduled appointments. He's also making reasonable progress on pre-contemplation tasks. In our last appointment, he stated, “I don’t think I’ve got a problem using, but everyone else does, and that’s a problem, I guess. ” This may not sound like progress to some. I’m sure it wouldn’t to that referring clinician. To me, though, it clearly represents signs of becoming unstuck.
Instead of the pessimism of resistance, a new perspective is offered by the combination of the Stages of Change model and motivational interviewing: Even the most reluctant clients are simply working on the tasks of their current stage. Thought of this way, the job of a professional helper is reframed from the thankless task of overcoming resistance to that of assisting clients to increase their readiness to change.
Works Cited
Miller, W., & Rollnick, S. (2002). Motivational Interviewing. New York: Guilford Press.
Prochaska, J., Norcross, J., & DiClemente, C. (1994). Changing for Good. New York: Harper Collins.
Selekman, M. (2005). Pathways to Change. New York: Guilford Press.
Seligman, M. (1990). Learned Optimism. New York: Random House.
Within the chemical dependency field, an individual’s readiness to change is given much important. Per standards set by the American Society of Addiction Medicine (ASAM), readiness to change has been identified as one of six areas, or dimensions, to be evaluated during an initial substance abuse assessment and to be re-evaluated during monthly updates.
As a drug/alcohol counselor, I clearly think a lot about readiness to change in others. Indeed, much of what I do as a clinician is really about helping clients to increase their readiness to change. However, it seems to me that this is presented as a vague concept within the ASAM assessment criteria. Basically, the more resistant an individual appears, the lower his readiness to change. However, if resistance truly is “an unhelpful idea that has handicapped therapists” (Selekman, p. 32), it seems unproductive to use it as a means of assessment. Worse, this pessimist mindset seems likely to keep the client stuck.
After all, if a client is resistant and therefore completely unwilling to engage in treatment, even the most skilled clinician would be left with no options. These clients sit in treatment for a while, refusing to engage, then get discharged for being non-compliant, not amiable to treatment, or unwilling to participate in their own recovery. Shame on them! Clients may not enter treatment resistant to the process, but they do sometimes leave that way. Or, as Seligman wrote, “Pessimistic prophecies are self-fulfilling” (p. 6).
Recently, I began working with “Michael.” Michael had been working with another clinician for about two months when he was referred to me. The clinician stated, “He doesn’t want to do any work and is completely unwilling to engage in treatment. I think he needs mental health services.” Michael’s attendance at group and individual sessions had been poor thus far, and the referring clinician stated that he was “adamant” about continuing to use marijuana and alcohol. The referring clinician also used that word resistant many, many times during our one conversation about this client.
The Process of Change
I believe a useful way to evaluate readiness to change is by assessing the individual’s Stage of Change. According to Stages of Change theory, lasting change is a process, with the individual moving through six distinct stages. These are pre-contemplation, contemplation, preparation, action, maintenance, and termination. Each stage “entails a series of tasks that need to be completed before progress to the next stage” (Prochaska, Norcross & DiClemente, p. 39). Sometimes, an individual returns to a prior stage in order to do more work. Within this model, that’s not a failure, just part of the process. In fact, I believe that recovery is an experiential process, and that relapse can be the most important part of that process.
Traditionally, most substance abuse programs assumed all clients entering treatment were in the action stage. To me, this is just absurd, especially when you consider that most clients—like Michael—are mandated in the first place. Perhaps resistance is really about this misfit of stages. If an individual is pre-contemplative and being treated as if he is ready to take action, wouldn’t he appear non-compliant, not amiable to treatment, and unwilling to engage? That certainly describes Michael. When I first met him, my perspective was a bit different than the referring clinician’s.
Michael was—and remains—a challenging client who tests boundaries, is likely to debate minor details, and always does the minimum required. However, he wasn’t resistant. Rather, he was stuck in pre-contemplation. Like anyone in pre-contemplation, Michael didn’t believe he had a problem. Since he didn’t have a problem, why should he change anything? And, the more people pushed him to take action, the less likely it would happen.
Miller and Rollnick wrote, “ When the idea of change or treatment is forced on an unwilling recipient it is not uncommon for the individual to engage in the problem behavior to a greater extent in an attempt to assert his or her freedom” (p. 337). According to the referring clinician, Michael’s using had increased since starting treatment. In fact, the referring clinician offered this information as proof of Michael’s resistance.
If Michael was actually stuck in pre-contemplation, my efforts shouldn't be to get him to take action. My efforts should be to help him get unstuck. Prochaska, Norcross and DiClemente have identified specific tasks for each Stage of Change. I have found these stage-specific tasks to be useful when working with clients. I've also found that the Stages of Change model and motivational interviewing have much in common. In fact, Miller and Rollnick wrote, “[M]otivational interviewing can be used to assist individuals to accomplish the various tasks required to transition form the pre-contemplation stage through the maintenance stage” (p. 202). Employing basic motivational interviewing principles when doing Stages of Change work seems a natural choice.
Miller and Rollnick identified four general principles for motivational interviewing. These are express empathy, develop discrepancy, roll with resistance, and support self-efficacy (p. 36). Especially when combined with stage-specific tasks, these principles are highly effective in helping clients move through the Stages of Change (Miller & Rollnick, p. 203). And, when the clients are successful, they are also developing the confidence to continue their change process.
The Confidence to Change
Miller and Rollnick wrote, “Readiness [to change] implies at least some degree of both importance and confidence. A person who does not see change as important is unlikely to be ready to change. Similarly, people who see change as impossible are unlikely to say they are ready to do it” (p. 54). Initially, Michael didn’t see change as important, but he also had doubts about his ability to make meaningful change.
I proposed two goals for Michael. First, address the tasks of pre-contemplation so he could start making some movement on the Stages of Change. Second, increase his sense of self-efficacy and thereby improve his optimism. When I presented this plan to Michael, his only response was, “Whatever. As long as I don’t get my probation revoked.” That lead to a third goal for Michael: do what is necessary to stay out of detention, which meant attending weekly individual sessions with me and having clear UAs.
Michael was reluctant to stop his use, but agreed to this plan because, in his words, “I’ll go to detention if I don’t.” I’ve only been working with this client for a short time, but clear progress has already occurred. Michael has been present at all his scheduled appointments. He's also making reasonable progress on pre-contemplation tasks. In our last appointment, he stated, “I don’t think I’ve got a problem using, but everyone else does, and that’s a problem, I guess. ” This may not sound like progress to some. I’m sure it wouldn’t to that referring clinician. To me, though, it clearly represents signs of becoming unstuck.
Instead of the pessimism of resistance, a new perspective is offered by the combination of the Stages of Change model and motivational interviewing: Even the most reluctant clients are simply working on the tasks of their current stage. Thought of this way, the job of a professional helper is reframed from the thankless task of overcoming resistance to that of assisting clients to increase their readiness to change.
Works Cited
Miller, W., & Rollnick, S. (2002). Motivational Interviewing. New York: Guilford Press.
Prochaska, J., Norcross, J., & DiClemente, C. (1994). Changing for Good. New York: Harper Collins.
Selekman, M. (2005). Pathways to Change. New York: Guilford Press.
Seligman, M. (1990). Learned Optimism. New York: Random House.
Saturday, November 15, 2008
Beyond Resistance
It is common in substance abuse treatment to hear clinicians label clients as resistant, meaning the individual is unmotivated to participate in the treatment process. Over the last year of so, I’ve been thinking a lot about the idea of resistance within teens. The more I think about this, the more I've come to believe that resistance is extremely rare in teens, if not in all client populations.
It seems to me that resistance is an easy answer to explain away non-engagement by clients, providing an easy excuse to not make further efforts at engagement. Selekman wrote, “The traditional psychotherapeutic concept of resistance is an unhelpful idea that has handicapped therapists” (p. 32). Motivational interviewing provides many useful ideas for moving beyond the easy excuse provided by labeling a client as resistant. According to Miller and Rollnick, motivational interviewing is a “client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (p. 25).
In my experience, most teens are not resistant. They are ambivalent. Indeed, most of the clients I’ve worked with have held as absolute fact two seemingly incongruent thoughts: 1.) I have a problem; and, 2.) I don’t want to do anything about my problem. Its worth noting that my clients rarely define their problems the way I do, at least not initially, but that doesn't mean they believe themselves to be problem-less. It also doesn't mean they are resistant.
From my perspective as a clinician, my clients have problems stemming from drug use, truancy, illegal behavior, mental health challenges, and family dysfunction. Rarely are these the problems my clients initially identify, though. Many of my clients reluctantly enter treatment with only one self-identified problem, being on probation or an at-risk youth petition, and only one self-identified goal, avoiding detention. It would be easy to dismiss these youth as resistant. After all, they don't agree with me, the professional. In fact, though, not agreeing with me probably shouldn’t be considered pathological.
Miller and Rollnick wrote, “Understanding the dynamics of ambivalence… provides an alternative to thinking of people as (and blaming them for being) ‘unmotivated.’ People are always motivated for something” (p. 18). Avoiding detention—the sole initial motivation with many of my clients—is an extremely concrete goal and an excellent place to begin. It is easy to develop discrepancy with these youth, a key principle of motivational interviewing (Miller & Rollnick, p. 37). This principle requires that the helper “create and amplify, from the client’s perspective, a discrepancy between present behavior and his or her broader goals and values” (Miller & Rollnick, p. 38).
“If we want to help people learn, we should not worry about how we can motivate them but try to identify what already is motivating them” (Zull, p. 53). For teens on probation or an at-risk youth petition, continued use of alcohol and other drugs will lead to a violation that could send them to detention. Staying out of detention—their self-defined goal—requires clean UAs and attendance at treatment. When I talk about this with a client, I’m not telling him to stop using alcohol and other drugs. Instead, I’m being collaborative and helping him solve his problem as he defined it. Sure, the client is doing what I hoped for, but he's doing he for his reasons, not mine.
The threat of detention may not motivate a youth to change her behavior, but it is usually sufficiently motivating to start the process. Once this process has begun, “the overall goal is to increase intrinsic motivation, so that change arises from within rather than being imposed from without and so that change serves the person’s own goals and values” (Miller & Rollnick, p. 34).
Mental Logjams
Many of my clients are adequately motivated by extrinsic rewards to start the change process. However, for a client who simultaneously hold as true “I have a problem” and “I don’t want to do anything about my problem,” the mental logjam created from these incongruent beliefs can serve to reinforce his maladaptive cognitive scripts, encouraging him to remain stuck. After all, resolving this discrepancy will be hard and brains are lazy. They’d rather continue to use the same ol’ well-rehearsed scripts. Those brains would rather continue to Act Up, Shut Down, or Use.
When lazy brains do what lazy brains do, it may appear to be resistance or a lack of motivation. However, it seems to me that this is really just basic neuroscience in action. What fires together wires together, and then wants to keep firing that way. Getting unstuck requires getting lazy brains to do something different; that requires overcoming an apparent lack of motivation. Miller and Rollnick wrote that lack of motivation “can be thought of as unresolved ambivalence. To explore ambivalence is to work at the heart of the problem of being stuck” (p. 14).
In my experience, professional helpers often do their work only on the “I have a problem” side of ambivalence. I believe this is ineffective for two reasons. First, as discussed above, my clients already know they have a problem. They don’t need me to repeatedly tell them that. If anything, doing so is invalidating and reaffirms their apparent inability to be effective or make change. In fact, it would seem to me that repeatedly telling a client she has a problem contributes to keeping her stuck.
The second reason working on the “I have a problem” side is ineffective is that it is developmentally inappropriate with adolescents. Lectures don’t persuade teens. Neither does forcing compliance to a pre-determined solution they had no input on. Adolescents are supposed to question, rebel against, and ultimately resist the plans authority figures. Most professional helpers may be reluctant to view themselves as authority figures, but our clients never forget it.
“The theory of psychological reactance predicts an increase in the rate and attractiveness of a ‘problem’ behavior if a person perceives that his or her personal freedom is being infringed or challenged” (Miller & Rollnick, p. 18). If I tell my clients to stop using alcohol and other drugs, I may be increasing the likelihood of them continuing their use! That's true for any client, child, adolescent, or adult. However, as an unavoidably authoritarian figure working with adolescents who are supposed to rebel against what I say, this is magnified. So, not only does telling a client he has a problem contributes to keeping him stuck, so does telling him what to do about his problem.
Reframing Resistance
I started this post by stating that resistance meant that the individual is not amiable to treatment. Miller and Rollnick propose a different definition for resistance, “movement away from change” (p.47). Forced compliance doesn’t lead to change, but as we’ve seen above it may lead to movement away from change.
With mandated clients, I could create a pressure cooker situation that forced them into compliance, and I’ve seen counselors, parents, and probation officers take this approach. However, it is vital to avoid this sort of taking sides. “If the counselor argues for one side of the conflict, it is natural for the client to give voice to the other side… Hearing themselves vigorously arguing that they don’t have a problem and don’t need to change, they become convinced” (p. 56-57).
One way to avoid taking sides is to externalize the problem (Selekman, p. 93). This therapeutic strategy involves talking about the problem as if it was a separate being from the client, complete with sentience and decision-making abilities. About two years ago, when I initially read Selekman, I started externalizing ambivalence when working with reluctant clients. Inspired by a treatment-oriented board game, I began talking about Addictive Voices and Rational Voices. I’ve integrated the Voices throughout my groups—including role plays, art activities, the board game, and experiential activities—and I’ve found my clients readily embrace this concept.
In both individual and group sessions, I often assume the role of a client’s Addictive Voice, leaving the Rational Voice to the client. According to Miller and Rollnick, “If taking up one side of the argument causes an ambivalent person to defend the other, then the process ought to work both ways… By the nature of ambivalence, when the counselor raises only one side the client is inclined to explore the other” (p. 107).
In my experience, even the most ambivalent client is able to effectively speak for her Rational Voice. According to Miller and Rollnick, this is exactly the goal of motivational interviewing—for the client to “present the arguments for change” (p. 76). In doing so, the client can begin the process of breaking through the mental logjam caused by ambivalence.
Mandates may bring clients into treatment, but they don’t lead to lasting change. Motivational interviewing “focuses on intrinsic motivation for change, even with those who initially come for counseling as a direct result of extrinsic pressure” (Miller & Rollnick, p. 26). Looking beyond the simple answer of resistance is vital if this process is to occur.
Works Cited
Miller, W., & Rollnick, S. (2002). Motivational Interviewing. New York: Guilford Press.
Selekman, M. (2005). Pathways to Change. New York: Guilford Press.
Zull, J. (2002). Art of Changing the Brain, The. Sterling, VA: Stylus Publishing.
It seems to me that resistance is an easy answer to explain away non-engagement by clients, providing an easy excuse to not make further efforts at engagement. Selekman wrote, “The traditional psychotherapeutic concept of resistance is an unhelpful idea that has handicapped therapists” (p. 32). Motivational interviewing provides many useful ideas for moving beyond the easy excuse provided by labeling a client as resistant. According to Miller and Rollnick, motivational interviewing is a “client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (p. 25).
In my experience, most teens are not resistant. They are ambivalent. Indeed, most of the clients I’ve worked with have held as absolute fact two seemingly incongruent thoughts: 1.) I have a problem; and, 2.) I don’t want to do anything about my problem. Its worth noting that my clients rarely define their problems the way I do, at least not initially, but that doesn't mean they believe themselves to be problem-less. It also doesn't mean they are resistant.
From my perspective as a clinician, my clients have problems stemming from drug use, truancy, illegal behavior, mental health challenges, and family dysfunction. Rarely are these the problems my clients initially identify, though. Many of my clients reluctantly enter treatment with only one self-identified problem, being on probation or an at-risk youth petition, and only one self-identified goal, avoiding detention. It would be easy to dismiss these youth as resistant. After all, they don't agree with me, the professional. In fact, though, not agreeing with me probably shouldn’t be considered pathological.
Miller and Rollnick wrote, “Understanding the dynamics of ambivalence… provides an alternative to thinking of people as (and blaming them for being) ‘unmotivated.’ People are always motivated for something” (p. 18). Avoiding detention—the sole initial motivation with many of my clients—is an extremely concrete goal and an excellent place to begin. It is easy to develop discrepancy with these youth, a key principle of motivational interviewing (Miller & Rollnick, p. 37). This principle requires that the helper “create and amplify, from the client’s perspective, a discrepancy between present behavior and his or her broader goals and values” (Miller & Rollnick, p. 38).
“If we want to help people learn, we should not worry about how we can motivate them but try to identify what already is motivating them” (Zull, p. 53). For teens on probation or an at-risk youth petition, continued use of alcohol and other drugs will lead to a violation that could send them to detention. Staying out of detention—their self-defined goal—requires clean UAs and attendance at treatment. When I talk about this with a client, I’m not telling him to stop using alcohol and other drugs. Instead, I’m being collaborative and helping him solve his problem as he defined it. Sure, the client is doing what I hoped for, but he's doing he for his reasons, not mine.
The threat of detention may not motivate a youth to change her behavior, but it is usually sufficiently motivating to start the process. Once this process has begun, “the overall goal is to increase intrinsic motivation, so that change arises from within rather than being imposed from without and so that change serves the person’s own goals and values” (Miller & Rollnick, p. 34).
Mental Logjams
Many of my clients are adequately motivated by extrinsic rewards to start the change process. However, for a client who simultaneously hold as true “I have a problem” and “I don’t want to do anything about my problem,” the mental logjam created from these incongruent beliefs can serve to reinforce his maladaptive cognitive scripts, encouraging him to remain stuck. After all, resolving this discrepancy will be hard and brains are lazy. They’d rather continue to use the same ol’ well-rehearsed scripts. Those brains would rather continue to Act Up, Shut Down, or Use.
When lazy brains do what lazy brains do, it may appear to be resistance or a lack of motivation. However, it seems to me that this is really just basic neuroscience in action. What fires together wires together, and then wants to keep firing that way. Getting unstuck requires getting lazy brains to do something different; that requires overcoming an apparent lack of motivation. Miller and Rollnick wrote that lack of motivation “can be thought of as unresolved ambivalence. To explore ambivalence is to work at the heart of the problem of being stuck” (p. 14).
In my experience, professional helpers often do their work only on the “I have a problem” side of ambivalence. I believe this is ineffective for two reasons. First, as discussed above, my clients already know they have a problem. They don’t need me to repeatedly tell them that. If anything, doing so is invalidating and reaffirms their apparent inability to be effective or make change. In fact, it would seem to me that repeatedly telling a client she has a problem contributes to keeping her stuck.
The second reason working on the “I have a problem” side is ineffective is that it is developmentally inappropriate with adolescents. Lectures don’t persuade teens. Neither does forcing compliance to a pre-determined solution they had no input on. Adolescents are supposed to question, rebel against, and ultimately resist the plans authority figures. Most professional helpers may be reluctant to view themselves as authority figures, but our clients never forget it.
“The theory of psychological reactance predicts an increase in the rate and attractiveness of a ‘problem’ behavior if a person perceives that his or her personal freedom is being infringed or challenged” (Miller & Rollnick, p. 18). If I tell my clients to stop using alcohol and other drugs, I may be increasing the likelihood of them continuing their use! That's true for any client, child, adolescent, or adult. However, as an unavoidably authoritarian figure working with adolescents who are supposed to rebel against what I say, this is magnified. So, not only does telling a client he has a problem contributes to keeping him stuck, so does telling him what to do about his problem.
Reframing Resistance
I started this post by stating that resistance meant that the individual is not amiable to treatment. Miller and Rollnick propose a different definition for resistance, “movement away from change” (p.47). Forced compliance doesn’t lead to change, but as we’ve seen above it may lead to movement away from change.
With mandated clients, I could create a pressure cooker situation that forced them into compliance, and I’ve seen counselors, parents, and probation officers take this approach. However, it is vital to avoid this sort of taking sides. “If the counselor argues for one side of the conflict, it is natural for the client to give voice to the other side… Hearing themselves vigorously arguing that they don’t have a problem and don’t need to change, they become convinced” (p. 56-57).
One way to avoid taking sides is to externalize the problem (Selekman, p. 93). This therapeutic strategy involves talking about the problem as if it was a separate being from the client, complete with sentience and decision-making abilities. About two years ago, when I initially read Selekman, I started externalizing ambivalence when working with reluctant clients. Inspired by a treatment-oriented board game, I began talking about Addictive Voices and Rational Voices. I’ve integrated the Voices throughout my groups—including role plays, art activities, the board game, and experiential activities—and I’ve found my clients readily embrace this concept.
In both individual and group sessions, I often assume the role of a client’s Addictive Voice, leaving the Rational Voice to the client. According to Miller and Rollnick, “If taking up one side of the argument causes an ambivalent person to defend the other, then the process ought to work both ways… By the nature of ambivalence, when the counselor raises only one side the client is inclined to explore the other” (p. 107).
In my experience, even the most ambivalent client is able to effectively speak for her Rational Voice. According to Miller and Rollnick, this is exactly the goal of motivational interviewing—for the client to “present the arguments for change” (p. 76). In doing so, the client can begin the process of breaking through the mental logjam caused by ambivalence.
Mandates may bring clients into treatment, but they don’t lead to lasting change. Motivational interviewing “focuses on intrinsic motivation for change, even with those who initially come for counseling as a direct result of extrinsic pressure” (Miller & Rollnick, p. 26). Looking beyond the simple answer of resistance is vital if this process is to occur.
Works Cited
Miller, W., & Rollnick, S. (2002). Motivational Interviewing. New York: Guilford Press.
Selekman, M. (2005). Pathways to Change. New York: Guilford Press.
Zull, J. (2002). Art of Changing the Brain, The. Sterling, VA: Stylus Publishing.
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