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 co-occurring disorders. Show all posts
Showing posts with label co-occurring disorders. 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.
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