Doing an End Run Around Resistance: Working with the Adolescent Substance Abuser

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This article originally appeared in The Therapist, Nov-Dec 2004.

Many therapists get frustrated when working with teens, especially in the context of substance abuse. Adolescent clients are often forced into therapy by their parents or other authority figures, and often resist buying in. Resistance to treatment, missing appointments, arriving late, and spending therapy sessions talking about peripheral issues are all assumed to be an indicator of poor motivation (Denning, 2000). Attempting to meet the resistance head-on may only make it worse. As a consequence, the therapy can get bogged down, and therapists may experience countertransference. Feelings of I’m failing, I’m being rejected, and Im frustrated are not uncommon. Sometimes, especially with teens, it can be helpful to take another tack.

Miller and Rollnick (1991) define motivation as a flexible state, and suggest a two-phased strategy they call motivational interviewing. The first stage is building the clients motivation to change, followed by strengthening the clients commitment to change. A number of techniques, as outlined by Patt Denning in Practicing Harm Reduction Psychotherapy, can be very effective with teen clients.

  • Express empathy. Let the client you know that you understand his or her wish to deal with the problem, and that you appreciate both the amount of effort required and the difficulty of the situation.
  • Develop discrepancy. Emphasize the client’s expressed awareness of any drawbacks to his or her use of alcohol or drugs.
  • Avoid argumentation. There is no right answer about a person’s drug or alcohol use. You are trying to understand the client’s perspective, not impose some external authority.
  • Roll with resistance. Ambivalence is normal and healthy, and resistance can be a sign of ego strength. Do not put yourself in the position of “boss.” Reflect back the client’s own ambivalence and confusions about his or her drug use.
  • Support self-efficacy. Research consistently shows that a person who feels confident about his or her ability to make a change is much more likely to do so.

Here’s an example of how motivational interviewing can be implemented in a clinical setting.

Meet Ashley

Ashley (not her real name) is an adolescent I worked with recently in an adolescent substance abuse program. I was her individual therapist and she also in family therapy with another staff therapist. When I met her, she was fifteen years old and living with her mother and one older sister. She had been expelled from her high school for possession of marijuana, shoplifting alcohol and attending classes while intoxicated. She had been placed on juvenile probation, and court-ordered into a school-based day treatment program for substance abuse with both group and individual therapy components. Regular urinalysis showed her to be a daily marijuana user.

History

Ashley is the younger of two daughters born to married parents who immigrated to the United States from Beijing while in their early twenties. Her parents were successful entrepreneurs who owned an import/export company. Talented in graphic composition and expression, Ashley excelled in art classes from early on. Painting and stained glass were two of her favorite media. And she maintained an A and B average up though the eighth grade.

In general, Ashley’s father was domineering, while her mother tended to be passive. Her parents fought often and Ashley was exposed to frequent instances of domestic violence. She began escaping via marijuana and other psychoactive substances at age eleven, and her drug and alcohol use escalated as her parent’s marital discord increased. I hypothesized that she chose marijuana for its dissociative effect. That would be particularly useful for a child in a home with strife, arguing and domestic violence.

When Ashley was thirteen, her parents divorced. She continued living with her mother. Her father left the family home and began spending long periods of time overseas on business. Although her mother did not withdraw via alcohol or drugs, she considered the post-divorce era to be my time, and paid minimal attention to her daughter. When she did interact with her, she tended to be very invasive. Ashley’s father moved overseas, and she saw him infrequently. She also had an older sister, not living at home, who was a weekend marijuana and alcohol user. As Ashley’s drug use increased, her school attendance became more and more inconsistent, her grades dropped, and her interest in art diminished.

Cultural aspects: As an Asian-American, Ashley is part of a culture where passivity for girls is commonly valued.

Program Overview

When I began working with Ashley, she was in a 12-step, abstinence-based, day treatment program for teens with substance abuse problems. Participants had to earn points via academic achievement, completing12-step assignments, and therapy participation. Accumulating points enabled them to gradually move up through four levels in order to graduate from the program. Urinalysis tests were performed weekly.

About 50 adolescents entered the program each year. Most stayed on Level 1 for three to four months. The majority didnt get past Level 2, and about a third reached Level 3. On average, two participants reached Level 4 and graduated in any given year.

Therapy: Beginning Phase

For our first few sessions, Ashley had difficulty making eye contact. Instead, she would look through her purse or school notebooks. When setting up therapy appointments, she would come up with many excuses why she couldn’t leave class. I conceptualized her as someone who is frightened of sitting in a room with a stranger. Given her family history, I thought she might be having transference reaction worried that I might invade her, as her mother sometimes did. Instead of scolding her about canceling appointments, I would occasionally make remarks like, “Yes, it’s kind of weird to meet with a stranger and talk about yourself, isn’t it?” She would nod and look relieved. (Expressing empathy.)

In response, I thought of slow ways to move towards her. I saw her behavior as an outgrowth of her need to set boundaries with me, so I respected her implied rules. For example, I didn’t tell her to put her purse away or insist that she interact with me during the first few sessions. I also noticed that Ashley seemed threatened if I sat across from her and looked at her. She would be more fidgety, distracted, and anxious, and would be even more reluctant to meet again. I rearranged the furniture so we could sit side-by-side, not looking at each other. Her level of anxiety appeared to diminish significantly. (Rolling with resistance.)

After two months of non-invasive therapy, Ashley looked at me closely one day in a session and remarked on the fact that I wore contact lenses. I concluded that she was able to tolerate being present with another person, and felt comfortable enough to engage and observe.

Therapy: Middle Phase

For the next few months, Ashley talked about her experience in the program. She was not a behavioral problem, not relapsing or acting out in classroom, but she made C’s on her school work, participated minimally in groups, and was not moving up the levels. A typical comment: “I could do more school work but I don’t feel like it. I don’t feel comfortable talking in groups because I don’t know what to say. I’d like to be able to go off-campus for lunch and but they won’t let me.” I would respond by reflecting her awareness of the drawbacks of her behavior: “In order to have more privileges, you would need to complete more school assignments and participate more in groups.” (Developing discrepancy.)

Some members of the program staff identified her as “resistant to the program.” After almost six months of low participation, they wanted to expel her. “She’s not buying in. Why is she here?” I defended her by bringing up cultural and psychodynamic issues. For example, in her family of origin, her mother was passive and her father was domineering. A common consequence of assertiveness on her mothers part would be violence from her father. Also, her family was part of a culture in which passivity in females was considered desired and appropriate behavior. Both these factors inclined her to avoid action.

I consciously refrained from presenting her with the possible consequences of the lack of motivation. This enabled her to engage with herself and make her own assessment of her position. I made a point of not invading, but instead listening and presenting names for what was happening. I refrained from judgement and allowed her to embrace the names if they fit. (Avoiding argumentation.) Over time, she began to name her own feelings without feeling confused or guilty about them.

I became a person she could be herself with. Motivated or unmotivated: however she came in, I accepted her. In the therapeutic environment, she learned that she could assert herself without being penalized. As a result, she slowly built her self-confidence and powers of introspection.

Therapy: End Phase

One day, Ashley asked “What do I have to do to graduate from this program?” I reacted with surprise and described what she would need to do to move up the levels. She said: “I could do that.” I agreed. (Supporting self-efficacy.)

Suddenly, it was as though she woke up. Once she decided it was valuable to her to move up and get points, she did not have trouble paying attention and excelling. She became the top point scorer in the school for the next fifteen weeks. And she grew more and more into the identity of a person who set goals and reached them.

Fifteen weeks later, Ashley graduated from the program. She was released from probation, and returned to her mainstream high school. Shell complete her high school degree next year. And she’s planing to go to college to “possibly study art.”

Conclusion

Pushing Ashley did not work. Anything which could be even remotely construed as domineering caused her to withdraw further into her protective immobility. Instead of presenting myself as an authority figure, I acted as a witness and a consultant. Following the techniques outlined above, I showed empathy, mirrored her awareness of the drawbacks of substance abuse, did not present arguments, reflected her ambivalent feelings, and supported her sense of her own efficacy. By letting her take control, and move at her own pace, I was able to coax her out of her static stance and show her that it was safe to act in the world and be a part of it.

©2004 Gayle Paul, M.A.

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