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CME/CE

Approaches to Dealing With Resistance in Addiction Patients

  • Authors: Edward C Senay, MD
  • THIS ACTIVITY HAS EXPIRED
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This activity is intended for psychiatrists, primary care physicians, psychologists, neurologists, pharmacists, and other mental health professionals.

The goal of this activity is to provide current treatment protocols and clinical strategies for the treatment and management of psychiatric disorders and to update the clinician and the researcher on the latest developments in psychiatry and mental health.

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  2. Evaluate the effectiveness of the current substance abuse treatments.
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Author(s)

  • Edward C Senay, MD

    Professor Emeritus of Psychiatry, Pritzker School of Medicine, University of Chicago, Chicago, Illinois.


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CME/CE

Approaches to Dealing With Resistance in Addiction Patients

Authors: Edward C Senay, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

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Introduction

At the American Psychiatric Association 153rd Annual Meeting in Chicago, Illinois, David Mee-Lee, MD,[1] of Davis, California, discussed the challenges psychiatrists face when patients who suffer from addiction become resistant to treatment.

 

Determining a Treatment Strategy

According to Dr. Mee-Lee, there are 3 questions that must be answered in order to clarify values before formulating a treatment plan:

 

  1. If a patient does not really agree with your assessment or with your treatment plan but goes along with it because it is expedient (eg, "I'll do time if I don't come here"), do you not accept him for treatment until he is ready to comply fully with the treatment plan, or do you accept him despite his ambivalence?  
  2. In treatment, do you want the patient to try to go at your pace, or at a pace he can "buy into"?  
  3. If a patient is at significant risk for relapse, do you want her to be honest with you about cravings, slips or lapses, or do you want her to minimize or even outright lie about her behavior?

Most clinicians, Dr. Mee-Lee said, would opt to keep the patient in question 1 in treatment even with a substantial degree of ambivalence. Ambivalence is to be expected, and it is a focus for therapeutic concern and action. With regard to the speed of treatment, it cannot exceed the pace that patients are willing to accept. One might hypothesize that treatment cannot occur without honesty on the part of both patient and therapist; thus, one would not want to encourages minimization or falsification of what is occurring. It takes work to create a liaison with the patient in which honesty is expected and facilitated by the therapeutic contract. Empathy is the center of such a contract.

 

Patient Resistance

Denial of the existence of a problem can help the patient deal with internal conflicts such as distress over a failing marriage or school performance. Such denial may require a confrontation and serves as an indication that there has been an inadequate analysis of the patient's ambivalence or stage of change. The goals of the treatment may have been set according to the counselor's priorities, thereby missing the clinically important opportunity to engage the patient in a participatory person-centered plan. The pathology-oriented perspective is at base paternalistic and patronizing, while the person-centered approach is based on facts rather than on judgments.

 

Models of Stages of Change

Identifying the stage of change for a given patient is as important as assessing detoxification needs. Dr. Mee-Lee emphasized that a treatment plan made without reference to the appropriate stage of change may be a recipe for failure. At least 2 models exist:

 

12-Step Model

There are 3 key considerations in this model: surrender vs comply, accept vs admit, and identify vs compare. Surrender can be based on the recognition and understanding that life has become unmanageable, accompanied by an openness to change or to comply with the program -- but without meaningful participation. Admitting a problem exists is not the same as accepting the problem with all of its implications for the need for personal change. Patients may identify with other patients even though their behaviors are not identical, or patients may be defensive in comparing themselves favorably with others (eg, "I've never killed anybody, unlike some of them."), ignoring their behaviors that defy favorable comparison, such as driving drunk.

 

Transtheoretical Model of Change

As outlined by Prochaska and DiClemente,[2] this model is more detailed than the 12-step model for change. It offers the following stages:

 

  1. Precontemplation: The patient has not yet considered the possibility that change is needed.  
  2. Contemplation: The patient is ambivalent about the problem or the need for change. Aggressive confrontation is counterproductive at this stage.  
  3. Preparation: The patient recognizes that change is needed and thinks through specific steps to effect the change.  
  4. Action: The patient implements the specific steps and needs support to prevent regression or drop out.  
  5. Maintenance: The patient requires new skills (eg, learning relapse triggers and how to manage them, consolidating changes, and developing a new health lifestyle);  
  6. Relapse: This is expectable but not inevitable. Thus, clinicians must work to combat demoralization.  
  7. Termination: The patient either exits the cycle of change or needs to practice maintenance strategies.

Further Contrasts in Stages of Change

Miller and Tonigan[3] have identified the tasks that a therapist must undertake, having first established a therapeutic alliance based on patient participation and empathic understanding:

 

  • Precontemplation: raising doubts about the adequacy of the patient's explanations for their current problems and discussing the ways in which these problems are to be addressed (eg, "It's true you haven't killed anybody driving drunk, but you passed out while driving drunk and can't remember anything about the episode.")  
  • Contemplation: tipping the balance by citing the risks of not making a change and strengthening self efficacy by continuing patient-centered planning and interacting  
  • Action: providing support and encouragement, perhaps increased frequency of monitoring  
  • Maintenance: assisting the client with relapse prevention strategies.

Miller and Tonigan[3] also contrasted confrontation of denial (the traditional, monolithic, clinical approach) with motivational interviewing, as summarized in the following Table.

 

Table. Confrontation vs Motivation

Confrontation of Denial Motivational Interviewing
Requires acceptance of a label and of personal pathology (eg "I'm Joe. I'm an alcoholic.") Views labels as irrelevant
Resistance is viewed as a trait requiring confrontation. Resistance is an interpersonal phenomenon that can be influenced by the therapist's behavior.
Goals for treatment are prescribed by the therapist. Treatment goals are negotiated based on data, with full patient participation throughout the process.

 

The Client-Centered Approach

The heart of the client-centered approach is determined by the treatment contract. It should assist the patient in determining what he wants, why he wants it, how he will get what he wants, where it will happen, and when it will happen.

This set of questions has a parallel set of clinical and treatment plan implications:

 

  • What does the patient need? The treatment plan should unify the patient's wants with his needs as much as possible. The question "What do you want?" is literal and requires the proof of consistent and serious application by the clinician.  
  • Does the patient buy into the plan? How can the clinician help the patient to see the differences between the clinician's assessment and the patient's perceptions? Because patient empowerment is central to this point of view, the clinician should expect and require the patient to lead the discussion. This is a radical change for some clinicians and patients.

References

  1. Mee-Lee D. Dealing with resistance in addiction patients. Program and abstracts from the 153rd Annual American Psychiatric Association Meeting, May 13-18, 2000; Chicago, Illinois. CME Course 60.
  2. Prochaska JO, DiClemente JC, Norcross JC. In search of how people change: application to addictive behaviors. Am Psychologist. 1992;47:1102-1114.
  3. Miller WR, Tonigan JS. Assessing drinkers' motivation for change: the stages of change readiness and treatment eagerness scale (SOCRATES). Psychology of Addictive Behaviors. 1996;10(2):81-89.

Suggested Reading

Mee-Lee D. Use of Patient Placement Criteria in the Selection of Treatment. Chapter 7, pp 363-370, Section 5. In: Overview of Addiction Medicine in Principles of Addiction Medicine. 2nd ed. Chevy Chase, Md: American Society of Addiction Medicine Inc.