It’s a huge decision to come into addiction treatment. People are entering into something completely new and unknown and everyone comes in with a degree of ambivalence.
It doesn’t take much to tip the balance one way or the other: they could fall in with people they immediately gel with, and that tips it in favour of them thinking: “The folk here are quite good. I can understand what they are talking about. It may be good for me after all.”
On the other hand if they arrive and have withdrawal symptoms which are unpleasant and they feel out-of-sorts with themselves they may find fault with the treatment centre: “This place is not making me feel good.”We have to understand that there is a chemical process at work in their bodies and brains which is making them restless – and this can result in them discharging and booking a taxi to the nearest station.
What happens in this situation? You don’t get very far by sitting the patient down and trying to persuade him or her to stay. For every reason you give them to stay they will counteract it. For example, if I was to say “If you don’t stay here you won’t get better,” they might reply: “Ah, but I knew someone with an addiction problem that was even worse than mine and he got better without any treatment.”
You don’t confront it in that way. You go back to baselines and ask about the reasons why they wanted to come here in the first place, and help them weigh up the pros and cons. I will ask them to tell me about the disadvantages, as they see it.
As he’s telling me the disadvantages – “I don’t like sleeping in a strange bed” – The people here are odd.” Or you may find him saying “but there was one guy that I rather liked. He reminded me of someone I knew, and I did listen to him.”
If you take an approach that doesn’t confront but, on the other hand, looks into the reasons for the ambivalence you may find the patient talking himself, or herself, into staying on. As they talk through the pros and cons of going home they may realise it’s not the right thing to do.
People tend to believe what they hear themselves saying. People who come here have been lectured an awful lot by other people – in particular they have been told what is or is not going to be good for them – and they have developed a strong immunity to that sort of talk.
When the community [the group of other patients] is working well you find that people recognise this ambivalence in others. They recognise it very much in themselves: “Oh yes!” they might say, “I know what that was like. I was in two minds about coming into treatment.”
It is very powerful when another individual can say: “I know how you are feeling. This is a difficult moment for you.”
That empathic way is usually more effective than attempts to ‘persuade’. The AA [Alcoholics Anonymous] philosophy is not to tell you what to do. AA is there as an example. Someone might say: “This has worked for me. Come to meetings, see how it’s working and see what fits for you.”
It’s All About Motivation
This process is about bringing out the aspect of motivation, the pros and the cons, and giving the individual the space, and relative tranquility, to weigh those up – and not act impulsively. Of course, people with addiction have a tendency to be impulsive.
Many of the people we see here have been very successful in their own right. I don’t necessarily mean running a highly successful business, but doing things in a very decisive and effective way and being used to making a lot of decisions on their own. They tend to think they know best about their alcohol problems, and they tend to regard this as a point of principle: they know what’s right for them.
At the end of the day everybody is the expert on himself. But, there is an interesting hurdle that AA is used to helping people over – to leave a bit of that ego behind and just accept that there may be others who do know something about it, and that they may not, on this subject, know everything.
This is how many people interpret the AA phraseology about handing over to a higher power, a “power greater than myself.” Many of the people I know in AA are re-framing that as: “Here is a body of other people, a wealth of knowledge and experience, that I could tap into because maybe I don’t know everything.”
Sometimes people who leave against the treatment team’s best advice do well, and sometimes they do not – and may wish to return at a later date. Perhaps the most important point is respecting patients’ decisions – they have their reasons for their decision. We should endeavour to avoid damaging the spirit of collaboration that is essential if a relationship is to be therapeutic.
This article is based on an interview with Consultant Psychiatrist Prof. Jonathan Chick, MA (Cantab), MPhil, MBChB, DSc, FRCPsych, FRCPE. Prof. Chick is Medical Director of Castle Craig and a published researcher in the field of alcohol addiction.