Evoking Humility in Clients and the Use of Confrontation in Treatment: A Classic Example of When the Ends Don’t Justify the Means
August 18th, 2008 by Daniel Jordan
“Blessed are the poor in spirit: for theirs is the kingdom of heaven” ~ Matthew 5:3
The Holy Bible considers being ‘poor in spirit,’ or humble, one of the most important requirements of those who want to be close to God. Alcoholics Anonymous considers humility a critical part of staying sober: “…the attainment of greater humility is the foundation principle of each of AA’s Twelve Steps. For without some degree of humility, no alcoholic can stay sober at all (page 70, 12 Steps and 12 Traditions ).”
At Sunshine Coast Health Center, much of the clinical work we do is designed to illicit motivation in the client. Often misunderstood, humility plays an important role in fostering motivation. However, over the past few years, we have distanced ourselves from using confrontation as a means of evoking humility and motivation in clients. It is a classic example of when the ends don’t justify the means.
Our Policy on Working with Clients
As detailed in previous postings, Sunshine Coast Health Center is committed to treating clients with the highest personal regard. Our approach to clients is based on the empathic, client-centred approach of psychologist Carl Rogers . True to the spirit of Rogerian therapy, we believe that clients are capable human beings and that the role of the counsellor is to partner with the client to achieve positive change.
The Fallout of Confrontation
The use of confrontation typically involves the use of shame, guilt, and humiliation to evoke humility or motivation in a client. These are powerful emotions which we have observed can immediately, and negatively, play out in a client’s behaviour.
While confrontation can hurt the peer group and the client’s relationship with all staff members, the most detrimental impact is the impact on the therapeutic relationship (*) between the client and his counsellor. Basically, confrontation often leaves the therapeutic relationship in tatters. The counsellor who confronted the client would be blissfully unaware of the problem they created since the fall-out from these confrontations would often play out in the evenings or weekends. Front-line staff (cooks, aides, drivers) and the rest of the peer group would become innocent bystanders of the confrontation’s aftermath. Senior clinical staff would be called in to clean up and help the client process the residual hurt and anger.
(*) Note: Scott Miller has some excellent data on the critical importance of creating and maintaining the therapeutic relationship in his article, “What Works” in Therapy?
Rationale for the Use of Confrontation in Addiction Treatment
One of the patterns we noticed with counsellors that would confront clients was how they would often resort to confrontation late in the day. We concluded that counsellors were resorting to confrontation not for therapeutic effect but simply because they were tired. When we looked into what started the confrontation, it turned out that, more often than not, a client was seeking permission to go to town for personal supplies or for a day pass to spend time with a visiting family member.
When senior clinical management would ask counsellors why they resorted to confrontation it would often turn out that it was part of their training or, if the counsellor was in recovery, one of the methods used that, they believed, got them clean and sober. Rarely, if ever, would a counsellor point to research proving the efficacy of confrontation.
More often than not, however, the real objective of confrontation is not to evoke humility or motivation but, rather, client compliance. While client compliance has short-term benefits such as minimizing disruption during treatment, the long-term clinical benefits of achieving client compliance have never been proven (*).
Another reason pointed out by counsellors for the use of confrontation came down to “tough love” which counsellors hope is interpreted by the client as saying “I care enough about you to tell you what you don’t want to hear. This is not easy for me to say but others around you have been afraid to tell you this so I will.”
Finally, for decades clinicians working in addiction treatment have been under the false notion that you can tear a client down, then build him/her back up after creating a foundation of positive attributes such as humility, gratitude, etc. This tactic, popularized by Synanon (*) in the 1970s, continues today (albeit, informally) in alcohol and drug treatment centers across North America.
(*) Note: for an excellent historical review of Synanon and other confrontation proponents as well as information on the lack of clinical trials showing the efficacy of confrontational counselling read Confrontation in Addiction Treatment.
Practical Solutions at Sunshine Coast to Lower the Incidence of Confrontational Counselling
While clearly explaining and reminding staff of our client-centred philosophy has certainly helped lower the use of confrontation by staff, it was not enough to dispel its use entirely. So other practices were incorporated to help reduce the need for direct confrontation. For example, Sunshine Coast has always had a weekly group exercise called Community where clients have the opportunity to express their concerns and suggestions. Since all staff and clients attend Community, solutions can often be found that would otherwise require a one-on-one, potentially confrontational, dialog between client and counsellor.
A second change Sunshine Coast decided to make was to offload the responsibility of approving client requests from counsellors to the Site Manager and Program Director. While we recognized that there was a clinical consideration in even the most mundane requests (e.g. permission to buy a pair of shoes at Wal-Mart in town), putting a counsellor on the spot to deny these requests was, in the end, deemed too costly when it came to the impact on the therapeutic relationship.
Finally, last winter Sunshine Coast Health Center added a Client Advocate to the staff roster. This volunteer, non-paid position was created to provide clients with a direct communication channel to ownership for clients that felt they weren’t being heard by operational, medical, or clinical staff.
These programming, procedural and staffing changes have made a positive impact by reducing the need for confrontation by staff. Current incidents of confrontation can be chalked up to staff fatigue, force of habit, personal philosophy, and personal difficulties spilling over to work. Resolving these staff issues while continuing to focus on the needs of clients is a fact of life for anyone engaged in running an alcohol and drug rehabilitation program.