Clients who have hidden alcohol dependencies present ethical and practical dilemmas for counselors. This article reviews these dilemmas and proposes an approach, rooted in Gestalt counseling theory, which confronts these issues and which is compatible with a current emerging alcohol treatment model. The author suggests specific activities for addressing client resistance to revealing a hidden alcohol dependence and provides the rationale for each.
Frequently, the astute and informed counselor will discover clients with an alcohol dependence who have neither presented nor disclosed this problem as an issue to explore. There are nearly 14 million Americans who abuse alcohol or are alcoholic (National Institute on Alcohol Abuse and Alcoholism, 1996). The vast majority of persons with alcohol and drug problems do not seek any treatment for their addiction. Estimates of the ratio of treated to untreated persons with substance use disorders range from 1:3 to 1:13 (Sobell, Sobell, Toneatto, & Leo, 1993).
Grant and colleagues (Grant et al., 1991), reporting from the 1988 National Health Interview Survey (as cited in Jung, 1994), provide a breakdown of alcohol abuse and dependence for men and women by age, separately for whites and nonwhites. Males had about three times more abuse and dependence than females. Whites showed almost twice the prevalence shown by nonwhites. The youngest age grouping (ages 18-29) showed the highest prevalence for both males and females, with each successively older group (ages 30-44; ages 45-64; and 65 and older) showing lower rates.
Since alcohol dependence affects all areas of one's life, it is not infrequent that an alcohol-dependent person will seek counseling for other issues such as problems with a significant relationship, employment or career concerns, depression, self-esteem, codependency, finances, or any number of other concerns (Kinney & Leaton, 1995). The client may even be distraught over a partner's drinking behavior. With some clients then, multiple issues will be presented and come to light over the course of counseling, but there will be little or no mention of alcohol use or abuse. This article focuses on the identification of alcohol dependence as a hidden issue and how to use Gestalt interventions to address the resistance and denial of that dependence.
Rotgers, Keller, and Morgenstern (1996) present a number of current perspectives in the treatment field of addictions. Two of the better known treatment models are the traditional or disease model and behavioral treatment techniques. Contrasting to these models is an emerging model that is more client centered and emphasizes client motivation.
The traditional model is the medical model, the conceptualization of alcoholism as a progressive disease, which was first advocated by Jellinek (1952,1960). The client is seen as someone who will not face the reality of his or her addiction. Confrontation and education are necessary to make clients aware of the nature and severity of their alcohol addiction. The aim of counseling is to have clients acknowledge their addiction, admit that they cannot control their addiction, and commit themselves to abstinence. Sessions tend to be counselor controlled and directed. The counselor educates, instructs, advises, confronts, and directs clients in how to solve their difficulties.
Behavioral Self-Control Training (BSCT) is another treatment approach that can be used to pursue a goal of moderate and nonproblematic drinking or "controlled drinking" (Hester & Miller, 1989, p. 141). BSCT procedures have been extensively studied. These studies collectively indicate that some problem drinkers do respond favorably to this approach. However, they assert that when "clients are assigned at random to treatment programs with abstinence or moderation goals, long-term results are consistently found to be comparable" (p. 147).
In contrast to both of the above models, the "emerging model" (Saunders, Wilkinson, & Towers, 1996, p. 259) views the client as someone who can acknowledge that alcohol use causes problems but is also aware that alcohol use provides real benefits. Motivation and denial are crucial in this theory of addictive behavior (Bell & Rollnick, 1996). Denial and lack of motivation are seen as exacerbated by the disease model treatment strategies of pressuring the client to quit, which is inconsistent with the client's position in the change process. The alcohol-dependent person exhibits the increased defense of denial just at the time he or she is most aware of the costs of continued addiction in order to protect the ego.
According to the emerging treatment model, the focus of counseling sessions is to elicit and assess the concerns clients may have about alcohol use and other current problems. The aim of sessions is to have clients consider the advantages and disadvantages of both continuing and stopping their drug use and assist them to decide one way or the other. The style of the session is counselor led but client centered. The counselor's role is to assist clients in making decisions about their future alcohol use--to continue, to curtail, or to cease--and to provide supportive, goal-directed counseling. The style of the counselor is considered to be an important factor in the client-counselor interaction. In fact, the approach taken by the counselor can be a powerful determinant of client resistance or change. "Motivation for change does not simply reside within the skin of the client, but involves an interpersonal context" (Miller & Rollnick, 1991, p. 35).
The Gestalt approach to the resistant, alcohol-dependent client is consistent with the emerging model. A strength of the Gestalt approach is that regardless of whether one subscribes to the disease model or the emerging model, or one of many other models of addiction behavior reviewed by Miller and Hester (1989), the Gestalt approach can assist the client in coming to grips with their addiction.
If a counselor chooses to work on a presenting issue when a hidden alcohol dependence exists, not only is the client unlikely to get better because the core issue is the hidden dependence, but also the client will continue to experience consequences of the problems. The client's time and money will likely be wasted, and without progress on the presenting issues, hope may wane and despair may set in. "Do no harm" is the first rule of the physician and the first rule of the helper (Egan, 1994). Ethically, the counselor has not upheld that mandate. Unfortunately, many helping professionals may lack the skills to diagnose hidden alcohol dependence. Many graduate programs still do not require a course in substance abuse. In a survey responded to by 70 CACREP-approved programs (Morgan, Toloczko, & Comly, 1997), only 21 (30%) required courses in substance abuse/dependency issues. Students in these programs may believe that unless they are going to work as a substance abuse counselor, knowledge of substance abuse is nice but not necessary. However, as stated above, alcohol abuse and dependence are so pervasive that it becomes crucial for counselors to be able to identify hidden dependencies.
The first step to finding a hidden alcohol dependence is to do a thorough intake. Ask the client directly about alcohol use, illicit drug use, and use of prescription medications. Get specific answers to your questions. If the client says he or she is a "social drinker," what does that mean? It could mean anything from a couple of drinks on a special occasion to drinking several drinks with a partner or friends every night after work. It may include smoking pot along with taking tranquilizers or other sedatives to potentiate the effect. Be aware that many clients, as a part of the denial process, will unintentionally under report their use of alcohol.
The next question for the counselor is "How much alcohol use is a problem?" Do not use your own alcohol consumption level as a gauge to how much is a problem for a client! (e.g., "If the client drinks and uses the same or less than I do, it's not a problem.") Instead, include as part of the intake, the Michigan Alcoholism Screening Test (Selzer, 1985). The MAST is one of the most widely used screening instruments in the country and is both reliable and valid. The instrument is a 25-item list of common signs and symptoms of alcohol dependence, which can be used as an interview format. Verbally ask your client the questions on the MAST Refusal to respond or hesitation in responding to questions is important information to note. Be familiar with the scoring procedure of the MAST and score the instrument in the client's presence. Scores on the MAST will separate those clients who are likely to be dependent on alcohol from those who are not. An in-depth discussion of the MAST and use of MAST scores can be found elsewhere (Jacobson, 1976, 1983, 1988, 1989).
Other screening instruments include the CAGE, which consists of only four questions whose key words form the acronym (Ewing & Rouse, 1970). The CAGE is one of the oldest and briefest of the direct identification techniques. Another alternative is the Diagnostic Interview Schedule (DIS) developed by the National Institute of Mental Health (Jacobson, 1989). It covers most of the major problems and symptoms associated with a disease model of alcoholism, and therefore has a good degree of content validity. There are a great deal of data attesting to its favorable validity and reliability (Eaton & Kessler, 1985). A discussion of additional instruments can be found in Jacobson (1989).
The counselor's next task is to communicate the screening results to the client. In the case of screening results that indicate alcohol dependence, seeing the results of the screening instrument will be a difficult confrontation for the client. Therefore, it is important that the counselor has established positive rapport with the client and that the counselor is exploring this issue with as much comfort, respect, and lack of judgmental attitude as any other issue that would be explored. Be ready with follow up questions such as "Do you sometimes drink alone? Do you drink for medicinal reasons? Do you work at protecting your supply of alcohol?" Additional follow-up questions are suggested by Kinney and Leaton (1995). The mature client will respond positively to the screening, take your referral to an alcohol treatment center for further assessment, begin attending Alcoholics Anonymous, and be on the road to improved health and well being. However, this is a rare client. A much more typical response, due to the centrality of denial associated with alcohol dependence, is to resist believing that alcohol use is the problem it has been identified to be and to choose not to address the issue (Phelps & Nourse, 1986).
Familiarity with and routine use of one of the screening instruments can signal the presence of an alcohol dependence which otherwise might remain hidden, thus masking a major component contributing to the client's distress.
An alcohol-dependent person needs help and needs that help as early as possible. The once widely accepted belief that the alcohol-dependent person has to "hit bottom" before he or she can be helped has been discredited (Milam & Ketcham, 1981). Waiting for the alcohol-dependent person to recognize the need for treatment is nontherapeutic and unethical. Left to their own devices, alcohol-dependent people will become less willing, rather than more willing to seek treatment for the addiction due to the agency of denial. If treatment for the addiction is delayed until the liver and brain are permanently damaged, the marriage or relationship has failed, the career is in ruins, and the client is financially destitute, intervention has been delayed too long (Milam & Ketcham, 1981).
When it becomes clear that the client has an alcohol problem that is not the presenting issue, the counselor is likely to respond in one of two ways, (1) go along with the client and provide the kind of help sought or (2) refuse to help the client with the presenting issue until the alcohol dependence has been treated.
If not trained adequately in alcohol abuse and dependence issues, the counselor may be inclined to ignore the issue. Since the client determines the goals of counseling, he or she may choose to avoid the underlying issue of alcohol dependence. The client may even be unaware of the connection between the alcohol dependence and other troublesome life issues. Even an experienced counselor, aware of the underlying dependence, may be tempted to employ this tactic. However, by responding this way, the counselor runs the very serious risk of collaborating with the client in denying the existence of the alcohol dependence. The counselor may think, "I'll go along with the client and provide help on the presenting issue, and later we'll get to the underlying issue of alcohol dependence." The reasoning that some help with something is better than none leads to enabling the client to continue to deny the root problem while dealing with one of its symptoms, and therefore, enables the client to continue to drink. The therapist risks complicity in the denial.
The second response is to clarify to the client the importance of working with the dependence as a treatment priority. The counselor gives the client a referral to an alcohol treatment center for further assessment and evaluation. The counselor hopes that the client will pursue a referral and take a step toward health and well being. With a hidden addiction, this almost never occurs because the client is not ready to acknowledge the addiction. If the client is not ready to take the referral, at least the counselor has made an intervention that the client is not: likely to soon forget, and the counselor can rest assured that he or she is not enabling the client's addiction. However, when the counselor refuses to help the client with the presenting issue until the client has been treated for alcohol dependence, the counselor risks losing the client altogether. Unready to work on the addiction, the client may not only refuse the referral to an alcohol treatment center, but might also leave counseling. The result is a missed opportunity for growth, development, and improved wellness. The counselor, while not ethically complicit with the client, seems to fail ethically by abandoning a client in need (American Counseling Association, 1995).
There is however, a third and unfortunately rare counselor response--to address the resistance to giving up the addiction in a caring, nonjudgmental manner, knowing that there is likely to be denial on the part of the client and to work with resistance. This prepares the client for accepting the painful reality and taking the necessary steps toward beginning recovery. Thus, the focus of counseling is neither the presenting problem, nor the addiction directly, but rather the resistance of the client to dealing with the addiction and, by inference, the bringing of the denial process (resistance) into full awareness.
Before describing interventions to accomplish this, a brief overview of relevant aspects of Gestalt theory and its relevance to the emerging model of alcohol treatment is provided.
The overall goal of Gestalt counseling is growth toward maturation, which is related to the degree of responsibility the client is willing to assume (Passons, 1975). Another goal is working toward integration of the person such that he or she functions as a systematic whole comprised of feelings, perceptions, thoughts, physical movements, and sensations. Change is not forced but is allowed to occur as the result of participation in various exercises ("experiments") that reveal key aspects of the client's present awareness. Change occurs as self-awareness is enhanced, because this permits organismic self-regulation to take place (Perls, 1969).
The function of the Gestalt counselor is to raise awareness, which is defined as knowing what one is sensing, feeling, and thinking. Such awareness can be achieved only in the "now," the present moment. Thus, the counselor assists the client to become aware of "what" and "how" he or she behaves in the moment (Perls, Hefferline, & Goodman, 1951).
Experiments in the Moment
The counselor employs a broad range of interventions to assist the client in enhancing awareness based on the assumption that, in the spontaneity of the present, core problems that need to be dealt with will emerge. Usually these approaches are presented as experiments for the client to try. Some of the most basic interventions include repeating significant statements, exaggerating gestures for clarification, focusing on the relationship between the client's verbal and nonverbal behavior, and acting out both sides of a dialogue. Considerable attention is also given to the client's verbal expressions. He or she is asked to use personal pronouns instead of the customary "you" or "they" when expressing thoughts. The therapist may ask the client to change such language as "can't" which implies powerlessness to "won't" which implies intention. Thus the client is assisted to feel the proactive elements of the behavior.
Bipolarities or Splits
Each aspect of a person is part of a duality, although typically only one side is observable. Greenberg (1983) discusses the theory of the significance of splits in human functioning; people often describe states in which aspects of themselves are experienced as being in opposition. According to Polster and Polster (1973), whenever an individual recognizes one aspect of the self, the presence of its antithesis is implicit. There is a tendency for one side of a polarity to be in the foreground with its counterpart residing in the background. The relationship between the two ends of the polarity is often like a teeter-totter, such that when one end is up the other end must be down. The end that is up is more in awareness, while the down side is less in awareness. Awareness of both polarities reduces the chance that one part will stay stuck in its invisibility and impotence, hanging onto the status quo. Instead, the down aspect is energized into making a vital statement of its own needs, thus asserting itself as a force that must be considered.
In a series of increasingly rigorous and sophisticated studies, Greenberg and his collaborators (Greenberg, 1979, 1980, 1983; Greenberg & Clarke, 1979; Greenberg & Higgins, 1980; Greenberg & Rice, 1981; Greenberg & Webster, 1982: Paivio & Greenberg, 1995) find empirical support for the use of a specific Gestalt intervention ("the two-chair dialogue") in resolving bipolarities and offer theoretical insight into the effects of this technique.
In the case of the alcohol-dependent client, the bipolarities can be identified as the part of the person who enjoys and wants to drink as opposed to the part of the self that wants to stop drinking due to negative consequences.
The Concept of Resistance
Traditionally, resistance implies that a person has specific goals that can be identified, such as carrying out an exercise program or writing a paper, and is prevented from realizing these goals by the resistive factors. Lewin' s (1935) seminal work in force field analysis explicates the interplay of forces that allow or prevent movement toward goals. Restraining forces correspond to barriers that must be weakened, according to this view, so the goal may be obtained. Movement results from strengthening driving forces and/or weakening restraining forces.
According to Gestalt theory (Polster & Polster, 1973), what usually passes for resistance is not just a barrier to be removed, but rather a creative force in itself for managing a difficult world. For example, alcohol dependent persons learn to hide their addiction from themselves and others in order to avoid shame and judgment from others. Instead of ignoring or overpowering resistance, as is done with the traditional disease model of treatment, it is better to focus on the resistance so the client is able to discover the strength and function of the resistance. Merely labeling the behavior as resistant and expecting that the client will no longer resist or deny is not effective, nor does it acknowledge the potential and the creative side of the resistance.
Thus, the Gestalt counselor views intrapsychic functioning and intrapersonal behavior as attempts to maintain personality organization. Rather than viewing defenses as obstacles to be attacked and overcome in treatment, the Gestalt counselor respects the individual's need for selfprotection and the creative meaning of the defenses. The individual uses defenses both to survive in the world and to avoid change (Buchbinder, 1986). The counselor's role is to facilitate awareness of the inner forces, because in this approach, increased awareness allows a person to make more fully human choices.
Addressing the resistance of the alcohol- or drug-dependent client often means accessing the polarity in the background and gently bringing it into the client's awareness through various interventions. Inevitably there is a part of a client that is aware of the alcohol or drug dependence. However, existing alongside that knowing part is a resistant part that: profoundly refuses to accept the reality of addiction. The client will not see himself or herself as alcohol or drug dependent. To do so would be too painful and too damaging to an already inadequate self-image, which the resistance is designed to protect and enhance. If counseling with the alcohol or drug dependent client is to be successful, a way must be found of allowing and then working with the resistance and denial, using the energy of the resistance to move beyond it. The counselor's interventions must also encourage the client to assume gradually increasing responsibility for drinking or drug use (Buchbinder, 1986).
Gestalt Treatment Interventions that Address Resistance
It is the counselor's responsibility to assist in developing the client's selfawareness. All Gestalt experiments and "techniques" are created for this purpose. Accordingly, the most important thing for the counselor to understand and remember is to not interfere with the client's process by acting from some preconceived agenda for the client. The challenge is to tailor the experiment to the particular client and to the experience of the moment. It is essential that the counselor avoid approaching the client with an agenda (i.e., "You must admit your problem.., take responsibility for it...stop drinking and reform your ways.") One of the guiding principles of Gestalt counseling is that the individual is always doing what he or she is capable of in tile moment. By allowing the client's denial/resistance, the therapist minimizes the need for rebellion. The client is then left to struggle with himself or herself rather than with the therapist. Thus the paradox of Gestalt counseling is that by not insisting upon client change, change is facilitated through examination of the status quo and of that often disowned part of the person that does not deny the need for change (Peris, 1969).
Three examples of treatment interventions that work with resistance follow. The trained Gestalt counselor is able to work in the present and create experiments tailored to each individual client that arise from the client's present moment experience.
1. A double chair experiment can be utilized. This is an expression of the within-self dialogue (Paivio & Greenberg, 1995; Passons, 1975). Two chairs are placed facing each other. The counselor observes and provides assistance from the side. In one chair is the healthiest part of the client, or the part that wants to recover from the addiction. In the other chair is the resistant part of the self, or the part of the client that wants to maintain the addiction and the status quo. The client sits in the chair that represents the part of the self that is currently the strongest (probably the resistant part). He or she speaks from that part using "I" statements. It might go something like this: "I like to drink. I like getting high. I like being with my friends when I'm high. We have a good time. I look forward to these times. I: think life would be boring without drinking. All my friends drink." The client should express all that comes to mind when experiencing that part of himself or herself.
Then the client takes the opposite chair and speaks from the weaker, less conscious part of the self. It might go something like this: "I know I drink too much sometimes. I've had two DUIs in the past 5 years. I'm late to work from time to time. My wife complains about my drinking. We don't spend a lot of time together unless we're drinking. I spend a lot of money on booze." The counselor encourages an in-depth exploration of these two polarities of the self. The client's awareness of the opposing sides is increased and the client determines which polarity is stronger. From this exploration, the client can make choices that are more informed and aware. The counselor has encouraged the resistant part of the self to speak rather than to push against the resistance with a mandate for what the client "should" do. Thus the impetus for change comes from within the client.
2. A second method of exploring opposing polarities is through the use of sentence fragments. This technique attempts to unlock the client from "locked in" identities, behaviors, and feelings (Passons, 1975). The client finishes the sentence fragment with as many responses as are true for him or her. Examples of sentence fragments might include the following:
A reason I choose to drink is ...
A reason I might choose not to drink is ...
If I continue to drink ...
If I choose not to drink ...
My life with alcohol is ...
Without alcohol I ...
Note that each statement is followed by its polar opposite.
The responses to these sentence fragments will serve to increase the client's awareness of attitudes of drinking, the purpose that drinking serves, and the emotional blocks to recovery. All exploration is done in a respectful manner. The client assumes increasing responsibility for his or her choices. The fact that the client has the choice becomes clearer to the client as the polarities are explored and the range of behaviors, feelings, and cognitions is extended.
3. A third intervention involves homework. The client is asked to make a list of all the reasons NOT to stop drinking and/or using, bring the list to the next counseling session, and be prepared to explain each reason in detail. The client is likely to be surprised by this homework assignment. After all, chances are that the client has had many directives about decreasing or stopping drinking. The purpose is to put the resistant forces "on the table" so that they are not compelled to go underground and sabotage efforts at growth and change. This focus on the reasons not to change often results in the client saying something like this: "But there's another side to this. There's another part of me that would like to stop drinking." When the resistant side has been expressed, the client is likely to be more ready to look at the possibility of further assessment. This assignment has something of Frankl's paradoxical intention embedded in it (Frankl, 1962).
In summary, the basic concept in working with polarities is to restore contact between the opposed forces. Often one of these forces is disowned, and the client may be unaware of many aspects of both polarities. When the polarities are experienced, each part of the warring struggle can be validated. Each can become essential in the search for quality in life, rather than opponents in that search. This experience of the polarities can increase the individual's awareness of and regard for the redeeming features of each polarity (Polster & Polster, 1973). The responsibility for change or maintaining the status quo is placed within the client, where Gestalt theory maintains it should reside.
Gestalt interventions are words and experiments designed to enhance the client's awareness. The power of Gestalt experiment lies with the person who is using them. The counselor's personality is a primary determinant in integrating Gestalt approaches into one's counseling style (Passons, 1975). Both the techniques that a counselor devises and those adopted from others must have some degree of congruity with his or her own personality make-up before the counselor can use them effectively. The counselor who is able to use Gestalt techniques effectively generally prefers activity to passivity, acts with firmness and assurance, accepts power but does not need it for personal gratification, enjoys improvising rather than following a fixed plan, and is not unduly afraid of intense emotional expression (Fagan & Shepherd, 1970).
The counselor who decides to use some Gestalt approaches will have questions about how and when to use them. Gestalt approaches are more likely to be successful when the counselor communicates to the client an experimental attitude such as "Let's try this and see how it goes." The counselor who works from an experimental frame of mind will have less investment in the client's response being "right." Some interventions will fit and illuminate the client's awareness and some will not. Not having a particular expectation for outcome will allow the client maximum freedom of expression. In this spirit the counselor and client can be colleagues in a process of discovery (Passons, 1975).
Throughout the counseling process, the counselor's role is that of facilitator of self-awareness and not that of evaluator. It is essential for the counselor to remember that Gestalt experiments are useful only when they are tailormade to particular situations with specific clients, and yield only mediocre results when misused as rigid formulas. Experiments and specific interventions are tools, and as such, they are meant to be constantly modified. The goal in this case is to bring into awareness the resistance to change and the denial of the addiction. The difficulty with this method is that it requires creativity and spontaneity on the part of the therapist, who must design the experiments in the moment. It takes courage and ingenuity to use this approach successfully, but with practice and experience, this approach can be rewarding and possesses great potential for breaking the resistance impasse.
Utilizing the suggestions provided in this article will not by any means guarantee that the client will be ready to accept alcohol treatment. What is provided are alternatives to enabling a client's alcohol dependence by not discovering it and/or not working with it and to refusing further treatment to a client because of his or her refusal of further assessment and treatment. Earlier intervention is likely to increase the client's chances for recovery as well as to prevent unnecessary deterioration in the client's health, well being, and life circumstances.
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By Luellen Ramey
Luellen Ramey, Ph.D., is an associate professor and chair of the Department of Counseling at Oakland University, Rochester, MI. Correspondence regarding this article should be sent to Luellen Ramey, School of Education and Human Services, Department of Counseling, 478 O'Dowd Hall, Oakland University, Rochester, MI 48309; email: ramey@oakland, edu.
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Source: Journal of Mental Health Counseling, Jul98, Vol. 20 Issue 3, p202, 14p