Resistance Is (not so) Futile
 

In this edition of EBP Times, Bryan Knowles (IDDT Consultant & Trainer,
KU School of Social Welfare) reflects upon his first memory of feeling as if something just wasn't quite right, and helps us to understand how IDDT clinicians can use this knowledge to help the individuals they are working with, as part of the Motivational Interviewing tool.

~ Part One ~
Dissonance

      I don’t remember how old I was when I learned the new word.  Surely not more than twelve or so.  It happened during my piano lesson.

      I wasn’t very good at sight-reading a new piece of music, but things were going fairly well until I hit a particular note.  I winced and immediately stopped playing.

      “What’s wrong?” asked the voice at my shoulder.

      I looked at my piano teacher as if he were tone-deaf.

      “It doesn’t sound right.”

      “No, that’s right,” he assured me.

      Doubtfully, I placed my fingers on the keys and started over.  When I played the note, I once again winced, taking my fingers off the keys.

      “That can’t be right.”

      “It is.  Look.” He pointed at the sheet music. “You got it right.”

      “Well, I don’t like it,” I insisted petulantly.  “It sounds ugly.”

      My instructor informed me that it was meant to sound that way and that not all music was meant to be beautiful throughout.  Sometimes a composer would throw in notes that contrasted one another.

      “It’s called dissonance,” he said helpfully.

      I was not convinced, but it seemed clear that my instructor would not let me play a note I preferred.  I continued practicing, forcing myself to play through that ugly sound.

~ Part Two ~
Motivational Interviewing and Dissonance

     The Integrated Dual Diagnosis Treatment (IDDT) model places special emphasis on discovering and working toward what clients strongly desire in their lives.  In part, this is because there is a temptation to assume that recovery from mental illness and substance abuse are ends unto themselves.  That is, we sometimes assume that people should and will work toward the ideals of mental health and substance abuse recovery just because we (or their family or society as a whole) consider these things valuable.  This often leads to the “helper” devising an array of stratagems designed to move quickly toward the goal, often “dragging” the client along behind them.  Then, when clients inevitably drag their feet at following a plan in which they have little or no personal investment, the “helper” assumes this is indicative of a flaw in character.  The client may now be described as “uncooperative,” “non-compliant”, or “stubborn.”  (Incidentally providing an explanation/scapegoat as to why all “helpful” efforts have thus far been unsuccessful.)

      Far more effective is to spend time exploring what it is that is important to the client.  What does the client value, and what is the client hoping to have in the future?  Both “helper” and client must have a solid notion of the “why’s” for working toward recovery before plunging into the “how’s” of working toward recovery.  Otherwise, when clients lose interest in working toward an amorphous ideal or goal (which may have originated with the “helper,” other involved parties or society in general), clinicians are likely to see that clients become (or remain) unreceptive, unwilling and inactive with regard to the prescribed treatment.

      What the “helper” is really experiencing is resistance, and given the above context, such resistance is not unexpected.  It is also not insurmountable.  However—and it’s this next concept that can be so difficult to accept—it is not the client’s job to “get in line” or “work harder” or “hit bottom” before things can progress.

      Here’s the part where my piano lesson comes into play.

      The IDDT model uses Motivational Interviewing as an intervention, and many of the skills and philosophies used in this intervention are helpful throughout the IDDT process.  A central tenet of Motivational Interviewing is that resistance is a sign of dissonance in the relationship, and that resistance doesn’t happen in a vacuum.  It happens in response to the other person in that relationship (Miller & Rollnick, 2002).

      That is, we’ve hit a wrong note.  We are not “on the same page” as the person we’re trying to help and have—as we often say in IDDT—“gotten ahead of” the client.

 ~ Part Three ~
Clinician's Role: Being Effective Vs. Being Right

      Miller and Rollnick are quick to point out that resistance is normal.  After all, when have you known two people in any kind of relationship who were always in perfect agreement?  We should expect a certain degree of resistance.  The key, however, is how the clinician responds to such resistance.  Arguing, commanding, or blaming is likely to provoke more resistance.  It is the clinician’s job to recognize the dissonance and respond differently to minimize the amount of resistance in the relationship.  In direct opposition to my piano instructor, we must “back up” and find a more harmonious approach.  This means challenging our (often unconscious) assumption that we are the “experts” therefore know what’s best.  I have encountered people who seem truly galled at the idea that resistance from a client calls for a different approach from them, the “helper.”  There seems to be an assumption that it’s the client’s job to recognize that the clinician is “right” and to do as they are told.  However, one of the most important lessons I’ve learned in practicing and training in the IDDT model is that it is far more important to be effective than “right.”

      After all, we are not the experts on what will work in a given person’s life.  Our suggestions may be completely unrealistic in the context of that other person’s reality.  Our job, then, is to help clients discover how recovery fits with what they really want out of life and—once they have decided for themselves what they want—to help them find a way to attain their goals.  If we encounter resistance, it is a sign (to which we should pay careful attention) that we’ve taken a step in the wrong direction.  Refusal on principal to adjust our approach would be like blaming the piano when we hit a wrong key.

Reference

Miller, W.R., & Rollnick, S. (2002) Motivational Interviewing (2^nd ed.): Preparing People for Change. New York: Guilford Press.

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