Tuesday, February 19, 2008

Confrontation Therapy, R.I.P.

Two of my favorite scholars have combined to write a powerhouse of an article that everyone interested in addiction treatment will want to read. William R. Miller, co-author of the Handbook of Alcoholism Treatment Approaches (reviewed here), and William L. White, author of the monumental history Slaying the Dragon (reviewed here), have written what hopefully will be an obituary for an era, entitled "Confrontation in Addiction Treatment." It's in Counselor Magazine. Here are a few snippets from this substantial, strongly researched and comprehensive treatment:

The use of confrontational strategies in individual, group and family substance abuse counseling emerged through a confluence of cultural factors in U.S. history, pre-dating the development of methods for reliably evaluating the effects of such treatment. Originally practiced within voluntary peer-based communities, confrontational approaches soon extended to authority-based professional relationships where the potential for abuse and harm greatly increased. Four decades of research have failed to yield a single clinical trial showing efficacy of confrontational counseling, whereas a number have documented harmful effects, particularly for more vulnerable populations. There are now numerous evidence-based alternatives to confrontational counseling, and clinical studies show that more effective substance abuse counselors are those who practice with an empathic, supportive style. It is time to accept that the harsh confrontational practices of the past are generally ineffective, potentially harmful, and professionally inappropriate.

....

Early claims of the superior effectiveness of confrontation and counterclaims that it was ineffective and potentially harmful relied primarily on statement of opinion buttressed by anecdotes. With the emergence of more science-grounded treatment approaches in the 1980s and 1990s came studies that began to tip the scales of this debate. Two recent reports, however, suggest that confrontation still has its proponents. A 2001 study on staff attitudes toward addiction treatment found that 46 percent of those surveyed agreed that “confrontation should be used more” (Forman, Bavasso & Woody, 2001); and a 2004 ethnographic survey of adolescent addiction treatment in the United States commonly encountered programs that were “explicitly designed to demean and humiliate” (Currie, 2004).

...

There never has been a scientific basis for believing that people with substance use disorders, let alone their family members, possess a unique personality or character disorder. Quite to the contrary, research on virtually any measure reflects wide diversity of personal characteristics among people with addictions, who are about as diverse as the general population, or as snowflakes. Studies of defense mechanisms among people in alcohol treatment have found no characteristic defensive structure, and higher denial was specifically found in a clinical sample to be associated not with worse, but with better treatment retention and outcomes (Donovan, Hague & O’Leary, 1975).

...

Reviewing four decades of treatment outcome research, we found no persuasive evidence for a therapeutic effect of confrontational interventions with substance use disorders. This was not for lack of studies. A large body of trials found no therapeutic effect relative to control or comparison treatment conditions, often contrary to the researchers’ expectations. Several have reported harmful effects including increased drop-out, elevated and more rapid relapse, and higher DWI recidivism. This pattern is consistent across a variety of confrontational techniques tested. In sum, there is not and never has been a scientific evidence base for the use of confrontational therapies.
If you've ever been exposed to confrontation therapy, or have a confrontational counselor now, by all means read this article, sure to be reprinted in textbooks and to become a classic.

If there's one defect in it, it's in glossing over the confrontational therapy element in AA itself. Dr. Harry Tiebout, whose psychiatric theorizing framed the confrontational approach, was hugely influential on Bill Wilson, and he was not alone. Dr. Silkworth echoed the theme, with his advice to Wilson to "give them the medical business, and give it to them hard." The "medical business" meant to convince the alcoholic that he was suffering from an incurable fatal illness. This revelation was designed to attack and to "shatter" the alcoholic's defenses, to "deflate" his ego, and render him hopelessly dependent on his "physician." The very first clause of step one, the foundation of the whole edifice, "powerless over alcohol," expresses a confrontational strategy, as thousands of counselors have found out in practice. To be fair, this is not the only element in AA; there are other strands that tend to counterbalance it. But the article is certainly wrong in claiming, as it does, that there is no attack therapy strand in AA at all. -- This cavil aside, the article is a masterful piece of work, by two giants in the field. Highly recommended.

10 comments:

Anonymous said...

I am glad that I did it myself; and, did not get any 'help' from these sorts of treatments.

Anonymous said...

Thank God this abusive therapy is on it's way out. I have seen so many people hurt from it.

Anonymous said...

i wept as i read your article. Confrontational BS destroyed my relationship with my family and created so much additional frustration, shame, fear, rejection and paranoia that my already shame based, abandonment based, and scapegoat based mentality skyrocketed... the devastation for my recovery has been catostrophic... i use big words to desribe the agonizing years of frustration due to this assinine, careless, reckless, harmful, irresponsible, shattering and family/relationship detroying "technique" for recovery... i have a hard time not hating AA for it, though i know it was not an AA thing.

Anonymous said...

It will come back-the narcistic selfish alky and junkie needs to be held to account.A good kick up the bum is also beneficial...

Anonymous said...

I completely agree that AA is confrontational. I have noticed that Miller will usually throw AA a bone like that. I'm sure it's because he knows that the 12 stepping colleagues would have his head and his career if he didn't. I love the way the article ends with reference to harm done and the need to make amends. I guess that makes it clear who he's referring to. It was a great article.

Anonymous said...

I am therapist myself and strongly belive that confrontational therapy is a MUST when patients do not want to open up to painful thoughts and feelings or have a critical time expressing themselves.

I am ALL PRO to CONFRONTATIONAL THERAPY and hope that more clinicians adopt this form of therapy to HELP patients who often denies having an addition or close up to the idea of opening up to explore painful and hurtful feelings.

Anonymous said...

Confrontational therapy has helped me a great deal in dealing with my eating disorder wich I dened for years.

At the beginning I was mad with my husband and my therapist.

One because my husband signed the forms for me to be submited to hospital treatment, and two because my therapist confronted me with my disorder which I didn't want to see.

But after being fully recovered, I am glad to both of them for the help I have received from both parts and I thanks my therapist for the COMFRONTATIONAL THERAPY that SAVED MY LIFE!

Today I am ED FREE! Thanks to this approach that very unfortunatelly is not being practice as much these days.

COMFRONTATIONAL THERAPY has done for me more than maybe years and years of empathetic and supportive therapy could have done!

In confrontational therapy you, the patient, gets to be confronted with all those aspects of your problems that don't want to see. Therapy is hard-work and going to a therapist just to talk doesn't work, you must work hard and get all that out in order to deal with it, otherwise you are waisting your time and the time of your therapist!

Anonymous said...

I am also a therapist/phd, and agree that with some patients, confrontational therapy is an absolute necessity. The key is to know who-what-when and how much, and the use of this requires a very skilled clinician, not someone venting.

Jesse Johnson said...

I am an experienced and trained mental health counselor. My experience is that there are many clients who need confrontation but only a small subset of these will benefit from it. Confrontation is not for every client. It requires a skilled counselor, a strong trusting relationship, compassion for the client, and the right client. Most counselor should not use it with any client

Anonymous said...

It's refreshing to hear this. It's not as simple as use/don't - it's more a cease of realising the options are broader and about matching client to therapy. Also the therapist is key - there's a difference between confrontation and abusive aggression.

I've never had addiction problems but had issues with anxiety. One therapist I had used confrontation therapy on me with no compassion - I could see how it could help some people. But this guy got basic FACTS wrong about my life, tried second guessing my thoughts and was outright nasty. I felt like he was disagreeing with me just to be an asshole. Frankly he shouldn't be allowed be near anyone - again the issue isn't the therapy but him being an idiot.