Monday, August 22nd, 2011
This guest post is by Dr. Michael Pantalon, author of “Instant Influence: How to Get Anyone to Do Anything–Fast” (Little, Brown and Company).
Imagine you are in the Emergency Department (ED) with your 16-year-old daughter who was brought in for her second episode of alcohol poisoning in six months. The doctor is about to discharge her because, medically, she’s fine, but you know she’s going to go right back to heavy drinking, if you don’t do something. You and your husband feel you’ve tried everything to help your daughter, but you also believe that there has to be some way to take advantage of this dire emergency to motivate her to get into treatment and to stop drinking.
I’ve seen hundreds of families in this very situation and their dilemma is always the same: they all want to influence their child to get on a better path, but they don’t know that there is a quick, easy and scientifically-proven way of getting the job done. The approach I’m referring to is called “Instant Influence.” It’s based on Motivational Interviewing, which in its briefest form, has been shown to reduce substance use among adolescents and young adults seen in the ED, as well as, my 20 years of experience motivating some of the most resistant to change substance abusing children and adults in a wide variety of settings.
People tend to only listen to one person — themselves. And, as a result, they’re only influenced by one person …again — themselves. So, as frustrating as this may be for a parent who would like to sternly say, “You have to stop!” and to have that be enough, the real trick to motivating someone is to get them to convince themselves to make a change for their own good reasons.
But how do you do this? How might the mom in the example above motivate her daughter to finally accept treatment for her drinking problem?
The two most important things to do are:
1) STOP trying to motivate your child by telling her about your feelings, thoughts or reasons for change, such as, “You’re worrying me to death!” “I think you HAVE to go to rehab right from the hospital” or “The best reason for you to stop drinking is for your health.”
2) START asking your child questions that are specially-designed to evoke her own good reasons for change.
To help you remember what things you should vs. should NOT say, I’ve devised two simple lists for parents to follow:
Express your anger. Of course, as a parent, you are feeling angry, but expressing it doesn’t motivate your daughter. Your anger is very likely legitimate, but if we stick to the idea that kids change when they hear themselves argue in favor of the change, yelling will NOT evoke such reasons - it may even make it harder for her to come up with good reasons to change.
Blame. It’s not a time to figure out who’s responsible for allowing the situation to get so bad, but instead, to garner some motivation to move forward with a better plan.
Confront her with admonitions to stop. Of course she knows you want her to stop drinking! She doesn’t need to hear that, nor will it be motivating. I know it feels almost irresponsible NOT to say that she HAS to stop drinking, but because of “reverse psychology,” it could be demotivating.
Tell her your reasons for why she needs to stop drinking by nagging. You may have some excellent reasons (her health, grades, family, etc.), but since only her reasons will ultimately influence her to take actual steps toward stopping or enrolling in treatment, your reasons will prevent you from getting at hers and they may backfire and create more resistance because they sound more like admonitions than reasons that motivate. You can express your concerns but focus on the behavior and why it worries you. Don’t make it sound like you think your teen is a bad person because he/she has tried drugs and alcohol.
Assume the ER will somehow scare her away from drinking in the long-term. Even if the doc has given her a “this-is-your-brain-on-drugs” speech and she seemed scared, the fear won’t last, nor will any temporary reduction in her drinking. And again, the fear invoked by the physician is based on HIS, not your child’s, reasons - they didn’t come from her. No personal reasons, no change. Additionally, our brains work very hard to suppress scary thoughts and images, so even if they seem to scare some kids straight at the moment, that effect will likely be forgotten very soon. Finally, remember that it is developmentally right on track for teenagers to feel invulnerable, so it’s pretty hard to truly scare them, anyway.
Use a “tough love” approach, such as threatening harsh punishments. Yes, consequences can be helpful, but when doled out in a tough, blaming and angry way, the likely side-effect is one of interpersonal conflict, which often leads the teen to focus on her anger at the mom (retaliatory toughness), which in turn leads back to alcohol or drug use, given that this sort of stress is a big trigger of relapse. Also, in order to help overcome an addiction, the teen needs a consistent and loving relationship with her parent, but such a relationship is hard to maintain when using the “tough love” approach. The bottom line here is that tough love makes love tough. A balanced approach with fair but firm boundaries and consequences is more effective than harsh discipline in motivating people.
Start by saying, “While I am very concerned about your drinking, I know that it’s ultimately your decision whether you choose to accept help. I can’t watch you 24-7 or force you not to drink, so you’re in the driver’s seat here. But can I ask you a few questions?” By frankly acknowledging your daughter’s autonomy, her defensiveness will go down, which makes her more open to answering the questions that follow, which will evoke her own more motivating reasons to change. And the fact of the matter is that she IS the only one who can make a change possible.
Ask , “Why might you decide to get help for your drinking?” This question basically corners her into saying something positive about getting help. If she says, “I don’t want to get help,” you say, “I didn’t ask IF you’re going to get help, but why you might ever decide to get help? In other words, if you were to ever get help, what would make you do that?” Because the question is hypothetical and very surprising (the typical question is “Why haven’t you gotten help for your drinking?”), the person’s defensiveness is further lowered. Because the question also focuses on the POSITIVE side of the issue (getting help vs. not getting help), the daughter is much more likely to say something positive about treatment (e.g., “Because it’s the only way I’ll be able to get back on the lacrosse team”).
Ask, “Have you ever done something you regretted while drinking? What was it?” This is helpful if your child has a hard time coming up with her own good reason for seeking help. Recounting such a story (e.g., the child might have gotten into a big fight with her best friend while intoxicated) helps her come up with a motive for getting help, such as, “Well, I might get help so that I don’t do that again.” By the way, this works even when they don’t tell you what the regretful behavior was.
Ask, “How ready are you to take a next step on getting help (e.g., looking up local specialists with you), on a scale from 1-10, where 1 means not at all and 10 means totally ready?” Get her to pick a number. This technique helps you get away from the all-too-common, but ineffective, Yes/No question of, “Are you going to go treatment or what?” which makes it too easy for the child to say no. She’ll say no even if she has a little motivation to go. The scale question allows her to reveal that little bit of motivation - it may only be at a 2 or 3, but it shows you that there is hope.
Ask her why she did not pick a LOWER (yes, lower) number? This forces her to defend why she has even a small amount of motivation. Again, we’re focusing on the positive. DO NOT ask why she didn’t pick a higher number because that will make her defend the negative - her resistance.
(If she said “1″ to the scale question), Ask, “What would turn that “1″ into a “2″? Usually, the child says something like, “If I thought I would have to keep coming to the hospital.”
Reiterate the good answers AND ignore the bad. Based on the above, this would sound like, “It looks like you might want to look into treatment so that you can get back on the lacrosse team and so that you don’t keep getting into big fights with your best friend.” They may not be the reasons the parents think are most important, but they’re going to be the most motivating, because they’ve come from the child.
Follow-up with an addiction specialist with expertise in motivational enhancement strategies.
Finally, you might also ask the ED doc why he/she might do what is called Screening & Brief Intervention and Referral to Treatment, or SBIRT, with your daughter. An SBIRT includes many of the above “DO’s” and could be the tipping point in terms of getting your daughter to get into treatment and stop drinking. In fact, more than any time in the past, ED docs are strongly encouraged to go beyond simply addressing the medical consequences of problem drinking and to try to motivate patients to address their substance problems. For more information on SBIRT, check out our Yale team’s website on the subject at www.yale.edu/sbirt.