EXPERT COMMENT: A BRIEF HISTORY OF CONFRONTATION IN ADDICTION TREATMENT

For many reasons, the U.S. treatment field fell into some rather aggressive, argumentative, “denial-busting” methods for confronting people with alcohol and drug problems. This perspective was guided, in part, by the belief that substance misuse links to a particular personality pattern characterized by such rigid defense mechanisms as denial and rationalization. In this perspective, the counselor must take responsibility for impressing reality on clients, who cannot see it on their own. Such confrontation found its way into the popular Minnesota model of treatment and into Synanon (a drug treatment community known for group sessions in which participants verbally attacked each other) and other similar therapeutic community programs.

After the 1970s, the treatment field began to move away from such methods. The Hazelden Foundation officially renounced the “tear them down to build them up” approach in 1985, expressing regret that such confrontational approaches had become associated with the Minnesota model. Psychological studies have found no consistent pattern of personality or defense mechanisms associated with SUDs. Clinical studies have linked worse outcomes to more confrontational counselors, groups, and programs (Miller & Wilbourne, 2002; Moos, 2012; Romano & Peters, 2016). Instead, successful outcomes (Moyers, Houck, Rice, Longabaugh, & Miller, 2016) generally have been associated with counselors showing high levels of empathy as defined by Carl Rogers (1980). The Johnson Institute now emphasizes a supportive, compassionate style for conducting family interventions.

I was at first surprised when counselors attending my MI workshops and watching me demonstrate the style observed, “In a different way, you're very confrontational.” This comes up in almost every training now. Some call it “gentle confrontation.” This got me thinking about what confrontation really means.

The linguistic roots of the verb “to confront” mean “to come face-to-face.” When you think about it that way, confrontation is precisely what we are trying to accomplish: to allow our clients to come face-to-face with a difficult and often threatening reality, to “let it in” rather than “block it out,” and to allow this reality to change them. That makes confrontation a goal of counseling rather than a particular style or technique.

Once you see this—namely, that opening to new information, face-to-face, is a goal of counseling—then the question becomes, “What is the best way to achieve that goal?” Strong evidence suggests that direct, forceful, aggressive approaches are perhaps the least effective way to help people consider new information and change their perceptions. Such confrontation increases the very phenomenon it is supposed to overcome—defensiveness—and decreases clients' likelihood of change (Miller, Benefeld, & Tonigan, 1993; Miller & Wilbourne, 2002; Moos, 2012; Romano & Peters, 2016). It is also inappropriate in many cultures. Getting in a client's face may work for some, but for most, it is exactly the opposite of what is needed—to come face-to-face with painful reality and to change.

William R. Miller, Ph.D., Consensus Panel Chair