Substance Users’ Perspectives on Helpful and Unhelpful Confrontation: Implications for Recovery

Abstract

Substance users commonly face confrontations about their use from family, friends, peers, and professionals. Yet confrontation is controversial and not well understood. To better understand the effects of confrontation we conducted qualitative interviews with 38 substance users (82% male and 79% white) about their experiences of being confronted. Confrontation was defined as warnings about potential harm related to substance use. Results from coded transcripts indicated that helpful confrontations were those that were perceived as legitimate, offered hope and practical support, and were delivered by persons who were trusted and respected. Unhelpful confrontations were those that were perceived as hypocritical, overtly hostile, or occurring within embattled relationships. Experiences of directive, persistent confrontation varied. Limitations of the study include a small and relatively high functioning sample. We conclude that contextual factors are important in determining how confrontation is experienced. Larger studies with more diverse samples are warranted.

Introduction

Confrontation of denial has historically been a standard part of many treatment approaches for alcohol and drug problems (Polcin, 2003). However, confrontational approaches vary and research findings on the impact of confrontation have been mixed. In an early study, confrontation was defined as an argumentative counseling style and found to be counterproductive among a sample of individuals being treated for alcohol problems (Miller et.al., 1993). A more recent study using a sample of residents of recovery houses defined confrontation more supportively as warnings about potential harm associated with substance use. Defined in this way, confrontation was typically experienced as supportive, accurate and helpful (Polcin et al, 2010).

Other studies have emphasized the role of contextual factors in determining how confrontation is experienced. Karno (2007) defined confrontation as challenging client defenses, assigning meaning to experiences, and interpreting resistance to treatment. Such confrontations were associated with worse outcomes in cognitive behavioral therapy but not in motivational interviewing or twelve-step facilitation. Karno and Longabaugh (2005) used a similar definition of confrontation and found that it was associated with worse outcomes for clients high on trait anger but better outcomes for clients who were low on trait anger (Karno & Longabaugh, 2005). Moyers et al (2005) also found differential effects for confrontation. They found interventions deemed inconsistent with motivational interviewing, including confrontation, facilitated the therapeutic alliance when they were delivered by therapists with high levels of clinical skills but not when they were delivered by relatively less skilled therapists.

Remarkably absent in these reports are descriptions of clients’ experiences depicting when and how confrontation is experienced as helpful or harmful. Our contention is that client experiences of confrontation can point to critically important factors about the circumstances under which confrontation helps or harms alcohol and drug problems. Only through qualitative interviews can we explore the wide array of factors that might be important. Once identified, these factors can be quantified and included in multivariate models that parse out their relative influences on how confrontation impacts outcome.

This paper begins by presenting a new definition of confrontation and a new way of measuring it. We then describe the overall purpose of the study, the methods used to collect the data and study findings. Important in the depiction of when confrontation is helpful or harmful are illustrative excerpts from study participants. We conclude with a summary depicting when confrontation was helpful and counterproductive, and contextual factors that can affect how it is experienced

A New Definition of Confrontation

The study reported here builds upon our previous quantitative work examining confrontation (Polcin, Galloway & Greenfield, 2006). We proposed a new definition that looked at confrontation from a broad perspective that included confrontational comments received from treatment professionals, family, friends, peers and criminal justice staff. The definition of confrontation consisted of warnings about potential harm (i.e., “bad things that might happen”) as a result of substance use (Polcin et al., 2006). To test this new construct, Polcin et al (2006) developed the Alcohol and Drug Confrontation Scale (ADCS). The ADCS used 8 items to assess confrontation (defined as warnings about potential harm that might result from substance use) from treatment professionals, family, friends, peers and criminal justice staff. In addition to assessing the quantity and frequency of confrontational comments, the ADCS assessed the context within which confrontation occurred. Thus, it assessed how the person confronted perceived their relationship with the confronter (general supportiveness, support for sobriety, and motivation for making the confrontational comment) and their perceptions about the confrontational statements (accuracy, helpfulness, and emotional intensity).

The ADCS was administered to a sample of 323 individuals entering sober living houses (SLHs) (Polcin, et al., 2009). Findings indicated that large proportions of residents received confrontational comments. For example, over 60% received at least one confrontational comment from family members during the month before they entered the SLH. sober living Factor analysis procedures yielded a 2-factor structure, with one factor labeled “Internal Support” (how supportive confrontational comments were experienced) and the other “External Intensity” (the frequency, emotional tone and accuracy of confrontational comments). On average, confrontation was experienced as supportive, accurate and helpful from all of the sources examined (e.g., family, friends, peers and various professionals, including substance use treatment and criminal justice staff). There was good reliability within and across sources of confrontation (the comparative fit index across all sources was 0.90) and the means of nearly all of the items loading on the Internal Support subscale were between 4 and 5 on a 5-point scale (Polcin et al., 2009). Over a 12-month period of time, the factor structure of the two factor based scales remained largely intact (Polcin et al., 2010).

Purpose: Understanding Confrontation from the Substance User’s Perspective

Although quantitative investigation of the ADCS suggested that confrontation was generally experienced as supportive and helpful, we were interested in elaborating on these findings and deepening our understanding about specific contexts and circumstances in which it was helpful and unhelpful to recovery. We therefore conducted a qualitative sub-study with a sample of individuals who had left the SLHs. The goal was to better understand substance users’ perspectives of when and how confrontation was helpful in leading to changes in alcohol and drug use and when it was counterproductive.

Methods

Sample

The sample consisted of 38 individuals who had taken part in our larger longitudinal study of sober living houses (SLHs) (N=245) (i.e., Polcin & Henderson, 2008). Participants from the larger study were recruited from Clean and Sober Transitional Living (CSTL) in a Northern California county. CSLT operates 16 freestanding SLHs (136 bed capacity). All recovery homes used a social model philosophy of recovery that emphasized peer support and the 12-step recovery principles of Alcoholics and Narcotics Anonymous. No formal treatment is offered by the SLHs but residents are free to pursue services outside the houses. Our analysis of 245 residents at CSTL found the primary substances abused were methamphetamine (53% dependent over the past year) and alcohol (49% dependent over the past year). Over 60% had attended some type of residential treatment program during the 6 months before they entered the SLH. On average, residents stayed in a SLH about 5 months and made significant improvement in terms of alcohol and drug problems, employment, and reductions in arrests (Polcin et al., 2010a). Improvements were maintained at 12 and 18 months even though the vast majority had had left the SLH by then (91%).

Among the 38 individuals who were recruited for the current qualitative study over half (56%) were renting an apartment at the time of the interview. . Demographic characteristics of the sample were very much representative of the larger parent study sample: mostly male (82%) and white (79%), with an age range of 20 to 52 and mean age of 38. A majority (58%) had a high school diploma or GED. Approximately three-quarters had been dependent on at least one illicit drug when they entered the SLH and 40% on alcohol. At the time of the interview, 80% (27 participants) had been abstinent from alcohol during the past 30 days and 88% (30 participants) had been abstinent from drugs. About 62% indicated they had attended at least one 12-step meeting over the past 30 days. To access a range of experiences in regard to confrontation we used study participants’ responses on the ADCS during the longitudinal parent study to stratify our sample into two groups: 1) a group who experienced confrontation as supportive, and 2) a group who experienced it as relatively unsupportive.

Procedures

During the parent study participants signed consents giving the study team permission to contact them about future projects for which they might qualify. Potential participants were contacted by phone, informed about the study, and invited to participate. Those who agreed were interviewed at the project office, the participant’s residence, or a mutually agreed alternate site provided there was sufficient privacy to conduct interviews. All interviews lasted about an hour and were audiotaped and transcribed. Participants were paid $30 for their time and effort to participate in the study.

Before asking questions about experiences of confrontation, residents were informed that by confrontation we meant being told “bad things might happen if you did not take action to address alcohol or drug problems or take action to maintain your recovery.” Participants were informed that examples of bad things included things like losing a job, losing an important relationship, eviction, being arrested, becoming homeless, relapse, and developing health or emotional problems.

To gain insight into the dynamics of confrontation and how its experience and effects can vary, we asked participants to recall and describe in detail an experience of a helpful and an unhelpful confrontation that they had received while they were using substances and when they were abstinent. For each of up to four confrontational experiences recollected, study participants were asked to discuss why the confrontation was helpful or unhelpful, to describe the nature and duration of the relationship with the confronter, the tone of the confrontation and how it came about, their substance use and life circumstances at the time, their reaction to the confrontation, and any consequences that resulted. Interviews were semi-structured, lasted approximately one hour on average, and were conducted by all three authors, with the third author responsible for the majority of interviews. During data collection and analysis, the team had regular debriefings and discussion of emerging findings. All interviews were audiotaped and professionally transcribed, then entered into NVivo 7.0 software for coding. Coding is the process of reading transcribed text, developing conceptual labels for phenomena described in the text, and “attaching” these labels to the appropriate segments of transcribed text (Strauss & Corbin, 1990). Through an iterative process of reading transcripts and developing codes as a team, we developed a list of codes that describe and conceptualize data on the confrontation experience and its contexts (e.g., codes such as “validity”; “near-death experience”). Subsequent to coding the data, NVivo 7.0 software was used to search and retrieve coded text for more focused analyses to identify commonalities and differences within and across cases. Through the constant comparison of cases (Glaser & Strauss, 1967), emerging themes were checked against other cases for verification and refinement.

3. Results

Respondents were free to discuss confrontational comments they received from anyone, as instructed by the interviewer. Although confrontation was mentioned from a variety of different sources, including the criminal justice system (e.g., drug courts and parole officers), sober living house staff, employers, treatment professionals, and clergy, the vast majority of the confrontations described were those received from family, friends, substance-using peers, and peers in recovery.

We present results grouped into sections depicting helpful confrontations, unhelp confrontations and factors that can affect each. See Table 1 for a summary of when confrontation is experienced as helpful and not helpful.

Table 1.

Themes Related to Helpful and Unhelpful Confrontation

Helpful Confrontations	Unhelpful Confrontations	Individual Differences about Helpfulness / Unhelpfulness
Perceived as legitimate Offer hope and practical support Delivered by persons who are trusted or respected Delivered by persons who are very important relationships Received after experiencing a severe event or an accumulation of negative events related to substance use Received during early recovery	Hypocritical Overtly hostile Occur within embattled relationships	Reminders about their past Directive approach Persistence

Helpful Confrontations

Legitimacy

One of the most prominent themes related to helpful confrontations concerned perceptions of the confronter’s legitimacy. While substance users encountered many confrontations from family, friends, and peers, only some confronters were perceived as understanding addiction and recovery. This understanding was what gave someone credibility and legitimacy in the eyes of many study participants. It was also often perceived as an important factor in making confrontations helpful.

According to many participants, the most valid knowledge comes from personal experiences of alcohol or drug problems and successful recovery, although there were a few cases in which non-users were also considered to have an understanding of addiction (e.g., a drug court judge, an employer whose spouse was in recovery). As one study participant put it, people with personal experience have “walked in my shoes. They understand, they aren’t on the outside looking in.”

Results from our interviews suggest that attendees of mutual-help meetings, such as Alcoholics Anonymous, evaluate their peers in recovery and form judgments about who is a “good example” of recovery. Confrontations from such individuals are perceived as having legitimacy and therefore worth heeding. This was illustrated by the words of one participant describing his reaction to a grand sponsor who spoke at a meeting: “This is a man with, you know, comin’ up on 30 years of sobriety and it’s a man that works a solid program day after day after day. And my ears were wide open… They’re not talkin’ to hear themselves talk; they’re not blowin’ smoke; they’re telling me facts and truths [emphasis added].”

In contrast, individuals who were “bad examples” of recovery were perceived as not sincere about making changes in their life. They were “there because they need a court card signed or whatever” and they were believed to be currently using or likely to relapse. Therefore, their advice tended to be dismissed. As one participant summed it up, “they were people that were probably gonna fall downbefore I was going to you know…so I don’t want to hear it.”

In cases where the confronter is a former user, it is specifically because of the similar life experiences of the substance user and confronter that issues of shame and stigma may be less apt to arise during confrontational interactions. Many participants we interviewed were acutely conscious of a morally inferior status they felt vis-à-vis persons around them, in some cases reinforced by family and friends’ disparagement, contempt, and estrangement. Some participants alluded to their previous manipulative behavior and “terrible things” that they had done during their addiction which they wished to forget. One woman who had been sober for 8 years before relapsing recalled a very helpful confrontation with a former user, in which she was encouraged to speak of her past without the fear of stigma:

What’s been helpful with [my new sponsor] is she let me know that we’ve all been through the same things; we’ve all had troubled lives. Nothing I’m going to tell her is going to be able to shock her and if it does she’s probably done something just as bad if not worse…

I: What did it feel like when she was telling you these things?

It felt good. I mean I just feel good all around now because I’m able to be honest and accept who I am and that I need to work on me; that I’m not all well and wonderful.

In this case, similar experiences of addiction and the confronter’s effort to negate any perceptions of moral superiority were important. It facilitated the participant’s feeling that she could be more open about her past and her need to work on her recovery.

A final benefit of receiving confrontations from persons with legitimacy based on experiential knowledge is that they serve as examples that change is possible. As such, they can help create and strengthen substance users’ beliefs that recovery is possible and that they too can turn their lives around. Study participants spoke of how it gave them hope to see individuals who are clean and sober achieving the kinds of things they want in their own lives – a decent job, a home, family, trust, and happiness.

Trust and Caring

In addition to legitimacy, trust and caring emerged as important ingredients of helpful confrontations, regardless of whether the confronter had personal experience of addiction and recovery. In the context of trusting and caring relationships, substance users may be less likely to feel manipulated by confronters and more open to listening to and considering the confrontational message. Participants indicated that helpful confrontations came from people whom they trusted as being concerned about their welfare. Typically, these were important relationships with persons the substance user had known for a long time, such as a family member or longtime friend, but in some cases they included an exceptional parole officer, drug court judge, employer, and pastor.

Confrontations were also experienced positively when they were delivered with emotional or practical support. The combination of confrontation and support was particularly helpful when substance users were ready to attempt a change in their lives. Several study participants recalled that they had needed money or temporary shelter before they could enter a treatment facility. In many of these cases it was the combination of practical support from a caring individual and confrontation about substance use that was instrumental in facilitating change. Some study participants indicated that even the offer of practical help in the future, when they might be ready to attempt a change in their lives, was helpful. As one man recalled, “it helped me in the fact that I knew that if I did make the right decision that I’d have someone to help me out along the way.”

Study participants also indicated confrontation combined with caring emotional support could be helpful during periods of abstinence from alcohol and drugs. As an illustration, a 46-year-old man described the supportive confrontations of his mother, who worried about him when he was in and out of jail and worries about him still in his sobriety:

…She tells me ‘don’t go out there and don’t be drinking or doing anything because you know you’re probably going to wind up falling back down … But she’s not angry with me. She tells me only because she cares and stuff you know…. it makes me feel good though cause she cares about me and stuff and she doesn’t want me to go wrong and stuff, you know, and it makes feel – it makes feel loved and wanted…

Unhelpful Confrontations: Hypocrisy, Hostile Aggression and Constant Reminders

The most consistent theme regarding unhelpful confrontations concerned hypocrisy on the part of confronters. For example, confrontation was perceived as extremely unhelpful when it was received from individuals who were themselves actively using substances. Particularly noxious were confrontations by persons who were intoxicated at the time of the confrontation. Related to this, confrontations were also unhelpful when they were delivered by persons who presented themselves as working a strong recovery program when they were not. These types of confrontations angered participants because they perceived the confronters as holding themselves to a different standard, or setting themselves apart as wiser or superior when they had no right to (“It’s shame on me but okay for you … I’d rather not even hear from you if you’re gonna be like … on this pedestal and I’m way down here. That doesn’t help.”) Such confrontations were dismissed as unjust and pointless, and also viewed as a diversion so that the confronter would not have to address his or her own substance use.

Confrontations delivered with open hostility or aggression were also perceived as very unhelpful, particularly when there was a long history of conflict with the confronter. Several participants spoke of older family members whose confrontations were dismissed because there had always been strong conflict with these individuals (“I never really paid attention to what my dad said because my dad’s always been so negative about everything and always saying that you’ll never amount to anything”). Aggressive, hostile confrontations often resulted in arguments that were described as antagonistic and did not motivate substance users to seek help; in fact, some participants indicated it made them want to get high or drunk. Illustrating this, a participant spoke of his mother who was a former user herself and was very aggressively pushing him to do certain things to ensure recovery, which was counterproductive: “Even when I was clean at the [sober living house] and doing everything I needed to do, she would still just strike chords to where it was, you know, it was like ‘well why am I even trying it? You don’t think of me any different. Why am I even trying?’ ”

Similarly, some participants spoke of aggressive12-step sponsors or treatment professionals who tried to force them to work a recovery program in a specific way. Referring to them as “NA Nazi’s”, one participant recalled:

He was very aggressive with the way he would tell you things. (Speaks in a stern tone:) “And I guarantee you, I will bet you…” Kind of like just, I don’t know, in a way baiting you in a verbal boxing match and always wanting to, like I said, be right… He rubbed me wrong and it made me want to just do it [use drugs] just to spite him… “It seems like you want me to fail. It seems like you really do…”

One aspect of confrontation that appeared to have varying effects on substance users was being reminded about the past. For some study participants, being reminded about past consequences associated with substance use reinforced motivation for change and the need to be vigilant. A poignant example of this type of confrontation was described by one participant, whose confronter asserted:

[if] you go back out what do you have to expect in return? Your misery will come back to you. There will be nothin’ but drama in your life…And what was it like when you were out there the last time…

Yet other participants experienced reminders of the past as demoralizing and counterproductive, particularly if there was blame and if confronters did not offer encouragement, support or helpful suggestions.

Just the blame game. Just when people constantly you know, it doesn’t help those situations when you bring up the past constantly. You’re not supposed to forget your past but if it’s constantly thrown in your face, you know telling you the negative things you’ve done, I don’t think that helps with your recovery.

In particular, some participants felt frustrated that the constant reminders were a lack of trust and faith in their recovery. This was especially the case when reminders of past problems were constant and not balanced with praise for recent improvements. For example, one participant commented…

… it makes me angry, you know, it’s like how long do you have to be sober before people -- maybe it’s never but it seems like they could cut you some slack after a few years you know…It gets me a little upset because I’m on the right path; got a good job you know, [I’m] a good father. It’s like how much do you have to do before you don’t hear that…

Factors that can Make a Difference

In addition to characteristics of the confronter and the manner in which confrontations are delivered, we found several contextual factors also influenced how confrontation was experienced. These included: 1) the timing of when the confrontation was delivered. Participants were clear that at certain points in their substance use and recovery they were more open to examining the validity of confrontational comments. 2) The confrontational style used by the confronter. Respondents varied in their views about whether a more neutral, suggestive style of confronting was more helpful than a directive, persistent style. 3) Important relationships in participants’ lives also influenced how confrontations were experienced.

Timing

Confrontational comments were especially well received at several specific points in the addiction-recovery process. The first was when participants reported they were tired of using substances (“I’m tired. And so I’m more able to listen and take suggestions about what I need to do … I’m getting older you know, I’m 45 and you know I might only have a few good years left on this earth and I want to make the best of it”). Some participants reported that they were more open to confrontational comments when it became too difficult to do what was necessary to maintain their addiction. Participants talked about being tired of their “misery” or “desperation”, of financing their addiction, being incarcerated, and finding themselves in dangerous situations. In particular, being in a life-threatening situation seemed to increase openness to confrontational comments. Life-threatening situations included serious auto accidents and violent conflicts over drugs. One participant recounted a time when he was suicidal, and his friends and sponsor were confronting him about how he had to try to change his life:

My discomfort, my level of pain and desperation reached a point where I could hear those [confrontational] things…

I: And what did it feel like when he said these things to you?

Scary and invigorating both at the same time. Scared that I knew this guy [sponsor] was gonna kinda ride me hard and bust my balls a little bit but at the same time I was excited because I had – deep down I felt like I had a shot at this thing cause, you know, it’s not a shot at winning the lotto, it’s a shot at stayin’ alive.

Some participants also indicated that confrontation was particularly helpful in early recovery. After they completed treatment or entered the sober living house, they tended to experience confrontational comments as attempts to help them succeed. Many confrontations during this time as well as later in recovery served as reminders about the importance of sobriety, the need to avoid risky situations and ways to handle these situations that could lead to relapse. One man commented:

…and when I have these confrontations sometimes they seem to come at the time when I need ‘em; when I need to take a step back, take a look at myself, take a look at my recovery in areas where I may be slacking…

Confrontational Style: The Right Fit

We found that participants varied in their reactions to different confrontational styles. Some participants rejected confrontations that were delivered in a strongly directive or highly persistent manner, regardless of the content of the confrontation. For example, even when confrontations were about maintaining sobriety, attending 12-step meetings, and avoiding substance-using friends, some participants perceived them as unhelpful if they were too directive or persistent. Instead, these individuals preferred confronters that honored their sense of autonomy and self-control. The content of the confrontation could be the same, but for them the process needed to be more suggestive.

My thing is if you’re gonna talk to me, talk to me in a respectful [way] and don’t just sit there and tell me what I need to do because you’re not me. I know what I have to do. You know what I mean? I’m my own person. Don’t say ‘you need to do this’…. Come at me in a respectful manner and I’ll come back at you respectfully; that’s my whole thing on it … You’re not my mom, you’re not my dad. Don’t tell me what to do.

On the other hand, some participants clearly wanted structure and a firm sense of direction during their recovery. For these individuals, a confrontational style that was more directive was welcomed, especially if the confrontation was received from a person whom they trusted and respected. Often this included people such as 12-step sponsors or peers in recovery who had been working a recovery program far longer than the participant. Some of these participants reported that they did not do well with 12-step sponsors who did not take an active approach. One man specifically commented that he needed someone who wasn’t laid back like him because he would never get anything accomplished. Another man indicated that he wanted a sponsor who would “call him on his stuff.” Unlike most participants, he did not even mind if the confrontational tone was aggressive because he considered himself such a “hardhead.”

Important Relationships

For some participants, there was a single individual in their lives who had a powerful influence on how they experienced confrontation. Participants often described this person as someone “who meant everything to me”, such as a father, mother, daughter, or in one case, a best friend. Such relationships can motivate change in different ways. Some participants reported that the fear of losing these profoundly important persons served as a wake-up call:

It was kinda heartbreaking cause you know [my dad], as much as he didn’t want to believe that I was doing things and following in the footsteps of my mom who did the same stuff, it was hard for him to actually realize that his only daughter was doing stuff like this….The next day I went to rehab in [city], and then 30 days after that, after I completed my program, I went into a clean and sober living house.

I: Okay. And how was that confrontation helpful to you?

It just got me thinking about life and that if I really want to continue down this path of you know heartbreak and heartache, and I didn’t want to so I decided to turn my life around.

In other cases it was the ongoing love and support of these special individuals that buoyed them and motivated them to attempt to change. Rather than leaving the relationship or threatening estrangement, the loved one remained. As one man poignantly described, he would sometimes use drugs in secret, but his daughter could always tell and it was the knowledge that his addiction could hurt his daughter that gave him pause:

[My daughter] gave me the look like don’t even think about it type look, you know…. I’d sit there and feel guilty as hell … And wish I didn’t do what I did, so that would keep me from using for quite a while longer…. She thought I was the cat’s meow. I don’t know why but…I was grateful for it you know … She didn’t want me to go back to prison. She knows that was one of the reasons that I would go to prison, for using you know, so she didn’t want to lose her dad again.

Another participant also explained how the continuing support of his daughter and best friend, helped him to recognize his need for help and eventually seek recovery:

I think that when people show you that your life has value and that you’re, you know, I didn’t get a lot of that from family but I did from friends and my daughter. I mean some of the value of your life is you gotta be there for your kids, and you know, you have friends that care and they tell you that they care… the main thing I would always feel even if I was at the bar drinking or even if I was angry is that these are important people in my life. I mean, that feeling never got out of my head and that’s what kept me going.

Limitations

A number of limitations are inherent in our study. First, the sample was limited to 38 individuals who were recruited within one SLH program. Second, although the sample was similar in demographic characteristics to the larger sample of 245 in the quantitative study, most of the participants were white males. Samples drawn from other SLHs with different demographic characteristics might have different experiences of confrontation. Third, most individuals in our sample were functioning well at the time of the interview. The vast majority had not used alcohol or drugs during the past 30 days and over 60% had attended a 12-step meeting during the same time period. It is possible that a sample of individuals who were actively using alcohol and drugs might respond differently to questions about their experiences of confrontation. Finally, our sample consisted of individuals recruited from sober living house, where mutual support was emphasized within the houses and at 12-step recovery groups. Themes around helpful confrontations may have thus been influenced by the predominant experience of self-help in the sample, even though the interview posed open-ended questions to recall experiences throughout the participant’s life. Studies using larger and more diverse samples would add to the findings reported here.

Discussion

This study represents the first in-depth examination of how individuals experience confrontation when it is defined as warnings about potential harm associated with substance use. The results complement our quantitative work on the Alcohol and Drug Confrontation Scale (Polcin et al, 2010) because they depict specific examples of when confrontation is helpful and unhelpful. In addition, the in-depth interviews provided information that was not elicited in our quantitative work. New issues covered include contextual factors that influenced how confrontation was experienced, such as timing, the confronter’s confrontational style, and the impact of important relationships.

Most often, participants discussed their experiences of confrontation from family, friends, and recovery peers. Discussions of confrontation from other sources, such as treatment staff, the workplace, and criminal justice professionals, were much less common in the interviews. In part, participants may have focused on confrontations from family, friends, and peers because they were experienced as more important and significant in their lives, as compared to professionals. In addition, all of our participants were previous residents of SLHs that strongly emphasized peer support and involvement in 12-step recovery. It is therefore understandable that interaction with 12-step peers would be salient in terms of confrontation about substances use.

Study findings suggest that there are a number of factors that friends, family, recovery peers and treatment professionals should consider when confronting individuals about their substance use. First, characteristics of the relationship need to be considered. Individuals in the best position to confront substance users are those who are perceived as legitimate because they have a history of their own problems with addiction, have successfully dealt with those problems, and presumably can draw on that experience in order to be helpful to others. These findings support treatment interventions that emphasize “experiential knowledge” (Polcin & Borkman, 2008) that is based on the personal experiences of client peers and staff. Clients in treatment programs with longer periods of abstinence and success in their recovery might be particularly important to mobilize in helping others. Particularly counterproductive were confrontations from substance users who were actively using substances.

Second, although confrontations from those with a previous history of addiction were perceived as having the greatest legitimacy, some confrontations from others were helpful as well. Family friends, peers and professionals can use confrontation in a helpful manner if there is a sense of trust, caring and respect in the relationship. Absent these characteristics, confrontation should be avoided because it is typically not experienced as helpful. In addition, how confrontation was delivered was important. Our findings suggest that confrontations that are delivered in a hostile, overly aggressive or contemptuous manner should be avoided, as they were rarely experienced as helpful.

Third, the data suggest that confrontational comments alone are not enough. To be helpful, the confronter needs to provide offers of practical help, encouragement, and perhaps most importantly, a sense of hope that change is possible. Particularly when an individual is considering making a change relative to their substance use, offers of practical help, such as assistance finding treatment or a temporary place to stay until treatment is available, are very helpful. In doing this, the person being confronted not only experiences concern about potential harm, but also practical support toward changing their lives. Our findings also suggest that when substance abusers reject warnings about potential harm associated with substance use and offers of help, it is wise to explicitly offer help in the future when they might be more open to making changes. Participants generally experienced these offers as helpful because they “planted a seed” or created a context for receiving help in the future.

Factors Affecting Experiences of Confrontation

We found some important differences in how participants responded to confrontation from family members and friends. Some participants experienced ongoing support from family and friends as helpful, even if they rejected their family and friends’ confrontations about potential harm related to substance use. In some cases, continuing support from family and friends during times of substance use eventually motivated them to make changes. However, other participants recounted how a very close family member threatened to leave the relationship if the participant did not make changes. They found the threat of losing the loved one to be an eye-opener, illuminating the extent to which their addiction was adversely affecting those who meant a great deal to them. The circumstances under which it would be better to use each of these strategies (on-going support versus the threat of leaving) are unclear and require further investigation. However, it was clear that family members who have a long history of conflict with the substance user will likely have some difficulty providing confrontations that are experienced as helpful. In fact, some participants reported that confrontation from these individuals made them want to rebel against them by using substances.

Another factor to consider that can influence the impact of confrontation is timing. In general, confrontation was experienced as more helpful after the person being confronted experienced serious consequences related to their use (e.g., near-death experiences, violent conflicts) or when they were tired of using substances due to the consequences associated with it. Warnings about potential harm might understandably resonate during these times.

A final context when confrontation was experienced as helpful was early in recovery. Participants noted that confrontational comments during early recovery often focused on reasons for maintaining sobriety, avoiding risky situations that could lead to relapse, and ways to maintain sobriety. Given that in early sobriety individuals make changes in their substance use that they presumably wish to maintain, it is understandable that comments designed to support those changes and help them succeed would be experienced as supportive.

While most of the themes we heard about confrontation were quite widespread in our sample, there were some areas that seemed to depend on the individual. One such area was the manner in which confrontational comments were delivered. Nearly all participants felt that hostile confrontations or aggressive demands to force change were unhelpful. Nevertheless, some participants expressed a view that a directive and persistent approach, even from an aggressive confronter, was helpful. It is unclear why this was the case, but it could be that individuals with a history of failed attempts at recovery might recognize the need to have an external force that helps keep them on track. Alternately, they might evaluate their own resistances to change as high and feel the need for persistent direction and reminders and feel supported by them. Notably, in these cases the aggressive and forceful individual was respected and trusted by the substance user.

On the other hand, some individuals in our study experienced directive and persistent approaches as intrusive. These individuals wanted to maintain a strong sense of autonomy and independence and responded better to a suggestive style of confrontation. It is unclear why, but it could be that they had psychological needs to feel in control and a higher need for autonomy.

Future Directions

Further research is needed to identify the characteristics of individuals who experience different styles of confrontation as helpful. In the meantime, family, friends, peers and professionals should recognize that confrontational style is not a “one size fits all” phenomenon. Rather, confronters should assess how individuals react to confrontational comments and the style that is used to deliver them. Based on the substance user’s reactions, the confronter can modify his or her approach.