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The connection between expressions of ambivalence and resistance can be illustrated thus; the client says, I d like to do it, but I can t ; to which the counsellor responds, But if you succeeded for a month last time, maybe you can do better this time ; to which the clients replies, Yes, but I can t because . . . . The conversation then continues, ad nauseam, in a spiral of wills, the two combatants locked as wrestlers until one party is exhausted and submits. Such activity has little connection with effective addiction counselling and certainly no similarity in style with motivational interviewing. What is resistance In the description of motivational interviewing, resistance is viewed as observable behaviour that arises when the counsellor loses demonstrable congruence with the client (Miller & Rollnick, 1991). In short, in its most active form, it is often a consequence of counsellor behaviour and therefore amenable to change provided that the counsellor understands the dynamic process in which he/she is engaged. Resistance may be conceived of as a general reluctance to make progress, or as opposition to the counsellor or what the counsellor thinks is best, or as the client s expectations as to the posture of the agency the counsellor represents, or even, more traditionally, as denial . Conceived of another way from the position and perspective of the client resistance might be viewed as we might view resistance movements in war: as an heroic defence and counteraction to a perceived or quite palpable threat. What might the client be defending or maintaining His/her self-esteem, personal values or the articulating of a particularly important opinion one, perhaps, that expresses a core belief held dear by the client. Most commonly, the threat is an injunction, not always expressly stated but felt nonetheless, Think differently, act differently! Such injunctions rarely elicit the response, Of course, whatever you say. You re absolutely right . Responding constructively to rapport damaged by miscommunication and confusion is particularly important in the early stages of counselling. This skill is at the heart of motivational interviewing.
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a change in one or more of the subsystem levels within the community system. The reverse, however, also needs to be considered. The collective impact of individual behaviour can itself create change within community structures and the external environment. The target of mass media marketing is squarely on individual behaviour change, while the target of mass media advocacy is on the external environment and other structural determinants of the behaviour targeted. The relative merit of these and other activities in reducing alcohol-related harm has been the subject of much empirical research over the years (Edwards et al., 1994). Andreasson and colleagues of the Stockholm North Centre for Addiction recently postulated that if we were to construct a list of effective methods [to prevent alcohol problems], availability measures would be at the top and mass media campaigns at the bottom (Andreasson et al., 1999). Although their ranking of 10 prevention methods in the alcohol eld according to effectiveness did not consider the role of media advocacy, the targets of media advocacy (i.e. policies and economic conditions) were rated well above mass media campaigns in terms of in uence on alcohol problems. The worldwide dominance of market-based economies with associated values of rugged individualism, self-determination, strong individual control and responsibility, and limited government involvement in social activity (Wallack et al., 1993, p. 7) fosters a parallel approach to health care delivery. Within such a market framework, governments see their role as assisting individuals to make their own health-care choices. There is an expectation that the market-based health care system, when utilized in association with wise, thoughtful and prudent consumerism, rewards individuals by giving them personal control over their health and health-care needs. With equal services available to all, it is assumed that consumers will act in their own best interests; they will identify risks to their health and select health-care products that reduce risk to the extent that they would like. This focus on the individual has been harnessed by public health practitioners through community interventions that use social marketing strategies. Marketing campaigns that seek to reduce alcohol-related harm compete for advertising space with other advertisers in the marketplace. One example from Australia of such competitive marketing occurred when a national football club promoting an anti-drink drive message on their uniforms played a game of football against another sponsored by a brewery, within a competition named after a brand of beer. The purpose of social marketing is to compete in the marketplace against forces that have opposing aims, so as to modify consumer behaviour to promote health rather than illness. Sometimes these campaigns also aim to increase the social pressure upon consumers to modify their behaviour by highlighting or actually seeking to create opposing social norms. The rst part of this chapter provides a broad overview of mass media marketing and examines the current theories of individual behaviour change that underpin the social marketing approach. The two main methods of mass media marketing are then described and illustrated. These are advertising and the more recent strategy of edutainment , which involves the placement of public health themes within popular entertainment. Unfortunately, an implicit tenet of the market-based, individual-focused health system is that those consumers who do not maintain health, or access health care services, are responsible for the consequences. Such an approach in its pure form does not acknowledge the structural determinants of health behaviour and, as a consequence, there is a real danger of blaming the victim (Howat & Fisher, 1986). Social marketing campaigns that change social norms contribute to this by highlighting unhealthy behaviour as both preventable and deviant. A further danger associated with the social marketing of health is that such approaches may become the modern equivalent of the moralistic health crusades of yesteryear, which produced such legislation as the British Act to Repress the Odious and Loathsome Sin of Drunkenness in 1606 (Powell, 1988, p. 4). The structural determinants of health behaviour not accounted for in social marketing
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