Saturday, February 15, 2014

Six dilemmas for drug and alcohol therapists

When asked to write this article for the UKATA magazine I thought I would do the usual thing and explain a Transactional Analysis theory of addiction that I provide in my book (White(2012)). Instead I decided to do something a little different. The counselling of drug users has some unique difficulties in it, that other forms of counseling do not, such as counselling depression or insomnia.

These are presented here. Six dilemmas the drug counselor will inevitably come across. Six dilemmas that are all to some extent unresolvable but yet the counselor must deal with them when presented by the client.

Dilemma 1. Duality of information on alcohol and drugs in society
A difficulty in treating problematic drug and alcohol use is that drugs are a political issue. Consequently, the circumstances around drug use and particularly about drugs and their effects are confusing. This results in an ongoing duality of information one finds about drugs that are out in the public arena.

In public health discussions one finds, not only in the press, but also stated by public health officials and in health department information which suggests that drugs and alcohol are very dangerous and can result in all kinds of psychological and physical disorders. The impression one tends to get is that drugs are very dangerous and can seduce our young people into serious drug addiction. For example, the youth of westernized society are experiencing an epidemic of amphetamine and crack cocaine at the moment. 

However the mainstream literature on drug counselling and finds quotes like, “Contrary to popular belief, most people who use substances do so in ways that cause them relatively little harm. Their use does not interfere significantly in their lives or the lives of others in terms of negative consequences’, (p.13) (Marsh and Dale (2006)). This view would not be held by all substance abuse counsellors but it is fair to say that it is held by many in the field of mainstream substance use counseling.

So we find ourselves in an odd situation where two quite contradictory pieces of information travel along in parallel in society about an important social issue. Both sides openly state it but it is often contradictory. 

It seems paramount that any counsellor is well informed about the area in which they are working. This means the person working with substance users must go directly to the scientific literature, journals and books on therapy. They cannot rely on public heath information particularly about the psychological and physical dangers of substance use. Governments are political organizations and drugs are a political issue, hence the negative effects of drug use will tend to be exaggerated so as to fit the current political agenda of the current government. Most governments tend to have some kind of “war on drugs” platform. Public health information on drug use will tend to misrepresent the actual consequences. Sometimes that misrepresentation is small and at other times it is large. However it is essential therapists have accurate Adult information about the area in which they are counselling and hence with substance use one has to go to the scientific literature directly.

Dilemma 2. Scare tactics
This leads directly to the next dilemma for drug counselors. The involves the use of scare tactics by therapists. This is commonly done often without therapists even being aware they are doing it. It involves the exaggeration of the dangers of drugs. The motive behind this is a noble one. “If I can scare the person about the dangers of drugs then they will be less likely to use”.

The counsellor may say to a young drug user, “Marijuana use can lead to schizophrenia”. However sooner or later the young drug user will realize he has not been told the truth, or at least the whole truth. After being told this he will go out and observe his friends smoking and see that not many, in fact very, very few develop a psychosis. The vast majority of marijuana users will not know anyone who develops a psychosis because the numbers where it happens are so small. 

He will begin to realize that his therapist has lied to him (by omission) on an important piece of information. What effect will this have on the therapeutic relationship? Not good effects it seems safe to say. At the very least the therapist will loose credibility in the eyes of the client.

However, and this is where we get to the very difficult dilemma for the counsellor, if he tells the client the whole truth then he would say, “Marijuana use can lead to schizophrenia but that will only happen in a very small number of people and if there is no family history of psychosis or pre-psychotic signs in you then it is very unlikely to happen to you.” If the young client hears this what is he possibly going to think. It could be argued that it gives him permission to use marijuana because you have basically told him it’s safe. Of course the counsellor does not want to do that.

Thus we have the dilemma. Don’t tell the whole truth to the client and later he learns he has been lied to and you loose credibility. Do tell the whole truth which gives the client some permission to use. A difficult situation for the therapist indeed.

Dilemma 3. The therapist’s drug and alcohol use
From time to time a client will ask the therapist about their history of alcohol and drug use. It is reasonable to assume that a number of clients would wonder about this as the transference with the drug counsellor increases. I have been asked the question a few times over the years which leaves the therapist in a dilemma. How does one respond to that question? In essence there are two ways to respond. One to answer the question and the other not to answer the question.

Some don’t answer the question because:
1. They are ashamed of their history because they have had a problematic substance use in the past.
2. If they have had some use they may think the client will loose respect for them and they are hypocritical in suggesting the client does not use drugs.
3. If they have had little or no substance use they may think the client will loose confidence in them because they don’t know what they are talking about.
4. They see it as a private matter and simply not wish to disclose that to the client.

If one refuses to answer the question because they say it’s private or by using a tangential response like, “Why is that important to you?”, it seems reasonable to assume that the client will still wonder why the therapist refused to answer the question. They will then consider the options listed as the real reason. It builds unwanted conjecture and intrigue in the mind of the client. Having said that it is by no means a significant rupture in the therapeutic relationship.

If one answers the question reasonably honestly and is believed by the client then they are not left with any unwanted intrigue but the client may then think the first three options listed above. This of course is also not conducive to the smooth functioning of the therapeutic relationship. Another dilemma for the therapist of substance users.

Dilemma 4. The harm reduction contract
The next dilemma relates to the harm reduction contract. Harm minimization is widely practiced in the addictions field. It involves working with the client such they become informed about the potential dangers of drug consumption. For instance injecting drug use is more dangerous oral drug use. Or using drugs when there is a possibility of overdose such as with heroin, using alone is more dangerous than using when others are there such that they can help if an overdose occurs.

A significant problem with this aspect of counselling is that many drug users know the dangers but do not alter their behaviour because of that knowledge. This has lead to the concept of negotiated safety. The therapist and drug user negotiate what safety strategies they are prepared to use. In essence the therapist is asking the client to make a contract about what they are willing to do in their drug taking. To assist with this is the idea of a harm reduction contract (HRC). The client makes a contract about the behaviour they will use and for how long the contract lasts.

The HRC involves the client making a short statement to self (in the presence of the therapist).

“I contract with myself to stop (the potentially harmful behaviour) and to (the harm reduction behaviour) for ‘x’ amount of time.”

For example:

“I contract with myself to stop sharing injecting equipment and to use only my own equipment for four days”.

“I contract with myself to stop using heroin alone and only use when there are others around me for two months”.

Whilst such HRCs can be useful in increasing a drug users safety it can also cause problems, in two possible ways. First it can have a negative result on the therapeutic alliance. Consider these two diagrams presented in White (2012)
Diagram 1.  Harm reduction contract using the Adult ego state.

Diagram 2. Harm reduction promise using the Child ego state. 
White (2012) (p.105)

This applies to any therapeutic contracting but particularly to the HRC (and the no suicide contract (NSC)). Any contract must not become a promise in the mind of the client. If it does then it is highly likely the contract will not last successfully. Of course it is most important that a HRC and NSC do work. If they do not the potential outcomes are more significant than other contracts about non life threatening matters.

In the transference relationship there is pressure on the client to begin seeing the therapist as a parent figure. The more this occurs the easier it is for a contract to change into a promise in the eyes of the client. In the transference they tend to become more childlike around the therapist and that will include childlike in their contracting such that contracts may start to become promises instead. As I stated this is unwanted for the long term outcome of the contract. 

However if this promise making process occurs over time, as it can indeed do, that can create quite a significant rupture in the therapeutic alliance. In working with the therapist the client knows at some level that they are not contacting and instead are making a promise to the therapist. Of course this can remain a secret which the therapist does not know about and thus can undermine the therapeutic alliance.

If one does not do such contracting the likelihood of a therapeutic rupture diminishes but then one cannot make a HRC and the client is put at higher risk. Hence we have the dilemma. There are other objections to contracts such as the HRC and NSC, which in particular come from family therapy. This approach sees such contracting as supporting and encouraging the idea of the ‘Identified Patient’, which of course is a negative in family therapy theory.

In my experience problematic drug use can sometimes be due to a dysfunctional family structure. This is not always so, but can be the case to varying degrees with some clients, particularly younger clients. Henceforth if one uses the HRC that is supporting the dysfunctional family system. On the other hand if one does not use the HRC the client is left at higher risk. A further significant dilemma for the therapist that can have potentially fatal outcomes.

Dilemma 5. Closing escape hatches
Following on from the previous point, when working with dependent drug users one not uncommonly comes across clients with varying degrees of suicidality. When this happens one is left with the dilemma of closing the suicide escape hatch or not.

The choice of the word “escape hatch”, originally by Holloway (1973), was an apt one. Most people would consider an escape hatch a comforting thing to have. Most people like to have a Plan B, if Plan A does not work out satisfactorily. The suicide escape hatch could be see as a Plan B type of situation that would make people feel more secure.

Also, White (2011) notes that having a suicide escape hatch can provide a method of self soothing expressed in a masochistic form. Closing the escape hatch may remove one of the individual’s important methods of self soothing. Consider the following client report:

“Having the option there in the back of my head actually serves to help me. It doesn't help once the danger is more immediate. When it starts making messes. But on a day to day basis it is nice....I visualize the method in my head a lot though during times of stress. It's soothing.” (White (2011)(p.240))

Another client, who had previously made two serious suicide attempts reported that he gets images in his mind up to ten times per day. It is the image of him hanging himself in a tree. He reports that he does not think of conjuring them up instead they tend to spontaneously arise in this consciousness. When he has the image he feels reassured and a sense of calmness. He has in essence developed a ritualized suicide fantasy about how he would try to suicide if the circumstances arose. This masochistic ritualized fantasy or escape hatch provides a way for him to self soothe.

To close the escape hatch is to remove the fantasy, or Plan B, which for some as we can see above means to remove a method of dealing with stress. If that happens they will be in worse condition and hence be at a higher risk of a suicide attempt. However if the client does not close the escape hatch they are still leaving suicide open as an option for them. Thus we are left with the dilemma.

It should be noted that this only applies to some suicidal people. Others when offered the option of closing the suicide escape hatch can experience relief. It’s as though the therapist is giving them permission to live when he suggests closing the escape hatch. Obviously the same dilemma is not apparent with these individuals.

Dilemma 6. Pharmacotherapy
A widely used way to treat drug dependence is with pharmacotherapy. One treats the drug abuse by using medications in various ways. Common examples are treating opioid dependence with drugs like methadone, buprenorphine and naltrexone. Or alcohol addition can be treated by using antabuse. Around the world today these are widely practiced.

Pharmacotherapy for treating drug addiction has an inherent contradiction in it. It says to the client - “Take this drug to stop taking drugs”. A double message is being given to the client. In substance use counselling, the therapist by their very presence in the counseling session, is saying to the client, “It is a good idea not to use drugs or to reduce your drug use.” The very act of working with a drug using client communicates this to the client. You are engaged in therapy with them and that is obviously not about encouraging their drug use. The therapist is seeking to discourage in some form the client’s drug use. That is why the therapist is there in the first place.

On the other hand if the therapist is providing drugs for the pharmacotherapy  treatment or is supportive of the pharmacotherapy it can be argued gives permission to the client to take drugs. The very act by the therapist of engaging in pharmacotherapy with the client says to the Child ego state of the client, “It’s OK to take drugs”. Of course we can provide all the Adult ego state explanations of why taking methadone is different to taking heroin and they are all true. There are clear differences. At the same time the very act of giving a client a drug to take, no matter what it is, gives permission to the Child ego state to take drugs. 

Unfortunately as far as the Child ego state is concerned actions speak louder, often much louder than words. This is not meant to be an argument against the use of pharmacotherapy for the treatment of drug addiction. I have seen methadone be very useful for some opiate users. What is being highlighted is the dilemma and that we must be clear about what we are communicating to our clients. With pharmacotherapy we are giving a double message and of course one does not want to do that. At the same time pharmacotherapy can be a of considerable assistance in treating drug addiction. A dilemma indeed.

The article set out to identify some of the dilemmas a drug counsellor has to deal with. There are more but word limitations prevent those from being articulated. However it is safe to say that six of the most common are described here.

As mentioned before these do not have obvious answers and thus need to be dealt with on a case by case basis. The solution in each situation depends on the clinical features of the client and the type of therapy being used at the time. The solution varies from situation to situation depending, as I said, on the clinical circumstances apparent at the time the dilemma surfaces.

Holloway, W.H. (1973). Shut the escape hatch: Monograph IV. The Monograph Series. Ohio: Midwest Institute for Human Understanding.
Marsh, A. and Dale, A. (2006) Addiction Counselling. Melbourne: IP Communications
White, T. (2011) Working With Suicidal Individuals: A Guide to Providing Understanding, Assessment and Support. London: Jessica Kingsley Publishers.
White, T. (2012) Working with Drug and Alcohol Users. London: Jessica Kingsley Publishers.