Sunday, November 25, 2012

Drug counselling - authoritarian or permissive?

I use this diagram in my book - Working with drug and alcohol users - to illustrate the position I take on the continuum when counselling drug and alcohol users. It would also be typical for me when I counsel clients for non drug related issues although there may be more instances when I am less permissive in my overall approach.

Permission contiunumn

As I mention in the book there are positives and negatives being authoritarian just as there are positives and negatives with the more permissive approach. Obviously in my view there are more positives up the permissive end than the authoritarian end and hence my decision to be where I am indicated on the diagram. The negatives of the permissive approach are a problem but in my view less of a problem than the negatives of the authoritarian approach.

I wish to add some further considerations to this diagram. At the authoritarian end the counsellor will of course be using more CP (Positive and negative CP). When this occurs the following will tend to happen as shown in the diagram

Response to therapist use of CP
As the counsellor uses more CP as shown in line 1 there will tend to be a similar increase in line 2 in the client. They will tend to respond to the therapist from either the CC or RC ego states as shown in line 2. If a ‘parent’ like figure (as a counsellor often is) gets critical or controlling, those around will tend to become more conforming or rebellious or switch between the two at varying times.

At the same time the likelihood of FC involvement decreases. The FC in the client will become less prominent and play less of a role in the clients decisions and transactions as line 3 shows. The more CP then the less FC. The problem here is the more FC there is in decision making around drug use the better the long term prognosis. Being CP makes it harder for the client to stop problem drug use in the long term.

However the CP approach can be seductive. If the counsellor says, “Drugs are bad. don’t do drugs, only abstinence is acceptable...” then the client may move into CC and stop using. When people see this reaction they think this is all very good and obviously is the approach to use in the future. The problem is the likelihood of a relapse is very real because the shift from CC to RC is possible even highly possible at some time in the future. When there is a switch to RC obviously then comes the drug use. The long term prognosis is not good in these circumstances.


Also if it is a CC decision to stop the drug use then there has to be a CP some where nearby for that to last. The CP approach can be found sometimes in religion based drug treatment approaches that are residential. The drug user lives in some kind of drug rehabilitation facility. This can allow for a more consistent CC response because the CP is there consistently in their life. If they leave or significantly reduce the contact with the CP then the CC response will tend to wane and relapse is more likely to occur. If there is more FC in the decision to reduce drug use then this is less likely to happen.

In addition to this I would like to highlight an exception to the idea of the more permissive type of approach that I did not mention in the book. There is a type of drug user where this is not helpful and indeed has serious limitations. This type of drug user is not uncommonly found in counselling or in the health system in some way. It is the drug dependent user who is living out quite a tragic life script. They may be homeless in varying degrees, their lives are chaotic and maybe quite non conventional in that they may be unemployed and exist within the criminal world in varying degrees. Often they have quite poor Parent and Adult ego state development

When I worked in drug rehabilitation people would make appointments to see me, usually once a week. This type of drug user would keep the appointments about 30% of the time. They simply did not have a life style that allowed them to plan and structure their lives the way the average person can such that they can keep an appointment they organized a week before. They simply do not have the Adult ego state development to achieve that. 

Pool player

With these people the counselor needs to seek them out in their homes and places where they hang out like with outreach work. The permissive approach that I describe is not very useful for them. Some of these people do respond to an authoritarian approach. They can take it on as their Parent ego state for a period of time and in some cases stay sober for long periods of time. They need to be told in a clear and direct way what to do and what not to do. The permissive approach does not do this and as a result is not that useful with such clients.


1 comment:

  1. Interesting post Tony :) With the drug user that does not respond well to your permissive approach, that may in some cases 'stay sober for long periods of time', would you say then that they are unlikely to be drug free for the rest of their life? There is also the question of value and worth as the counsellor is having to seek them out, that if they do not motivate themselves to get help that they will not invest their time and energy into resolving their problems, with this in mind is outreach work something that you think works, or even something that you would recommend?