Monday, November 26, 2012

Drug counselling - authoritarian or permissive - part 2?

Thanks for your comment in the pervious post Dena. The two points you raise were exactly the ones I had considered including in the original post but decided not to as it would have made it too long. Now you have asked them I will address them in part two here.

Dena: “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?” (end quote)

There are three (well 4 really) possible outcomes with this Dena which I cover when I talk about the dependent drug user. These people are not uncommonly found in the health system and legal system even though they actually constitute a small number of the overall drug using population.

Clown smoker

These are the truly problematic drug users who often have tragic lives. This is the kind of person you see in Hollywood movies who is the ‘drug addict’. Again this is only a small group of drug users but they are often quite noticeable. In my book I use this chart to indicate who I am talking about when I discuss the treatment of the dependent drug user.

Length of heroin career - 10 years
Male gender - 66.5%
Employed - 17%
Ever been in treatment - 90.5%
First age of intoxication - 13.7 years
Age of first heroin use - 19.7 years
Daily heroin use - 80%
Ever overdosed - 59%
Ever imprisoned - 46%

As you can see this is a person who lives a tragic life script. Some don’t make it during their drug using career. With that level of overdose they are walking close to the line of death. Most however do not die and come out the end of their drug using careers with criminal records and/or some unpleasant viruses or other significant health problems.

Some get relatively drug free by combining the authoritarian and permissive approaches. They initially go into a strict residential program (Authoritarian) and get their lives less chaotic and more conventional. When this has been achieved they can then ‘leave’ the strict program to some degree and then enter a more permissive treatment approach where the FC can make its decisions about being drug free. If that happens then they can be drug free for very long periods of time.

Pool player

Your second point Dena: “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?” (end quote)

My view is that with some drug users I would recommend it. Well it’s not so much a matter of it working as you don’t really have any choice in the matter. I worked in a drug rehabilitation center for 5 years and this point you raised often came up in supervision and at times lead to heated discussion. The key phrase you use is:

If they do not motivate themselves to get help that they will not invest their time and energy into resolving their problems

The two schools of thought on this are
1. They agree with your point. It is a matter of the client not being interested in seeking treatment consistently and does not turn up to appointments regularly. If this is true then outreach work could be seen as perpetuating the problem where the therapist becomes a rescuer and makes the client more of a victim who can’t help  himself.

2. They do not have the psychological capability to get regular help. To make an hour long appointment in one weeks time for many weeks in a row requires the ability to be able to plan ones life such that those appointments can be kept. To you and I and the average Joe this seems like a pretty basic thing that anyone could do.

Caravan girl

However if you get someone whose Adult ego state is just functioning and the Parent ego state is basically nonexistent then it becomes a much more onerous task. In my view there are some dependent drug users who are like this. They are simply not going to get to a lot of appointments and it is not because they couldn’t care less or because want to be rescued by the therapist.

This is where the therapist’s clinical judgement is tested. Is the client not attending because he wants to play a game and be rescued or is it because he does not currently have the psychological capabilities to keep such regular appointments? At times a difficult question to answer.

Thanks for your question Dena.


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