Six dilemmas for drug and alcohol therapists

Introduction

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.

Conclusion

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.

References

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.

Posters Volume 5.

See volume 5 here.

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Drugs as a disease in society

This view one could say is widely held in the general population. Promoted mostly in the public arena by a variety of parties. The war on drugs approach typifies this view of drugs and alcohol in society. Indeed not uncommonly people will use terminology like 'disease' and ‘tearing at the fabric of society’ when talking about drugs and alcohol. Others will suggest that we are on the brink of a drug fueled crisis in society, especially with the youth of society. 

The most recent being the alleged are, methamphetamine and crack cocaine epidemics occurring in society. Such prophecies come and go but there is generally speaking a new one occurring semi regularly.

Of course there is considerable evidence to the contrary and in the field of addictions counselling it is widely acknowledged that the vast majority of drug and alcohol users suffer very few, if any deleterious effects. It is only a quite small group who do.

A similar result is seen when one assesses the results of the stated drug epidemics. I am not aware of any society in the history of mankind that has been reduced to anarchy or has even been significantly negatively impacted by a drug problem. Plenty of societies have collapsed because of political problems, economic problems or religious disputes. These things are far more dangerous to society than mood altering drugs.

Here is a chart of American rates of problematic usage of illicit drugs taken from the DSM 5 (Note: these are not the drug use rates but the problematic drug use rates)

Problematic drug use	Prevalence
Cannabis use disorder	3.4% (12 - 17 year olds) 1.5% (18+ years)
Hallucinogen use disorder	0.5% (12 - 17 year olds) 0.1% (18+ years)
Inhalant use disorder	0.4% (12 - 17 year olds) 0.02% (18+ years)
Opioid use disorder	0.37% (18+ years)
Sedative use disorder	0.3% (12 - 17 year olds) 0.2% (18+ years)
Amphetamine use disorder	0.2% (12 - 17 year olds) 0.2% (18+ years)
Cocaine use disorder	0.2% (12 - 17 year olds) 0.3% (18+ years)

As you can see they are very small numbers, again highlighting the point that problematic drug use only occurs in a very small group of the overall drug users

What are some of the possible consequences of this view that drugs are a disease in society? First it must be acknowledged that humans have been using mood altering drugs since civilization began

In my book - Working with drug and alcohol users - I state the following:

“The Australian Psychological Society (2005) note a long history of drug use in societies from all over the world. 

Alcohol use dates back at least eight thousand years.
Tobacco has also been used for many hundreds of years probably originating in the Americas before being taken to Europe
Evidence has shown that opium was used in Mesopotamia at least seven thousand years ago
Archeologists in Northern Europe found remnants of cannabis dating back to the fifth century B.C.
Hallucinogenic drugs have also been very widely used throughout history dating back at least seven thousand five hundred years. 

Mood altering drugs are not a new or abnormal in human society. The Australian Psychological Society (2005) states, “Substance use has always been and continues to be a part of ordinary human behaviour.” (p.36). However they are often seen as being abnormal and dangerous. Many governments, religions and various other groups over history have promoted mood altering drugs as bad and evil things which will destroy society and our youth.” (end quote)

From this it is fair to say that in the human psyche the use of mood altering drugs is a normal event for a substantial number of people. It is a psychologically normal thing to do. Thus we have our first problem.

For a society to view itself as disease ridden is not a constructive thing. Indeed it could argued to be quite a deleterious thing for a society. Especially when what is seen as the disease is a psychologically normal thing for humans to do.

The 'war on drugs' and ‘drugs as a societal disease’ philosophy could be seen to significantly contribute to the view that we as a society have a disease or a bad bit in us. We are told this regularly in westernized societies. I wonder what it would be like if people started to see that drug use was not a disease in society. That it did not reflect a morally corrupt or dark bad bit in the cultural psyche. What would it feel like to feel good about ourselves in this way?

I know that in individual psychology for a person to stop seeing self as having a bad bit inside is a significant move forward with the corresponding increases in self respect and self esteem. If we as a society start doing the same would we as a society have the same positive results in our cultural psyches?

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Different types of drug use

This is a diagram of drug use that I came across the other day.



The explanation for it follows:

"The road to addiction is different for every person. Some people take their time while others go from zero to 60 in a short period of time. No matter how long your journey is, most rehabilitation counselors agree that there are five main stages of drug addiction: experimentation, regular use, risky use/abuse, and drug addiction and dependency. Not everyone in the first two stages will develop a drug addiction, but individuals in the third stage of drug abuse are very likely to progress into full-blown addicts. Here’s a closer look at the five main stages of drug addiction.

Experimentation is defined as the voluntary use of drugs without experiencing any negative social or legal consequences. For many, experimenting may occur once or several times as a way to “have fun” or even to help the individual cope with a problem. For many, experimentation can occur without any desire to continue using the drug. For others, it can start to become a problem when it moves into the next stage of addiction.

Some people will be able to enter the stage of regular use without developing a dependence or addiction. These people will be able to stop the drug use on their own. The problem with regular use is that the risk for substance abuse greatly increases during this stage. It also increases risky behaviors such as driving under the influence, unexplained violence, and symptoms of depression and anxiety.

Many people stay in the stage of regular use for months or years. Some may not develop a problem but many may not be able to stop by themselves. This is ordinarily the period of time where the consequences of using drugs and/or alcohol regularly begin to show up. Some will completely stop at this point. Others will stop for a period of time in order to get back into the good graces of loved ones or possibly the law; for example if someone gets a DWI and is put on probation they may quit drinking completely or agree with their family never to drink and drive again but as soon as they complete their probation they feel they are “off the hook” and can finally return to their old behaviors. 

Characteristics of dependence include constant use of alcohol or other drugs that lead to the inability to take care of major responsibilities related to work, family, school and other roles. Repeatedly using drugs in situations that are physically hazardous, such as sharing needles or driving while under the influence, repeated legal problems, or any combination of these. Their risky behavior may also escalate to things such as prostitution and stealing from society because they can no longer take from their family. Many dependent people could be categorized as functioning, and are able to work, maintain family relationships, and friendships. They will attempt to limit their use of alcohol or other drugs to certain times, such as evenings or weekends. 

The last stage of persistent abuse of substances is addiction. At this point they have been addicted for some time but this is the point where change is inevitable because continued use will only lead to a few places. Addiction is a disease involving serious psychological and physical changes from constant heavy use of alcohol, drugs, or both. Symptoms include withdrawal and uncontrollable alcohol use and/or other drug craving, seeking, and use that continues even in the face of repeated negative consequences. Addiction is a progressive, chronic, and fatal disease. If left untreated, it can only lead to jails, institutions, death, and dereliction, in no specific order". (End of explanation)

My response

I find this has some accuracies or parts I would agree with. It also is an interesting statement because it typifies some of the ways misconceptions about drug use are presented to the public. I discuss these below:

It says that not everyone in the first two stages will develop a drug addiction. The majority or even the vast majority do not develop a drug addiction. The largest group by far are the social (recreational) users. The dependent users are quite a small group in number.

It kind of implies the gateway drug use scare tactics approach by saying there are 5 main stages to drug addiction from experimentation to dependency. This is true but again it is only quite a small group of users who go through all the five stages and most stop at stage 2. It is like saying eating leads to obesity. Yes it does for a small group but the vast majority of eaters do not become obese. 

To quote them, “Some may not develop a problem but many may not be able to stop by themselves.” This is a typical media driven statement that is using scare tactics. A more correct statement would be - Most will not develop a problem but a few may not be able to stop by themselves.

If these five women all took drugs. Only about one tenth of one of them would ever develop a drug dependency. Four of them would only ever remain recreational users.

It says many stay at the stage of regular use for months or years. As I say in my book - Working with drug and alcohol users - if this happens then a move on to dependent use is unlikely. Most dependent users when they begin using their drug of choice the escalation to dependent use is rapid, within months. It most often does not develop slowly over time. So when they hit what the diagram calls social use they quickly skip to dependent use. If they stay in social use or regular use for months or years then they are unlikely to develop to dependent use.

It says addiction is a disease. This is one view of addiction and is commonly the psychiatric view of addiction. There are other views which see it resulting from adverse psychological development and is not a disease in the medical sense of the word. This psychological view is a widely held view of addiction around the world. 

It says addiction is a progressive, chronic and fatal disease. For the vast majority of dependent uses this is not so. The vast majority do not die when addicted. The  average time of use for the dependent user is 10 years and then they stop using. The vast majority do not die by overdose or due to medical problems when addicted. It may shorten their life span in the long term in varying degrees when they get old but the vast majority will not die when using drugs.

It says that if left untreated it can only lead to jail, institution, death and so forth. I have spoken about the death statement above. In addition research shows that only 40% to 50% of dependent users will ever do any prison time. For at least half or for a small majority, it does not lead to jail.

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Parenting the teenager who drinks alcohol

I was recently listening to the radio and heard an announcement about a new government initiative regarding drinking alcohol. The programme is called DrinkWise Australia. Part of it is about parents dealing with teenagers who drink. In my recent book - Working with drug and alcohol users - I discuss in depth the area of teenagers and alcohol and drug use. I decided to go to the website and have a look to see what they had to say.  

The things teenagers do

This is basically what they say:

“3A Parents and carers should be advised that children under 15 years of age are at the greatest risk of harm from drinking and that for this age group, not drinking alcohol is especially important.

3B For young people aged 15–17 years the safest option is to delay the initiation of drinking for as long as possible.”

“Communicate your concerns about drinking alcohol to your teen. Discuss the range of risks involved and the impact on their physical, psychological and social health. They may not agree with your views on the matter but they need to understand why you have created the rules that exist in your home.

Involve your teenager in the development of the rules. As you and your partner decide on the rules and boundaries have your teenager with you. They may not like the rules but they are more likely to follow them if they understand your reasoning.

Renegotiate rules as they become dated – every six months. If you’ve created a set of rules around alcohol for a 15 year old, these need to be re-examined to suit different stages in your teen’s development.” (end quote)

In essence they are advising parents to tell their teenagers not to drink or at least have very restricted drinking.

In my book I note that there are two approaches here that parents can use.

1. To do what DrinkWise Australia suggests and recommend no alcohol use and possibly use punishments if they do not keep to those rules.

2. To not make any statements to the teenager about alcohol use being ‘bad’ and something you disapprove of. The parent does not tell the teenager not to drink. You simply listen to them talk about their drinking and make comments from time to time such as reflective listening or appreciating them being open with you.

The advantage to number 1 approach is it gives the teenager a clear sense of what is right and wrong which they will incorporate from the parents. The disadvantage of approach 2 is the teenager does not get the clear boundary set by the parents. 

The disadvantage to number 1 is you ‘loose’ the teenager in varying degrees. As soon as the teenager hears the parents say “don’t drink” it is likely from then on they will not get the truth about the drinking. The teenager who is drinking will either deny it completely or give the parents a significantly modified version that understates the amount they are drinking. Even if the parents deliver the ‘Don’t drink’ message in a soft form the teenager will still usually ‘hide’ their drinking at least to some degree.

This can be a problem as it can damage the relationship with the teenager in that they withdraw from the relationship with the parents. Hence they can experience more of a sense of isolation from the family. The teenager thinks, 

“I can’t tell my parents stuff as they will (disapprove, lecture me, worry about me....)”

If this is minor the negative effects are not so bad but if the teenager experiences it to a significant degree then it can be quite a problem.

One thing you do not want is a teenager who feels isolated from the parents and family. The more a teenager has a sense of isolation the more psychologically vulnerable they are. This is why the most basic ‘rule’ of parenting a teenager is never break off the lines of communication. No matter how offensively they have behaved it is strongly advised that a parent never ceases communication with the teenager.

If they stop telling parents about their drinking, what else are they not telling the parents? If they stop talking with the parents about sensitive issues like drug and alcohol use that usually results in them giving more power and influence to the peers as they become the teenager’s main confidant rather than the parents. Obviously an undesirable situation.

As stated before approach 2 does not give the teenager a clear boundary set by the parents about drinking. However it is more likely to avoid the difficulties just mentioned which go along with approach 1. 

Approach 1 = directing from the front

Approach 2 = persuading from behind

In approach 2 the parents do not openly state that the teenager should not drink or take drugs. They simply listen to the teenager, reflect back to them and generally keep the teenager talking. As I said before the downside of this approach is that it gives implicit permission for the teenager to use alcohol but it does not have the negatives of damaging the relationship with the teenager that approach 1 can. Approach 2 tends to give the teenager a sense of a connection with the parents and the parents can become a key person who the teenager confides in. The parents can remain more influential in the teenager psyche for longer. This reduces the negative impact that can come from ‘advice’ given by peers. Also the teenager does not experience a sense of isolation which makes them more psychologically robust.

The parent would tend to be saying things like

That’s a good point

What do yo think would happen if you did this..?

It seems like that worries you

It’s more of a counselling approach to parenting but if at all possible the parent should avoid becoming a ‘therapist’ to the child. Unlike approach 1 which is a directive approach, approach 2 is persuading from behind. This is done by highlighting certain points and ignoring other points. It’s a much more subtle approach to the parenting of the teenager.

As so often happens when dealing with teenagers about alcohol use the parents are left with two bad choices. The goal is to choose the least bad one. Both approaches have positives and negatives.

Parents have all sorts of different appraoches to teenagers depending on their own personalities.

However as also is the case in parenting often the best approach to use ends up being dependent on the personality of the child and the parent. If the teenager tends to be somewhat conservative in their attitudes and somewhat conforming then approach 1 may be best. If one has a strong willed, rebellious teenager who is in a group who use alcohol and drugs then approach 2 may be the best choice. In these circumstances to use the approach suggested by DrinkWise Australia could result in some quite negative outcomes.

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Drug and alcohol use history of the therapist

In my book I discuss a situation that all drug and alcohol counsellors fear. It lurks in the back of the mind and can surface at any time. The client can raise it at anytime and leave a conundrum for the counsellor. The client can ask, 

“What is your drug and alcohol use history?”

In my experience I have not been asked this question often but it does happen from time to time. How does one answer? There are two schools of thought on this.

Should I choose the red or the blue?

First the counsellor can in essence refuse to answer the question and say that it is not relevant and move onto another topic. Others may use the distraction technique and answer the question with another question:
Client:  “What is your drug and alcohol use history?”
Therapist: “Why is that important to you?”
Sooner or later however the client will realize the therapist is not going to answer the question.

Second the counsellor answers the question and does some self disclosure about their history of alcohol and drug use.

I think the first response is not a wise one to take. It in my view builds intrigue you do not want. The client is left wondering why you ‘really’ refused to answer. Is there something you are ashamed of or maybe your drug and alcohol use history has been extensive. Also you are asking the client to disclose many things, some of them quite intimate and then you refuse to disclose something to the client. This may leave them feeling problematic emotions about your refusal.

If you take the second option and answer that you have had little or no history in this way then some clients will feel you are somewhat ignorant about such matters. To most it probably make little difference but there is a group to which it is quite important and it can damage your potency as a therapist in the eyes of the client.

If you answer that you have used drugs and alcohol at times in the past then that can leave some clients feeling that you do know what they are talking about. However it is also permission giving to the client to take drugs. If you are a strong transference figure to the client this can be particularly so. If you stopped using drugs when you were 30 and the client is only 25 some could take this as permission to keep using for 5 more years. Other clients may view you as hypocritical. You are suggesting a client do something that you did not do yourself. 

Then of course there is the situation of the counsellor who is currently using significant amounts of illicit drugs or abusing alcohol. That can also provide permission to the client and is a more delicate clinical scenario.

On the positive side it can engender trust in the client towards the therapist. If the therapist reports a history of drug and alcohol use the client may respect the therapist for being honest with them by reporting previous ‘bad’ and ‘unprofessional’ behaviour. If you say you don’t have any significant drug and alcohol use history the client is going to wonder if that is true or are you lying to them. To tell such a truth can build respect of you in this way.

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The teenage alcohol and drug user

In my book - Working with drug and alcohol users - I make quite a long statement on the teenage drug and alcohol user. I spend some time discussing the psychology of teenagers and how they differ from the adult population. This means of course that one needs to treat them differently when doing drug and alcohol counselling.

This is a short excerpt from the book:

 Adolescents are also somewhat tribal in nature, they congregate in groups to hang out together. Hence the peer group (tribe) for the adolescent can assume significant importance in many ways including drug and alcohol use. Although parents sometimes like to think that their teenage boy is taking drugs because he has fallen in with a bad crowd, in the majority of cases peer groups and peer relationships are bi-directional in nature. Their ‘good’ teenage boy is probably contributing to the 'bad' behaviour of other teenagers in his peer group. He is effecting their behaviour as much as the others are effecting his.

There are some adolescents (and adults for that matter) who are highly dependent and passive individuals, who are significantly influenced by the ideas and wishes of others. However this is a small group and most are quite capable of making their own decisions even if there is peer pressure to take drugs which they may not wish to take. Despite this, any member of a peer group (passive/dependent or otherwise) who smokes marijuana gives permission to the other members to also smoke marijuana. It says to the others watching, "In our group this is the thing to do." So all peer group members influence the drug taking behavior of the others involved in the tribe. Hence the bi-directional nature of influence in peer group behavior. (end excerpt)

It is a very convenient excuse, like the alcohol excuse. Invariably a defence lawyer will say their client was intoxicated at the time of the crime. The hidden transaction being, “It’s not really his fault but it was the alcohol that made him do it.” 

To say the teenager did it because of peer pressure says the same, “It’s not really his fault but he only did it because he was pressured to do it.” Parents and the teenager often both want this to be the case and at times they will collude with each other in this way without even realizing they are doing so. It is a very convenient psychological position to take and any counselor should consider it with suspicion when presented by the parents and/or teenager.

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Fetal Alcohol Spectrum Disorder - The new sexism.

Once upon a time there was a condition called Fetal Alcohol Syndrome (FAS). This was a condition with identifiable physical and psychological symptoms. It would sometimes occur in children from mothers who engaged in frequent and protracted binge drinking during pregnancy.

This diagnosis has now been changed to Fetal Alcohol Spectrum Disorder (FASD).

FAS has now become FASD

“dum dum, dum dum, dum dum...”

This is meant to be music from the movie, Jaws. I am building atmosphere here. Impending evil is about to descend on women.

FASD as it says, is a spectrum disorder which means it includes far greater numbers than FAS did. Now children only have to have a few of the diagnostic symptoms to be diagnosed with FASD. The ‘edges’ of the diagnosis are now more blurry, so a lot more children can be included in the spectrum.

Public health officials are now highlighting the dangers of alcohol by quoting this new condition called FASD and the ever increasing numbers of children effected. 

And the impending evil? 

The potential for over diagnosis is large, and the consequences of that over diagnosis on the self esteem if women is potentially severe.

In Australia we are quite prepared to label people with mental health conditions. Nowadays in Australia, any badly behaved child is seen to have ADD. The prescription rates of medication to children with ADD in Australia is amongst the highest in the world. There is significant over diagnosis. The same has happened with the diagnosis of a drug induced psychosis. I discuss this in my new book - Working with drug and alcohol users - and how there is over diagnosis on a large scale for a number of reasons.

It will be easy for men to pontificate about FASD

In Australia we are now told by public health officials that there is no safe drinking level for women during pregnancy. Even a little alcohol consumption by a pregnant woman is considered dangerous to the child and it can cause all sorts of brain damage leading to low IQ, speech disorders, coordination problems and so forth.

A study by Jones and Streissguth (2010) looked at the children of alcoholic mothers and it found that 32% were born with FAS. A shocking statistic indeed for these children born to mothers who drank very heavily all through the pregnancy. However this means that 68% of children born to heavily drinking mothers did not get FAS. A significant majority of children born to women who consumed large quantities of alcohol did not get FAS.

But public health officials tell us there is no safe level of alcohol consumption for pregnant women, not even the odd glass of wine. The potential for over diagnosis is large especially now we have a spectrum disorder diagnosis.

I am a psychologist who has spent 25 years doing neuropsychological investigations of children who are brought to me for a variety of reasons. Often the child is not doing well academically at school and the parents want a neuropsycholigcal assessment done to find out what is going on. Lots of psychologists do the same sort of thing.

Typically the parents are asked many questions about the child’s development, any problems during pregnancy, was it a forceps delivery and so forth and now with FASD mothers will be asked if they drank alcohol during pregnancy. The child is then given an IQ test and one can begin to ascertain if there is any potential brain damage.

25% of children are above average IQ, 50% are average and 25% are below average IQ. That is how IQ tests are constructed. Some children are just born with a low IQ . There does not have to be a cause of brain damage. Some people are born with wonderful sporting ability and some are born such that if they run they trip over themselves. Some people are born with musical ability and some people when they sing the cat runs away. Some people are born with low IQ and some with high IQ. People are just naturally different in these ways.

If FASD goes the same way as the over diagnosis of ADD, then many women are going to suffer and suffer badly. A child who is performing poorly at school and mother wants to find out why will come into contact with mental health experts of all kinds -psychologists, psychiatrists, GPs, social workers, neurologists, pediatricians and so forth. She will be asked if she drank alcohol during pregnancy and if she says yes then there will be some who say directly to her that it was her drinking that caused the brain damage in the child. Even if she is not told directly she will see the look on some of the experts faces which says, “You should be ashamed of yourself”.

This will create guilt of the worst kind for the woman, “My selfish behaviour during pregnancy caused my child to be brain damaged” she may think. A woman living with that kind of guilt for years is going to have her self esteem eroded significantly. She listens to public health officials tell her that any alcohol consumption is dangerous for the child. They don’t tell her about studies which showed 68% of children did not get FAS from alcoholic mothers. They don’t tell her that sometimes children are just born with a low IQ and it was not her alcohol consumption that caused it. There are going to be many times when a woman is completely not at fault but will suffer years of this terrible guilt.

Society likes the temperate woman.

Even if she didn’t drink she may still suffer prejudice. If the child is performing poorly and she is asked if she drank and she says no there are going to be those who will still think, “Not only is she to blame because she probably did drink but now she is also lying about it.” If the FASD diagnosis becomes over used like ADD has, she is going to come up against prejudice like this from all sorts of people including family and friends. Even the husband may think such things because when she was pregnant and they socialized he always got too inebriated to remember if he saw her drinking.

Again from the Jones and Streissguth (2010) studies, they state:

“The developmental profile of the child with foetal alcohol spectrum disorders is variable, and the severity of presentation is not necessarily indicative of the severity of impairment (Stratton et al., 1996). Some children will not present any observable characteristics of FASD; their symptoms will be purely behavioural.”

“Children with foetal alcohol spectrum disorders may score within normal limits on measures of IQ, appear physically mature and give the appearance of functioning at a level consistent with their chronological age.”

In other words they don’t know clearly, it is inconsistent and it at times is going to involve guess work for the diagnosis of FASD. What it does mean is that with a diagnosis like this the potential for over diagnosis is very real and potentially large as could be the sexism and prejudice against women that may go along with it. Then there is also the possibility of years of guilt women could suffer when the child’s lower IQ has nothing to do with her alcohol consumption.

Women need to nip this in the bud before the diagnosis of FASD gets out of control like ADD has. With public health officials starting to say that any alcohol consumption during pregnancy is dangerous. These people need to be questioned on making such public health statements as this potentially new form of sexism evolves.

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