Drug counselling approaches

In my book - Working with alcohol and drug users - I make the point that there is no such thing as drug counselling instead there is a group of drug counselling approaches. People use drugs for a variety of reasons and the drug counselling approach varies for each differing reason. I discuss this in chapter 4 when I list the 6 main reasons or types of drug use. These being:

Experimental drug use and counselling. 

Rebellious drug use and counselling. 

Recreational drug use and counselling. 

Situational drug use and counselling. 

Symptomatic drug use and counselling. 

Dependent drug use and counselling.

If one is working with a recreational drug user, what one does is quite different compared to working with a dependent drug user. Indeed we have a somewhat odd situation when it comes to counselling drug users. By far the largest group in number are the recreational users but one rarely sees them in drug counselling. They rarely seek drug counselling because they do not see they have a drug problem and indeed the drug use does result in very little disturbance in their life. One only tends to see them in counselling when they come for some other reason and the drug use gets mentioned as a sideline to the counselling for other difficulties.

A much smaller group is the dependent drug user who is the ‘addict’ type of user. One sees them much more often in counselling even though over all they represent only a small group of drug users. In counselling these people, in my book, I focus on the relationship the person has with their drug of choice. 

In this sense the drug counsellor becomes like a couples counsellor but working in reverse. Instead of counselling the ‘couple’ to repair their relationship the drug counsellor is working with the drug user to end his relationship with the drug. Working with how to break the attachment to the drug, just like one can have an attachment to another person. I highlight three main ways this can be done.

This approach does provide some insight for the average person on what the life of the dependent drug user is like. Think of a time when you were in a relationship that was not good for you but you stayed in it despite that. Recall how difficult it was for you to leave and how hard it was to break the attachment to the other person and all the pain and grief you experienced when it ended. Recall how you went back to the relationship knowing that it was the wrong thing to do. If you have had this experience then you are given some insight into what the dependent drug user feels and what they experience as they endeavor to give up the drug.

It is very easy to sit on the sideline an have the view that the drug addict is simply a weak willed individual who is a loser and just a drain on society. Have you ever stayed in a relationship which you knew was not good for you and may have even been quite destructive for you and the other party? If you have then you know that is not just a matter of being weak willed. Leaving a relationship where there is a significant attachment is not an easy thing to do and that is the dilemma for the dependent drug user.

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Working with drug and alcohol users

New book!! Two weeks until release

Working with drug and alcohol users 

by

Tony White

Topics covered

Chapter 1 - Drugs in society and addiction

Historical and contemporary views of addiction. Drugs are a political issue and how this negatively impacts on drug counselling. 

Chapter 2 - Fundamental components of drug counseling 

Facts about the three groups of drugs. Peak age of use and other drug features. Gateway drugs. Drug of choice. Polydrug use. The need to be truthful about drug effects and dangers with clients. Urine testing. Paruresis. Drug induced psychosis.

Chapter 3 - Transactional Analysis and the theory of addiction

Theory of personality. Ego states and the newborn child. The functional ego states. Transactions. Transactional analysis theory of dependence and addiction. Addiction and attachment. 

Chapter 4 - Why people use drugs and their treatment

The effects of alcohol on personality. Reasons for using drugs. Experimental drug use and counselling. Rebellious drug use and counselling. Recreational drug use and counselling. Situational drug use and counselling. Symptomatic drug use and counselling. Dependent drug use and counselling.

Chapter 5 - The harm reduction contract and harm reduction counseling

The moral issue in harm minimization. The difficulty of using harm minimization information. Ego states and negotiating safety. Therapeutic relationship and negotiating safety. The harm reduction contracting process. Harm reduction counselling. Suicide and drug use. Harm reduction counselling and defence mechanisms. Harm minimization and youth.

Chapter 6 - Assessment of the drug and alcohol user

Presenting issues. Taking a client history. Drug use history. Drug use timeline. Assessing drug users who have been in prison. How do they get their drugs? Relationships with peers and partner. Stages of change.

Chapter 7 - Drug use ambivalence

The drug use ambivalence therapeutic technique.

Chapter 8 - Relapse process work

Diagnosing the type of drug use. The relapse process. The dependent drug using career. Problems with the stages of change model. Geographically relocating as a therapeutic strategy. Relapse prevention counselling. Drug/drink refusal skills. Assessing the level of deprivation in relapse prevention. The parts party technique in relapse prevention. Drug use ambivalence and relapse work. 

Chapter 9 - Motivational interviewing

Two types of motivational interviewing. Cognitive (Adult ego state) motivational interviewing. Experiential (Child ego state) motivational interviewing. Motivational interviewing and the impasse. 

Chapter 10 - The teenage drug user

Changes in the adolescent stage of development in the last 50 years. Why teenagers use drugs. Peers and drug use. Working with the teenage client. How the counsellor relates to the teenage drug user. Teenage drug use and family structure. The hot potatoe and the teenager. Parents and the teenager. Scare tactics with the teenager. Dealing with a disclosure by the teenager. Urine testing teenagers.

Suicidality and war

“Female soldiers' suicide rate triples when at war”.

Recent research reported in the magazine USA TODAY (March 2011) Gregg Zoroya

(http://www.usatoday.com/) 

This research on US military found

1. When female soldiers deploy to Afghanistan and Iraq the suicide rate triples from 5/100,000 to 15/100,000.

2. When male soldiers deploy to Afghanistan and Iraq there is a 30% increase in the suicide rate from 15/100,000 to 21/100,000.

This could be seen to support the contention that going into a war zone can be used as a way to fulfil the suicide decision:

I will get you to kill me.

Obviously in a war zone there are plenty of people trying to kill you.

Or at least those who have made some kind of suicide decision

Those who are actually deployed may be a self selecting group to some extent. Those who have made this suicide decision will get themselves into the circumstances where they are more likely to be deployed than other non suicidal people in the military. One reason why the suicide rate increases is because the group has selected in more suicidal people.

In the report the researches say the usual stuff. People deployed to such war zones are more stressed and so forth and this maybe the cause of such statistics. 

There is an alternate explanation. Stress has never made anyone suicidal. What stress can do is make an already suicidal person more likely to act on their self destructive urges. Thus a person who has made the suicide decision is more likely to end up in a war zone and when stressed is more likely to act on that decision. Hence the rate of suicide goes up.

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Suicidal ambivalence in war time

It has been noted that during war time there tends to be a significant drop in the suicide rate. This has been reported in many different countries so it seems to be a universal phenomena. One theory is that this decline is due to the social cohesion that war creates. 

An alternative theory can relate to the idea of suicidal ambivalence. All suicidal individuals are ambivalent to some degree - “I do want to die vs I do not want to die”.

All suicidal people have this contradictory set of thoughts and urges inside themselves. The suicidal individual has percentages of both with the levels waxing and waning over time. Sometimes it will be 50/50 and then on other days it might be 60/40.

In war time or when there is an external threat to life the FC aspect of the personality could be stimulated as people tend to think more about how they are going to survive this period of threat. All those around them would be doing the same. This would make the FC part more prominent in the personality and hence the AC urges to die diminish and the suicide rate drops.

This could be further supported by other data as well. In Australia some of the highest rates of suicide were during times of depression and the lowest during the war years. In Serbia the highest rate of suicides recorded were during the hyper-inflation period and the lowest during the NATO bombing in 1999.

It could be argued that during times of economic hardship there is not so much a threat to life but a threat to the standard of living. People have to live with hardship but their lives generally are not under direct threat as can happen in war time. Hence in times of economic depression the FC is not stimulated as it is during war.

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Recreational drug testing

A small extract from my soon to be released book

“Urine testing
With the increase in random urine testing for drugs an ever increasing number of clients bring this issue to counseling. Most want to discuss ways to get around the testing, usually how long before testing do they have to stop using and the possibility of masking agents.There have been a lot of possible masking agents put forth by clients over the years. There are many rumors and myths about masking agents.  However as the number of people being urine tested grows it is quite possible that in the future it will become economic to produce and sell reliable masking agents for recreational drugs.”

My prediction may have come true! 

Last week I was supervising someone who works in a drug rehab centre and he was discussing a particular client. This person was disrupting the center and other clients. It was suspected that he was smoking marijuana which of course is a direct trigger for all the others there and quite disruptive to the functioning to the center. He was required to give a urine sample for testing and it came up negative. He was then subsequently given another more involved (and much more expensive) test and it still came up negative. 

It was suspected that he was smoking kronic which is a new synthetically produced marijuana. Eventually he caused a fight with another client, his room was searched and the marijuana found. He admitted to smoking it and was removed from the centre. This confirms what has been suspected for some time that some varieties of kronic do not show up on drug tests. Perhaps this is the start of chemists producing drugs and masking agents which can avoid detection. Maybe this is the first serious and effective venture into masking for recreational drugs.

With kronic the molecular structure can be repeatedly slightly altered such that the effects of the marijuana remain the same but it becomes a different drug. This indeed has caused consternation for legislators as the newly produced varieties of kronic sometimes fall outside the current legislation.

As we have seen with sports people and performing enhancing drugs it becomes a never ending game of “catch me if you can”. The chemists are continually making new masking agents and the drug testers are continually trying to catch up. This is a very expensive exercise but in the arena of professional sport it is big business so the money can be spent.

However with recreational drug use there is no money involved. The ‘prize’ at the end is just getting stoned not a gold medal and then millions of dollars in endorsements. To play catch up with the masking of recreational drugs simply is going to be uneconomic.

Interesting times indeed. It will be interesting to see how society reacts to this new development should it continue. The grapevine in the drug subculture is very effective and one would imagine many already know about kronic and its ability to be undetected in urine tests.

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Command hallucinations and self destructiveness

Sometimes people can engage in suicidal behaviour due to command hallucinations. They report hearing voices that are telling them to be suicidal in some way.

There are two schools of thought on this. One school says that you should confront the crazy beliefs in this case the auditory hallucinations. Saying in a clear and direct way that the voices are not real and endeavoring to get the the person into Adult ego state.

The other school of thought says that you don’t confront the irrational belief, instead you engage the voices with questions such as

Ask - do you recognize the voices? 

Ask - what are they saying?

Then one can talk to the voices in an effort to defuse their destructiveness. The problem in doing this is the therapist is colluding with the crazy part of the Child ego state which believes the voices are real when in fact they are not. So in this way one is supporting the problem.

My personal view is that when you have a crisis situation one talks with the voices in an effort to defuse them. In the longer term the treatment goal is to confront the hallucinations and the delusion that there are voices talking, when there are not. 

I used to do this when I worked for an organization that assisted people who were primarily suffering from chronic schizophrenia, bipolar, psychotic depression and borderline personality disorder. When they reported feeling distress about the voices I leant to address the voices directly. Fortunately I had a coworker who was a psychiatric nurse and I learnt a great deal from her on how to do this.

However, even more interestingly these people just described would be diagnosed as psychotic and in transactional analysis terms that means there is a severe disturbance of the Adult ego state which can occur in two ways as shown in the diagrams. 




When I worked in a prison there were a number who I dealt with who also reported hearing voices. Most of these would not have been diagnosed as psychotic and this raises the question of does a person who hears voices have to be diagnosed as suffering auditory hallucinations. In recent times there has been a lot written on this and it is now accepted that voice hearing does not have to equate to a psychotic symptom.

Such as this from the mental health foundation

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Hearing voices can be a very disturbing experience, both for the person who hears voices and family and friends. Until recently voices were regarded as a symptom of a mental illness and not talked about because of fear of stigma.

Hearing voices are still considered by psychiatry as an auditory hallucination and as a symptom of conditions such as schizophrenic disorders, manic depression and psychosis. The orthodox treatment is with major tranquilizers. These do not get rid of the voices.

In the past mental health professionals were taught not to let voice hearers talk about their voices as this was thought to be colluding with the person’s delusions and not helpful. Most often professionals sought to distract the voice hearer from their voices.

Research has shown that many people hear voices, and some cope well with their voices, without psychiatric intervention. It has also been found that many people who hear voices regard them as a positive part of their lives.

Throughout history and even today there are people who hear voices who find their voices inspirational and comforting. Many researchers, practitioners and voice hearers believe it is mistaken to regard voice hearing as part of a psychopathic disease syndrome. Rather, they consider it to be more akin to a variation in human experience - a special faculty or difference that definitely does not need a cure.

This means it is no longer a sustainable position to think of voices as part of a disease syndrome, such as schizophrenia. Instead hearing voices can be regarded as a meaningful, real (although sometimes painful, fearful and overwhelming) experience that speak to the person in a metaphorical way about their life, emotions and environment. For instance, people experiencing distress as a consequence of abusive or commanding voices can often recognize their voices as those of their 

actual abusers and the voices have the effect of attacking their sense of self esteem and worth.

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Thus some voices are auditory hallucinations and some are not. Which raises a most interesting question. If they are not auditory hallucinations, then what are they? 

These people often have quite good functioning Adult ego states and at the same time they hear voices 
the voice may be experienced as coming from inside your head or from outside the head or even outside the body
the voice may talk about you or to you
the voices maybe distressing and abusive
you don’t know what they are going to say next
at times there can be more than one voice and sometimes the voices are from people you know and sometimes they are unknown

Either way if there are command hallucinations that are directing the person to kill self then my suggestion is the therapist engages the voices whether they are hallcinations or not. The goal is to diffuse the current crisis even if it means colluding with the crazy Child in the short term.

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Ego syntonic and ego dystonic

Something is said to be ego dystonic when the person perceives it to be foreign to them, outside them or not belonging to them. Something is ego syntonic when the person sees it to be part of them, belonging to them or forms part of who they are

These are two important concepts in psychotherapy. Is the problem ego syntonic or ego dystonic for the client?

A client may present with agoraphobia or perhaps insomnia. The therapist needs to ascertain in his own mind does the client see self as

1. A person who can experience agoraphobia, (ego dystonic)

2. An agoraphobic (ego syntonic)

Does the client experience self as  

1. A person who can suffer insomnia, (ego dystonic)

2. An insomniac (ego syntonic)

Unfortunately in most circumstances by the time the client gets to therapy the problem has become ego syntonic.

Ego dystonic I believe

A person sleeps normally and then for some reasons starts to sleep poorly. Initially this will feel abnormal to the person and the problem is seen as ego dystonic. They perceive self as someone who sometimes does not sleep well but not as an insomniac.

Over time if the insomnia continues the person’s view of it changes. It becomes something that they expect to happen because it has happened many times before. They tend to start to view it as part of who they are - an insomniac. When this change occurs the problem then becomes ego syntonic. The insomnia is perceived by the person as part of who they are and how they live.




The shift from ego dystonic to ego syntonic can be seen to have at least three aspects.

1. It becomes habitual

If a person has slept poorly most nights for the past year then the insomnia is partly a habitual way of being for the person regardless of any other causes for it.

2. It becomes part of the persons life style

As it becomes a habitual pattern of being the person will adjust the practicalities of their life style to fit for it. They will tend to do the same things like get up and do such and such and then go back to bed and then wake up again. They develop a routine at night time that incorporates the wake times.

3. It becomes part of the person’s self perception or part of their identity.

Finally it becomes how the person sees self and a sense of who they are as a person. I am an insomniac is part of the person’s sense of identity.

If a person has slept poorly three nights in the last four months then it wont be habitual, they have no routine when being awake and it is not part of who they see they are.


Eunuch



How long does it take a problem to shift from being ego dystonic to ego syntonic?

In trauma debriefing research indicates that therapy should start within 6 weeks of the trauma. The earlier you start the better. After 6 weeks it is harder to treat the problem (PTSD) as it has become ego syntonic.

Research on the formation of new habits indicates that it takes 66 days for a new habit to fully form. After that the person will behave habitually in the new way. Of course this varies on how often the new behaviour occurs and if there are any relapses along the way.

This suggests that it will take about 1.5 to 2 months for a problem to move from being ego dystonic to ego syntonic if the new problem occurs regularly.

If it is ego syntonic then not only does one have to treat the insomnia, but also the habit of not sleeping and the routine involved, along with the self perception of the client as an insomniac.

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