Related articles

• by Sue Wilders
 Sam Robinson
  Counselling substance users can be satisfying and enlightening, but also daunting. Clients who are experiencing the effects of substances, along with other related social, emotional or physical difficulties, may cause us to question our own attitudes and abilities. Yet there is a positive way of counselling drug and alcohol users, even when they are intoxicated, chaotic, or erratic in their behaviour.
  
  Contrary to popular belief, counselling substance users does not require a therapist to have any specialist knowledge or expertise, although information on the effects of substances may assist their understanding. The therapist may also want to acquire information to share with clients, for example on overdose and safe withdrawal from addiction – or at least know how to access this information. There are many resources that can help with factual information on substances, ranging from the Internet and national helplines,¹ to local drug and alcohol services.
  
  However, each person’s experience of using substances is specific and unique. Therefore general truths, while interesting and informative, do not necessarily give us information pertaining to the use and effects of substances on an individual client. For this, we need to be willing to set aside any preconceptions and hear their experience – best done through empathic listening.
  
  Awareness of our own values and perceptions is important in helping us to focus on the client’s frame of reference without imposing these values. This way of working also facilitates a lack of defensiveness.
  
  Is medical intervention needed?
  Concerns about the usefulness of counselling alcohol and drug users are in part related to the theoretical foundations of some counselling and psychotherapeutic approaches. However, some of the reticence concerning such work derives from an acceptance of the medical model idea that chaotic or habitual drug and alcohol users are in the grip of a physical disease that will not respond to counselling or psychotherapy alone, and which requires the help of specialist medical experts. It may be helpful to clarify here which aspects of substance use require specialist help, and which do not.
  
  Treatment of the physical symptoms of withdrawal from addictive substances is the main area for which clients may benefit from specialist medical help. The other is the treatment of medical problems that may occur as a consequence of substance use. It is worth remembering that whilst addiction may be an aspect of substance use, not all substance use leads to addiction – only some of the many substances used recreationally can and do create a physical dependency.
  
  Helping people withdraw from drugs and alcohol safely is important, since withdrawal symptoms can be severe, and sudden withdrawal in the case of benzodiazepines and alcohol can be fatal. Yet although the medical treatment of the physical effects of addiction is only one aspect of therapeutic work with drug and alcohol users, this came to dominate recovery work until fairly recently. Unfortunately, such a predominantly medical approach has nothing to offer the many users who either do not want to give up all use, or who are not physically addicted.
  
  Although doctors are ultimately responsible for the medication they prescribe, clients are ultimately responsible for the choices they make over their own lives. Until recently, within specialist services, the practitioners – doctors, nurses, drug and alcohol workers – assumed the overarching role of expert, not just in the sphere of medical treatment, but also over the client’s pace, process, and direction. Although some individual practitioners were client-centred in their approach, the procedures within these services put clients firmly in the role of passive recipients of external expertise. The medical model approach distracted clients from their internal gut feeling, their internal locus of evaluation, as they struggled to either accept or reject external direction.
  
  Although the medical model has lost some of its influence over work with this client group (the current Labour government recognises the relevance of counselling in work with drug users as well as the need to be more responsive to clients’ wishes²), there remains a legacy of directive interventions – and these methods are still prevalent, especially in detox and rehabilitation centres. It is as an expression of external directivity that a theoretical philosophy has emerged around the concept of ‘relapse’. The concept of relapse, which means ‘to degenerate’, or ‘go back’, is imbued with judgement. Although some clients may at times wish to achieve certain goals, there is a world of difference between understanding our clients’ goals, whether fixed or transitory, and leading our clients toward them or supporting them with a partisan attitude that inhibits and curtails clients.
  
  Therapists who attempt to direct or re-shape their clients’ lives often become frustrated with this client group as they find that they may be more focused on specific outcomes than their clients. Whether we are able to work with drug and alcohol users depends largely on the foundation model of our work and our theoretical approach. It particularly depends on our ability to be with our clients without judging them, by genuinely experiencing what client-centred therapists refer to as ‘unconditional positive regard’ for each client.³
  
  It is not our clients’ issues, cognitive ability, level of intoxication or manner of presentation that determines their likelihood of attaining therapeutic growth and improved wellbeing through their interactions with us, but our ability to accept them and to communicate that acceptance effectively. I base this observation on the results I have seen in the 15 years I have worked with drug and alcohol users.
  
  Does intoxication obstruct the therapeutic relationship?
  Within the classical, or Rogerian, person-centred approach there is nothing that a client can do in a counselling session to obstruct or inhibit the therapeutic process. For the therapy to be successful, the therapist must embody the core therapeutic conditions of empathy, congruence, and unconditional positive regard, which together create the environment necessary for therapeutic change to occur.³ However there are no requirements whatever upon the client.
  
  This means that there is no way of being, within the client, which is valued over any other. So for instance, attending a session while under the influence of substances does not in itself constitute a barrier to successful therapy.
  
  Within this inherently nondirective approach, the therapist is equally accepting of incoherent rambling in clients, as of cathartic emoting or intellectual analysis. There is no agenda to promote form over content, or content over form. Deep revelations and insight are of no more, or less, value to this therapeutic process than is discussing the quality of street heroin for an hour. It is not surprising to encounter clients who talk superficially throughout their entire time in therapy, and who nonetheless report significant positive change.
  
  This approach to therapy, whilst relevant for all clients, is especially significant for substance users who may at times be unable to articulate their experience in ways that can be easily understood, or who may be erratic and unpredictable in terms of their memory, cognitive ability, emotions and behaviour. Sometimes, drug and alcohol users may not even remember the content of sessions. Therapeutic approaches that rely on the cognitive ability of clients to absorb and understand external insights, or to create their own intellectual understandings, will fare less well in work with intoxicated clients. Requiring clients to abstain from use before sessions places an often unachievable requirement on someone who is intoxicated most of the time. It may also place an unrealistic and potentially life-threatening requirement on a client with a physical addiction. Failure to attain this therapist-set goal may then lead to the aforementioned judgement that a client has ‘relapsed’ or failed in some way, which adds to their overall misery.
  
  Should the counsellor attempt to motivate drug and alcohol users?
  Problematic drug and alcohol use can appear to be a very out of control experience, and yet classical, non-directive person-centred practitioners work from the premise that it is a therapeutic necessity for clients to be in control of the content, direction, pace, and process of sessions. This is not due to some irrational optimism, but is at the heart of Carl Rogers’ experientially based theory that individuals have within themselves vast resources for self-understanding and positive transformation, which can be tapped within a facilitative psychological climate.⁴
  
  Although other psychologists, including Abraham Maslow, Erich Fromm and Kurt Goldstein, had written from a theoretical perspective about the actualisation of human potential, Rogers developed these ideas into a central concept within psychology: the concept of the actualising tendency, which forms the bedrock of client-centred personality theory and further encompasses all life forms. It is based on the idea that all living things will strive to move in a constructive direction.
  
  Disagreements with this theory are often based on a misunderstanding of it. The most common misunderstandings are that the theory is about people being essentially good, or behaving in positive ways. In fact, the theory is not about personal morality or types of behaviour, but has a partly biological basis. This is demonstrated in the often quoted observations of Carl Rogers, of potatoes growing in less than ideal circumstances: ‘The actualising tendency can, of course, be thwarted or warped, but it cannot be destroyed without destroying the organism. I remember that in my boyhood, the bin in which we stored our winter supply of potatoes was in the basement, several feet below a small window. The conditions were unfavourable, but the potatoes would begin to sprout – pale white sprouts, so unlike the healthy green shoots they sent up when planted in the soil in the spring … under the most adverse circumstances they were striving to become.’⁴
  
  ‘Adverse conditions’ is a very apt way of describing the extremely difficult conditions often faced by substance users, such as homelessness, emotional trauma and desperation, poverty, imprisonment, ill-health, separation from children and loved ones and so on, and which may have led to their problematic substance use, or have been caused by it, or both. In looking at the lives of some of these clients and the way in which substances may be being used, some counsellors may question whether a person’s actualising tendency can be killed off in certain circumstances, as it may appear that there are only destructive forces present.
  
  Understanding the sub-systems
  To understand why our clients sometimes behave in ways that appear to be self-defeating or harmful, we need to understand the development of a sub-system, which in person-centred theory co-exists alongside the actualising tendency, and which client-centred therapists refer to as the selfstructure.⁵ Although the actualising tendency is the only motivational force, and is always moving in a constructive direction, one development of this tendency is the organisation of aspects of our being into this separate sub-system of the self-structure, described by Tony Merry as ‘an organisation of perceptions, precepts, concepts, values and qualities that are either currently in awareness or easily made available to awareness’.⁶
  
  Our self-structure is formed by our life experiences and the value or understanding that we give to these experiences. For example, a person might say, ‘The sun feels pleasantly warm on my face and therefore I like to be in the sun.’
  
  However, our self-structure not only integrates our pleasant experiences, it also has to find a way to incorporate bad experiences. Furthermore, from a very young age we need to deal with external ideas about who we are and how we should behave, from significant others such as our parents or siblings.
  
  If these external ideas conflict with our actual experiencing, then we may distort or deny our own evaluation of these experiences and instead develop internal value judgements called internalised conditions of worth. An example might be the belief of a drug user who frequently overdoses, that he can handle vast quantities of drugs. Perhaps his self-concept has been built around the idea that ‘he is as strong as an ox’. Perhaps his parents showed him love for his strength and disdain for any weakness. This client has a concept of himself and his behaviour that does not match his actual experience.
  
  In describing the development of the self-structure, Merry wrote: ‘A self-structure is developed which, in the absence of threat or perceived threat during its formation, would be entirely open to admitting all experience accurately into awareness. However, some experiences are denied or distorted because they are perceived as threatening the current consistency of the selfconcept.’⁶
  
  The self-concept, even with distortions created by conditions of worth, provides evidence of the existence of the actualising tendency, which works in the interests of the organism to defend the self-structure. Thus, according to Merry, ‘it is possible to conceive of conditions of worth as acting to the individual’s benefit in that they serve to guide the person’s behaviour away from the possibility of further ‘hurt’ or psychological damage’.⁶
  
  This is helpful in understanding why directive approaches can be counterproductive in work with drug and alcohol users. That clients seek to defend their existing self-concept may explain both the high drop-out rate in drug and alcohol services, and also the perception of substance users as ‘untrustworthy’, or ‘liars’. In some circumstances, external evaluations by professionals may themselves become incorporated as new conditions of worth, obstructing the development of the client’s own internal valuing system. These may further coincide with ‘societal conditions of worth’⁷ – the attitudes and discrimination that society holds towards those it designates as ‘junkies’ and ‘drunks’. When drug or alcohol use is given as a reason not to proceed with therapy, then the therapist is effectively saying that he (the client) is not appropriate or acceptable to the therapist, and furthermore is not able to judge for himself the potential usefulness of therapy.⁷
  
  How can counsellors be of help to their clients?
  In their 1991 Handbook of Self Actualisation,⁸ Jerold Bozarth and Barbara Temaner Brodley wrote: ‘The fundamental notion of client-centred therapy is that the therapist can trust the tendency of the client, and the only role of the therapist is to create an interpersonal climate that promotes the individual’s actualising tendency.’
  
  This means that the client will make his or her own progress if we are able to create a suitable therapeutic environment. The core therapeutic conditions of empathy, congruence, and unconditional positive regard are the inter-related conditions that create the environment necessary for therapeutic change to occur.
  
  The curative factor
  Unconditional positive regard, which Bozarth has described as ‘the curative factor in client-centred therapy’,⁹ is often misconstrued as therapists ‘agreeing’ with their clients, whereas in fact it is the opposite of these types of judgments or evaluations.
  
  Rogers put it as follows: ‘To the extent that the therapist finds himself experiencing a warm acceptance of each aspect of the client’s experience as being a part of that client, he is experiencing unconditional positive regard…It means there are no conditions of acceptance, no feeling of “I like you only if you are thus and so”.’¹⁰
  
  Person-centred counsellors convey this acceptance through an empathic understanding of the client. Far from parroting words back to the client, we try to take in the client’s meaning in as full a way as possible, as for example in the following exchange:
  
  Client: ‘When I first started using I… well, I didn’t think I’d keep on using…by now I thought I’d have stopped. Strange to think so many years have passed and here I am…still…’
  
  Therapist: ‘still using….’
  
  Client: ‘Yes. And now I can’t remember why I still do it.’ Therapist: ‘It’s puzzling to you. You started doing it all that time ago and now it’s become…it’s just something that you do.’
  
  In this empathic response the therapist accepts all of the client’s experience, not valuing one aspect any more than any other, nor attempting to go beyond the client’s words, or to push or probe. In Rogers’ words: ‘It is the client who knows what hurts, what directions to go, what problems are crucial, what problems have been deeply buried. It began to occur to me that unless I had a need to demonstrate my own cleverness and learning, I would do better to rely on the client for the direction of movement in the process.’¹¹
  
  Therapist incongruence
  The emergence of strong reactions within us as counsellors, such as a desire to push the client in a certain direction, is an indicator of incongruence, meaning that we may have some issues within us that require attention before we can be fully open to our clients’ experiences. Working on this in supervision or personal therapy is crucial, since person-centred counselling is based on a real relationship between client and counsellor. Bozarth says about congruence that ‘the congruent therapist lives in the session in a way that her conscious and unconscious thoughts and feelings, and her actions and behaviours are in harmony. The therapist’s congruence fosters the relationship as a reality’.⁹
  
  Lessening the client’s conditions of worth
  One of the outcomes of classical non-directive person-centred therapy is a lessening of a client’s conditions of worth (as a result of their feeling accepted and understood), leading to an increase in their congruence (which in other psychotherapeutic traditions might be referred to as their becoming more ‘integrated’ or ‘whole’). Typically, a client who is deeply sad will stop pronouncing that she drinks alcohol because she is happy. And conversely, a client who enjoys drinking will be able to acknowledge this aspect of her use, instead of incongruently claiming to hate drinking. In Rogers’ words, ‘the client is more congruent, more open to his experience, less defensive’³ and this increase in congruence correlates with changes in our clients’ self-concept and behaviour.
  
  Users re-learn how to be themselves
  In conclusion, although counselling drug and alcohol users can be a challenging experience, there is no therapeutic reason to avoid it, since such clients can, and do, benefit from counselling.
  
  Tony Merry illustrates this best when he says: ‘It is not true that our childhood-acquired conditions of worth need control and limit our behaviour forever. If this were so, there would be no such thing as counselling or psychotherapy. In person-centred psychology, it is believed that we can relearn how to be ourselves, and how to free ourselves of destructive or self-defeating behaviour.’¹²

• This article was first published in March 2006, CPJ (now Therapy Today)
  
  Sue Wilders is a person-centred psychotherapist who has worked with drug and alcohol users for 15 years. She has a small private practice and is also the service manager for Turning Point Ealing in West London. Email suewilders@yahoo.co.uk 


  
  Sam Robinson is a person-centred therapist, specialising in bereavement counselling with an interest in person-centred theory.



• References:
  

  1. Talk to Frank: tel 0800 77 66 00, www.talktofrank.com; Drugscope: tel 0207 928 1211, www.drugscope.org.uk; Alcohol Concern: tel 0208 928 7377, www.alcoholconcern.org.uk
  2. National Treatment Agency. Models of care for the treatment of adult drug misusers. London: National Treatment Agency; 2002 (revised 2005)
  3. Rogers CR. A theory of therapy, personality, and interpersonal relationships, as developed in the client-centered framework. In: Kirschenbaum H, Henderson VL. (eds) The Carl Rogers reader. London: Constable; 1989
  4. Rogers CR. A way of being. Boston: Houghton Mifflin; 1980.
  5. Rogers CR. Client-centered therapy. Boston: Houghton Mifflin; 1951.
  6. Merry T. The actualisation conundrum. Person-centred practice. 2003; 11:85
  7. Wilders S. An exploration of non-directive work with drug and alcohol users. In: Embracing non-directivity. Re-assessing person-centered theory and practice in the 21st century. Ross-on-Wye: PCCS Books; 2005
  8. Bozarth JD, Brodley BT. Actualization: a functional concept in client-centered psychotherapy: a statement. Journal of Social Behaviour and Personality. 1991; 6(5):54-9
  9. Bozarth J. Person-centered therapy: a revolutionary paradigm. PCCS Books: Ross-on-Wye; 1998
  10. Rogers CR. The necessary and sufficient conditions of therapeutic personality change. In: Kirschenbaum H, Henderson VL. (eds) The Carl Rogers reader. London: Constable; 1989
  11. Rogers CR. On becoming a person: a therapist’s view of ?psychotherapy. Boston: Houghton Mifflin; 1961
  12. Merry T. Invitation to person-centred? psychology. London: Whurr; 1995