Counselling and Psychotherapy Author, Consultant in Equalities and Diversity, Counselling and Self-Awareness Trainer
On Becoming an Alcohol Counsellor
From 1995 (to 2003) I worked within the NHS as an alcohol counsellor, working out of Primary Health Care settings. It was not a planned career move, I simply happened to apply for the job having recently obtained my ‘diploma in person-centred counselling and psychotherapy’. It took me into a different world, one that I had little or no appreciation of previously. I knew my way around primary health care (I had previously been a fundholding/development manager at a GP surgery), but people with alcohol problems … it was going to be a steep learning curve.
I am still learning, and I am grateful to have gained the insights that I have. I believe it has helped me to be a more effective counsellor. I sometimes wonder quite what I have that enables clients to feel they can work with me. Feedback from clients confirms ‘you listen’, ‘you don’t make judgements’, ‘you seem to have a sense of what my world is like’, ‘you don’t put me under pressure’.
Whenever I run training events I always ask how many of the counsellors/psychotherapists attending have explored the issues around working with people with alcohol problems during their training, or since. Few answer ‘yes’. Most say ‘no’. It highlights for me that this is an area of unmet training need. I do not mean we have to all become ‘experts’ on alcohol use. As a person-centred counsellor I would not want to classify myself as an expert on anyone else’s life. However, I would argue that a basic appreciation of how alcohol affects the person, why people choose to use alcohol, and what issues often need resolving as part of the process of working with someone with an alcohol problem, is helpful. The effects of problematic alcohol use are widespread, they are unlikely to go away, and in fact are much more likely to become more prevalent and invade our counselling rooms. This for the following reasons:
•More and more people are being socialised into alcohol use, and heavy alcohol use, at an earlier age
•Mental Health Services are concentrating their efforts increasingly on the high risk/high mental health need group of people, and offering less or nothing to ‘alcohol problem only’ patients
•Specialist alcohol services that have historically been ‘health-care or social-care centred’ are finding themselves squeezed by increasing emphasis and funding from the government’s criminal justice agenda.
The result is that the provision of services for people who are experiencing problems with their alcohol use, who have no criminal or serious and enduring mental health problems, is likely to diminish. We can therefore expect to see more members of this increasing client group seeking help through counselling agencies, from counsellors in Primary Health Care settings, from workplace counsellors, from independent counsellors, from all us.
Attitudes to the problem drinker
Are counsellors and psychotherapists equipped to work with this client group? Do they feel confident and adequate to the task? Have they worked through their own issues regarding alcohol problems (others or their own), clarified who they will work with and understood the impact alcohol as an addictive and mood-altering substance can have on the person and it’s implications for building a therapeutic relationship and establishing psychological contact?
There are some fundamental prejudices around. Imagine you have received a new referral. The letter is in front of you. You read it through. You come to the last sentence: ‘This person uses alcohol to cope’. Take a moment to be with what you feel about this. Does it trouble you, or are you simply feeling out to a person who is clearly in distress?
Another referral letter, it is very similar. However, it has a different final sentence: ‘This person is an alcoholic.’ Does this leave you with different feelings and assumptions? How does it impact on your sense of being adequate to the task? We will all have our own feelings and reactions. We need to be clear why we have, where they come from and what effect they will have on the therapeutic relationship that our client might want to build with us.
In the world of alcohol use there are powerful labels around yet not everyone who has a problem with alcohol is drinking through the day, sleeping rough and generally maintaining a somewhat dishevelled appearance that is frequently associated with the word ‘alcoholic’. Most of the people I have seen with alcohol problems you could pass in the street and be quite unaware of their daily struggle.
1 in 25 people are dependent on alcohol, according to Alcohol Concern. There are many more who are experiencing problems, or who are using alcohol as a method of psychological support. Physical or chemical dependence means the person has to drink to avoid going into withdrawal (shakes, sweats, in extreme cases DTs, fits, hallucinations). The dependent drink who suddenly stops can be putting themselves in a life-threatening situation. Others are psychologically dependent
needing a drink to face certain situations: getting out of the house, going to the supermarket, giving a presentation at work, facing the day;
needing a drink to deal with feelings, thoughts or memories on a regular basis: feelings associated with loss, memories of abuse, worries about life
It is not that people plan to become dependent, it develops over time as tolerance increases and more alcohol is needed for the same effect. For people who have accepted the fact that they have, or have had, a problem with alcohol, it is common that they can name the day when it stopped being a solution to something and became instead a problem, or stopped being an enjoyable feature of their lives and started to become an uncontrollable need.
Loss and sensitivity
I have learned an awful lot from my clients. I have realised that many people who develop an alcohol problem have been using alcohol to cope with something difficult or painful. I have also found that most clients are actually very sensitive people, but that they struggle to cope with their ‘fluid emotionality. The alcohol use becomes their chosen method of anaesthetising this sensitivity. This sensitivity may have genetic roots, or it may be the result of traumatic experiences in childhood or adulthood. The issues behind the drinking will need addressing if sustainable change in the alcohol use is to be achieved (Bryant-Jefferies, 2001).
I have also noted how many clients experience significant losses which in their own minds are connected to their use of alcohol. In a snapshot survey of 117 clients it was found that 116 had experienced significant losses (of a parent, friends, childhood, consistent parenting, love, partner, job, relationship) or significant disruption in their lives that were linked to later alcohol use. (Bryant-Jefferies 1999). People are left with heightened anxiety, low self-esteem, lack of confidence, paranoia, depression, obsessive-compulsive traits, all of which people may use alcohol to try and overcome. Clients comment, too, how it is the uncertainty and unpredictability in their childhood that has left them vulnerable to alcohol use. Velleman has written and conducted research on the impact of problematic drinking parents on their children, the family behaviours that stem from problematic drinking and the impact on the child in adulthood (Velleman, 1993, 1995) (Velleman and Orford, 1993).
Person centred approach
I am a strong advocate of a person centred approach to counselling people with alcohol problems. So many people develop reliance on alcohol as a result of problematic relational experiences and it seems reasonable that a relational approach to counselling is likely to be most effective in enabling individuals to re-define themselves and create a more self-reliant and less alcohol-reliant, lifestyle. I therefore regard the attitudinal values of the person-centred approach as having a great deal to offer.
Congruence from the therapist enables the client to experience the extent of their incongruence (often exacerbated by alcohol use) (Bryant-Jefferies, 2000); empathy communicated by the therapist and experienced by the client fosters a clearer sense of their own inner world and of feeling that their world is understandable, allowing them to explore it more fully; unconditional positive regard challenges any beliefs that the client may have of themselves as a person as being worthless or unlovable.
Individuals develop ‘configurations of self’ within the self-structure which the therapist can meet when working at relational depth (Mearns, 1998 ). I find clients developing what I term ‘drinking configurations’. These are discreet identities within the self-structure having attendant sets of feelings, thoughts and behaviours, that are connected with the alcohol use. For instance, the person whose early life experiences were chaotic, arguments between significant others, possible violence, promises not being kept, will provoke anxiety within the child. During teenage years that child, now a young person, discovers that alcohol makes them feel so much better. It takes the edge off their anxieties and nervousness. The potential is there fore this person to create a drinking configuration based on ‘anxious me’. Anxiety will trigger the urge to drink. Where the anxiety is intense, the reaction is instinctual. The triggering of anxiety in later life is comparable to someone putting their finger into a physical would. The person jumps instinctively. People jump instinctively from psychological wounds as well, and the instinct can take the form of turning to alcohol.
People can develop a whole range of drinking and non-drinking configurations of self. Huge conflicts and tensions can be present, and exacerbated as the person seeks change. Providing the therapeutic climate, where warmth and acceptance are conveyed equally to the many fragments of self the client brings into the counselling relationship, helps the person to accept themselves, cultivate new configurations of self in response to the experience of the therapeutic relationship, and heal the psychological wounds that fuel their alcohol use.
The alcohol-affected client
Can one genuinely offer a therapeutic relationship to an alcohol-affected client? My experience tells me that you can, that people do retain the content and the therapeutic impact of sessions even though they have had a drink. Indeed, even if someone is highly intoxicated, the offering of the necessary and sufficient conditions for change has an impact, however minimal. Yet we must all make our own choices on this, and be clear as to why we have made the decision that we reach. I do work with client’s who are alcohol affected. Clients who are alcohol-dependent are having to drink daily to function, to avoid withdrawal reactions that can be life-threatening. I work for a specialist service, so there is an expectation of seeing people in this condition. Yet it is also my choice.
Am I colluding with the drinking behaviour? I am not encouraging them to drink, and I am not discouraging them. I am seeking to be accepting of them as they are. I could reject them, tell them to come back when they are not drinking, but this may simply not be possible for them. They might also be someone who just might be usin333g alcohol to cope with childhood rejection, so another rejection is unlikely to be helpful in my view. I will also seek to be congruent. I will be attending to my own feelings and thoughts which may lead me to voice genuine concern for a client’s health and well-being, or an acute sense of despair that has been unvoiced by the client. It can be hard for people to feel able to trust another with their vulnerability. Alcohol can be a suit of armour, protecting hurt. I want to honour the client’s need for their protection, and as the client feels able, to acknowledge and be with the vulnerable person who is wearing it.
Some people with alcohol problems will want to change, others not. Some will want to focus simply on their drinking patterns and how to change it, others will want a much more in-depth exploration of what is going on for them and fuelling their need for alcohol. It is surely important to able to offer what they are looking for, or if it is something you genuinely feel is beyond your remit, or competence, know who else they might contact for help. All regions have specialist alcohol services.
I am a person-centred therapist and I feel that this approach has much to offer the client group both theoretically and in practice. I am aware that the counselling world has many theoretic views, and ways of working. You may want to check out what your theoretical model has to say about working with people with alcohol problems.
Alcohol Concern (1997) Measure for measures, A framework for alcohol policy. London: Alcohol Concern.
Bryant-Jefferies, R (1999) Dual Diagnosis – Multiple Issues: A Challenge to Service Provision. A talk given at the Durham Addictions Forum, 1999.
Bryant-Jefferies, R (2000) An exploration on the themes of congruence, incongruence and alcohol use. In Bower, D. (ed) (2000) The Person-Centred Approach: Applications for Living. iUniverse.com.
Bryant-Jefferies, R. (2001) Counselling the Person Beyond the Alcohol Problem. London: Jessica Kingsley Publishers.
Mearns, D. (1998) Working at Relational Depth: Person-Centred Intrapsychic Family Therapy. Paper presented at the 1998 BAC Conference.
Velleman, R. (1993) Alcohol and the Family. (Occasional Paper). London: Institute of Alcohol Studies.
Velleman, R. (1995) Resilient and un-resilient transitions to adulthood: the children of problem drinking parents..
Velleman, R. and Orford, J (1993) ‘The Adulthood Adjustment of Offspring of Parents with Drinking Problems.’ British Journal of Psychiatry 162.
This article was published in Counselling and Psychotherapy Journal, August 2001 (BACP, Rugby).
Richard Bryant-Jefferies has had a range of books published addressing alcohol use and other counselling issues that can be accessed at: http://richardbj.co.uk/books/index.html