Navigating Professional Complexities When Counselling in Alcohol and Other Drug Settings
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The dynamics of shame: navigating professional complexities when counselling in alcohol and other drug settings Rebecca Gray A thesis in fulfilment of the requirements for the degree of Doctor of Philosophy Centre for Social Research in Health Faculty of Arts and Social Sciences September 2013 THE UNIVERSITY OF NEW SOUTH WALES Thesis/Dissertation Sheet Surname or Family name: Gray First name: Rebecca Other name/s: Margaret Abbreviation for degree as given in the University calendar: PhD School: Centre for Social Research in Health (formerly National Faculty: Faculty of Arts and Social Sciences Centre in HIV Social Research) Title: The dynamics of shame: navigating the professional complexities when counselling in alcohol and other drug settings. Abstract 350 words maximum: Shame, and its connection to problematic alcohol and other drug use, has been widely theorised in counselling literature. Less attention has been paid, however, to the way in which the therapeutic relationship is affected by the context of alcohol and other drug (AOD) settings. This qualitative study gathered the professional accounts of seventeen counsellors and other frontline workers in order to gain new understandings of what enables and challenges their approach to this work. The principles of grounded theory and reflexive practitioner/research informed the analysis, which investigated the initial research question of: how does shame prevent or enable the relational factors of counselling practice in alcohol and other drug settings? Three major insights were developed through this research. The first is that shame is intimately entangled with the labelling of problematic AOD-use behaviour. Terms used by participants, such as 'addiction' and 'dependence', are value-laden and rarely clearly defined. These professionals described clients as being positioned in contradictory and complex ways in relation to their treatment for problematic drug use, and this was described as having the potential to significantly disrupt the counselling process. The second insight is that shame, guilt and stigma are often conflated in AOD counselling. Participants were insightful about the collision between the multifactorial determinants of problematic AOD use and social edicts that define certain drugs as illicit and certain behaviours as pathological. This collision appeared to lead to a series of inherent contradictions in treatment goals. The third insight is that the dynamics of shame create significant workforce issues for AOD counselling professionals. Participants described workplace conflict, undue pressure on individual counsellors, and the pressure to conform to directive approaches. This thesis outlines and discusses these dilemmas and, in doing so, contributes to what is known about counselling practice in AOD settings, especially professional perceptions and experiences of the dynamics between shame and drug use in those settings. New practice implications are articulated for counsellors working with clients around shame issues, and for the more appropriate development and navigation of practice and policy guidelines for counsellino in alcohol and other drua settinas. Declaration relating to disposition of project thesis/dissertation I hereby grant to the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or in part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all property rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation. I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstracts International (this is applicable to doctoral theses only). ... 3.f!.j..4 .. /..1..3. ............. Signature O~ie The University recognises that tliere may be exceptional circumstances requiring restrictions on copying or conditions on use. Requests for restriction for a period of up to 2 years must be made in writing. Requests for a longer period of restriction may be considered in exceptional circumstances and re uire the a roval of the Dean of Graduate Research. FOR OFFICE USE ONLY Date of completion of requirements for Award: THIS SHEET IS TO BE GLUED TO THE INSIDE FRONT COVER OF THE THESIS The dynamics of shame: navigating professional complexities when counselling in AOD settings ORIGINALITY STATEMENT 'I hereby declare that this submission is my own work and to the best of my knowledge it contains no materials previously published or written by another person, or substantial proportions of material which have been accepted for the award of any other degree or diploma at UNSW or any other educational institution, except where due acknowledgement is made in the thesis. Any contribution made to the research by others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project's design and conception or in style, presentation and linguistic expression is acknowledged.' Signed Date ....... 3.9./.1./..1.3 ................................. COPYRIGHT STATEMENT 'I hereby grant the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all proprietary rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation. I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstract International (this is applicable to doctoral theses only). I have either used no substantial portions of copyright material in my thesis or I have obtained permission to use copyright material; where permission has not been granted I have applied/will apply for a partial restriction of the digital copy of my thesis or dissertation.' Signed Date ........ P9/.r:J./..J ..';>. .......................................... AUTHENTICITY STATEMENT 'I certify that the Library deposit digital copy is a direct equivalent of the final officially approved version of my thesis. No emendation of content has occurred and if there are any minor variations in formatting, they are the result of the conversion to digital format.' Signed Date ........... P..?../.~.1! .. ~ ....................................... The dynamics of shame: navigating professional complexities when counselling in AOD settings Abstract Shame, and its connection to problematic alcohol and other drug use, has been widely theorised in counselling literature. Less attention has been paid, however, to the way in which the therapeutic relationship is affected by the context of alcohol and other drug (AOD) settings. This qualitative study gathered the professional accounts of seventeen counsellors and other frontline workers in order to gain new understandings of what enables and challenges their approach to this work. The principles of grounded theory and reflexive practitioner/research informed the analysis, which investigated the initial research question of: how does shame prevent or enable the relational factors of counselling practice in alcohol and other drug settings? Three major insights were developed through this research. The first is that shame is intimately entangled with the labelling of problematic AOD- use behaviour. Terms used by participants, such as ‘addiction’ and ‘dependence’, are value-laden and rarely clearly defined. These professionals described clients as being positioned in contradictory and complex ways in relation to their treatment for problematic drug use, and this was described as having the potential to significantly disrupt the counselling process. The second insight is that shame, guilt and stigma are often conflated in AOD counselling. Participants were insightful about the collision between the multifactorial determinants of problematic AOD use and social edicts that define certain drugs as illicit and certain behaviours as pathological. This collision appeared to lead to a series of inherent contradictions in treatment goals. The third insight is that the dynamics of shame create significant workforce issues for AOD counselling professionals. Participants described workplace conflict, undue pressure on individual counsellors, and the pressure to conform to directive approaches. This thesis outlines and discusses these dilemmas and, in doing so, contributes to what is known about counselling practice in AOD settings, especially professional perceptions and experiences of the dynamics between shame and drug use in those settings. New practice implications are articulated for counsellors working with clients The dynamics of shame: navigating professional complexities when counselling in AOD settings around shame issues, and for the more appropriate development and navigation of practice and policy guidelines for counselling in alcohol and other drug settings. Outputs emanating from this study Journal articles Gray, R. (Winter 2010) ‘Shame, labelling and stigma: barriers to counselling clients in alcohol and other drug settings’, invited paper for Contemporary Drug Problems: an interdisciplinary quarterly,