Navigating Professional Complexities When Counselling in Alcohol and Other Drug Settings

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.

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'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.'

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Abstract

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 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, vol. 37, pp. 685-703.

Gray, R. (November 2009) ‘The Dynamics of Shame: implications for counsellors working across alcohol and other drug settings’, Psychotherapy Australia, vol. 16, pp. 30-36.

Conference presentations

Gray, R. (April 2010) National Centre in HIV Social Research (UNSW) Biennale Conference Sydney: Evolving Knowledge and Practice Oral presentation: ‘Shame, stigma and covert moralism: barriers to counselling clients in alcohol and other drug settings’

Gray, R. (July 2009) Division of Counselling Psychology Annual Conference, Warwick University, United Kingdom (Organised by the British Psychological Society) Riding the tide of change in Counselling Practice. Peer-reviewed oral presentation: ‘Dynamics of shame: implications for counsellors working across diverse settings’

Gray, R. (July 2009) International Association of Counselling Annual Conference, Warwick University, United Kingdom: Counselling and the Challenge of Social Transformations: Promoting Human Dignity Across the Lifespan. Oral presentation: ‘Moralism, stigma and shame: marginalised clients caught between practice paradigms’

Gray, R. (January 2009) SELF Research Centre Biennial Conference, United Arab Emirates: Enabling Human Potential: The Centrality of Self and Identity. Oral presentation: ‘Dynamics of shame: implications for counsellors working in AOD settings’

Gray, R. (July 2008) International Association of Counselling Annual Conference, Malta: Counselling: A Means for Bridging Difference. Oral presentation: ‘Dynamics of shame: implications for the drug and alcohol counsellor when working in residential rehab.’

Gray, R. (November 2008) Australian Professional Society for Alcohol and other Drugs Annual Conference, Sydney: Evidence, Policy, Practice. Poster Presentation: ‘Dynamics of shame: implications for counsellors working in AOD settings - emerging themes’

The dynamics of shame: navigating professional complexities when counselling in AOD settings

Gray, R. (March 2008) National Centre of HIV Social Research Biennial Conference, Sydney: The 10th Social Research Conference on HIV, Hepatitis C and Related Diseases, Everyday Lives. Oral Presentation: ‘The dynamics of shame: implications for drug and alcohol counsellors’

The dynamics of shame: navigating professional complexities when counselling in AOD settings

Acknowledgements

I acknowledge the traditional owners and custodians of the lands of New South Wales and pay my respects to the Elders, families and ancestors.

Several people were instrumental in the completion of this thesis. I owe much to my three academic supervisors who influenced the formulation of my research question, supported me in gaining the skills I needed to undertake this task and critiqued the many drafts of the text. I acknowledge Dr Robert Reynolds, my first supervisor, who provided insightful and empathic feedback that helped me adapt to an academic context and articulate my research question. His approach to supervision was both witty and wise and I thank him for his input. I acknowledge Dr kylie valentine, my joint supervisor, whose ongoing support has adapted to my evolving candidature. Our intelligent discussions were inspiring and facilitated a clearer expression of my findings and I thank her for her input. I acknowledge Dr Christy Newman who began joint supervision at a crucial stage of the project. Her flexible and energetic involvement enabled the completion of the project and helped me to maintain my stamina throughout the final stages. Her intelligence and attitude to academic work are both an example and an inspiration and I thank her for her input.

In addition to my academic supervisors, I acknowledge the tutors and colleagues who contributed to my learning. Dr Kane Race was my post graduate coordinator at the outset of the project and his seminars for the “Bodies, Habits, Pleasures” module were both exciting and challenging. His intelligence and commitment are awe-inspiring. I also acknowledge Dr Jeanne Ellard, my post-graduate coordinator during the bulk of my candidature. Her support and sense of humour were therapeutic and refreshing, and her door was always open. Her tutoring in the Qualitative Methods module was invaluable in providing the tools and processes required for me to undertake my research tasks and her knowledge of ethical concerns and interpretative styles has enabled me to work as a social researcher both as a student and as an employee. I also thank Dr Carla Treloar and Dr Loren Brener who gave me the opportunity to develop my research skills in a professional context. The field work and analytic processes were

The dynamics of shame: navigating professional complexities when counselling in AOD settings

fascinating and observing their management of complex projects in sensitive areas was educational.

I also acknowledge my high school teachers Alan Brookes, Robin MacGibbon and Chris Taylor who taught me at Northolt High School, throughout the late 1980s and early 1990s. Mr Brookes, Mr MacGibbon and Mr Taylor worked hard to facilitate challenging and exciting learning environments and went out of their way to support my education and develop my potential. They were supportive during some difficult and overwhelming personal events and had it not been for their input, I doubt I would have passed my examinations or made it to university. Above all, they listened to my ideas and treated me with respect, an unusual occurrence in a large comprehensive high school in a poor London suburb. Despite the passing of two decades, I still think of our conversations and use their insights to guide me. I thank them for their influence and encouragement.

Alongside my academic and professional development, I gained support from my clinical supervisor Julie Rea. Her experience and knowledge are inexhaustible. Words fail to convey the gratitude I feel towards our therapeutic relationship which has been formative in all aspects of my life. Our discussions have helped me develop my skills as a practitioner, but also hugely influenced my approach to my thesis and the ways in which I developed my relationships in my professional and personal life. Her empathy, integrity and humour are a constant guide. I thank her for her invaluable input.

This thesis would not have been possible without the contribution of the participants who offered their time and who opened their professional and personal lives to my scrutiny. The rich contributions made in their interviews resulted in a challenging and complex analysis that was both intimidating and rewarding. The implications and suggestions of this thesis draw heavily on their expertise and I thank them sincerely.

I would also like to acknowledge my grandmothers, Margaret St Clair Gray and Adrienne “Shirley” Black. I come from a family of stoic women, and their resilience and intelligence were an influence on my formative years. Granny Gray was always excited to hear about my university studies and her enthusiasm buoyed me to continue

The dynamics of shame: navigating professional complexities when counselling in AOD settings

despite limited resources and external pressures. Even after they had died, they continued to be the role models I needed to overcome some difficult and painful experiences. I dedicate this thesis to them.

Finally, I acknowledge my partner David Jory. He supported me throughout this project, and provided a sounding board, proofreading services and patience when I lacked time and perspective. He is a kind and insightful man whose ability to use wit in the face of adversity is humbling. With Dave, I became the proud mother of a beautiful and energetic daughter, Georgia Louise Gray-Jory. Her constant curiosity and innocent wonder made the world new again. I hope to use the experience and knowledge gained during the creation of this thesis to assist me in relating to my family with honesty, sensitivity and kindness. I dedicate this work to you both.

The dynamics of shame: navigating professional complexities when counselling in AOD settings

Contents

1. Introduction ...... 1 1.1 Background ...... 3 1.2 Overview ...... 8

2. Literature Review ...... 10 2.1 Theories of counselling ...... 10 2.1.1 Studies on the effectiveness of person-centred counselling ...... 14

2.1.2 Counselling in an Australian context ...... 17

2.2 Theories of alcohol and other drug use ...... 18 2.2.1 Theories of AOD treatment and counselling ...... 23

2.2.2 The local AOD workforce ...... 27

2.3 Theories of shame ...... 30 2.3.1 The dynamics of shame: counselling for shame and problematic AOD use ...... 33

2.4 Summary ...... 36

3. Methodology ...... 38 3.1 Research design ...... 38 3.1.1 Constructivist grounded theory ...... 39

3.1.2 Reflexive practitioner/research ...... 41

3.2 Data collection and analysis...... 43 3.2.1 Initial phase of data collection ...... 44

3.2.2 Focused phase of data collection: theoretical sampling ...... 46

3.2.3 Thematic suggestion ...... 50

3.3 Ethical issues ...... 52 3.4 Assumptions and limitations ...... 53 3.5 Summary ...... 55

The dynamics of shame: navigating professional complexities when counselling in AOD settings

4. Participant profile and textual data ...... 57 4.1 Interview participant characteristics ...... 57 4.2 Interview data...... 61 4.3 Textual data ...... 62 4.4 Summary ...... 63

5. What is the presenting problem? Negotiating definitions of addiction when counselling in AOD settings ...... 64 5.1 Negotiating definitions of AOD use and addiction...... 64 5.2 Motivating counselling clients in AOD settings ...... 71 5.3 Inviting responsibility through counselling in AOD settings ...... 81 5.4 Conclusions ...... 94

6. Navigating the dynamics of shame when counselling in AOD settings ...... 97 6.1 The ubiquity of client shame in AOD settings...... 99 6.2 Managing shame and trauma when counselling in AOD settings ...... 107 6.3 The dynamics of shame and stigma when counselling in AOD settings ...... 116 6.4 Interrogating negative labels when counselling in AOD settings ...... 124 6.5 Conclusions ...... 132

7. Dynamics of shame: workforce issues for counselors in AOD settings ...... 136 7.1 Professional challenges of counselling in AOD settings ...... 136 7.2 Different ways of working with shame and ‘addiction’ ...... 144 7.3 Managing the maverick: the personal impact of counselling in AOD settings ...... 150 7.4 Conclusions ...... 162

8. Summary, conclusions and implications ...... 165 8.1 Summary ...... 165 8.2 Conclusions about the research question: implications for practice ...... 167 8.3 Limitations of the research project ...... 175 8.4 Suggestions for future research ...... 176

8. References ...... 178

Appendix One: Recruitment flyers

The dynamics of shame: navigating professional complexities when counselling in AOD settings

Appendix Two: Interview guide Appendix Three: Coding framework

1. Introduction

This thesis is based on a study which used social research methods to explore how alcohol and other drug (AOD) workers, particularly counsellors, perceived and dealt with shame in their clients. I use participant accounts from qualitative interviews and textual data sourced from service homepages to describe the complex and contradictory ways in which clients are positioned in relation to their treatment for problematic drug use, and consider how this can disrupt the counselling process.

In clinical literature directed at counsellors who work with clients presenting with AOD issues, shame is often described as a cause for problematic drug use and a treatment barrier in the therapeutic relationship (Potter-Efron 2011; Dearing and Tangney 2004; Lee & Wheeler 2003, preface; Pattison 2000; Potter-Efron and Potter-Efron 1999; Kaufman 1996; Lewis 1995; Kaufman 1992; Potter-Efron 1989; Fossum and Mason 1989; Bradshaw 1988; Cook 1987). These texts provide case studies or clinical suggestions for counsellors of clients presenting with shame but do not provide practice guidelines that take into account the diverse range of settings in which they work. Indeed, I will argue that the philosophical and psychological frameworks of counselling are often at odds with the medicalising, moralising or punitive culture that can be typical of many AOD treatment settings. Further, critical analyses of ‘addiction’ or treatment settings tend to conflate counselling practice with peer based organisations and self-help literature when noting the pathologising and labelling dynamics inherent in medical and moral discourses (see Keane 2002 and Kippax 2008). In this thesis, I explore the complexities of counselling AOD clients around shame, given the influence of these various treatment settings and philosophical frameworks.

This large body of work provides suggestions and interventions for counselling clients who present with shame. There is, however, a dearth of research on how the context, in this case the AOD treatment setting, affects counselling practice (Kirsh & Tate 2006), and how this in turn affects client experiences of shame. AOD treatment is not currently standardised, nor cohesive, and potential clients to an AOD service will experience a wide range of settings. These include charitable organisations, private

The dynamics of shame: navigating professional complexities when counselling in AOD settings

rehabs or health services and may be residential, based on out-patient processes or available through peer based self-help organisations, like Alcoholics Anonymous (AA). Each setting will be informed by an understanding of addiction that is based on a range of principles, including one or all of the following: the ‘disease’ model that defines addiction as an affliction requiring abstinence; the therapeutic model that attempts to address the underlying issues that inspire drug use by means of a relationship or working alliance; or the behavioural model that attempts to address the current negative coping strategies by providing alternative mechanisms.

Research evidence on the outcomes of AOD interventions is complex and inconclusive. Survey data demonstrates that rates of recovery for those who receive treatment are similar to those who do not receive treatment (Schaler 2011, p.216; Klingemann & Sobell 2001; Schaler 2000; Fingarette 1988; Waldorf 1983; Edwards et al 1977). Some commentators point out that the vast majority of problematic drug users spontaneously recover without recourse to formal treatment (Blume 2005, p.18). For many, though, timely access to appropriate treatment is the beginning of sustained recovery (Rose & Farrow 2010). At present, AOD treatment is a common and often prescribed strategy for those members of society who are deemed ‘substance dependent’ or ‘addicted’ and who may be court-mandated to attend. This is not to say that all clients of AOD services are attending under duress. Previous research, however, has neglected to recognise the variability of motivational factors in treatment outcomes, including the difference between clients who self-refer to treatment strategies and those who are mandated (Klag, O’Callaghan and Creed 2004).

Even a cursory review of the literature reveals that the field of ‘addiction’ research engages with disparate and often value-laden definitions of what constitutes use and problematic use of alcohol and other drugs. As a result, AOD treatment settings are subject to a range of legal, social and political influences that result in complex funding stipulations and policy dictates. Definitions and reactions to drug use are contested and vociferously debated, which is unsurprising given the shifts in public opinion towards alcohol and other drugs over the past hundred years, and the high levels of prohibition directed toward some substances and practices (Buchanan 2006; Wodak and Moore 2002; Buchanan & Young 2000). Given the resulting stigmatisation and discrimination

The dynamics of shame: navigating professional complexities when counselling in AOD settings

that occurs for people who use drugs, some researchers have highlighted the potential of clients to be further shamed by the internalisation of negative social attitudes towards such practices (Luoma, Kohlenburg, Hayes, Bunting and Rye 2008). As counselling is an integral part of interventions for problematic alcohol and other drug use in formal treatment settings, counsellors working in AOD settings need to consider the additional challenge this presents for their clients.

The research questions and aims of this study evolved throughout the research process but were never intended to prove that counselling should be the preferred strategy for treating clients with alcohol and other drug issues. As a trained counsellor, I have an investment in my chosen profession and hold beliefs about the positive benefits of a therapeutic relationship, but the aim of this study was not to assert the value of counselling against other treatment outcomes. Rather, I am interested in exploring the ways in which counselling practice is affected when it is undertaken in arenas that potentially hinder the tenets and ethical position of the process. The goal of this study is not to prove that counselling should be provided as part of AOD treatment. Arguably, counselling practice is grounded in the idea that a client must initiate the process. To compel an individual into counselling is in itself a contradiction. Ultimately, I wish to understand how counsellors might manage the potentially contradictory dynamics that relate to their work in AOD settings, and thus do the least possible harm to their clients. In this thesis, I present the clinical dilemmas that have emerged in the literature and record the everyday experiences and perceptions of counsellors working in (and outside) the AOD field. I hope this will provide other counsellors with a set of guidelines for practice that may assist them in navigating these ethical dilemmas and managing the challenges of working in such a field.

1.1 Background In this section I will summarise my training and professional experience as it relates to this topic and then describe the professional experience I have gained in working as a counsellor in an AOD setting. This description should help to clarify what led to the conceptualisation of my research question and resulting thesis as the project was inspired by my working experiences.

The dynamics of shame: navigating professional complexities when counselling in AOD settings

I began training as a counsellor and group worker four years after arriving in Australia as an emigrant from England. I had been employed as a youth worker in London and was therefore familiar with concepts like social justice and strengths-based facilitation. At university I gained an undergraduate degree in English language and literature where I was exposed to various literary theories, such as psychoanalysis and deconstructionism. This led to a Masters in Critical Theory where I specialised in Post Structuralism and Freudian psychoanalytic thought. Through the process of the Master’s degree, I became more interested in political philosophy, in particular analysing processes and texts in order to uncover the inherent contradictions that relate to identity formation or assignation. Once in Australia, I decided to undertake vocational training in counselling because I had had positive experiences as a client of counselling and was familiar with many of the philosophical theorists that had influenced counselling, such as, Freud, Jung, Lacan, Husserl, Levinas and Buber. I chose an institution that taught generalist counselling and techniques from systemic approaches (Australian Institute for Relationship Studies (AIRS) at Relationships Australia NSW). Through this process, I engaged first in voluntary work and then secured a paid counselling position seven months before I was qualified. This position was at a women’s dual diagnosis residential rehabilitation service (non-government organisation). The term ‘dual diagnosis’ describes the comorbid condition of a person considered to be suffering from a mental illness and an alcohol and other drug problem. Thus, a dual diagnosis clinic will accept and treat clients with a mental health diagnosis and a problem with alcohol and other drug use.

When interviewed for this paid position in the residential rehab, I had thought I was being hired as a counsellor. Upon receipt of my contract I realised my job title was Alcohol and Other Drug (AOD) Worker. I had not had AOD training and was obliged to undergo additional training by the service in urinalysis, medication distribution, needle and syringe disposal and interagency liaison. It is common for an AOD worker to engage in informal therapeutic activities, such as peer group facilitation or emergency support. I have since learned, however, that the role of a counsellor and an AOD worker are generally distinct in most AOD settings. The main outcome of my dual roles was that I was expected to undertake the tasks of an AOD worker, such as, gathering urine samples or searching client bags on intake, as well as facilitating

The dynamics of shame: navigating professional complexities when counselling in AOD settings

psychotherapeutic groups or engaging in individual counselling with long term clients. I have come to understand that this resulted in unethical overlaps of my duties, in particular various conflicts of interest in relation to my clients and colleagues. For example, an intake process to a facility would normally be administrated by an intake officer who would not engage in clinical work with the clients. In any counselling service with multiple counsellors, intake would usually be undertaken by a receptionist or secretary. At the service where I worked, the senior caseworker would monitor the waiting list to assess the appropriateness of potential clients. Should a potentially challenging client be accepted to the service, she/he would be allocated to me. As a newer member of staff, I was deemed ‘fresher’, and therefore possessed of more energy to cope with ‘complex clients’. This situation created a conflict of interests. My senior colleagues would cherry-pick their own clients as they were reluctant to take ‘complex clients’. These were often women with a diagnosis of Borderline Personality Disorder, or a history of injecting drug use, and were perceived as being too difficult to work with. Such a discriminatory assessment has the potential to negatively influence how a counsellor might approach her/his new client, if they feel that they are being presented with clients who have a label of ‘too difficult’. This way of working potentially fosters an environment that leads to burn-out of the individual worker who is over-loaded with clients presenting with complex needs.

Professional group supervision would include discussion of how much the client should be told about treatment, prior to entry to the service. A client in early recovery is often viewed as ‘unmanageable’ or ‘chaotic’ and, therefore, incapable of making ‘healthy’ decisions. After having been trained to view clients without prejudice or labels, I could not understand how such labels might benefit the client’s change process. When I raised my concern I was told that when I was more experienced I would understand. I was also told that “addicts are rule-breakers”, that I had to be aware I would be challenged around my boundaries, and that “addicts have no boundaries”. I had to be a good role model, staying rigidly within my boundaries, being professional at all times. From what I witnessed, to enter a rehab is to be labelled as an ‘addict’ or an ‘alcoholic’ and viewed in the context of a range of associated negative appraisals, like ‘unmanageable’, ‘chaotic’, or ‘difficult’.

The dynamics of shame: navigating professional complexities when counselling in AOD settings

Clients at this service must adhere to strict guidelines. Discussion between clients and staff about these boundaries was viewed as unhelpful. At this time, I was witnessing a culture where it appeared that the onus was on the client to accept the treatment as set by the workers. I also understood these practices to be potentially shaming. For example, it was common in the first stage of treatment (first month of six months), for clients to be forbidden to leave the facility unsupervised. They had to hand over their keys, phones and bank account cards. In some cases, clients were strip-searched. Intake procedures could take up to two hours. This included contract-signing and clients being asked to offer a signed agreement to a wide range of rules, such as “I will not engage in passive aggressive behaviour”. Where the client had limited literacy this intake procedure could take even longer.

These procedures were outlined in the promotional material of the service, which clearly stated that intake-eligibility-criteria included the statement “applicants must sign an agreement to follow program structure, guidelines and rules.” Despite the intake eligibility criteria stating that signed agreements were required, I believed this minatory statement to be at odds with the environment described on the service’s Internet home-page: “we aim to provide a safe, nurturing and supportive environment essential for recovery and for developing a drug free lifestyle” (viewed April 9th, 2009.) This was not an unusual description of the treatment environment as promoted on AOD service homepages. Similar descriptions were used by a range of settings, such as private, charitable, health and psychotherapeutic. Typically, descriptions included: “a safe and welcoming environment”, “a non-judgemental and supportive environment” or “compassion, respect and understanding underpins everything we do”.

Clients had to produce weekly urine samples throughout their stay, and throughout aftercare to satisfy the child protection services or the Magistrates Court of their ongoing sobriety. The result of breaking these contracts would be a loss of privileges or ejection from the facility. This ‘loss of privileges’ might include removal of ‘time off’ or recreational items like music CDs, or could involve punishments like scrubbing the skirting boards throughout the residence. Not only was this attitude towards clients in stark contrast to the one I had received in my counselling training, it was compromised by contradictory views of clients as being both powerless and yet maintaining

The dynamics of shame: navigating professional complexities when counselling in AOD settings

responsibility for their situation. In another section of the service’s Internet homepage the mission statement reads:

We are committed to assisting women who are dealing with the impact of domestic violence, eating disorders, sexual abuse and depression [...] our mission is to create a service which will assist women to take responsibility for their decisions and their lives. To take a courageous look at where they have come from, why they are here and where they wish to go now. Taking responsibility is the first step on the road to empowerment. (viewed April 9th, 2009)

I found the contradiction of imposing sanctions and punishments while paying lip- service to client responsibility deeply unsettling and it ultimately led me to withdraw from the industry after a period of twelve months.

It could be argued that voluntary, or self-referring, clients enter rehab in order to be supported, treated and monitored around their problematic drug use. Due to the dangers of overdose, seizure and self-harm it is important that a client who still craves be watched and that timely treatment be available. I was aware of incidents where unsupervised clients continued to use drugs in treatment and this was a source of temptation to other clients who were at risk of relapsing. Also, a mix of prescribed medication and illicit drugs can be dangerous, as the overseeing medical practitioner would not be able to monitor dosage or the possible interaction between substances. In keeping with the involuntary intervention model used in various clinics where mental health issues are prevalent, a decision may be made which over-rides clients’ desires or choices, in order to keep them sober and alive. As a result of my professional experience working in a dual diagnosis service, however, I question the use of involuntary interventions, as it is a mandate that is open to exploitation by staff members. Further, given the lack of clear delineation between mental health diagnoses, it is hard for workers to decide where to draw the line in relation to mental health ‘incompetency’. This raises further questions as to the extent to which this approach is actually violating the clients, and to what extent these coercive treatment plans and involuntary interventions actually counteract treatment objectives.

The dynamics of shame: navigating professional complexities when counselling in AOD settings

In this research I was interested in understanding the extent to which a coercive environment generates potentially shaming and punitive practices. I also explored the extent to which the effect of labels and discrimination affect treatment, given the potential stigmatisation of clients. Finally, I acknowledge the influence that my training in political philosophy and generalist counselling techniques has had on this study, namely that I had an awareness of the inherent power dynamics at work within workplace settings, and how this related to the tenets of person-centred counselling.

1.2 Overview The thesis is organised into eight chapters. Chapter Two will provide an overview of the literature relating to: a) counselling philosophy and techniques, b) counselling in an Australian context, c) drug use and problematic drug use, d) treatment for problematic alcohol and other drug use, e) the Australian AOD workforce, f) theories of shame, and g) counselling implications for shame and problematic drug use. Chapter Three will provide a detailed description of the methodology employed while Chapter Four will provide an overview of the data collected and outline the subsequent findings chapters.

The three findings chapters describe and interpret the analysis of the interview and textual material, which have been organised into recurring themes. Chapter Five outlines the complex understandings that participants had of drug use including their perception of the determinants of problematic drug use. In this chapter I also explore how participants’ accounts incorporated and conflated contradictory notions of drug use and their reluctance to define drug use in ways that were viewed as totalising, generalising or shaming in therapeutic dialogue. Chapter Six is focused on shame in participants’ accounts of counselling in AOD contexts, with stigma framed as an important issue for clients presenting at AOD services. Chapter Seven examines participants’ experiences of working as counsellors in AOD settings, including workplace conflicts and the undue pressure placed on individual workers. By taking this approach, I am interested in spelling out the ways in which counsellors are compelled to choose between maintaining an ethical position in relation to counselling tenets and prioritising an approach that prevents further shaming of clients, or abandoning these and adopting a clinical stance that is in line with team and service

The dynamics of shame: navigating professional complexities when counselling in AOD settings

structures. Chapter Eight considers these ethical tensions more directly and provides suggestions for ways in which counsellors and other allied health workers might more satisfactorily navigate the complex and value-laden territory of AOD treatment centres. This final chapter will also provide suggestions for future research.

The dynamics of shame: navigating professional complexities when counselling in AOD settings

2. Literature Review

The literature review for this study was ongoing and undertaken in two phases. During the first phase I explored the existing literature on shame, counselling and problematic drug use, as well as key texts for the research design process. The second phase took place during and after data collection and analysis. This process enabled me to engage in inductive, deductive and abductive ways of thinking, and to make inferences from the data, opening up new possibilities for understanding the phenomenon (Ezzy 2001). Through this process, I was able to move between generating categories from data (induction) to considering the fit with other data (deduction) (Dingwall, Murphy, Watson, Greatbatch and Packer 1998), before arriving at an explanatory hypothesis (abduction). During the data collection and analysis phases, the literature review was constantly updated in response to emerging themes, and to enable the generation of new approaches to the analysis. The goals of this literature review are to present existing literature on shame, counselling and problematic drug use, and to provide an indication of the limits of this research and show the gaps in the field. I also describe the research drawn from other fields of inquiry that informed the conceptual framework employed during the analysis phase. In terms of structure, this chapter presents an overview of the most important theories and debates on counselling, shame and problematic drug use.

2.1 Theories of counselling While psychological therapies trace a common history back to the work of Sigmund Freud, many modern approaches to counselling incorporate, or are grounded in, other bodies of thought, such as philosophy, medicine and theology (Cooper 2007; Martin, Garske & Davis 2000; Miller 2000, p.6; King 2002; Storr 1990; Lomas 1966, p.116). Rather than being resolved through academic and clinical debates, these different schools of thought have largely been absorbed into subsequent approaches that aim to combine the positivist and humanist traditions. The term “counselling” was adopted by Carl Rogers because as a psychologist he was not permitted by the psychiatry profession to call himself a psychotherapist (Mulhauser 2009; Grant, Mullings and Denham 2008; Rogers 1974; see also Strachey 1970). Subsequent theorists and practitioners have used different terms to describe the different aspects of the

The dynamics of shame: navigating professional complexities when counselling in AOD settings

relationship, such as therapeutic alliance, working alliance, therapeutic bond, and helping alliance (Martin, Garske & Davis 2000). For the purpose of this literature review, I will adopt the term used by the author at hand, and I will then resume my use of the term counselling for the remainder of the thesis. This is due to the fact that while an intervention can be imbued with the qualities of a therapeutic alliance, such as a case management session that is somewhat relevant, I am focusing here on the facilitative aspects of counselling practice.

The seminal good practice framework, outlined by the British Association of Counselling Psychology (BACP 2009), suggests that counselling is usually enacted at the request of the client because no one can be 'sent' for counselling. The aim of the counsellor is to listen attentively and patiently, in order to perceive difficulties from the client's point of view and help her/him to see things more clearly, or from a different perspective. Counselling, then, is a way of enabling choice, or change, or of reducing confusion. It does not involve giving advice or directing a client to take a particular course of action and counsellors should not judge or exploit their clients in any way (The BACP’s Code of Ethics was also used as a basis for outlining the ethical framework used by the Psychotherapy and Counselling Federation of Australia, see PACFA (2012) Code of Ethics, p.3). In addition to Carl Rogers, contemporary counselling method in Australia has been influenced most heavily by the work of Gerard Egan, whose counselling text is widely used in Australian training courses (Miller 2000; see also Egan 2002). Their combined approaches have resulted in an approach that can be described as strengths-based and person-centred (Nelson-Jones 2001; Ivey, Ivey & Simek-Morgan 1997). Ultimately, the emphasis within contemporary counselling practice is on strengthening the relational dynamics between counselling professionals and their clients.

Kirsch and Tate (2006) wrote that therapeutic processes in community mental health settings have been heavily influenced by psychotherapy and counselling articles (see also Busseri & Tyler 2004). The concept of the ‘working alliance’ has been emphasised by community health researchers and practitioners and described as a key ingredient within therapeutic processes. However, few studies have provided insights into the dimensions and operationalisation of the concepts (Kirsh & Tate 2006). Some authors

The dynamics of shame: navigating professional complexities when counselling in AOD settings

have reflected that this has necessarily involved the adoption of conceptual frameworks and measures outlined for psychotherapy in the community mental health field (McCabe & Priebe 2004). Literature on service delivery sheds some light on the principles relevant to the therapeutic relationship. This literature also reflects a high value placed on the professional/client relationships (Hromco, Lyons & Nikkel 1997) and points to the wide variety of roles adopted by community mental health practitioners (Williams & Schwartz 1998). Researchers have maintained that community health service delivery models require special training to enable the development of collaborative relationships with clients and to balance structure and support effectively (Kanter 1989). In the mental health/recovery literature, much has been written on the need to see the person beyond the illness, the importance of capitalising on strengths, and the value of hope (Jacobson & Greenley 2001). Techniques that help the practitioner to achieve these aims are seldom, however, elucidated, leaving professionals with few strategies to guide them (Kirsh & Tate 2006).

A revision of Rogers’ main points outlines the elements of the relationship that have influenced counselling practice, builds upon the guidelines listed by BACP, and provides a contrast to the observations and experiences described in the introductory chapter. Central to his theories and practice suggestions, Rogers advocates for a client or person centred approach, that is, adopting an approach that resists imposing diagnoses or judgements on the clients presenting problems and instead focuses on helping the client in relation to how they conceptualise or describe their problems. Rogers states that three things are essential to the therapeutic relationship: authenticity, empathy, and unconditional positive regard. For counsellors to be authentic, they must remain congruent in what they think and what they say (Rogers 2004). Rogers resolved to drop the façade of the expert and instead retained his honesty about his own flaws and vulnerability (Rogers 1995). This is intended to enrich the relationship with clients, which results in constructive (rather than defensive) conversation and includes spontaneous, humane responses to client statements, unconcerned with external diagnoses (Rogers 2003). Second, to be empathic requires the counsellor to focus on the client’s frame of reference, and to remain non-judgemental (Rogers 2003). The concept of empathy plays out in Roger’s approach in a number of ways. At the very

The dynamics of shame: navigating professional complexities when counselling in AOD settings

least, it requires the counsellor to not just listen to the client’s narrative but to really hear it. This is intended to counteract the possible distress and frustration that a client might experience by not being properly understood by the clinician. In order to really hear the client, the counsellor must be open to understanding the whole of the person, including her/his experiences, values and interpersonal relationships. He describes this as hearing deeply (Rogers 2003, p.98), permitting what the person says to resonate in her/him and her/his own physical/emotional experience. This is in stark contrast to the clinical or medical model that requires the practitioner to remain aloof, unaffected and objective. The counsellor cannot just do empathic, they must be empathic which involves empathic listening, which is attending, observing, listening and identifying with the client (Yalom 2006; O’Leary and Sheedy 2006, p.167; Egan 2002). Counsellors are thus required to draw from their own experiences, to be in a frame of mind which makes it possible to remain open to another person’s story, and then to demonstrate empathy through tone of voice and a verbal response which indicates the emotional reaction in the counsellor.

Clearly, there is an implicit tension in a client-centred approach. Counsellors are obliged to retain their sense of self or personhood while simultaneously using that personhood to encourage expression in the client, and forgoing their self’s needs for the benefit of the client. The practitioner’s sense of self plays an important role in the process and cannot be easily separated from it (O’Leary and Sheedy 2006; Yalom 2006; Cooper 2007; Yalom 1991, p.14). This requires extensive self-reflection and ongoing supervision which has been a long term aspect of the tradition (O’Leary and Sheedy 2006; Cooper 2007; Perls 1969; Freud 1937). Thus the approach is not well suited to every professional because the practice is as much about the professional’s own humanity as that of the client (Cooper 2007). As such, an integral aspect of counselling practice is the commitment to personal development. Personal development allows practitioners to explore and clarify their own values, enabling them to be more authentic with clients in order to avoid the dangers of negative feelings, misperceptions and conflicts of interest. Being a therapist does not preclude an individual from being biased or prejudiced (O’Leary and Sheedy 2006) but as Etherington (2008, p.210) has illustrated, through a personal account, worker-self-development enables greater awareness of the dynamics of trauma, shame and reluctance that might otherwise

The dynamics of shame: navigating professional complexities when counselling in AOD settings

inhibit the relational process. Personal development has been described as a prerequisite to empathy that allows for the counsellor to experience the feelings of clients without the loss of their own separateness (O’Leary 1982).

In describing unconditional positive regard and the possible challenges in maintaining this, Rogers reiterated the need to abandon the professional standpoint that can distance counsellor from client and examined the barriers to maintaining a relational stance in counselling practice. Rogers (2004) maintained that the responsibility is on the counsellor to manage her/his fears, boundaries and experiences for the benefit of the client. The power inherent in treatment relationships is modified by an expectation that the counsellor optimistically assumes that the individual is basically able to: relate, even when exhibiting intimacy issues; respond, even when suffering a mental health diagnosis; and change, even when the behaviours have been fixed in place for a considerable length of time. Professional boundaries and strategies for maintaining confidentiality are established in early sessions, and clients and their counsellors may revise and re-negotiate these as the work progresses (Rogers 2003; Egan 2002).

2.1.1 Studies on the effectiveness of person-centred counselling Criticisms of person or client-centred counselling, and Rogers’ techniques, focus on the theory of self-actualisation, the nature of empathy, and aspects of authenticity. Critics argue that the approach is based on false concepts, and is incoherent (Geller 1982) and unworkable in practice (Kahn 1999). While researchers have pointed out that most critiques misunderstand the concepts of person-centred therapy, (Bozarth 2002; Guthrie-Ford 1991), ongoing academic commentary describes the potential of the model to oversimplify the therapeutic process, and to engender professional passivity (Kahn 1999; Quinn 1993). Some question the universal assumption that people have a basic tendency towards actualisation, or optimal psychological functioning and growth (Guthrie-Ford 1991), or that the Rogerian model is able to address change factors or issues of human development satisfactorily (O’Leary 2006). In particular, researchers have questioned the model’s suitability for working with abusive and violent clients (since empathising with clients who use violence and abuse is problematic) (O’Leary, Chung & Zannettino 2004; Quinn 1993,) or suggest that it is inappropriate to use in

The dynamics of shame: navigating professional complexities when counselling in AOD settings

settings that aim to facilitate behaviour change, due to a reluctance to exert authority over clients (Kahn 1999; Storr 1990; see also Rogers & Skinner’s Debate 1956).

A recent meta-analytic review has outlined the empirical evidence supporting the effectiveness of person-centred therapy (Cooper 2010, p.162) and there is a growing body of work on how a counsellor might apply this framework within contexts of behaviour change, coerced attendance or with clients who report violent and abusive behaviours (Jenkins 2009; Jenkins 2001, p.206; White and Epston 1990, p.59). Findings to date suggest that the research methods used to evaluate person-centred counselling need improvement. Persistent criticism points out that studies that prove the effectiveness of counselling can be accounted for in terms of an allegiance effect (Cooper 2010) and have been developed almost exclusively from a stance that aims to support the model (Kirsh & Tate 2006). More independent studies are needed (Cooper 2010, p.158) as are alternative methods of research (Kirsh & Tate 200). There are also doubts about the extent to which research findings inform current practice. Some commentators have accused practitioners of working within an information vacuum and call for better dissemination of research findings to the frontline workforce (Murray and Welch 2010; Maiuro and Eberle 2008; Bogard and Mederos 1999; Jacobson and Gottman 1998).

Work grounded in mental health settings has focused on the measurement of the strength of the alliance between the counsellor and client (Fenton, Cecero, Nich, Frankforter & Carroll 2001), the association of that alliance to outcomes (Horvath & Symonds 1991; Weerasekera, Linder, Greenberg & Watson 2001) or psychotherapeutic interpretation of the dynamics of the therapeutic relationship (Sauer, Lopez & Gormley 2003; Thurston 2003). The significance of the working alliance in community mental health is addressed to only a limited degree in the literature (Kirsh & Tate 2006). In a published review of literature examining associations between therapeutic alliance and outcomes for mental health case management by Howgego and colleagues (2003), the link was described as sparse but encouraging. These reviewers conclude that focusing on relationship strategies has the potential to enhance service provision. The ingredients of the alliance, the interpersonal mechanisms, remain unexplored (Kirsh & Tate 2006). Moreover, few studies reflect the voices of those who use and deliver

The dynamics of shame: navigating professional complexities when counselling in AOD settings

services in order to better understand the nature and meaning of working alliances (Kirsh & Tate 2006, Lehman et al. 2004). Consequently, Kirsh & Tate (2006) aimed to identify key ingredients of the therapeutic relationship/working alliance, within the practices and realities of community mental health.

Using Greenson’s (1965) and Bordin’s (1994) models, Kirsh and Tate (2006) define the working alliance as collaborative work that is based on mutual agreement on goals and outcomes, and the bonds that are created within the relationship between clients and service providers. While this study focuses on services provided for the severely mentally ill, it is a rare qualitative exploration of the everyday tasks that facilitate outcomes through relationship. Reminiscent of Rogerian principles, their study developed three key themes which can be summarised as: building and negotiating trust by laying the foundations of the relationship; working on day-to-day issues; and conveying to clients that the service provider is on their side by supporting them through their challenges. Significantly, respondents viewed ‘being there’, ‘knowing the person well’ and ‘acceptance’ as precursors to the comfort level of the client. By collaboratively strategising with them, they aimed to enhance the working alliance through both relationship skills and more pragmatic tasks. Support, availability, caring and respect were found to be necessary but not sufficient as dimensions of community mental health care. There was an emphasis on ‘moving forward’ suggesting that there is work to be done, and a future direction in the working alliance in community mental health. Ultimately, Kirsh and Tate were able to complement existing literature that prioritised outcomes, with interview excerpts that serve to activate these characteristics within a community context.

Empathy, caring and respect have long been recognised as necessary components of therapeutic relationships in various populations. The pathways to developing this are, however, less developed in the literature. The complex and multidimensional nature of the therapeutic relationship in community settings requires further research so that discourses can be developed and strategies can be applied and tested. Currently there is a lack of discussion of good practice within the arena of relationship development, and service providers have been left to rely on instinct and experience to work through these challenging and powerful relationships (Kirsh & Tate 2006). My study aimed to

The dynamics of shame: navigating professional complexities when counselling in AOD settings

complement the few examples available by capturing the insights of counsellors working in AOD settings, and other community settings, around notions of therapeutic relationship enhancement by articulating professional dilemmas and contextualising the nature of this alliance.

2.1.2 Counselling in an Australian context The counselling concepts examined above are largely grounded in the practice traditions of North America and the United Kingdom. These traditions have been influential to counselling in Australia, but as Grant, Mullings and Denham (2008) point out, there are unique cultural and contextual factors that need to be recognised here. It is also important to note that modern counselling practice, like other disciplines, is not unified or monolithic but incorporates theories, influences and elements from other traditions. The extent to which these different schools of thought are combined will depend upon multiple factors, including: counsellor’s training, counsellor’s personality style, practice setting, supervisor’s affiliation, and factors inherent to working in the health or church-based sectors. For example, counsellors trained in psychology and working in health departments are more likely to adopt attachment and behavioural strategies in their work, while those who have undertaken pure counselling training are more likely to adopt a humanist, psychodynamic and/or phenomenological approach. This combination of factors is too complex to define, however, and as counselling in Australia emerged later than in the UK and the US, different trajectories and emphases have taken place (Grant, Mullings and Denham 2008). This section will summarise additional concepts relevant to counselling practice as it is undertaken in an Australian context.

There are few published histories of Australian counselling but a useful source is Grant, Mullings and Denham’s “Counselling Psychology in Australia: past, present and future” (2008). This article describes the emergence of Australian counselling practice in the 1970s. The distinctively Australian approach asserted that counselling psychology needed to reach all sectors of the population, in order to help them overcome barriers and fully develop. The approach was to be undertaken in clinical settings and in the community. There was a great deal of confusion about the word “counselling” in Australia and in differentiating it from psychology. In addition to this,

The dynamics of shame: navigating professional complexities when counselling in AOD settings

informal and voluntary counselling work was simultaneously being undertaken in Church contexts, as per the marriage guidance movements that had been underway since the Second World War (see Miller 2000). Grant, Mulling and Denham explain that by the 1980s, there was still no cohesive group of counsellors or post-graduate standards of counselling in Australia. As a result of the merger of clinical psychology and counselling psychology in the late 80s, very few practical differences were found but some important philosophical distinctions remained, particularly the shift from the relational focus of Roger’s work to a more outcome-oriented process. A greater emphasis was also placed on evidence-based practice and practice-based evidence. This has led counselling researchers to place particular emphasis on research in issues such as the therapeutic alliance, client variables (like culture or gender) and processes of client engagement and relationship maintenance (Grant, Mullings and Denham 2008).

Counselling in Australia is influenced by various schools of thought, and some of these influence practice and may result in a shift in focus from the therapeutic relationship to an outcome-oriented process. To build on this, I will now summarise contemporary conceptualisations of drug use and problematic drug use in Australia and comparable settings, before describing contemporary theories of counselling around shame and alcohol and other drug issues.

2.2 Theories of alcohol and other drug use Conceptualisations of alcohol and other drug use have been dominated by two models: the medical and the moral (Morse 2004; Husack 2004). Despite the move towards a medical approach to alcohol issues in the nineteenth century, the field was still deeply characterised by a discourse of sin at that time. The twentieth century saw the emergence of ‘alcoholism’ as a disease category (see Jellinek 1952 and 1960) and despite the fact that the term was never operationally defined this diagnostic tool was required so that an individual could gain access to medical treatment (Schaler 2011; Edwards, Marshall and Cook 2003).

Current research and clinical literature on alcohol and other drug use often starts with recognition of the diverse and disparate public debates that shape the definitions of alcohol and other drug use (Rose & Farrow 2010; Room 2003; Wodak & Moore 2002;

The dynamics of shame: navigating professional complexities when counselling in AOD settings

Keane 2002; Sedgwick 1993; Kessel & Watson 1979). Writers often comment on the social and cultural factors that shape and influence drug use and treatment policy, both locally and internationally (Wodak & Moore 2002; Keane 2002; Stall et al 2001). In the West, alcohol and other drug use has at times been associated with social disorder (Musto 2005, p.1) and as a consequence has often been drawn upon as material for generating moral panic in the community (Cohen 1972, p.9). A fear of social disintegration (Miller and Carroll 2006, p. xi) motivates moral and religious commentators to exhort those who use to stop and to dissuade others from starting (Blocker, Fahey & Tyrrell 2003). Both historically and currently, the political response to alcohol and other drug use has involved regulations to manage the availability and use of certain substances. Often, policy choices are made within the context of competing demands arising out of community concerns on the one hand and tax revenues on the other (Johnson & Meier 1990, p.577-95). How issues relating to drug use are discussed depends on whether the topic is raised within the context of prohibition, legalisation, medical discourses, service provision or moral debates (Edwards, Marshall and Cook, 2003; Wodak & Moore 2002; Keane 2002). Definitions pertaining to alcohol and other drug use, and problematic use, are rarely neutral. Arguably, the development of AOD treatment services owes as much to the religious and political influences (Ropke 1996) as it does to philosophical movements, scientific responses, and to the helping professions (O’Brien and Penna 1998).

Consequently, treatment models are subject to a range of pressures and influences. For example, due to intake dynamics and funding issues, a client wishing to receive treatment may need to gain a diagnosis before being eligible for treatment (Edwards, Marshall and Cook, 2003 page 9). The current DSM 4 definition of addiction, or substance dependence, is: “a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the (provided set of behaviours or physical characteristics), occurring at any time in the same 12-month period” (DSM IV online resource, retrieved April 8th, 2011). This criterion is being revised (the updated diagnostics manual was not available at the time of writing) but the current version is provided to clinicians to guide the diagnosis of a client’s presenting problem. Research has highlighted the differences in client expectations, coping strategies and forms of support seeking based on patterns of consumption

The dynamics of shame: navigating professional complexities when counselling in AOD settings

(Hasking & Oei 2004). Reaching a diagnosis is often negotiated between clinicians and clients through a process of consultation and clarification and involves physical examination, discussion of social indicators and observation. Research that explores the dynamics of diagnoses in general practice, however, has highlighted the difficulties (Bryant et al. 2011; Saltman, Newman, Mao, Kippax & Kidd 2008). Moreover, a diagnosis of addiction or substance use disorder can have detrimental outcomes on an individual’s identity, in that they can be potentially stigmatised and discriminated against (National Centre for Education and Training in Addiction 2006; Wodak and Moore 2002). Studies of problematic AOD use, then, need to pay attention to processes of stigmatisation and discrimination (Room 2005). While some writers of counselling tenets assert that counselling practice should not be concerned with diagnoses, it is apparent that counselling takes place within fields that engage in client diagnosis for various reasons including treatment plans and pharmacotherapy prescription, and also to gain access to treatment or certain services.

Reaching an effective diagnosis can be hindered by the fact that the lines between what constitutes recreational and problematic drug use are not clearly defined. This is very much the case for definitions that surround legal and illicit substances (Wodak & Moore 2002; Race 2005), an argument that is extended by valentine and Fraser (2008), who assert that while drug use is occasionally acknowledged as pleasurable, this is limited to those who are socially privileged. Drug use among impoverished or marginalised communities is conceptually linked to discourses of crime, misery and addiction. They warn that common distinctions between recreational or problematic use are limited and neglect the role of pleasure (valentine & Fraser 2008).

Defining the point at which use becomes problematic is complex, as is ascertaining the determinants of problematic use (Schaler 2011). Research has demonstrated that a variety of factors contribute to drug use and problematic outcomes, (Etherington 2006; Buchanan 2006; Spooner and Hetherington 2005; Stall et al 2001). While traditional treatment has focused on changing individual behaviours, such efforts can only have a limited impact so long as the environment remains unchanged. The definition of environment used here is broad and includes cultural, social, economic and physical factors (Spooner & Hetherington 2005). Spooner and Hetherington’s report, which

The dynamics of shame: navigating professional complexities when counselling in AOD settings

synthesised literature on problematic AOD use, can be used to challenge the extent to which problematic AOD use is an individual’s choice, and the extent to which they are wholly responsible for this use becoming problematic.

The various factors which contribute to AOD use and the development or exacerbation of problems associated with use, are outlined as: human development across the life course (such as, family of origin influences, the relationship with parents/care-givers, or prolonged exposure to stress); social and cultural aspects (such as race, class, gender and so on) with an emphasis on systems of power and domination; the physical environment (such as housing, geographic factors like urban density or rural isolation, and public spaces (like exposure to drug markets); and the access to particular programs, not only treatment but also programs that affect the legislation or police response to various drugs. In conclusion, Spooner and Hetherington recommend approaches to policy and treatment that take into account the complexity of the factors that contribute to the development of drug use and related problems.

Despite this, a discourse of individual choice and responsibility is commonly used alongside descriptions of clients who are understood to have lost control of their behaviour (Rose & Farrow 2010). Moreover, the attribution of responsibility has been shown to affect healthcare workers’ attitudes towards clients negatively, who may question the ‘deservingness’ of healthcare for AOD clients (National Centre for Education and Training in Addiction 2006), thereby compounding issues that relate to treatment outcomes. This loss of control discourse is common to theories of addiction that view the person as not able to control their regulation of consumption (Humphreys 2004; Flores 1997) and assert that the only possible recourse is abstinence (see Rose & Farrow 2010 p.249). In contrast, to be accountable (and therefore to receive punishment and consequences for an action) suggests that a person is in control of her/his behaviour and can choose to control or abstain. Given that ideas about ‘addiction’ are fraught with contradiction and inconsistency, Schaler suggests that mental health professionals keep in mind that behaviour remains behaviour even when it is labelled a disease (Schaler 2011). Nevertheless, there exists a tension between professionals working in the AOD sector who view clients as people who have failed to make correct life choices and those who view clients as unwell and in need of therapy (Schaler 2011; Rose and

The dynamics of shame: navigating professional complexities when counselling in AOD settings

Farrow 2010). Rose and Farrow (2010) conclude that these professionals should be mindful of the various and opposing perspectives that colleagues may have in relation to clients.

The conceptualising of problematic AOD use is clearly a complex issue, highlighted by the growing body of work that relates to “dual diagnosis” service provision. Whether a rehab is formally acknowledged as a mental health facility or not, a large number of clients will be diagnosed with and affected by mental health issues and disorders alongside their diagnosis of substance use disorder (Roche, Duraisingham, Wang & Tovell 2008; Saunders and Robinson 2002). These diagnoses often include depression, anxiety, post-traumatic stress disorder, borderline personality disorder, anti-social personality disorder (Roche, Duraisingham, Wang & Tovell 2008), psychosis, schizophrenia and/or bipolar disorder (Gethin 2009). Clients are prescribed and contractually obliged to take medication and see a clinical psychologist or psychiatrist, while undertaking AOD treatment. In mental health contexts, this coercion is called involuntary intervention. This is where a decision may be made by staff, which over- rides a client’s choices, in order to keep them sober and alive (Noordsy, Mercer & Drake 2002, Backlar & Cutler 2002). Yet, whether the mental illness is the result of long-term drug use, or the client was using illicit substances to manage undiagnosed mental illness, is usually unclear and impossible to determine with accuracy (Rose and Farrow 2010). Also, some commentators have argued against the use of coercion because of its potential to do harm (Szasz 2012).

Drug use is a value-laden topic and one that has implications as to how an individual is identified, diagnosed or treated. In the case of illicit drug use, an otherwise law-abiding citizen who is convicted of a simple drugs offence may be subjected to prosecution, which can lead to discrimination, disruption of home life, loss of employment and a restriction on travel opportunities (Wodak & Moore 2002, p.55). Critics have argued that value-neutrality is a preferable stance to the moralised arena of the drugs debate (valentine 2009; Keane 2004; 2002). Keane argues that the benefits of a “harm reduction” approach lie in the fact that it is essentially an assemblage of practices and goals with varied outcomes (2002, p. 70). Other research that attends to the moral relevance of addiction, asserts that while some commentators believe there is a place

The dynamics of shame: navigating professional complexities when counselling in AOD settings

for analysing problematic drug use through a moral lens, this does not justify a punitive response to people who use drugs (Husak 2004).

In summary, recreational and problematic use of alcohol and other drugs are contested topics, subject to popular commentaries that may propose ill-informed or unhelpful solutions. So far, the literature reviewed for this thesis demonstrates how drug use is characterised and influenced by cultural and social phenomena, and more importantly that an individual once diagnosed or labelled as “addicted” is subject to a wide range of consequences, many of these negative and enduring. Not surprisingly, such complexities can lead to schisms between professionals and leaders in the recovery field. At this point, I will examine recent research and clinical literature that explores the various approaches to treating and counselling clients presenting with drug use issues, and focus on the schisms that might occur between practitioners and clients.

2.2.1 Theories of AOD treatment and counselling Numerous writers and researchers have adopted a broad perspective to examine the various moral and ethical underpinnings of interventions in relation to recreational and problematic AOD use (Kleinig 2004; Husack 2004; Kasachkoff 2004; Wasserman 2004; Palm 2006; 2004). AOD treatment has become an intensive business, first as a hospital in-patient process, and then with the help of Alcoholics Anonymous (AA) for managing the continuing process of ‘recovery’ in the community (Edwards, Marshall and Cook 2003). Rooted in both religious and medical insights (Humphreys 2004) current programs understand problematic drug use as both a disease process and a spiritual crisis requiring abstinence, and prioritise the role of peer support and understanding.

However, the dynamics between medical institutions and self-help movements were not always straightforward (Rose & Farrow 2010). Around forty years ago, survey research began to show that there were problems with alcohol use across the population (Room 1977). As a result, treatment services in some countries (Australia and the UK) began to broaden their focus (Wallace, Cutler & Haines 1988; Chick et al 1985). A new conceptual framework was promoted by the World Health Organisation which entailed a two dimensional framework for understanding problematic alcohol use (Edwards

The dynamics of shame: navigating professional complexities when counselling in AOD settings

1976). This framework distinguished dependence from alcohol related problems and within that a suitable case becomes anyone who wants help with their drinking, whether or not they are physically dependent (Stockwell, Hodgson, Edwards, Taylor & Rankin 1979). Rose and Farrow (2010) demonstrated that even a cursory examination of the problematic drug use issue uncovers a complex array of contradictions and paradoxes. From analysing prevalence data and treatment utilisation rates, it is known that many people use drugs, but only a small proportion go on to develop problematic drug use patterns. Of those who do, some respond well to treatment, others undertake treatment over many years with many relapses, while others manage to stop of their own accord (2010, p.252). Definitions of alcohol and other drug use have been influenced, then, by ideological and institutional factors, as well as factors that relate to access to treatment programs. In a sense, the emergence of these definitions has been initiated by such treatment dynamics and, in turn, an individual may become identified in terms of these definitions.

While Schaler (2011) has argued that rates of recovery are not increased by community members attending treatment, recent Australian meta-analyses have concluded that AOD treatment in Australia is as effective as treatments provided for other chronic health conditions (Siggins Miller 2009), and that psychosocial and therapeutic strategies have proven efficacy (National Centre for Education and Training in Addiction 2004, chapter 13). Counselling in the Australian AOD context is understood to provide an opportunity for individuals, their families and significant others to understand and change patterns of behaviour and thinking that may be contributing to problematic drug use (Rose & Farrow 2010, p.256). Clients may be self-referring or seeking treatment as the result of an externally imposed mandate, such as magisterial mandates via the MERIT system (Magistrates Early Referral into Treatment).

For decades, there has been available a growing body of clinical literature and empirical research which provides suggestions for generalist and specialist counsellors working with AOD clients (see Potter-Efron 2011; Dearing and Tangney 2004; Clayton-Rivers 1994; Fossum and Mason 1989; Potter-Efron 1989; Bradshaw 1988; Saunders 1985). These tend, however, to be case studies, survey-driven studies or clinical reports, and do not elaborate on the specifics of counselling in particular

The dynamics of shame: navigating professional complexities when counselling in AOD settings

settings, nor do they engage in discussions about the differences between drugs used and the social constructs surrounding alcohol or illicit drugs. Research has also indicated that motivational factors are a salient issue in AOD treatment. Most research tends to dichotomise self-referred and mandated clients without accounting for the shifts in motivation over time, as well as the cyclical rather than chronological movement of change (Klag, O’Callaghan and Creed 2004; Prochaska, DiClemenente & Norcross 1992). Entrenched dependent drug use is most commonly understood as a chronic relapsing condition (Marsden et al. 2004), thus intervention evaluations would benefit from including an assessment of client motivation levels prior to treatment.

An influential model for assessing readiness for treatment is the stages-of-change model, or trans-theoretical paradigm (Prochaska, DiClemente & Norcross 1992; Prochaska & DiClemente 1986). This model attempts to work with the client at each level of motivation, including those not willing to take action. The focus is on what works for each individual rather than the dogmatic application of a particular model. Again, it is worth remembering that a large number of problematic drug users spontaneously recover without recourse to formal treatment (Schaler 2011; Blume 2005). Therefore, robust evidence-based AOD treatment will not benefit everyone because of factors such as motivation, intervention-fit, and the awareness or perception of the diagnosis on the part of the individual client. In any case, as Edwards, Marshall and Cook (2003 p.322) point out, dogmatic views of the psychodynamics of drug use are as unhelpful for work in this field as are any fixed formulae for drug use interpretations in the general field of therapy. Alcohol and other drug use and excessive use will have different meanings for different clients, and often multiple meanings for any one client.

In addition to the motivational factors of clients, the treatment setting has received some attention in recent years. Research suggests that some approaches, like the Minnesota 12 step model, appear to produce outcomes regardless of whether a residential or outpatient setting is used. Despite this, there is evidence that residential care can be more beneficial for some cohorts, like adolescents (Morral, McCaffrey & Ridgeway 2004). Most notable is the link between length of stay or treatment completion to positive outcomes (Latimer, Winters, Stinchfield & Newcomb 2000; Stevens et al 2003). Residential rehab services for alcohol and other drugs have high 25

The dynamics of shame: navigating professional complexities when counselling in AOD settings

attrition rates, typically 40% by three months (United Nations 2002). A report by the Salvation Army in Australia suggests that less than a quarter of clients complete full residential programs (Brunt 2002).

Another distinguishing characteristic of AOD counselling, is the degree to which individuals presenting at drug treatment services have needs that cut across other fields of practice, such as mental health, criminal justice, and child and family welfare. Increasingly, it is recognised that collaboration between these sectors is vital if treatment is to be effective (Rose & Farrow 2010, p.257; see also Roche, Duraisingham, Wang and Tovell 2008). However, the philosophical differences between these various fields of practice can lead to professional schisms that can impact on treatment and referral dynamics. In Australia, AOD counsellors tend to work from a bio-psycho-social perspective that recognises that the biological, psychological and social aspects of drug use all need to be considered in effective drug treatment interventions (Rasmussen 2000). Texts that aim to support effective clinical practice suggest that choosing the best treatment for an individual client is a skilled and highly responsible undertaking which needs to be negotiated and later reviewed with the client, guided by clinical experience and illuminated by critical understanding of what an evolving research base can tell (Edwards, Marshall and Cook 2003). Moreover, the extent to which the professional community adopts evidence based practice, and absorbs it into their practice, is influenced by a range of factors, not least their exposure to certain approaches and the influence of the setting on enabling this shift (Bride, Kintzle, Abraham and Roman 2012; Gjersing, Waal, Caplehorn, Gossop & Clausen 2010; Palm 2004).

Examination of the literature that pertains to the treatment of alcohol and other drugs demonstrates that it is characterised by a multitude of conceptualisations, which are sometimes contradictory. Given that what defines problematic drug use is contentious, it is perhaps not surprising that theories of good practice in the treatment for problematic drug use are also controversial. Alongside definitional concerns that underpin the definition of problematic drug use, the literature indicates the complexity of the recovery process and reveals the diverse factors at play for clients presenting at a treatment setting. These include motivational levels, socio-economic status, age and style of service, to name a few. Ultimately, a review of the literature throws into 26

The dynamics of shame: navigating professional complexities when counselling in AOD settings

question the extent to which treatment and counselling can be credited for facilitating recovery from problematic drug use, given the large numbers of individuals who recover without either treatment or counselling. Nonetheless, treatment services remain in high demand and employ a growing workforce of counsellors and frontline workers to provide them. In the next section, I examine recent literature which outlines the Australian AOD workplace with a focus on workforce profiles and current development goals.

2.2.2 The local alcohol and other drug workplace The Australian alcohol and other drug treatment sector is comprised of a diverse range of providers including, but not limited to: private practitioners, non-government organisations (also known as ‘not for profit’ organisations), government-funded healthcare services, therapeutic communities, and volunteer-based services (Rose & Farrow 2010; Proudfoot & Teesson 2000). In addition to counselling, treatment for problematic drug use consists of: pharmacotherapies, Cognitive Behavioural Therapy (CBT), Motivational Interviewing (MI), isolation from family and friends who use alcohol and other drugs, group work, and case management (Rose and Farrow 2010; Spooner & Hetherington 2005; National Centre for Education and Training in Addiction 2004, chapter 13; Day, Ross, White & Dolan 2002; Proudfoot 2001; Saunders 1985). Treatment in the criminal justice context has also produced an approach that attempts to use shame deliberately, to facilitate the reintegration accountability and responsibility in the individual (Harris 2006).

This diversity of treatment services is not necessarily beneficial to clients, and often results in an unhelpful patchwork of responses (Rose & Farrow 2010) which some researchers have taken to signify the persistent societal ambivalence towards drug use (McCarty & Goldman 2005). Recently, Australia has seen considerable advances in AOD workforce development research however this is yet to be translated into practice (Roche and Pidd 2010). Ascertaining the effectiveness of services is challenging given the lack of reports that are available on outcomes. Much of the literature on AOD treatment effectiveness is based on treatment services that are located in the United States of America and are not therefore automatically transferrable to Australian services, Aboriginal services, in particular (Chenhall 2007). The non-government

The dynamics of shame: navigating professional complexities when counselling in AOD settings

sector is in the process of developing self-regulatory strategies and in recent years began conducting workforce surveys on a State-wide basis. Prior to this, the workforce had not been accurately profiled, nor had there been a systematic appraisal of the main issues affecting employees in the different States (Gethin 2009). Further, while government-run organisations are able to monitor and track employee conditions and professional development, there has been little or no information available about the non-government sector which accounts for a considerable section of the workforce.

In one of the first surveys undertaken in Australia (see Gethin 2009), the New South Wales non-government sector was characterised as a highly diverse range of agencies, treatment models and philosophical orientations. This diversity was illustrated by describing philosophical orientations ranging from religiously based abstinence models (21%) to models that draw on the principles of harm minimisation (79%). It is noteworthy that philosophical orientation was also found to vary between colleagues or programs within organisations. The workforce (approx. 1065 employees) included trained AOD workers, counsellors (33% of the overall workforce), support workers, nurses, psychologists, doctors, former and current drug users, researchers, drug educators and health promotion workers. Within the Network of Alcohol and other Drug Agencies (NADA) membership (107 services), AOD workers are employed in two broad categories of sites: specialist sites, whose focus is AOD related; and a social service agency with AOD programs or workers (e.g. a counsellor or project worker).

In addition to developing a profile of the AOD workforce, the NADA survey (Gethin 2009) also outlined a range of issues affecting the workforce, particularly barriers to recruiting and retaining staff and high levels of staff burn-out, which is consistent with findings from recent evaluations conducted on AOD workforces outside Australia (Garner & Hunter et al. 2012a; 2012b; Eby & Rothrauff-Laschober 2012; Knight & Becan et al 2012; Knight & Landrum et al. 2012). The New South Wales report stated that filling staff positions was becoming an increasing problem for most agencies. Managers reported a severe drop in responses to job advertisements. Cited reasons relevant to this study include: low salaries (NGO personnel are offered less remuneration than government-employed counterparts); a lack of opportunity for career progression; and the decreased appeal of working in the AOD field. A minority of

The dynamics of shame: navigating professional complexities when counselling in AOD settings

agencies reported no difficulties in recruiting staff and these differed from the others in two important aspects: they were able to offer wages comparable to government positions, and they offered high levels of training and professional development. In addition to survey data, staff members were interviewed so that respondents’ perceptions of their working conditions could be gathered. Key findings indicate that the terms of service provision and program definition were unclear, and this was thought to affect funding allocation adversely (in the case of charitable organisations) and key performance indicators (in relation to evaluation of services) (Gethin 2009). The potential difficulties that stem from philosophical differences and low funding were understood by respondents as being evident in the operational, even structural, levels of service provision.

While the 2009 NADA report was able to demonstrate that a lack of sufficient funding is connected to recruitment issues, other research has outlined additional barriers for the AOD workforce. In comprehensive Australia-wide evaluations that have resulted in a number of workforce resources, the National Centre of Education and Training in Addition (NCETA) at Flinders University have established key areas for workforce development. In doing so, NCETA confirm that the Australian AOD workforce is inadequately staffed. Their findings also connect poor staffing to barriers for the professional development of employees, as well as limits to the extent to which many services are able to offer effective supervision for clinical staff members. In other words, small teams hinder training and supervision due to the sheer lack of employees able to attend training, and cover for staff who are in training. In addition there is the lack of available time away from the frontline that is required for supervision sessions. Poor resourcing has thus been connected to the high rates of staff burn-out and turnover. Worryingly this research highlights the potential for low levels of adequate supervision and staffing to impact negatively on the capacity of services to maintain duty of care procedures (Roche and Pidd 2010; National Centre in Education in Training and Addiction 2009).

Poor resourcing has been connected to poor staffing in many AOD services, in Australia. By interpreting findings from recent reports, it becomes clear that adequate pay and good quality professional development help to attract and retain AOD workers.

The dynamics of shame: navigating professional complexities when counselling in AOD settings

Failure to provide these has the potential to put additional strain on some AOD services, which are run by small teams who are overburdened with an increasingly complex and challenging client cohort (Roche 2010; Gethin 2009). A recent American survey also demonstrated that high stress levels and burn-out has the potential to impact negatively on workers’ capacity to effectively engage clients to treatment (Landrum, Knight et al. 2012). Therefore, it is clear that poor resourcing of Australian AOD services can have a negative effect on attracting clients to treatment, in addition to exacerbating the complex range of workforce issues affecting those engaged in the sector. In the next section, I build upon the previous sections by exploring theories of shame and how researchers have accounted for the influence of shame on problematic AOD use, and its effect as a barrier and facilitator in therapeutic relationships.

2.3 Theories of shame While some of the literature points to the prevalence of shame narratives in accounts of clients presenting with AOD issues, there is currently a dearth of qualitative research on how shame disrupts counselling practices in alcohol and other drug settings. What has been written tends to be survey driven or directed towards counsellors working in private practice. This section will provide a background on shame concepts to elucidate the research question for this thesis, before critically reviewing literature that informs the counselling field.

Conceptualisations of shame are derived from a range of knowledge bases, including biology, psychology, sociology and philosophy. Many writers, clinicians and researchers have commented on the dearth of research on shame (Pattison 2000; Kaufman 1996; Wheeler 1997; Tangney and Dearing 2002). This is largely understood to be due to the fact that shame has been hidden in many ways or subsumed into other phenomena, like guilt or morality. However, one of the common elements among the existing theories of shame is ‘exposure’. Indeed, the word ‘shame’ is itself derived from notions of covering and concealing. Thus, many writers put exposure at the centre of the shame experience (Pattison 2000; Kaufman 1996; Lewis 1995). This idea of exposure is of something painful, creating a desire to escape or avoid it, and is a common feature of clinicians’ descriptions of treatment dynamics (Kaufman 1992, p.4). Further, there is often a tendency for the observer to turn away from it, which adds the

The dynamics of shame: navigating professional complexities when counselling in AOD settings

concept of contagion. Such is the stigma of shame that some people shy away from it to avoid social contamination (Lewis 1995).

Shame is described as a barrier to expression because it can have the effect of silencing the client and is of particular concern to those workers who engage in talking therapies (Kaufman and Raphael 1996). A key feature of shame is the affected person’s inability to articulate or verbalise an experience or reaction (Kaufman and Raphael 1996). Clinical literature has focused on the dilemma of naming the problem as ‘shame’ that can result in inadvertently shaming the client (Lee & Wheeler 2003, preface; Lewis 1987). Dearing and Tangney (2004) note the shame that is commonly experienced by clients who enter a service for any mental health treatment. There is a pervading stigma that exists in relation to mental health illness that can pose ongoing barriers to individuals seeking help. In relation to counselling, Dearing and Tangney highlight the shame a client may experience when feeling exposed through the therapeutic process, in addition to presenting as ‘ill’ to a professional who is assumed to be a paragon of mental health. Not only is the reality of the therapeutic context likely to induce feelings of shame, but clients’ previous experiences of therapy may have been shaming (Dearing and Tangney 2004, p.172). From a psychoanalytic framework, shame is often presented as a pre-verbal and ‘primitive’ experience that is typically located in the individual’s family of origin (Lewis 1971), hence texts which use a family therapy framework to address shame in counselling (see Fossum & Mason 1989), and recommend their use in AOD treatment (see Lee, Christie, Copello & Kellet 2012).

In terms of the relational dynamic inherent in talking therapies, a sense of shame can further hinder counselling practice in that it can cause clients to see themselves as unworthy, and potentially undeserving of treatment (Lewis 1987). Wurmser (1995) describes the shame experience as hanging on a conviction of the self as being unloved and unlovable. The self has a sense that it is defective and has a basic flaw that ensures its unacceptability and rejection by those it loves. Shame is thus seen to contain the fear of abandonment, loss of love and loss of self. It is described as an annihilating experience that causes a view of the self as a ‘despicable nothing’ (Wurmser 1995, p. 235). In experiencing shame, people are believed to see themselves as dirty and defective which contributes to a sense of the self as fundamentally defective. It is

The dynamics of shame: navigating professional complexities when counselling in AOD settings

dehumanising to the extent that the person feels they are something low, stained, unpleasant and unwanted (Pattison 2000). Shame is, in this sense, a group of negative feelings about the self.

Dearing and Tangney have conducted research on shame and guilt from the perspective of shame as a moral emotion. In their 2002 text, they describe shame as an intimate, personal experience that is produced in response to a transgression or error, whereby the self turns toward self - evaluating and rendering judgement. The experience of shame in this rendering can play a role in guiding human behaviour and influencing self-perception. In this way, shame is linked to the self in relationship to others (see also Brown 2004). Shame develops from our earliest interpersonal experiences and throughout life these emotions exert a profound and continuing influence on our behaviour in interpersonal contexts. Shame is thus represented as a self-conscious and moral emotion: self-conscious in that it involves evaluating the self, and moral in that it presumably plays a key role in fostering morally acceptable behaviour (Tangney and Dearing 2002, page 2). In this model, shame is experienced as a relational dynamic. It is a moral emotion that can hinder communication. The individuals believe they are undeserving of a relationship and so they can be shamed. This is crucial to counselling which, as a talking therapy, relies heavily on the verbal dynamics established in a relationship as the central forum of treatment.

It is only recently that psychologists have begun to conduct systematic empirical research on the nature and implications of shame. This has been largely due to the difficulty of measuring shame as a researchable phenomenon. Shame is a difficult construct to assess because it is an internal phenomenon and, therefore, less amenable to observation, particularly because it is difficult to distinguish from other emotions, like guilt (Tangney and Dearing 2002). Indeed, this is congruent with accounts in the clinical literature that describe the difficulty counsellors have in evaluating a client’s emotions (Potter-Efron 2011 and 1989), an issue that will be further explored in the next section. Sensitivity to shame is seen to manifest in continued blaming (self and others), resentful anger and hostility, and a lessened ability to empathise with others in general (Tangney and Dearing 2002, p. 3).

The dynamics of shame: navigating professional complexities when counselling in AOD settings

A completely different psychological approach was formulated in the US by Silvan Tomkins who attempted to construct a theory of human affect. In psychology and behavioural sectors, affect is often used to define a feeling or emotion that is manifested in facial expression and / or body language. Tomkins argues that there is a distinct and innate biologically based affect system within each individual that amplifies perceptions so that things matter (Tomkins 1987). Tomkins’ understanding of shame is rooted in genetically determined models of basic physiological affect responses. While every individual is seen to be hard wired to experience shame, the responses are modified by a complex set of factors such as experience, interpersonal interaction and culture. The affect may be activated more in some than in others, but it is still largely formed through relationship and cultural cues. Tomkins (1963, p.118) states that: “shame strikes deepest into the heart of man...he feels himself naked, defeated, alienated, and lacking in dignity and worth”.

A common thread between these various theoretical approaches, then, is understanding shame as a relational dynamic. Although there is limited literature on counselling practice in alcohol and other drug settings, among the various factors implicated in problematic drug use, the experience of shame has been mentioned often, particularly in discussions of alcoholism (Fossum & Mason 1986; Bradshaw 1992; Potter-Efron 1989; Potter-Efron & Potter-Efron1988). Fossum and Mason (1986) claim that “addiction and shame are inseparable” and confronting shame in the context of a supportive therapeutic relationship is vital to the process of recovery. The focus of this review will now shift to explore the relationship between shame and problematic AOD use, and how this plays out when counselling in AOD settings. The next section will provide an overview of published recommendations that have been available to counsellors, to date.

2.3.1 The dynamics of shame: counselling for shame and problematic AOD use In general, there has been a lack of work on the factors that contribute to drug use regulation, or the adaptive role of emotions with regard to drug use in the literature on shame and alcohol use. Despite this general gap in research, several theories have been offered that might help to explain the relationship between shame and problematic

The dynamics of shame: navigating professional complexities when counselling in AOD settings

AOD use (Stuewig and Tangney 2007; Dearing, Stuewig & Tangney 2005; Tangney and Dearing 2004; Potter-Efron 1989).

A formative text was written in the 1980s by Gestalt psychotherapist Ronald Potter- Efron (Shame, Guilt and Alcoholism 1989). In this text, he emphasises the distinction between shame and guilt, and demonstrates through clinical examples that a predisposition to shame can often be related to a focus on the “defective self”. Shame- proneness is a reaction to the subject’s experience of her/his family-of-origin, and a significant precursor to a variety of treatment barriers. These may include denial, rage, impaired empathy, low self-esteem and defective inter-relational skills whereas “guilt proneness” is related to behaviours, and is more readily adaptive (see also Potter-Efron & Potter-Efron 1988; Dearing, Stuewig & Tangney 2005; Taylor 1995). Potter-Efron makes the distinction between moderate shame and guilt and chronic shame and guilt. From that perspective, the first aim of counselling is to determine whether the client is presenting with chronic shame or chronic guilt, as these affects are understood to be prevalent in alcohol dependant clients. They are often experienced together, however, and as a result they can be confused by both client and counsellor.

While shame and guilt may be experienced simultaneously by a client, they are nonetheless believed to be different phenomena and to require different counselling responses. Guilt can be viewed as the internal punishment mechanism for anti-social behaviour (Potter-Efron 1989). In contrast, shame is seen to be produced in contexts where the individual feels deeply self-conscious, humiliated or worthless. Potter-Efron views moderate shame as healthy and a sign of a client’s humanity, but states that counsellors will often encounter guilt and shame in excessive amounts in their clients, and thus see it as their primary goal to eradicate it entirely. They also tend to believe that this experience of chronic shame or guilt is so unpleasant and anxiety-provoking that the client is compelled to drugs or alcohol, as a coping mechanism or form of self- medication. In this theory, which is reminiscent of Lewis’ work on shame and psychopathology (1987), shame is described as a downwards spiral or cyclical trap. Potter-Efron adds that the individual, remembering an unpleasant and shameful experience, seeks to manage the attendant emotions with alcohol and, once intoxicated, may behave again with equally regrettable and shameful behaviours, which are later remembered and need to be managed and so the cycle commences again (Potter-Efron 34

The dynamics of shame: navigating professional complexities when counselling in AOD settings

1989). Managing the anxiety provoking elements of shame of actions undertaken while intoxicated is a periodically reported motivation or reason for consuming alcohol (see Grant, Stewart, O’Connor, Blackwell & Conrod 2007; Cooper, Frone, Russell & Mudar 1995; Carver, Scheier and Weintraub 1989), which is associated with increased drinking and the experience of alcohol-related negative consequences (Grant, Stewart, O’Connor, Blackwell & Conrod 2007). It is possible to surmise, therefore, that the experience of attending a treatment service that shames clients (whether deliberately or inadvertently) is likely to increase the desire for alcohol rather than reduce it. This is, however, an issue that has not been addressed in the literature on shame and AOD treatment, a gap this study aims to address.

Shame has been observed as occurring more often in counselling clients who grew up in families where shaming practices were over employed in daily interactions or where the client has suffered ongoing trauma by abuse or neglect. This hypothesis has been supported by subsequent researchers and writers (Linehan 1993a and 1993b). According to these self-psychologists and family therapy theorists, shame becomes part of the client’s central identity, whereas guilt relates to acts or behaviours. Shame is believed to provoke a client to question her/his right to exist and even describe their self as monstrous or even unhuman. At its core, shame is theorised to contain the fear of abandonment (Potter-Efron 1989; see also Fonagy et al 1997). Significantly, guilt contains the dynamic of reparation in that the individual can pay a penalty and be cleared of their transgression (Potter-Efron 1989). Consequently, Potter-Efron suggests that counsellors help their clients develop a new and re-humanised concept of self. By developing alternative coping mechanisms, clients may be able to relinquish their chemical dependency and, as with anger or stress management, feeling shame becomes a signal that the counsellor and client can recognise, address and act on appropriately. Finally, a client is invited to create her/his own mechanisms for morality, through the reintegration of moderate shame. The counsellor and client can use any shame-reaction as a signal by which to direct interventions and acknowledge growth, where the client agrees to this process, of course (Potter-Efron 1989; see also Potter-Efron & Potter- Efron 1988).

The literature on shame and alcoholism adds to the broader shame literature by identifying the links between shame and trauma, and the differences between shame 35

The dynamics of shame: navigating professional complexities when counselling in AOD settings

and guilt. As a result, some clear implications for practice are indicated that build on shame research undertaken in comparable fields, such as domestic violence and anger management. Ultimately, seminal texts in the shame and AOD research field recommend using counselling as a space to separate shame and guilt while in treatment, as well as integrating shame reactions so that they are moderate and helpful to clients. However, researchers and writers do not make any distinctions between counselling in residential rehabs, private clinics or psychotherapy couches and their work does not examine how the dynamics of rules, mandates or stigma hinder shame-work and the counselling relationship. The subsequent chapters in this thesis will explore how a counsellor might untangle the central contradiction of how to re-humanise clients in a de-humanising context, how participants of this process try to navigate the contradictory set of treatment goals, and how a counsellor might understand signals of recovery in a setting that potentially inspires a performed recovery.

2.4 Summary A great deal of research has been published on shame, and many theories proposed for how shame relates to problematic drug use. The available quantitative research provides large scale, empirical findings that reveal the prevalence of shame in different cohorts and the effect of different treatments on shame. Case studies provide clinically focused, experiential accounts that aim to discuss the benefits and barriers of different therapeutic approaches, and include a series of implications for practice. Far less research is available, however, on how counsellors navigate the dynamics of shame in AOD treatment settings.

Counselling forms one part of the current treatment programs provided in many of the diverse range of AOD service settings in Australia. The practice of counselling presumes the voluntary and respectful use of talking therapy to facilitate change that is client-centred. Recent clinical literature, however, also indicates the prevalence of shame in client accounts and this it can be a barrier to counselling processes. These studies describe a number of clinical complexities that relate to shame in counselling dynamics including, but not limited to, the client’s difficulty in articulating her/his shame experiences and the disruption of the therapeutic alliance. While much of this literature is helpful in articulating how shame can hinder the therapeutic alliance, with

The dynamics of shame: navigating professional complexities when counselling in AOD settings

suggestions for counsellors on how they might use shame for positive effect, the majority of texts focus on counsellors who work in private practice with self-referring, fee-paying clients. There is a dearth of research on how shame affects the counselling process for clients presenting at AOD services, with little acknowledgement of the influence of client motivation or coerced attendance. Further, recent research tends to utilise survey-driven methods and conflate counselling with other treatment modalities, such as, clinical psychology and self-help, peer based movements.

In summary, there are a number of factors involved in researching and undertaking counselling practice in relation to shame, in an AOD setting, and these provide the theoretical background for this study. Counselling practice is conducted in a diverse range of settings and each of these creates different issues for counsellors (and clients) to negotiate. In subsequent chapters, an analysis will be presented of in-depth interviews with counsellors and AOD workers and numerous textual excerpts drawn from treatment websites and professional affiliations, in an attempt to address some of the key gaps in the literature on the dynamics of shame in AOD counselling. Before the themes are presented, the methods used to gather and analyse this data will be outlined and discussed.

The dynamics of shame: navigating professional complexities when counselling in AOD settings

3. Methodology

As outlined in the last chapter, there is a dearth of research that focuses on the experiences of counsellors working in AOD settings, and how these settings might impact on the counselling experience, the clients’ experience and treatment outcomes. This study employed a qualitative research design to capture the lived experiences and values of AOD counsellors and frontline workers. The benefits of this approach include gathering workers’ perceptions of practice in AOD settings, which have the potential to deepen our understanding of the relationship between shame, problematic drug use and counselling. This chapter outlines the research design, theoretical sampling strategies, data collection and analysis procedures, ethical issues and the limitations of the research.

3.1 Research design This study was influenced by a practitioner research model (see Etherington 2004a) and informed by the principles of constructivist grounded theory (Charmaz 2006). The evolving research question was inspired by my own professional experiences and so was intimately entangled with my own assumptions and interests that influenced the conceptualisation, collection and analysis of the data. Rather than merely reading this as researcher ‘bias’, this experience was seen to contribute to the rigour and value of the study. Finding ways to build a process of reflexivity into the research will be addressed throughout this chapter. In an attempt to ensure that my own professional interests did not pre-determine the focus and findings of the research, a constructivist grounded theory approach was employed which allowed the categories in the data to emerge, rather than be developed on the basis of preconceived theories. In other words, the goal of the study was to permit the researcher to discover ideas without imposing preconceptions on it (Dey 2007, p.80).

The study design employed here did, however, depart from orthodox Grounded Theory methodology, which attempts to generate theory through research rather than testing ideas formulated in advance of data collection (Glaser and Straus 1968). This study was informed by those grounded theory principles, but recognises the existence of previous hypotheses, in this case that using a person-centred approach in AOD counselling is

The dynamics of shame: navigating professional complexities when counselling in AOD settings

incompatible with punitive models, and that counselling around shame in an AOD setting is more challenging than counselling in generalist settings. As a researcher/practitioner and a social researcher, I believed very strongly in recognising that I am not an empty receptacle but have been shaped by my personal life, as well as by my professional experiences as a counsellor and that this and the broader politics that I hold will always have some influence on the research I undertake (Charmaz 2006, p. 16). This will be discussed in more detail in the ‘reflexive research’ and ‘assumptions and limitations’ sections.

3.1.1 Constructivist grounded theory First introduced by Glaser and Strauss (1968), grounded theory has evolved to such a degree that there is no longer any single unified method. Because of the number of limitations of the method which have been identified over time, new interpretations of grounded theory have been developed, particularly addressing the issue of paying insufficient attention to the role of the researcher and assuming that the data can speak for itself (Willig 2009; Dey 2007; Charmaz 2006). Grounded theory has also been criticised for not addressing issues of reflexivity satisfactorily (Willig 2009, p.46). Social constructivist versions of grounded theory, specifically those developed by Kathy Charmaz (2004, 2006), attempt to develop a more reflexive grounded theory which recognises that categories and concepts do not simply emerge, but are constructed by the researcher during the research process (Willig 2009; Dey 2007).

Additionally, a constructivist stance was viewed as important to this study because of the social frame that relates to problematic drug use. This study is in part a social research project, undertaken at a research centre which promotes the idea of a ‘social’ public health:

Prevention programs and policies are currently informed by a ‘modern’ public health, a public health underpinned by neo-liberal notions of agency and individual responsibility and the personal blame, stigma and discrimination that inevitably accompany such a doctrine […] a ‘social’ public health […] is a model that recognises the collective nature of epidemics […] recognises that persons are constituted in the social and recognises that actions/behaviours are

The dynamics of shame: navigating professional complexities when counselling in AOD settings

socially produced […] In other words, individual behaviour is always contextual, always socially embedded […] (Kippax 2008, p. 17)

The social dimensions of public health are relevant here for a number of reasons. First, I trained as a counsellor at a training institute which uses a Systems framework, and this has shaped my perspective and practice in terms of always viewing individuals within their social context, in both counselling and in research on counselling practice. Second, counselling does not adopt an expert-driven approach that instructs (and often pathologises) the individual seeking help. Instead, the counsellor is viewed as the facilitator of the clients’ self-directed change processes, always within their social context. The maintenance of ongoing change is seen to involve the management of reactions and counter-reactions by the system (or context) in relation to the self. Third, one aspect of shame is that it is both an internal (or intra-psychic) and a social emotion. Shame manifestations have been theorised as an internal response to perceived or actual breaches of social conduct. Shame responds to social cues.

Despite the different emphases in the various interpretations of grounded theory, there are three important themes that are common to the approach, namely: how to start, progress, and end the research project. At the outset, the researcher is encouraged to be sensitive to empirical evidence and open to emergent ideas rather than being bound by particular hypotheses (Willig 2009; Dey 2007). The researcher then employs a process of theoretical sampling, which involves selecting sites and participants flexibly for their theoretical relevance or for the purpose of extending ideas or generating comparisons, rather than achieving representativeness (Dey 2007; Charmaz 2006). Grounded theory relies on data acquired through a variety of methods, mostly observation and in-depth interviews, followed by more structured data collection as the study becomes more focused (Dey 2007; Charmaz 2006). Data analysis relies on coding and categorising for the purpose of comparison. The construction of coding categories is analytic and ongoing and is intended to further sensitise the researcher to the data (Dey 2007). In grounded theory, the researcher simultaneously gathers and analyses data throughout the project, rather than initiating these processes in a chronological sequence (Charmaz 2006, p.96). The process of grounded theory ceases once categories are deemed to have reached ‘theoretical saturation’, that is when core categories emerge around which the

The dynamics of shame: navigating professional complexities when counselling in AOD settings

researcher can integrate the analysis and develop a story encapsulating the main themes of the study, and when no additional themes are being identified (Willig 2009; Dey 2007; Charmaz 2006). While this study has not adopted a pure or orthodox grounded theory approach, the processes of data collection and analysis were very much guided and informed by these principles.

3.1.2 Reflexive practitioner research The research design combines these principles of grounded theory with a reflexive researcher/practitioner model of research practice. That is additional research tools, such as journaling, peer review of coding categories and feedback forums to test work- in-progress analyses. I have noted that I stand to directly benefit from the recommendations I make through this research. This could potentially be viewed as a conflict of interest. Also, given that I theoretically position myself as a humanist, person-centred counsellor, my work, and my research which focuses on this work, are clearly shaped by the values I bring to it, which could be at odds with the values or ideas expressed by the participants of this study.

While grounded theory emphasizes inductively conducted research process (Ezzy 2001), the values I brought to this research mean that the analysis is at least partially a deductive exploration of the data, in order to explore ideas that I was already interested in. The use of person-centred counselling concepts in the coding paradigm, however, is a deductive element that sensitises the author to those aspects of the data that are considered to be essential to our understanding of social phenomena (see Willig 2009, p.44). Further, Charmaz (2004) has argued that too many researchers position themselves at a distance from their data, as if obtaining an insider’s view is problematic or too arduous or complicated a path to navigate. In order to be incisive about experiences as lived, researchers must enter that life, and go native (Charmaz 2004). Through the process of this research study, I did not go native: rather I was already native to this research field and, to some extent, already an ‘insider’ in my understanding of the experiences and perspectives of workers in this field. For a considerable proportion of this project, I continued counselling in an AOD residential rehab service, and I continue to work in the field. This was acknowledged and discussed with my participants before and during the in-depth interviews, and the

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findings here, at least partially, represent a co-creation of data, as we reflected together on the meaning of our work.

While quantitative designs require as much objectivity as possible, qualitative models fully acknowledge the subjective influences that impact on research inquiry, both qualitative and quantitative. By acknowledging potential personal biases, I was able to continuously reflect upon the degree to which these might be impacting upon data collection and analysis. This self-check method is similar to the way in which a practising counsellor attempts to monitor transference within the therapeutic relationship. Therefore, rather than simply viewing this as a conflict of interests, my training and experience as a counsellor was engaged as a tool to deepen the research and strengthen my capacity for developing insights from the data. Kim Etherington, a counsellor/researcher, has published on reflexive research models (2004a, 2004b) and has described the primary dangers of these as being: the temptation to indulge oneself at the expense of the study; the loud voice of the author, the subjective nature of validation in the reflexive research process; the dearth of guidelines or information about how a researcher undertakes the reflexive process; and the tendency of the research to have an inward focus (2004a, p.11, p.15, p.17). In addition to these issues, my initial fears of combining my research interests with my professional world included the danger that I may be more directly and negatively affected by the research process as well as any outcomes I may develop, given the greater commitment of the self to the process than may be typical.

There are also many perceived benefits to this close connection, however, particularly for researchers who are based in the therapeutic fields. Etherington states that there is congruence between the reflexive model of research and the transition that counselling students undergo in their training, and further, that this model is well-suited to a wide range of practitioners whose work is focused on aspects of being human. She writes (2004a, p.15): “Reflexive methodologies seem to be close to the hearts and minds of practitioners who value using themselves in all areas of their practices (including research) and who also value transparency in relationships”.

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So far, I have argued that my position as a researcher/practitioner raises some issues and challenges, but that as an insider, my training, experience and position also benefited the study by facilitating access to participants, sensitising me to the possibilities in data collection and analysis, and building upon my own experiences as a counsellor (see Abu-Lughod, 1991, p. 140). What this means for this study is that the reflexive research model had to include an awareness of issues of power in relation to how and where the research will be presented, the influence my changing-self has in relation to the analytic process, and a utilisation of the more accurate perception of participants’ statements as disclosures, made in relation to my position, as a colleague and also a researcher evaluating our/their work.

3.2 Data collection and analysis Qualitative research methods, informed by the principles of grounded theory, require data collection and data analysis to occur in an iterative and simultaneous manner. For clarity, however, this chapter will present the data collection and then the analysis process, organised into the initial phase, the focused phase, and the themes suggestion phase.

The dynamics of shame: navigating professional complexities when counselling in AOD settings

3.2.1 Initial phase of data collection The initial sampling process provided a ‘point of departure’ (Charmaz 2006, p.100). During this phase of the study, residential settings were chosen as the main focus of inquiry. As described throughout the Background section, my professional experiences of working in a residential rehab initially created concerns in me about the intake procedures and the unique structural factors associated with residential treatment, as well as the coercive tone of the treatment that I had both witnessed and been compelled to administer. I therefore began by seeking interviews with counsellors who worked in AOD residential settings, in Australia, to generate rich data from which new treatment guidelines could be developed. During the initial phase, counsellors working in residential rehabs were seen as ‘typical’ cases and seen to fit most directly with the aims of the study (Ezzy 2001).

As a comprehensive database of counsellors who work across AOD settings does not exist, a project specific directory was created. This directory recorded the names and contact details of the various services to be approached, as well as additional information, such as date of contact and treatment design statements. This directory identified thirty residential organisations across New South Wales, using professional and affiliate internet databases, including the Network of Alcohol and Other Drug Agencies (NADA), the Australian Drug Information Network (ADIN), the Australian Drug Foundation’s directory (DRUGINFO), New South Wales Health Department directory, the Salvation Army, the New South Wales Users & AIDS Association (NUAA), the National Centre for Education and Training on Addiction (NCETA), and Google. AOD treatment settings in New South Wales have now been mapped (Gethin 2009) but this was not available at the time of data collection. The study-directory was updated on a twice yearly basis and the final version gathered more textual data, such as codes of conduct, mission statements and service information, which was later incorporated into the analysis as an additional data set. This textual data underwent the same analysis process as the interview data, which will be described in more detail below. The project specific directory was used to guide recruitment process and as the sample was adjusted over the life of the project, the directory was extended. Search criteria for identifying services online used key words and phrases: ‘alcohol counselling’, ‘drug counselling’, ‘residential rehabilitation’, ‘addiction’, and ‘drug and

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alcohol rehabilitation’. In line with the process, the initial research invitation was circulated to a broad range of services: residential AOD services first, then non- residential AOD services and finally generalist counselling services in New South Wales. The generalist services were: Relationships Australia (New South Wales), Centacare (New South Wales), and the Family Systems Institute (New South Wales). These services were known to me and were chosen due to their large numbers of personnel. The research invitation to Relationships Australia NSW, however, was withdrawn at a later date when I was informed that to recruit from this organisation, additional approval was required from their in-house ethics committee, and the next committee meeting fell outside the extended data collection period.

The process of recruitment involved sending an email to the receptionist or administration department of each organisation, requesting that the research circular be distributed to counselling staff. Ethical approval for the conduct of the study stipulated that I should not directly approach or invite counsellors to be interviewed, to avoid the possibility of coercion. Counsellors then contacted the researcher directly (by email or telephone) and made arrangements for conducting audio-recorded, in-depth interviews for a time and place that was convenient to the participant. These interviews were mostly conducted in person (fifteen) but two interviews were conducted over the telephone at the request of the participants. Participants self-selected and responded to a research invitation (see Appendix One). To be included in the study, participants were required to: 1) counsel clients presenting with alcohol and other drug issues; 2) be 21 years and over; and 3) live and work in Australia. Even though the initial visualisation of the sampling strategy sought to interview counsellors working in drug and alcohol residential rehabilitation, the inclusion criteria was broadened over time to include: AOD workers who did not have counselling training; counsellors who worked in non- residential settings; and counsellors who had not worked in the AOD sector. All the participants interviewed had counselled clients presenting with alcohol and other drug issues, although this may not have been the client’s primary motivation to seek treatment.

The interview schedule (see Appendix Two) was flexible and used as a guide only, as the interviews were expected to generate their own momentum. Participants were

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allowed to punctuate their descriptions with relevant thoughts, feelings, experiences and values. I was careful to ask the participants, in a broad and open manner to describe their work and how they perceived and experienced it, before introducing any questions about how the participants understood the dynamics of counselling, problematic drug use and shame. I also attempted to use the same terms of reference as the participants, and as data collection became more focused, the participants were prompted to describe their reasons or preference for the terms they used. The interview technique and questions were provided as a guide to inspire reflection and discussion and every effort was made to ensure that the participants’ narrative included information and experiences they deemed important. The same interview schedule was used throughout the project although during subsequent interviews the researcher would make a note of additional questions to ask. These were intended to encourage the participant to unpack those terms or statements deemed pertinent to the research, given the emerging categories of the initial coding phase. The additional questions were asked later in the interview, so as not to disrupt the flow of the narrative. Similarly, field notes became more focused and began to record analytical questions about the interview data, as well as the researcher’s experience of the interview and reflexive phenomena. Interview questions were typically initiated with statements such as: ‘tell me about…?’ or ‘how do you understand…?’ in order to invite open discussion. The interview schedule was divided into four sections: background information, understandings of counselling practice, understandings of ‘addiction’ (or participant’s preferred term), and understandings of shame. The interview schedule was used as a guide only and questions would not be asked if the participant had already addressed those topics. The schedule included an engagement process and a closing section.

3.2.2 Focused phase of data collection: theoretical sampling Data collection took a longer time period than initially expected. On the original timeline, recruitment and interviewing of participants was predicted to take twelve months. However, this timeframe had to be extended to twenty four months, due to the slow process of recruiting participants. Six of the respondents who had originally agreed to take part cancelled their interview times due to time-poverty. This meant that the sampling strategy needed to be expanded (the final data set will be outlined in the following chapter). As the initial sampling strategy targeted counsellors working in

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AOD residential settings, I next attempted to target staff working in government-run AOD services (NSW Health). I had had a positive response from recruits working in non-government organisations, but no respondents working in health services had volunteered to date. At that time, there were changes made to the ethical approval processes for these services. This meant that site-specific approval was required from each service covered by the NSW Health HREC before the circular could be distributed. Consequently, this strategy was abandoned. The time required to apply for multiple additional ethics approvals was judged as too onerous for the scale and timeframe of the project. Further, initial sampling revealed that participants recruited to the study had worked in multiple settings (including health settings) and this was deemed to provide an adequate reflection of the experiences of staff members working in a range of health settings.

Other gaps in the sample of respondents were noted at this stage. No men had agreed to be interviewed at that point, and the sample lacked respondents who identified with an Aboriginal or Torres Strait Islander background. Ongoing sampling sought male respondents, by approaching male services and through snowball sampling methods. Attempts to recruit participants from the Aboriginal community were repeated, through the dissemination of the circular inviting counsellors to take part in the research. In one instance, an interviewee made a recommendation about a potential recruit but that person stated they were too busy to be interviewed, and that they believed the Aboriginal community were overly researched/surveyed. While it is disappointing that this collection of interviews lacks the perspectives and experiences of Aboriginal interviewees, ongoing attempts to gain their perspective went beyond the scope and resources of this project. Future research into the dynamics of shame, AOD use and counselling models could incorporate Aboriginal professional accounts on the topic, but arguably would benefit from exploring these perspectives and experiences through a standalone project. This would enable the researcher to allocate the additional time and resources required to follow approved cultural protocols, and adapt recruitment and data collection tools to ensure they were culturally appropriate and culturally safe. Ultimately, attracting Aboriginal interviewees, and honouring their contributions, requires more time and experience than was available to me at that stage of my research training and writing. Future endeavours, however, will aim to ensure that the research

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methods and skills prioritised will facilitate the inclusion of Aboriginal Australian voices to this issue.

During recruitment, it was clear that training, experience and supervision of counselling tasks varied widely between individuals and services. In response to this, the first step was to adjust the recruitment strategy to include Alcohol and Other Drug (AOD) workers and psychologists. AOD workers include frontline staff that work in AOD settings and undertake a wide range of tasks in the administration and implementation of AOD work, such as intake procedures, urine tests, case management and psycho- educational group work. They are expected to have a Certificate IV in AOD work as a baseline qualification. Unlike trained counsellors, AOD workers are not required to be tertiary trained in counselling and so receive a low income (approximately $30,000 per annum at the time of data collection). Typically, they have completed only basic counselling skills for a single module and are not therefore expected to join professional bodies, such as the Psychotherapy and Counselling Federation of Australia (PACFA). Psychologists will have undertaken one counselling module at university, as part of their Psychology degree. While undergoing registration, they may have received training via internships and have agreed to a set of ethical guidelines. The psychology model, however, is based within health guidelines and favours cognitive-behavioural therapy, and diagnosing anxiety or depression through licensed tests, which is different from the person-centred approach used by counsellors. Counsellors are expected to train for two years at Diploma level, join a professional body and seek clinical supervision to maintain their standards. Further, counselling training in Australia requires competency at two reflexive modules, where trainees are required to undergo a process of self-reflection in relation to their work, and to manage the ‘shadow’ side of counselling, such as projection, corruption and counter-transference (see Egan 2002). Given the diversity of workers’ vocational pathways and experiences, ongoing sampling and data collection were adapted to include all of these professional experiences.

If you start with initial coding, theoretical sampling directs where to go next. Therefore, the focus of the research shifted as I explored my initial data and the sampling strategy was adjusted to respond to these findings (Charmaz 2006, p.97). The adjusted strategy

The dynamics of shame: navigating professional complexities when counselling in AOD settings

included: adjusting the research circular to include AOD workers, given the role that these professionals play in counselling activities in AOD services; targeting male services to attract male participants, given that I had only recruited female respondents in the first phase; targeting AOD non-residential services by emailing the circular to a wider range of counselling services; and utilising snowballing recruitment strategies to increase opportunities to attract participants to the study. As with the initial phase of data collection, an updated directory recorded contact details of services, as well as additional information, such as date of contact, mission statements and whether the service was residential, a therapeutic community or a church based mission. The updated directory included the double-checking of contact details in the first directory, because of the low response rates, and the adding of services that were non-residential. The second directory was extended to include forty four services and organisations, still within Australia.

As the data was collected and examined, the research question and the aims of the study also evolved. This process was not chronological or clearly delineated, as the following list represents, but the direction of data collection can be summarised as: 1) target participants who are trained counsellors working in residential rehab settings; 2) extend textual data gathered from creating the study specific directory; 3) target participants who are counsellors, psychologists and AOD workers who undertake counselling practice in AOD settings; 4) expand textual data collection to include codes of conduct and mission statements of AOD services in Australia; 5) include participants who have not worked in AOD settings to ascertain general attitudes, values and beliefs about shame, problematic drug use and the impact of their setting, to deepen the analysis; and 6) extend the textual data set to codes of conduct and mission statements that are not AOD specific. The final categories of data collection (5 and 6) were not sought to provide negative cases, to find new variables, nor to provide alternative explanations. Instead, these cases were imported in response to peer feedback from counsellors, psychologists and psychotherapists at conferences and through the submitting of a journal article.

Theoretical sampling is emergent and follows construction of tentative categories. To further validate these categories, I sought to participate in conferences in both the AOD

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sector and the counselling sector to present these emerging themes and gain feedback on my emerging analysis. On two occasions, through a peer review process that was not affiliated with the AOD industry, I was asked to clarify how a professional might manage working with AOD clients given the ‘deceit and crime’ common to the cohort. Therefore, it became clear that the stigmatisation and “criminalisation” of clients, and resulting practices, might not be limited to residential settings, or AOD settings in general. It seemed a good idea to test if the idea was industry specific or if a client presenting with AOD issues, at a generalist service, might experience similar treatment barriers around chronic shame. As with all of the emerging themes in the data set, this required an ongoing process of comparing data with data and a process of inductive and deductive reasoning. However, rather than using external preconceived theory to formulate concepts, the deductions emerge from the data set and provide opportunities to test out these themes by reviewing collected data and by collecting new data. This has been described as an abductive method, and includes reasoning about experience for making theoretical conjectures and then checking them through further experience. Abductive inference entails considering all possible theoretical explanations for the data, forming research questions, checking these by re-examining the data and pursuing the most plausible explanation (Charmaz 2006: 103-4). As I refined my key categories, my memo writing also became more involved and included reviewing journals, field notes and notes made while coding and re-coding.

3.2.3 Thematic suggestion The terms ‘code’, ‘category’ and ‘concept’ are often used interchangeably in qualitative research, however in this section, I use concept to refer to an idea, and by category I mean the idea, plus all the data about that idea and the position that the category holds in relation to the other concepts. Every concept brought into the study was considered to be provisional until it was identified as being repeated across the data in one form or another. Creating categories in this way allowed me to organise and summarise the extensive and bulky data effectively. At each point that the data was categorised, those segments of data pertaining to the various categories could then be assembled and looked at together, or compared with other categories, by selecting different attributes, thus intensifying the analysis. This process includes making comparisons between categories by comparing segments of the text, comparing experiences related in the

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interview, re-reading the whole interview, comparing the data and personal experience, and finally by comparing the data with similar studies (see Browne 2004, pp. 635-640). It is hoped that these processes helped to strengthen the validity of the research, which as Patton (2002) has stressed can be achieved in qualitative research through verifying the authenticity of the data, identifying similar findings across various data sources, peer review, and the degree to which the findings contribute to the formation of new hypotheses or theories.

During the course of the project, interviews were transcribed verbatim, using an outsourced professional to audio-type the interviews, before the researcher de- identified and cleaned the transcripts. After five interviews, initial coding procedures were undertaken. This was an opportunity to stop and ask questions of the data gathered so far, not only to further my understanding of the studied phenomena but to direct subsequent data collection towards the analytical issues I was beginning to define. Coding was undertaken in two phases: initial and focused. During the initial coding phase, I focused on particular fragments of data, words, lines, segments and incidents. This included turning what I identified as my participants ‘telling terms’ into codes (Charmaz 2006, p. 42). The initial coding frame was validated through discussion with academic supervisors who viewed the coding labels alongside numerous, lengthy and detailed quotes from the interviews. This initial coding frame was later developed to inform the more focused round of coding procedures which were undertaken using the qualitative software NVivo 7 (Charmaz 2006, page 42, Bazeley 2007). Once I reached ten interviews, I developed two preliminary analysis papers which were presented at conferences and then reviewed and published in two different journals (Gray 2010, Gray 2009). From the outset, I noted that my study straddled two overlapping but different fields of enquiry, that of counselling and the AOD treatment field, and I strongly believed that gaining early feedback from researchers and practitioners in these different fields would enable me to develop and expand my thinking regarding the interpretation of my data. Receiving feedback from reviewers and conference delegates on these early approaches to the analysis facilitated my interpretation of these initial findings and was beneficial for helping me to articulate it an a way that is relevant to the work that professionals undertake. There is a small amount of crossover between the material published in those early journal articles

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and sections of analysis included in this thesis. However the material in the final draft of the thesis is based on the complete set of interviews as well as a far more developed analysis.

Employed as a data management tool, the use of NVIVO software allowed me to generate reports listing the coded extracts of interviews. This enabled me to read the various coded statements separately, which helped me gain a better sense of the emerging themes in relation to various key topics in the interviews. As new insights emerged, and new research questions were ascertained, I could then re-read extracts from these interviews in new and different ways, such as looking at training background or personal experience of AOD use, which helped me to explore these subjects and perceptions. In doing so, however, I began to get a sense that the extracts were becoming isolated from the dialogue in which they had been embedded. To prevent the detachment of these excerpts from the overall narrative, I also decided to re-read the interviews in their entirety during the final stages of writing. This enabled me to reflect upon the narratives as something that had developed over the course of an hour or more, in response to my questions and comments, and which, therefore, had been co-created through our exchange. Ultimately, while some of these analytic experiments had been less fruitful than others, the process of iterative reading and re- reading of the transcripts enabled a deep sense of familiarisation with the full range of data, and this then facilitated the development of ideas over time in relation to, or sometimes in contrast to, associated theories and reports in the field. Undertaking such a task without Nvivo would have meant clumsily shuffling transcripts and MS Word documents, which is time consuming. It would also have made it difficult to appraise different perspectives on the same interview simultaneously.

3.3 Ethical issues The conduct of this study was approved by The University of New South Wales Human Research Ethics Committee (07623). In keeping with the stipulations of the approval, all research participants were made aware of requirements pertaining to confidentiality and informed consent. The researcher informed prospective participants of the nature, purpose and requirements of the study and participants were assured that their involvement was completely voluntary and would not impact on future

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employment processes. For this reason, I chose not to include any potential participants who were known to me in my professional life, as trainees or line managers. A further attempt to remain ethical in this research process included providing an explicit description of my prior beliefs and professional experiences, as described in the background to the study section.

3.4 Assumptions and limitations Charmaz writes that some grounded theorists sample until their categories are saturated and that this logic supersedes sample size, which may be very small. However, she also points out that while small data sets may suffice for certain projects, it invites scepticism when the author aims to contradict the established research (Charmaz 2006, p.114). Themes saturation in this study was limited by a number of structural factors. These include the lengthy ethical approval processes required by government health services that excluded some of the possible sites at which data might have been collected. The recruitment of participants took twice as long as originally predicted which meant that data collection within the time-period of the PhD process could not be extended beyond seventeen interviews. Despite this, the final interviews were not producing new themes and so it was concluded that themes saturation had been reached.

Finally, as a new social researcher, it took time to acquire skills in qualitative research methods and to gain confidence in understanding and applying these tools and processes. Nonetheless, while this project does not claim to question established canons of human behaviour nor to contradict established research, the collected data are able to problematise some of the underlying assumptions and practices associated with AOD counselling, including the impacts on AOD workers. The data are also able to raise some important questions as to how we might reduce the levels of harm in AOD services and to increase the rates of program completion, through a deeper understanding of the relationship between shame, counselling and AOD settings. In keeping with this contention, my approach was to remain open to what was happening in the field and make the time to return to recode earlier data. This approach to analysis is never complete, thus the material presented here is emergent, time-specific and

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localised. It is hoped that future projects will enable a resumption of this analytic process, so that these findings may be complemented by additional data from the field.

In describing the reflexive research process that I have undertaken in this research, I have acknowledged that I support taking a person-centred approach to counselling. Indeed, I have stated from the outset that I also hold strong beliefs about the stigmatisation of problematic drug use and the associated service and workforce issues that shape the way these clients should (or should not) be treated. Employing a qualitative methodology assisted me to recognise and uncover the assumptions that are built into my own value-set as part of the very foundations of the research process. This provided the opportunity to question the assumptions and contradictions of the person- centred approach to counselling itself, as part of the analytic process. So, for example, as data collection progressed, it became clear that participants’ perceptions of person centred processes might play out differently in their behaviours and attitudes, and that my understanding of the dictates of person-centred counselling might be at odds with the participant’s understanding of it. Therefore, assumptions about how we work and the outcomes we perceive and experience, as a result of this work were increasingly questioned as data collection and analysis progressed. This included remaining open to the many different interpretations that were possible regarding the dynamics of shame in AOD counselling practice and the relationship between AOD counselling and recovery rates or client autonomy.

In terms of limitations, this study is entirely focused on understanding the little described perspectives of professionals working in the drug and alcohol field, and so the data is entirely made up of their beliefs, attitudes and experiences. However, counsellors and AOD workers only provide one perspective from which to understand the dynamics of shame in AOD counselling. The narratives they provided to me cannot be tested, and much of that data is shaped by the limitations of memory and by the complexities of reflecting on working practices when you are still involved in conducting them. While it is an ethical stipulation that all counsellors undertake activities that enable them to reflect on their work, and the personal factors that affect this work, the ability to self-reflect is of course going to be practised differently by different people. However, there was no attempt made here to measure participants’

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skill levels in self-reflection. Instead, the accounts they provided were taken to be revealing of important social constructions relating to drug use, counselling and shame, rather than somehow directly indicative of the truths of their own or others experiences in these settings.

Interviewing fellow workers in my own area of professional practice also creates some limitations in relation to the distance and objectivity that was able to be maintained throughout data collection and analysis. As described in the reflexive practitioner research section, some elements of assumed knowledge may have hindered my ability to adopt a completely naïve position in relation to accounts provided by participants, and this may have shaped my own capacity to form spontaneous responses, and to be entirely open to the meanings being produced in these interview exchanges. It was hoped that through the various stages of data collection and analysis, including writing field notes, journaling while coding, writing analytic memos and sharing these emerging themes with supervisors and peers, my own position as a counsellor would do more to facilitate the process, through access and immersion in the field, and sensitising my analytic process, than to disrupt or negate it.

3.5 Summary This study investigated the professional experiences of counsellors and other workers based in AOD service settings, a field in which I have been employed in a professional capacity. Employing a qualitative model that used reflexive practitioner/researcher processes, informed by the principles of constructivist grounded theory, was deemed to be the most appropriate method for conducting the research. Data collection was performed by the researcher, primarily through face-to-face, in-depth interviews that were digitally audio-recorded and transcribed verbatim. Data was managed using qualitative software (NVivo 7) and analysis consisted of an iterative process of conceptualisation, coding and categorisation. These categories underwent a number of review processes, were compared with other categories, and compared with the data. Ongoing analysis of the categories created thematic insights which will be presented and discussed in subsequent chapters. Exploratory questions guided the inquiry to deepen current studies of counselling around shame in AOD settings, and problematise current clinical processes. The following chapter provides an overview of the data that

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was collected, including demographic profiles of the participants, before turning to the thematic analysis of the results.

The dynamics of shame: navigating professional complexities when counselling in AOD settings

4. Participant profile and textual data

This chapter provides an overview of the interviews and texts collected for this study. The aim was to address the central research questions, ”How does shame prevent or enable the relational factors of counselling practice in AOD settings?” and “How does the AOD setting affect counselling around shame issues?”. The findings that relate to the recruitment strategy will be explained in greater detail, as will the demographic profiles of interview participants. All names used in this thesis are pseudonyms.

4.1 Interview participant characteristics Seventeen participants were recruited into this study over a two year period. As seen in table 1, the majority of participants were women. Three of the five interviews with men were undertaken during the final stage of data collection, as a result of purposive sampling. The percentage of female participants is consistent with workforce surveys undertaken at that time and current workforce profiles (Workplace Gender Equity Agency 2012; National Centre for Education and Training in Addiction 2010; Gethin 2009).

Table 1: Gender of participants Gender n = 17 % Female 12 70 Male 5 30

The age range of participants, as noted in Table 2, included four under 30 years, five between 30 – 39 years, three between 40 – 49 years, three between 50 – 59 years and two participants older than 60 years. Therefore, the majority of the participants in this study were younger than 40 years. This sample includes younger professionals than is represented in current workforce profiles. In the AOD sector (Duraisingham, Pidd, Roche and O’Connor 2006), as well as Australian workforce more broadly (Workplace Gender Equity Agency 2012), employees are generally considered to be older than 44 years and an aging population.

The dynamics of shame: navigating professional complexities when counselling in AOD settings

Table 2: Age of participants Age n = 17 % 21-29 4 23 30-39 5 29 40-49 3 17 50-59 3 17 60+ 2 12

As noted in Table 3, nine of the participants reported that Australia was their country of origin. A further three were from New Zealand and two identified England as their country of origin. The remaining participants also came from English-speaking countries: Ireland, South Africa and North America. However, the majority of participants were from Australia. No counsellors from a non-English speaking background self-selected to take part in the study. Indeed, the interview data set for this study is dominated by professionals from English speaking backgrounds and countries- of-origin. This is consistent with recent local workforce profile surveys which show that employees from culturally and linguistically diverse backgrounds make up just 6% of the AOD workforce (Gethin 2009). However, the lack of representation of counsellors from non-English speaking backgrounds in this study could also be due to a culturally inappropriate sampling strategy. In future research, deliberate consultation with counsellors or workers from non-English speaking backgrounds will be sought in order to ensure that the research invitation and sampling strategy will be appropriately framed to attract these counsellors.

It was also noted that while there are a range of services that target the Aboriginal Australian community, no counsellors who identify as Aboriginal approached me to be included in the study. Unfortunately, the study lacks participants who identify as Aboriginal or Torres Strait Island descent. This is consistent with survey data that has demonstrated that Aboriginal and Torres Strait Islanders represent a minority in the workforce (4%) further research is needed, however, to ascertain more culturally appropriate sampling or information dissemination strategies for this community.

The dynamics of shame: navigating professional complexities when counselling in AOD settings

Table 3: Country of Origin Countries n = 17 % Australia 9 53 New Zealand 3 17 England 2 12 Ireland 1 6 South Africa 1 6 North America 1 6

As indicated in the following table, a large proportion of the participants (7) had completed a diploma in either AOD work or counselling practice. Of the seven participants who had completed a Bachelor’s degree, all had undertaken a diploma or additional training in counselling skills. Therefore, sixteen of the seventeen participants had undertaken vocational training at either a certificate or diploma level. However, it should also be noted that five of the participants had not completed their training while they were formerly counselling clients. None of the participants had a PhD, and only one had completed a Master’s degree, but two were working in the research field, in both qualitative and quantitative research. A large proportion of the participants (6) had trained in Systemic counselling techniques. This is an approach that goes beyond the individual to incorporate issues as part of a wider system such as an intimate relationship or a family unit and had trained to a graduate diploma level. Further, a large number of the participants (7) regularly engaged in conference activities and workplace training. It is therefore acknowledged that even though the majority of participants were primarily engaged in clinical/vocational activities, it was common for the participants of this study to reflect regularly on their practice in formal contexts alongside peers or professionals from other industries. The data presented in succeeding chapters is indicative of this reflexive professional practice.

The dynamics of shame: navigating professional complexities when counselling in AOD settings

Table 4: Formal education completion Level of Education n = 17 % Doctoral 0 Masters 1 6 Degree 7 36 Diploma 7 42 Certificate IV 2 12

As noted in Table 5, the majority of participants (9) completed a Bachelor’s degree in Psychology, but this in itself is not indicative of counselling training. However, the psychology graduates in this study had undertaken additional training in counselling practice. Seven of the participants had trained in counselling techniques and two had undertaken counselling training that was specific to AOD work. In contemporaneous workforce profile surveys, Australian AOD professionals were more likely to have vocational training at a diploma level, while counselling professionals working in the sector were tertiary trained and had undertaken additional vocation-specific professional development training (Roche & Pidd 2010). In New South Wales surveys, the workforce was categorised as well trained and highly qualified (Gethin 2009) suggesting that the study-sample reflected the broader workforce profile.

Table 5: Subject or area of training Subject n = 17 % Psychology 9 50 Counselling 7 40 Alcohol and Other Drug Specific 2 10

Four of the interviews were conducted in one setting and the data set includes material from colleagues who took part. To avoid possible identification of the participants, information is not provided about which participants worked together. Significantly, many of the participants had worked across multiple settings and so their input can be seen to reflect upon the diversity of different workplaces.

The dynamics of shame: navigating professional complexities when counselling in AOD settings

These demographics are largely in line with the general trends observed by Australian- wide AOD workforce studies at the time of data collection. That is, the workforce was female dominated, non-Aboriginal and from English speaking backgrounds (Gethin 2009). Respondents in this study were, however, younger than the general workforce.

4.2 Interview data During data collection and initial analysis, three pertinent findings emerged. First, participants were often expected to undertake counselling activities in the AOD sector before they had completed their counselling training. Second, participants often reflected on their own life experience in relation to their work, especially their own experience of problematic drug use or that of a significant other. Third, participants viewed general AOD settings, not just residential, as frightening and confronting places for clients to enter, and AOD clients as resistant to being labelled and discriminated against as a result of attendance. These findings will be explored in the following chapters.

As the initial process of open coding continued, a number of categories were used to develop the analysis. The ongoing analysis of the coding reports, field notes and analytic memos resulted in a number of themes that will be described and discussed in the following chapters. These are: addiction, motivation and responsibility in counselling; shame, stigma and labelling in AOD settings; and finally the dynamics of shame: impact on the workforce. Thematic analysis suggested that the research axis of shame/counselling/addiction is wrought with contradictory issues that have the potential to complicate the treatment process and have a detrimental impact on the workers undertaking this practice. It is important to note here that participants commonly described themselves as both under-trained and unsupported, while they viewed their clients as courageous and insightful. Despite harsh working conditions, participants also described their work as rewarding, in particular through the mutual learning that they felt they had gained through the therapeutic alliance. Participants often perceived themselves as having a lot in common with their clients and in some cases, as noted above, participants sometimes spoke about their own experiences of problematic drug use. At times, they reflected upon their own families of origin,

The dynamics of shame: navigating professional complexities when counselling in AOD settings

particularly if they felt they had been typified by dysfunctional relationships or traumatic incidents.

4.3 Textual Data The textual data used for this thesis were drawn from directories and websites for AOD services, in New South Wales. This material was originally collated for the purpose of recruiting participants, but when it was revealed to be rich and relevant to the research question, this material became a target of the second phase of data collection. It is acknowledged that many of the participants involved in this study did not write this material, and many of them were not likely to have read it. In any case, no attempt was made to compare the two data sets, and the material was handled separately to avoid jeopardising the confidentiality of the participants who may have worked at these services before or at the time of the interview.

The majority of clients who attend AOD services will also have not read this Internet material either, as they are more commonly referred by other health care professionals or directed through peer networks and word-of-mouth. The Internet material, however, provided an important complementary set of data to help understand the aims and positions of the various services, which provides a useful counterpoint to the accounts of counsellors and other AOD workers who were employed in those settings.

The majority of textual excerpts were short paragraphs that outlined the particular therapeutic process and target cohort of each service. These paragraphs were usually also duplicated on the interagency directories and service homepages. Some of the services included additional and lengthy descriptions of treatment processes as well as definitions of addiction and recovery. In some cases, these descriptions included client testimonials and art work. The textual excerpts were not used in the analysis to contextualise quotes, as this would have risked identifying the participants. Instead the textual material was incorporated where it was deemed to broaden the discussion by contrasting the participants’ accounts with service mission statements and definitions.

It should also be noted that much of the textual data was gathered from websites that were out of date or unmaintained. Services contacted about the study confirmed this, explaining that much of the contact information, staff listings and treatment criteria had 62

The dynamics of shame: navigating professional complexities when counselling in AOD settings

not been updated for some time. Despite attempts to get the most up-to-date textual data for these services, some of this may still be considered somewhat out of date. There is one final comment about the textual data that is important to note at this point: the majority of websites included a statement about how ‘responsibility’ for the recovery process was viewed by that service. In each case, the responsibility was explicitly seen to lie with the patient. These issues will be explored more fully in Chapter Five.

4.4 Summary The AOD counselling workforce is difficult to access for research purposes due to time-poverty and inadequate staffing in their workplaces. However, a sufficient and diverse number of participants agreed to take part in the study, providing a unique set of insights regarding the dynamics of shame in counselling practice in these settings. Through the course of gathering and analysing interview and textual material, a set of recurring themes emerged and these will be presented in the following chapters. As the textual data did not yield any additional findings that pertain to shame and stigma (Chapter Six) or worker impact (Chapter Seven), the textual data is represented in the background section of the Introduction and Chapter Five only. The analysis chapters commence with a discussion of the ways in which participants described concepts of alcohol and drug use and problematic use, and treatment processes. This is followed by a discussion of the ways in which participants described the role of shame and stigma in AOD counselling practice. The analysis then focuses on participants’ descriptions of the ways in which these factors affected the relational factors of counselling in AOD settings, and ultimately the potentially negative impacts of these factors on workers.

The dynamics of shame: navigating professional complexities when counselling in AOD settings

5. What is the presenting problem? Negotiating definitions of addiction when counselling in AOD settings

In this chapter I will present and closely interpret participant statements that explore problematic alcohol and other drug use, and consider how these relate to counselling in AOD settings. I will complement this material with excerpts identified in the textual component of this study. The following data demonstrate complex dynamics at work, and are presented as: negotiating definitions of addiction, motivating AOD clients in treatment, and the effect of notions of client responsibility, as they relate to counselling in AOD settings. In doing so, participant accounts will complement existing research that highlights the importance of client motivation when attending AOD treatment, and will help to inform increasing reports about the connection between notions of personal responsibility for problematic AOD use. This analysis will add to other research by providing insights into how AOD professionals perceive their work, in particular the importance of engaging clients by providing a space in which they can understand what elements of their AOD use are problematic. Moreover, these participants emphasise the need for professionals to remain tentative and gentle in their professional approach, which was contrasted against other approaches that were viewed as punitive and even brutal. This chapter will therefore explore how conceptual frameworks of ‘addiction’ and AOD treatment create a context that can facilitate or disrupt the relational factors of counselling, before I more closely examine how this becomes entangled with shame in Chapter Six.

5.1 Negotiating definitions of AOD use and addiction Consistent with the ‘disease’ (or Jellinek) model, a recurring theme in participant accounts was problematic AOD use as ‘addiction’. This perspective views drug use as a permanent state, and sees the only possible recourse in recovery as abstinence. This was reflected in promotional material found on service Internet homepages. One such organisation stated: “whatever the substance, whatever the cause, drug dependency is a disease that damages the emotional, physical and spiritual health” (private health clinic, viewed April 9th, 2009). Interestingly, ‘addiction’ and ‘disease’ were viewed as permanent and static and were combined with other more dynamic and changeable factors, such as those relating to social or psychological factors. While the two attitudes

The dynamics of shame: navigating professional complexities when counselling in AOD settings

may seem to be at odds, this combination could be understood as congruent with the bio-psycho-social approach which some have deemed most appropriate in contemporary practice texts directed at social workers (see Rose & Farrow 2010). Despite the joining of these disparate notions, when defining problematic drug use as a ‘disease’ or ‘addiction’, participants also tended to describe the issue as a problem and permanent. For example, Brett preferred to use the word ‘addiction’, which he described as an affliction:

How do I understand addiction? I see it as an affliction. Yeah, a bit like an affliction, you know? I subscribe to like the disease model, that it’s...stuck with all my life. It’s something I was prepared to put up with...yeah, it’s just what I do...I subscribe to the whole bio-psycho-social model...I see it, yeah as a combination of, you know genetics, biological, predisposition, as well as, environmental factors. (Brett, AOD worker, residential community AOD service)

Participants in this study often drew from their personal history in defining drug use. For example, Joanne (counsellor, AOD private residential service) described the hereditary characteristics in her own family and alluded to her pessimism regarding the possibility of ongoing sobriety for an addict: “Like I have that gene – my father was an alcoholic and my grandfather... [but we] have been able to claw our way back, whereas an addict can’t.” Later in her interview, Joanne reflected on how she viewed an addiction as manifesting in behaviours that did not include drug use, such as sexual practice and exercise. At the private residential AOD service she had left by this time, she stated it was necessary to incorporate all compulsions due to the pervasive nature of addiction:

I used to work in a private treatment centre. So that was all addictions, you know…eating disorders and everything. Gambling. Everything. Internet sex. Love. Everything. Exercise. Everything. But predominantly drug and alcohol because a lot of those all feed in or…are addictions or by-products of …an addict is an addict in whatever they use. (Joanne, counsellor, family therapy clinic)

The dynamics of shame: navigating professional complexities when counselling in AOD settings

Material published on service internet homepages promoted similar understandings of addiction. One such service stated that:

A successful detox needs to combat the emotional and physical stresses of withdrawal [...] our programs are designed to help anyone struggling with recreational drugs, prescription and non-prescription medication, other substances like alcohol, and relationship or life problems that result from substance abuse. (Private residential health facility, viewed April 9th, 2009)

Another way participants described addiction was as a separate ‘thing’, an automaton, like a self-driving machine that works autonomously of the individual. Such a perception was offered by Joanne:

That part of them is very specific … it’s like a… an entity, you know? And so it operates on its own kind of energy. When the addict starts to operate anything can happen. You know, they’ll sneak out and go and drink, or you know, smuggle in contraband and all that kind of stuff. Or become aggressive or hard to manage. (Joanne, counsellor, family therapy clinic)

Another example was found on a mental health service Internet homepage, (aimed at attracting self-referring clients) which described alcohol use as: “a powerful driving force...no longer is it your choice...it causes your life to unravel...it is disastrous to ignore it” (private, church based, not-for-profit mental health service, viewed April 9th 2009). Brett was keen to emphasise the powerful attraction of illicit drugs and their pleasures. He described a possible motivation behind AOD treatment as stemming from a desire to reduce the problematic aspects of its use, without denying the appeal of drug use. In this way, he reconciled the pathological elements of drug use with the pleasurable elements, without dichotomising them:

The dynamics of shame: navigating professional complexities when counselling in AOD settings

Addiction’s very powerful. Cunning, powerful and baffling. And it’s really nonsensical in many respects. As much as it’s evil and has a horrid side to it, it actually has appeal to it... I didn’t give up drugs because I didn’t like drugs. I love drugs. I still love drugs, but I gave it up because of all the collateral damage around me, you know, my life. (Brett, AOD worker, residential community AOD service)

For Terry, alcohol and drug use was described as a mechanism by which to manage emotions or to stop experiencing an emotion, in this case to stop caring:

[The client] drinks to the point where he stops caring [about a particular incident]. He doesn’t give a damn. And I think that’s what alcohol and probably marijuana – not that I’ve used marijuana but I’ve certainly used alcohol – that’s what alcohol does. (Terry, couples counsellor, non-government organisation)

Indeed, Terry felt this was the mechanism through which general drug use could be separated from use that might be defined as problematic:

Well, where there’s a need to have something, and I’m sure everybody who drinks at times will say: “God, I’d love a drink right now!” I don’t mean that kind of dependence, but I mean a dependence where...if you don’t you feel there is something missing. That you drink to the detriment of your bank balance or to your relationship, or to your work or your family in some way. So, in some way your drinking comes before them. (Terry, couples counsellor, non-government organisation)

Similarly, while Joanne saw ‘addiction’ as overtaking an individual’s motivations, her terminology would shift so that at other times the use of the term was less totalising. A common theme in the participants’ interviews was the importance of locating ‘addiction’ or the problem in one part of the person, and capitalising on the part that could regulate use:

The dynamics of shame: navigating professional complexities when counselling in AOD settings

[Through treatment] they could really see another side of who they were. They started to be able to learn there was an addict part of themselves...and then there was also another... the other self that wasn’t the addict. And they were starting to learn about who that was, and starting to like that person. (Joanne, counsellor, private residential AOD service)

While some research has indicated that a history of problematic AOD use, and or experience in AOD treatment, has the potential to affect how counsellors view the objectives of their work (Skuja 1981), a common theme among all participant accounts was the importance of defining the problematic behaviour, and further, of separating the problem form the person. This perception had ramifications for participants’ understanding of the role of counselling in AOD treatment. For example, Terry said that he preferred the term: “drug problem” to dependence as the latter might reduce client motivation by engendering a sense of helplessness. Similarly, when Sally was asked how she preferred to describe problematic drug use, she focused on her awareness that such terms can have an impact on how the client understands their presenting problem. Consequently, this was viewed as potentially reducing how empowered they felt they were to make a change. A recurring theme of participant perceptions of drug use related to the sense of agency a client may have over their ‘addiction’. In the following excerpt, Sally gives her reasons for preferring to use the term ‘dependence’ rather than ‘addiction’:

I prefer dependence because dependence, I feel like it’s something that they’ve developed but they’re not, they’re not a victim to […] I guess ‘addiction’ is kind of, you know, you have no control over it. (Sally, psychologist, AOD health service)

Throughout the interviews, participants used a variety of terms to describe AOD issues as a presenting problem. Obviously, the terminology might be different when a client is attending a family therapy clinic as opposed to a mandated client who attends a specific AOD service. In these descriptions, terms were tied to understandings of how these definitions influenced treatment dynamics and how these then related to client motivations and potential outcomes. This might be a diagnostic mechanism, at other

The dynamics of shame: navigating professional complexities when counselling in AOD settings

times a term might be used to analyse, in collaboration with a client, the presenting problem in order to develop alternative coping strategies or resolve underlying issues that were triggering problematic drug use. The process of exploring the presenting problem or negotiating the most appropriate definition becomes part of the therapeutic process in itself, and serves to externalise the ‘addict’ or ‘alcoholic’ from the person’s identity. Thus, concepts that might appear to be at odds, such as the ‘disease’ model and the ‘social’ model, became blended in participants’ approaches. Through focusing on what works, these accounts demonstrate the ways in which counselling theorists have termed building a ‘therapeutic working alliance’, which uses the trusting relationship between service provider and client as the means of attaining positive outcomes in mental healthcare, in this case, AOD recovery.

In this vein, Paula felt that defining drug use through a single factor was short-sighted in terms of treatment potential. As a result, she was keen that ‘medical’ services drop the expert position and adopt a more holistic approach:

The medical model’s an expert kind of model...I think [the social model of drug use is] under-utilised because I think people do come in with multiple problems and we would often see that alcohol or drugs; it’s actually a solution, not a problem […] Don’t forget, drugs and alcohol feel really great, you know? […] I guess there’s new adaptation that occurs for people. This isn’t just, you know a character defect or something…and not necessarily people have to have child sexual abuse or anything problematic. (Paula, psychotherapist, community health service)

In doing so, Paula contributes anecdotal evidence consistent with previous research which has demonstrated that those practitioners based in a health setting had different views of clients and drug use to those who worked settings that use other approaches in a social model (Palm 2004). In contrast to Palm’s research, this study reports professional narratives that help to illustrate the multi-layered understandings of drug use enacted in this setting. Paula’s conceptualisation enabled her to promote clients’ power over or awareness of how they define their use, and therefore which approach should be used in their treatment. Participant narratives included perceptions of drugs

The dynamics of shame: navigating professional complexities when counselling in AOD settings

as ‘useful’ or having a ‘purpose’, rather than wholly problematic representations. Despite indication of preferred terms, participants drew from a wide theoretical base in describing how they understood AOD use. This influenced their attitude to their work, which was largely about maintaining a relationship with clients that was operational, facilitated change, remained balanced and adopted a fluid and non-expert stance. Not surprisingly, participants felt that focusing on one concept of AOD use could be problematic in itself.

This supports previous qualitative work that gathered AOD client accounts of change (Hanninen & Koski-Jannes 1999). This work demonstrated that there are several ways of construing change in AOD use behaviour, and moreover clients could be encouraged to make full use of the available narratives in creating an account that fits their own experience of change. The narratives in this study provide more examples of people who have undertaken AOD treatment, how they articulate their AOD use and their changes to this, and importantly how they incorporate these narratives into their understanding of their work. In reflecting on the work by Hanninen and Koski-Jannes, it is important to add that such narratives are not complete or static, but subject to development and in process. Further, as outlined in the literature review, the preferred position in generalist counselling is that the client manage the process of defining behaviour as problematic. However, in an arena characterised by court mandates and coerced attendance, as well as duty-of-care responsibilities that relate to risk factors like over-dose, ill health and blood borne viruses, counsellors in AOD settings may need to engage and motivate clients who do not deem their drug use to be problematic at all.

To recap, in this section I explored the ways in which interviewees conceptualised AOD, general and recreational use, against that which was considered problematic. Significantly, despite some adamant opinions on the permanence of addiction, a recurring theme across the interviews was that the approach to defining the presenting problem should be tentative and undertaken in negotiation with attending clients. In the next section, I build on this by presenting excerpts which describe the fissures that can occur in counselling in AOD settings in relation to multifaceted and at times contentious understandings of alcohol and other drug use. The analysis will now focus

The dynamics of shame: navigating professional complexities when counselling in AOD settings

on how definitions and understandings of drug use play out in relation to treatment, with a particular focus on participants’ views of the role of counselling in these dynamics.

5.2 Motivating counselling clients in AOD settings In describing how they perceived AOD use and addiction, participants also suggested that the discursive meanings attributed to different types of drugs could result in people having an inaccurate understanding of their level of dependency and how problematic it might be. This was thought to influence treatment dynamics. For example, alcohol was often understood to be less of an issue than other drugs, due to its social acceptance and legality. Building on the point she made earlier in her interview, Kristine said:

Most people, even if they’re okay with their own use, know that a lot of society shuns it. There’s so much bad press about illicit drugs but there’s not bad press about alcohol because it’s legal. And that’s one of the things I find a lot of people have real difficulty with because realising well actually just because it’s legal doesn’t mean that it’s okay. (Kristine, psychologist, residential community AOD service)

The difference ascribed to different drugs, and consequently their levels of ‘addiction’, has received attention in the broader research context. The higher degree stigmatisation directed towards illicit drug users has been periodically reported (Bourgeouis & Schonberg 2009; Wodak & Moore 2002; Kallen 1989), as has the additional healthcare and treatment barriers associated with this discrimination (Ahern 2007). In this study, participants ruminated on the potential influence that concepts of dependence have on clients levels of shame, relating to AOD use. In other words, iterviewees perceived clients to be impacted by additional challenges that related to how they viewed their dependency as well as how this might affect their potential for recovery. For example, recovery might be considered harder for people who engage in injecting drug use, whereas clients who use ‘softer’ drugs might be viewed as less in need of treatment. Sally, who worked in a community outpatient setting, described how these issues affect people who smoke marijuana:

The dynamics of shame: navigating professional complexities when counselling in AOD settings

I think cannabis is a really interesting drug in that there’s still a lot of controversy about it. And there’s actually not a lot of research about it. … I guess I wanted to add that, I still run into a lot of professionals who are like, “Cannabis? Why would you need to stop using that?” (Sally, psychologist, AOD health service)

As this shows, conceptualisations of problematic drug use were complex in these interviews and were seen to have the potential to affect treatment of clients negatively. Discourses relating to drugs and problematic drug use were understood to be value laden, and external negative appraisals of use were understood to have more to do with social attitudes to certain substances than with particular behaviours or research evidence.

Significantly, participants often felt that an overly fixed or closed account of ‘drug use’ was to be avoided. In his interview, Brett reflected on his own experience of long term drug use drawing from both biographical and clinical understandings of drug use. In the excerpt above, he described addiction as an affliction and something quite fixed and permanent. But in the following account, he reflected on the cultural and social aspects of a drug injecting lifestyle. Reminiscent of work on the social aspects of becoming a drug user (see Becker 1953; Bigus 1977), Brett described the transformation that occurs for people who use alcohol and other drugs for long periods of time. In doing so, he raised awareness as to the multifaceted and complex motivations that might inspire ongoing AOD use:

It wasn’t just about the drugs; it was a sub-culture, belonging to something. It was more than putting a needle in your arm every day. It was the camaraderie. So there was a whole social aspect to it [...] it becomes a social thing, and then you get swept up in it, and consumed by it, and everything just gets excluded. It’s very exclusive. I think it’s an exclusive lifestyle. We exclude all other normality, well social normality. And become very elitist. Be part of an elitist culture, exclusive culture. (Brett, AOD worker, residential community AOD service)

The dynamics of shame: navigating professional complexities when counselling in AOD settings

Brett’s comment has the potential to remind professionals that drug use is often a social activity, and not necessarily an individual’s pathology or problem. He also asserts that while a particular lifestyle might be illicit or associated with pejorative descriptions, the individual may have an understanding of their drug and/or alcohol use as something that is imbued with social status in particular sub-cultures, or to be revered. This aspect of the drug-using lifestyle has the potential to provide a sense of belonging and community. Therefore, a definition that focuses on individual factors will potentially miss an important determining factor, such as the social aspects.

When asked about preferred treatment approaches, participants ruminated on the fact that problematic drug use might be only one part of the issue and that many other factors were likely to contribute to the presenting problems. In other words, just as determinants of problematic AOD use are numerous and shifting, AOD use could be conceptualised as one part of a range of other issues. In this way, they raise the issue which is the extent to which clients might remain motivated to work on their AOD issues in treatment, when other determining issues fail to be addressed. As such, the motivation to undertake or continue AOD treatment may be thwarted when the therapeutic process focuses on abstinence, as this is felt to be too narrow. These professionals felt it was important to frame their counselling holistically, namely that counselling be used to work on AOD issues but not to the extent that other presenting problems are sidelined. This is the case against focusing too heavily on any presenting problem, including shame. For example, when asked how he viewed treatment options for clients, Brett said:

I think addiction is bio-psycho-social, but there’s also these other aspects to it that can be part of it as well...there’s all the socialisation that can be looked at, you know? And environmental stuff...And I think, shame is a contributing, can be a contributing factor to addiction, the same as grief and loss can be a contributing factor. So I think I look at shame as just one part of the holistic thing, you know. (Brett, AOD worker, residential community AOD service)

The dynamics of shame: navigating professional complexities when counselling in AOD settings

Where problematic drug use was understood to be related to one of many possible underlying issues, it was sometimes constructed as a coping strategy, in that it serves to manage the negative manifestations of an underlying issue, rather than being a symptom. One service Internet homepage starts with a promise: “by addressing underlying issues or dynamics in your life that may be driving substance abuse...our intention is to support you to remain drug free” (Private residential facility viewed April 9th, 2009). James also described drug use as a strategy that a client might use to cope with a number of compounding issues:

It could be a combination of all sorts of different things. People have predispositions, I guess. But certainly life events have to have happened and probably more than one. Probably most people can be resilient to withstand one thing [...] So the first thing could be the family of origin stuff. The second thing could be some other loss of some kind. And the third thing could be absolutely anything [...] it looks like just that final thing but actually it’s not. So if you’re just treating the addiction itself, you’re looking at just the symptoms. (James, psychologist, generalist counselling clinic)

Other participants described the frustration they felt at having to focus on drug and alcohol issues when they felt that there was something else more pressing to focus on. Sally described her professional frustration that her remit was to work on the AOD issues, which she felt was short-sighted, given the variety of issues that lead to problematic drug use and the desire to change:

I don’t know a lot about shame. But I think that’s definitely something like … as a drug and alcohol service you’re very aware of the fact that your clients probably have a variety of issues, but your service is to address the drug and alcohol issues. And whatever is contributing to those or preventing them from maintaining their abstinence. (Sally, psychologist, AOD health service)

Participants suggested that to focus wholly on problematic drug use was to neglect these underlying issues, which in turn would prevent the counselling process from

The dynamics of shame: navigating professional complexities when counselling in AOD settings

addressing the core issues at hand. Indeed, a paradox that was seen to emerge from these interviews was that the most effective AOD counselling did not focus on AOD issues. For example, Robert said:

There’s something underlying that needs to be addressed or touched, or confronted, or brought to light that the, the addiction is a symptom; it’s not the thing in itself. There is something underneath it. (Robert, grief counsellor, never worked in an AOD setting)

Despite this recurring theme, participants were also keen to avoid generalisations and were reticent to assume that every client has some underlying issue or unresolved trauma that is triggering problematic drug use. For John, if counsellors and AOD workers assume that all clients are trauma-survivors, it is likely that progress will be hindered in the same way as a counsellor missing an underlying issue. He built upon this idea by suggesting that misguided counselling can become a problem in itself. In doing so, he seems to be arguing that drug treatment programs should not assume that counselling is useful in all situations:

I can’t help thinking that there’s an over-emphasis on counselling, in a fairly strict, programmatic kind of way that operates within drug and alcohol [services], that I think can become part of the problem rather than the solution. (John, AOD worker, community health service)

Later in his interview, he added:

You just end up with a whole lot of people walking around, maybe even additionally burdened by a sense of...this sort of excavation of one’s history... And you know, it’s… it’s …kind of a prescriptive, slow, tedious, born-again process where people are encouraged…in some drug and alcohol counselling, to believe that they’ve got a big problem. And even if they don’t feel that they have, sooner or later they’re gonna start believing it. But they may continue to labour under this impression that they’ve got this unresolved issue.

The dynamics of shame: navigating professional complexities when counselling in AOD settings

Therefore, in reflecting upon what defines problematic use of alcohol and other drugs, participants appreciated the multitude of issues that might inspire an individual to embark upon AOD treatment. However, AOD issues were viewed as just one aspect of various potential presenting problems. In this way, participant accounts provide insights into some of the ways an AOD setting can disrupt a recovery process, by its very remit. In other words, problematic AOD use may be the presenting problem but it need not be the only goal in therapy, once the underlying issues are addressed. Similarly, John felt that it was important to work with clients in a way that was not dependent upon them abstaining. Building on an argument he made earlier in his interview, he explained that he felt that imposing misguided therapeutic processes on clients might prevent them from having their more immediate needs addressed:

Sometimes, particularly older people who…they just continue to use and, or they’re on their methadone and this and that, and they’re kind of just getting through life. You know? They may even be chronically homeless. What are they really? Or what I sometimes felt that they needed was not more fucking counselling; they just needed somewhere warm and dry to live. They just wanted a fucking house. They didn’t need yet more, you know, 23-year-olds with tertiary qualifications who want them to undergo kind of all these ridiculous processes before they’ll even be considered for like emergency housing […] there’s a presumption in counselling, that resolution is always possible. (John, AOD worker, community health service)

These quotes help to problematise the role that counselling can play in AOD settings, and to question the relevance of mandated AOD treatment for clients presenting with a variety of issues. Despite participants describing a process of negotiation with their clients, when defining AOD use or the presenting problem, there were examples where participants felt that the AOD sector too often failed to provide such a therapeutic climate. In John’s example, failure to engage in counselling or treatment might not be an example of low motivation, or a lack of treatment readiness, but simply having other more urgent priorities at that time. He hints at the potential frustration of clients who want housing but are compelled to undertake counselling. Worryingly, some

The dynamics of shame: navigating professional complexities when counselling in AOD settings

participants described witnessing the victimisation of clients in AOD services. For example, in reflecting upon her early professional experience, Josie said:

In a way I think substance abusers can be very much victimised by the society. And I think that they were victimised in the industry. And for some of them, I think for some of those people, you know, people were able to say, “It really helped me and I really pulled myself together and got my act together.” Those people in a way are somehow used to that brutality in some way. And they might actually do that to themselves in some way. But I think there are other people that were badly mistreated by and maybe didn’t benefit from that sort of treatment. (Josie, counsellor, private practice)

Participants described the effort required for clients to initiate treatment, given the various factors described, and it was seen as important to resist exacerbating this shame through treatment strategies which might further alienate clients. In research that explored the relationship between client motivation and positive treatment outcomes, Klag, O’Callaghan and Creed (2004) suggested that treatment providers need to enhance and maximise motivation levels at intake and then sustain them throughout treatment. Consistent with this, study participants perceived entering an AOD treatment setting as requiring high levels of motivation for some clients. They also articulated the various, previously underreported, reasons that clients might have for not being engaged in treatment. Rather than locating a lack of treatment-readiness in the client, these interviews demonstrate the professional complexities of motivating clients in a context that ignores the presenting problem, imposes irrelevant goals and even victimises them.

By exploring these mismatched approaches to treatment, the interviewees provide insight into the multitude of barriers counsellors might face when attempting to build rapport and develop a therapeutic relationship. When I asked Paula what she thought about the role of counselling in AOD treatment, she described her use of counselling techniques to build trust with a particular client. She could better engage clients to AOD treatment through building rapport. She also felt, however, that this was

The dynamics of shame: navigating professional complexities when counselling in AOD settings

challenging because the client in question had been unable to trust other counsellors in the AOD field until that point:

Oh well, I would see it as, unconditional positive regard, your congruence, your empathy. That’s my basic training. It’s based on those kind of fundamental principles. I think that’s fundamental… and in drug and alcohol …that’s continued. […] A client of mine […] he didn’t really trust counsellors, but I was one of the first people he could trust. (Paula, psychotherapist, community health service)

Paula described the ways in which other approaches had the potential to impinge upon her approach. She was able to build a trusting relationship with this client but her comment speaks to the additional barriers she faced in relation to her client’s previous experiences of counselling. This is perhaps not surprising. One could argue that this is a likely finding for any counselling study. However, in a field marked by low client motivation and high attrition rates, these comments help to elucidate some of the structural or context-specific barriers that clients face in approaching treatment.

During these interviews, participants used examples of ineffective and coercive treatment to explain why counselling should be undertaken in a way that is client- paced, tentative and empathic. In articulating this position, participants contrasted their work with that of other services or other colleagues. These other services were described as exemplifying negative or shaming treatment patterns. This was seen as something to avoid in counselling clients, in general, but in particular with those clients presenting with shame and trauma issues. Participants also stated that they felt hindered in undertaking a gentle way of working, which requires time and trust building, due to the models they were asked to work within or the funding stipulations that favour quicker methods. For example, Josie, who started as an alcohol and other drug counsellor and now works as a family therapist in private practice, said: “this society wants to lean always towards quick methods […] brief therapy [...] let’s try and fix you up!”. This rushed or brief approach was largely seen to be at odds with the tentative and slow pace of counselling that addresses trauma or shame. Moreover, Paula asserted

The dynamics of shame: navigating professional complexities when counselling in AOD settings

that, without a gentle approach, it is possible that the clients will be ‘re-traumatised’ through counselling:

I think especially with things like violence or drug and alcohol, or sexual abuse, there’s so much potential for re-shaming that you need to be very mindful and tentative...and kind of pacing stuff that’s all going…when we were talking earlier, I was thinking if I was to inadvertently shame them through my inexperience, or something like that … because it can still happen. I’m not saying I don’t shame people, you know? Unintentionally, of course, but it’s whenever I’ve gone into it with a fixed idea or something... (Paula, psychotherapist, community health service)

This potential to accidentally shame a client will be explored in greater detail in the following chapter, but the sense of trepidation that participants felt towards working from a fixed notion of what causes drug use to become problematic is relevant here. In other words, participants understood their role as exploring the role that drug use had in the client’s life and working with them to ascertain appropriate goals in therapy. In another example, Sally described the potential shame that can be experienced in relation to assumptions about ceasing use of ‘softer’ drugs. Sally explained that some clients may experience shame because they have issues with cannabis:

And I guess the ‘shame’ thing: some of my clients are ashamed that they can’t just give it up, and it’s expected in society that it’s just something that you do for fun, and you grow out of it. And some people are actually, you know, have very significant difficulties doing that. (Sally, psychologist, community AOD service)

The shame that is associated with alcohol and other drug use is complex and multifactorial. This shame was seen to relate to different substances in different ways, and in some cases this might relate to issues around dependency or failures in treatment, as some substances are seen as easier to cease than others. Ultimately, despite the prevalence of shame in accounts of counselling clients presenting with AOD issues, participants were keen to avoid imposing shame on that client. This was

The dynamics of shame: navigating professional complexities when counselling in AOD settings

seen to foreground the relationship between the counsellor and client, for their benefit and to potentially improve treatment outcomes by maintaining the therapeutic relationship.

In these examples, I have demonstrated some of the ways that participants conceptualised problematic drug use as related to underlying issues. Participant accounts articulated the varied and complex nature of drug use and recalled that in their dialogue with clients, drug use need not be understood as wholly problematic. Further, as a value-laden field of practice, which tends to be defined in relation to particular treatment dynamics, there is a danger that clients may be pathologised, misinterpreted or that the underlying issue for a client’s problematic drug use could be missed due to the ardent application of a diagnosis, therapeutic model or moral ideal. Indeed, participants were keen to acknowledge that each case is different and that counselling may not be the most appropriate recourse for some clients. Further, assuming that there is an underlying issue for every client was perceived as equally misguided. Even in narratives that employed the most pervasive conceptualisations of problematic drug use, these labels were neither exhaustive nor totalising. Participants remarked that in order to achieve effective practice, a counsellor would be advised to remain mindful of these factors and consider the ways in which this affects the client’s perceptions of their drug use and how they view the therapeutic alliance.

In this section, I described recurring themes that related to counselling in a context where disparate notions of drug use circulate. In short, participants perceived counselling as ideally being client centred, client paced and tentative. Some participants added that clients might not always need counselling and that there is room for improvement in relation to treatment-matching at current services. This was seen to work with the client at their motivation level, on any given day, and to capitalise on the presenting problem whether that be AOD issues or other underlying issues. Ultimately, participants perceived counselling around AOD issues as something that should be gentle. This is understood to be at odds with the culture at many AOD services that is seen to foster a therapeutic culture that is brief, rushed and, at times, brutal. In this way, I have gained some insight into the influence that the AOD setting has on counselling around shame issues? In attempting to understand the relationship between shame,

The dynamics of shame: navigating professional complexities when counselling in AOD settings

counselling and AOD settings, through the accounts of professionals, I have found that these participants perceive the AOD setting to potentially thwart counselling around any core issue. While counselling has the potential to provide a therapeutic space to facilitate recovery from any issue that relates to AOD issues, paradoxically, a rigid focus on this remit might take the process off course. Worryingly, it could even result in the victimisation of clients. I will now build on this by illustrating how conceptions of responsibility were seen to impact negatively on the therapeutic approach in AOD services, and in turn counselling dynamics.

5.3 Inviting responsibility through counselling in AOD settings Despite the recurrent descriptions of AOD use which were seen to be linked to underlying issues, like experiences of shame or trauma, AOD treatment engagement was often described as hanging on the ability of the client to take responsibility. This was evident in both textual material gathered from service websites and interview material gathered from participating counsellors and AOD workers. For example, one service internet homepage stated: “Whilst dependency is no one’s fault, recovery from dependency is the individual’s responsibility” (non-government residential service, viewed 12th December 2006). Responsibility among clients was typically described by the participants as something which was important, and which should be supported and encouraged. As Charlie said:

I think that it is a fairly safe place for them to start taking responsibility for, you know, if they’ve got shame about what they’ve done in the past, taking responsibility for that. [We] definitely encourage that, and for them to start talking about what they’ve been through. (Charlie, counsellor, residential community AOD service)

Likewise, Kristine felt that the process of treatment was dependent on clients adopting responsibility for their problematic drug use. This was seen as a process of defining the acts for which they are responsible and the acts that require a process of re-framing in order to allocate responsibility:

The dynamics of shame: navigating professional complexities when counselling in AOD settings

They can learn from it, you can look at the experience, look at whatever it was that you have so much guilt about or shame about, and actually learn about that as to whether you’re actually responsible for it. And responsibility is a huge one with a lot of these women because they’ve been trained to, you know: “It’s your fault that I beat the crap out of you because you should have had the house clean when I came home.” It’s about helping them to differentiate when it was their responsibility. If it was their responsibility, working out what they’re going do with that. (Kristine, psychologist, residential community AOD service)

These excerpts are reminiscent of other research with service providers, which explored the conceptualisation of problematic AOD use through the language of responsibility (Palm 2004). These narratives, however, align responsibility with a practitioners attempts to find evidence that clients’ are engaged with their process, in order to provide more appropriate treatment, rather than a process of blame. In another example, Sally made the point that words like ‘addiction’ and ‘disease’ have the potential to permanently align a behaviour or practice to the person’s identity. She was particularly concerned that such terms would diminish the motivation or clients’ sense of agency in dealing with their problematic drug use:

I feel like ‘addiction’ and ‘alcoholic’, and things like that, they tend to be words that people use to relinquish responsibility and say, you know, “It’s a disease and I’m a victim of that, and I don’t have to take …” not “I don’t have to take responsibility” but “I’m just helpless to make any changes” and I think that’s a really difficult, risky sort of thing to say. (Sally, psychologist, AOD health service)

Sally’s concern was that the term ‘addiction’ would undermine the clients’ agency in treatment and would remove their sense of personal responsibility, thereby sabotaging the engagement and the therapeutic alliance. The concept of an affliction or disease was thought to render the afflicted powerless. Presumably in a context where low levels of client motivation abound, participants perceived the taking up of responsibility as evidence of engagement with treatment. Attributing responsibility for problematic

The dynamics of shame: navigating professional complexities when counselling in AOD settings

AOD use, however, creates a culture that increases the potential to impose blame on the client.

Terry described counselling as affected by motivational factors in clients by using the concept of resistance. He believed that clients presented with a range of internal and external pressures that compelled them to attend counselling but was keen to add that counsellors needed to contribute to managing this:

Like working with people when you don’t have the … what’s the word? You don’t have the leverage, because they’re there because somebody, like a partner might have said: “If you don't do that group, I’m leaving you.” [...] that’s the difficulty if they need to acknowledge that they have a problem. And that can be very difficult, that can make those [domestic violence] groups I ran very, very destructive because the group leaders then spend their time trying to show “you” how bad you are...which, of course isn’t the way to work because all you get is resistance. (Terry, counsellor, family therapy service)

Another issue is the extent to which clients with mental health issues can be held responsible for their behaviours. This is a salient point, given the co-morbidity with mental health issues and problematic drug use, as well as the potential damage that long-term drug use may have had on a client’s reasoning potential. Study participants questioned the clarity or extent of client responsibility. Paula suggested that before initiating counselling (or AOD treatment more broadly) consideration had to be taken around the client’s potential to change, particularly given that talking therapy is believed to require some level of responsibility-adoption or at least cognitive capacity:

Sometimes it’s really difficult because there’s also a part that’s going, “Okay, how much of this is brain damage? [How] much can someone not actually be responsible?” There are dilemmas in that sort of way. (Paula, psychotherapist, community health service)

The dynamics of shame: navigating professional complexities when counselling in AOD settings

Participants also expressed dilemmas about how a treatment setting may inspire this responsibility in clients. For example, Mary felt that it was important for her to remain gentle in her approach, while colleagues felt it important to direct the clients to face up to their role in their drug use:

I mean that’s the major part that I would struggle with because I’m quite gentle, you know? Colleagues say: “face up!” Whereas, I’ll go: “How did you feel? … Do you want to change this?” [...] In my personal opinion, and just from what I’ve seen, when you take the directive approach, they will comply. But as soon as you’re not there, then they’ll go back to it [problematic behaviours] whereas, if you guide them gently and then it’s like their idea, it sticks and it lasts more. (Mary, counsellor, residential community AOD service)

Mary stated that a directive approach was a short term solution and that it was important to work with the client’s process in order to allow for longer term recovery. Mary also highlighted the dangers of forced treatment, viewing it as reducing individual autonomy or positing clients as either compliant or non-compliant. Thus, a recurring theme in relation to counselling around AOD use was the confrontational nature of treatment dynamics. When asked about how she understood treatment for AOD clients, Charlie perceived the act of presenting for treatment as being a confronting process:

That’s a really good question, because I’ve thought about that a lot. What would it be like to turn up with your two suitcases, a child or no child, walking into a place you’ve never, ever been to before, knowing that you’re gonna look at some issues, whatever they are, around your past? Stuff that you don’t tell people because it’s against the law or you’re ashamed of it, or whatever? Like just standing on that front doorstep and knowing what they’re about to walk into in a six to 12 month period [...] And I just think that would be such a hard thing to do. (Charlie, counsellor, residential community AOD service)

The dynamics of shame: navigating professional complexities when counselling in AOD settings

Similarly, Jackie stated that entering a residential AOD setting is confronting for clients and that the context alone can provide an opportunity for clients to address some issues, without the need for staff fervently directing this:

[Clients] they can’t hide behind a mask...you can hide for the rest of the time behind pretence, you know? Pretending that you know it all. Pretending that you’re okay. Pretending that everything’s fine. Whereas there’s no way you can hide in a rehab. It all comes out. It all comes out really quite quickly. Just living with each other. Just the mere day-to-day, being in contact with other people around you who are noticing everything you do. (Jackie, counsellor, residential community AOD service)

The residential context was seen as a setting that engendered personal scrutiny and self- examination without the use of imposed responsibility, and blame. Similarly, Brett (AOD worker, residential community setting) described his experience of working with men who found AOD treatment confronting:

It can be quite confronting, I’d say, for somebody […] who’s just come off the street, who’s never been through a rehabilitation program before. Even for somebody who’s come from gaol, it can be even more confronting. It’s even more confronting than gaol! They just sit in gaol!

Given the exposing nature of residential rehabilitation, and counselling practice, these selected quotes raise questions about the purpose of directive treatment practices which attempt to inspire responsibility by force. In writing about professional boundaries in counselling, Nielsen (1988) wrote that the process of setting and maintaining boundaries specific to the counsellor’s role involved taking into consideration all that accompanies that role. In differing contexts, in this case AOD treatment settings, frontline workers need to assess their role, the client’s vulnerabilities and the nature of the particular setting. What differentiates the counselling relationship from other relationships is that clients enter the relationship expecting a counsellor to act on their behalf; they enter the relationship from a place of need; assuming the counsellor is the expert, and all these components create a disparity of power. Even when using

The dynamics of shame: navigating professional complexities when counselling in AOD settings

modalities that aim to level the power between client and professional, the counsellor always has more power than the client. Thus, the client never has a true power of consent with the counsellor. Participant accounts complement Nielsen’s points by describing the various factors that relate to this negotiation, and illuminates the ways in which counsellors view power and their responsibility in the therapeutic relationship.

Despite the fact that participants considered entering rehab to be a confronting experience and one that might cause distress, this was not seen as a necessarily negative scenario for everyone. Indeed, some participants understood it as the very crux of treatment:

Because my experience is that shame can be very painful for people because they can’t be seen or don’t want to be seen. And that’s part of the healing process; is to be seen in the shame and to have someone be there with you, hanging out there. And that it’s okay. Because a lot of people with shame, it might have started before they even had words; like pre-verbal. So they would go to that place. And that could be part of the shame, is if they don’t know any words of how to even say how they are … and that could be part of what the shame is. (Joanne, counsellor, residential private AOD service)

It is, therefore, difficult to determine the point at which feeling exposed is therapeutic for clients, and when clients may be experiencing additional trauma as a result of this scrutiny. As with any counselling session that utilises the exploration of painful histories or uncomfortable aspects of the self, the counsellor may be unaware of the extent to which they are actually doing harm. Further, these comments remind us that the client may be unclear about the extent to which they are experiencing additional abuse, due to these power differentials. For example, when Josie reflected on the confrontational nature of some treatment settings, she felt that this more punitive approach was the outcome of inept professionals. In building on her earlier point, she adds the perspective that clients might not experience victimisation as such. Due to clients assuming that professionals are working in their interest, combining with a history of abuse, these individuals are unable to question the coercive approach:

The dynamics of shame: navigating professional complexities when counselling in AOD settings

When I came to Australia, there were AOD centres who had reputations of really ripping clients to shreds. You know, they kind of tear you down and build you up again. […] And I guess to some degree that did influence me as well, you know: “clients have to be confronted!” And I’ve done things in my professional life that I look back on and I cringe because I think, “I could never do that now.” […] That was just the industry and the professionals being quite inept. (Josie, counsellor, private practice)

This victimisation of clients was not only seen as a treatment barrier, in that it inspires an inauthentic counselling relationship, but also because it hinders the capacity of clients to achieve an effective recovery from problematic AOD use. In forcing clients to adopt personal responsibility, professionals were seen to be at risk of engendering a therapeutic alliance with a performed recovery that would not last without the counsellor’s input. As John put it:

[When clients finish treatment] what are they? Cured, fixed, you know, resolved? I don’t know. And it’s unlikely that they’ll be the one who gets to decide that anyway. (John, AOD worker, community health service)

While recognising that counselling is not necessarily the most appropriate treatment strategy for all AOD clients, participant statements also indicate the implicit power relations involved in diagnosing and treating a particular issue. This evaluation or judgement dynamic is potentially a treatment barrier in that it removes the locus of awareness from the client, but it also sits outside the goals of conventional counselling philosophy.

More commonly participants described their gentle approach as being at odds with that of their colleagues. For example, Mary stated that she was expected to deliver ‘consequences’ in her work. These are formal punishments delivered in reaction to a transgression on the part of the client. She found this difficult because in her role as a

The dynamics of shame: navigating professional complexities when counselling in AOD settings

counsellor she may be privy to knowledge of a client’s painful history. She described an awareness of her dilemmas around this in relation to working alongside colleagues who engage in punitive approaches. She felt conflicted about this even when clients seemed to be responding positively to this approach:

But there’s lots of incidents like that: “Oh, she needs the restrictions,” or, “She needs a boundary.” And I’m going like: “Look this person’s had such a hard life, you know? Like can we do it a different way rather than just whacking on the consequences and things?” But at the same time there’s ‘consequences’. You know, they seem to, the clients like that: “You have to be hard on me!” (Mary, counsellor, residential community AOD service)

Mary’s quote points to the different approaches that disparate notions of drug use can inspire, and the role that concepts of responsibility can play within these. She states that her intention is to build a therapeutic relationship with her clients and through this mechanism to achieve a resolution of past trauma in order to reduce the need for coping strategies like problematic drug use. However, she may be working alongside colleagues who understand drug use as a relinquishment of responsibility and who aim to deliver blunt revelations about clients to inspire an appraisal of previous lifestyle choices.

This was not an isolated perception. Like the others, Joanne felt at odds with this more punitive approach and was concerned that such approaches might replicate the coercive dynamics that clients may have been subjected to in previous significant relationships:

So, if you’re kind of modelling to them the same as what they had before, I could see that they might start to go into their adapted behaviour that they learnt initially from their family of origin experience – their parents – either to be compliant or to be rebellious, you know? And so then it’s how that gets played...So, if you’re playing or approaching them as an authoritative, punitive parent, then you’re going to get the response of what they learnt as a child if that was their experience, you know. And so they would, it’s not offering them a place to be able to, to be authentic, who they really, or to even know. You

The dynamics of shame: navigating professional complexities when counselling in AOD settings

know, they need to learn, “Who, who am I really?” because the adaptive behaviour starts to form then as an addict, you know? (Joanne, counsellor, residential private AOD service)

In forcing a particular style of therapy on a client, the counsellor might inspire the client to adopt a passive or aggressive reaction to the coercion, based on the very experience the counselling process aims to resolve. Participants perceived this to be outside the goals of counselling for problematic drug use, in that the therapeutic alliance becomes characterised by old and dysfunctional relationship patterns.

Rogers (2004) argued that using positive regard in counselling is a way of enabling the therapeutic conversation to be freed from evaluation and judgement. He wrote that in most aspects of our personal and professional lives, humans are under the scrutiny of external evaluation. In counselling practice, these evaluations do not allow for personal growth and even a positive judgement can render a relationship threatening since it informs the individual that if we have the right to tell her she is good, we also have to right to tell her she is bad. By keeping the relationship free of judgement, the other person is free to recognise themselves as the locus of evaluation, and thus the centre of responsibility lies within the self (Rogers 2004, p.55). In line with this, John described the act of ‘not judging’ to be a therapeutic intervention in itself:

In the client comment book, not being judged is one of the most consistent themes throughout, you know? Seven or eight books of client comments, not feeling judged. That’s a huge thing. That in itself: to not feel judged, and to manage to provide a service where people don’t feel judged is in and of itself a kind of therapeutic intervention, I think. (John, AOD worker, community health service)

John’s comment is consistent with recent qualitative health research that analysed factors that help clients who use injection drugs to access services. Neale and colleagues (2007) found that client-research-participants, in England, were often satisfied with their access to services, despite the low resourcing and high staff turnover, but made suggestions to improve engagement. Client accounts of staff-related

The dynamics of shame: navigating professional complexities when counselling in AOD settings

improvements included being less judgemental and having more supportive attitudes, by behaving in ways that are more welcoming and more encouraging of clients when they do make progress. Such changes were viewed as important for reducing the shame and embarrassment clients feel when they approach services for the first time, and they have the potential to encourage retention of contact between clients and service providers. Significantly, these clients felt that having better trained staff and more peer workers would increase treatment uptake. While some participants felt that those who had been through recovery might moralise or preach to those still using drugs, others felt that peer workers were less likely to approach interventions programmatically and speak from experience instead. Neale, Sheard and Tomkins conclude that these aspects of workplace development would enhance current service delivery without requiring extensive additional funding. This finding has been partially supported in a local study by Brener and associates (Brener, Von Hippel, Von Hippel, Resnick and Treloar. (2010). In exploring client perceptions of discriminatory treatment by staff they found that perceived discrimination significantly affected client completion rates, with greater rates of perceived discrimination associated with greater rates of drop out. This research highlights the importance of ascertaining experiences of discrimination in previous treatment settings, and acknowledging the impact of this history on the current episode. Significantly, staff interviewed for Brener’s study stated that they were open to addressing issues of perceived discrimination and working on the issue. Professional interview narratives, presented here, complement these findings by showing that motivation to attend AOD settings may be influenced by client-service provider relationships and past experiences in other healthcare settings.

John built on his last point by connecting therapeutic judgements to an imposition of morality on the client. He interpreted this dynamic as an extension between morality and ethics:

I have sort of pejorative associations with the word ‘moral’ […] I’ll often use the word ‘moralising’ to describe a kind of debate. Whereas, there isn’t the equivalent around the word ‘ethics’ and its various sort of permutations. I like the word. To me it implies autonomy as much as one can have, you know? Moral, I also see as having, at least implied, a kind of moral order that we live

The dynamics of shame: navigating professional complexities when counselling in AOD settings

in and that still pervades. And that changes over time. And I think people can have an ethical position, which is strongly critical of the dominant moral paradigm, if you like. (John, AOD worker, community health service)

It seems that John feels that applying a moral framework on AOD use behaviour was akin to judging and could render the treatment processes as misguided and rigid. By remaining within an ethical framework, counsellors and other allied health workers could retain their professional flexibility and thereby achieve a client-centred approach. Other commentators who have explored mental health care ethics have questioned the differences between ethical and moral positions. Barker (2011) grounds morality in ethical positions given that both are concerned with being good or being bad and how one ought to behave. What seems to be important in these interviews is the degrees to which an individual can formulate her/his own ethical position. Following Barker, ‘mental health’ ethics is problematic, if not contradictory because, in principle, ethics is only meaningful where people are self-governing and have the option to make choices free from coercion. Given the lack of self-governance in the mental health field, and some AOD settings, ‘choice’ is something that is ‘facilitated’, when in reality it can only be restricted. Therefore, ‘choice’ in mental health contexts is partial and dependent upon the degree of power the practitioner is willing to relinquish. Barker concludes that the key responsibility for shaping how ethical a practice might be lies with practitioners.

In exploring what constitutes ethics in psychotherapy, Bond (2007) has emphasised the concept of trust between client and practitioner as the primary ethical factor of the relationship. He wrote that clients understand ethics as grounded in the character of the professional and they use this criterion to help them decide whether they should enter or continue counselling. While competence, compassion and respect are frequently mentioned, trust appears to be a critical issue and where it is present any deficiencies in other desirable ethical criteria may be ameliorated or overcome. Significantly, Bond has pointed out that the notion of trust does not always feature as frequently in counsellors’ priorities, and is not given the same degree of attention. The participants of this study contribute to Bond’s work on ethics in psychotherapy by describing their

The dynamics of shame: navigating professional complexities when counselling in AOD settings

perception of what trust means to their clients, and the ways in which the context of the various workplaces can hinder this. Further, they describe the therapeutic working alliance or counselling space as a forum through which trust is prioritised, and how they attempt to gain trust with a client who may have felt betrayed in previous clinical encounters. This attention to trust provides additional insight in to the challenges that practitioners face in constructing therapeutic relationships with clients in contexts where treatment can take a coercive tone, and interventions may be administered under duress.

Within texts for person-centred approaches to counselling, there is an emphasis on the ‘intelligibility’ of the client’s difficulties, that is, their problems being seen not as pathological errors of functioning but as valid and meaningful attempts by people to do their best in difficult or restrictive circumstances. The emphasis here is on trusting that clients have the answers to their own problems, given a facilitative environment (Cooper 2007). Therefore, positive regard is not the verbal listing of compliments, although affirming has been shown to enable engagement (Yalom 2006). Rather, it is an attempt at relinquishing the power of the professional to evaluate and judge, in order to empower the client to embrace their own therapeutic process. Consistent with clinical guidelines, participant accounts provide insights in to how the invitational and tentative nature of counselling can enable space through which clients can negotiate the definition of their addiction. However, these descriptions also provide evidence that complements research findings in the broader healthcare sector, that AOD clients are discriminated against and potentially victimised. In responding to Bond’s work on the components of ethical therapeutic relationships, recurring themes in interviews for this study demonstrate the high regard that clients place on trust (at least from these practitioners’ experiences) and provides insight into the challenges for counsellors in fostering trust from their clients, and the strategies they have used to overcome these challenges.

In the domestic violence field, one which is similarly characterised by mandated treatment orders and low levels of client motivation, Jenkins (2001) has placed emphasis on engaging clients through an invitation to responsibility. As with counsellors working with clients attending under duress, he writes that positive

The dynamics of shame: navigating professional complexities when counselling in AOD settings

outcomes are assumed to be associated with high levels of responsibility accepted by the client. In particular, an acknowledgement of the negative impact created by their behaviours. However, Jenkins does not find helpful the explanations for why men use violence and warns that they can lead to harmful intervention approaches. Moreover, the why is about imposing a causal explanation, to attribute responsibility for the problem, which enables discourse about what action should be taken to resolve it. The attribution of responsibility can be misguided, and paradoxically has the potential to relieve, excuse or pacify a perpetrator of negative behaviours. Counsellors may incorrectly feel their job is to challenge this abdication of responsibility and argue more strongly for accountability from their increasingly resistant clients. Instead, Jenkins urges counsellors to attempt to understand the client’s explanations before attributing client responsibility, thus facilitating client cooperation and participation in treatment. Jenkins contributes to counselling theory dialogue which is as yet unformulated in research directed at counsellors working in AOD settings.

As highlighted in the literature review, the therapeutic working alliance has been postulated in the AOD sector and community mental health field for some time, but the components of what enables positive outcomes are vague. The strategies required by practitioners to facilitate these aims need further elucidating (Kirsh and Tate 2006, Silberbogen, Ulloa, Janke & More 2009). Few studies reflect the voices of those who use or deliver services to understand the nature of working alliances, or the difficulties of maintaining therapeutic relationships in stigmatising contexts, namely alcohol and other drug settings (Lehman 2004). These interview narratives, therefore, offer insights into the areas of workforce development required, and also the strategies that professionals currently use to overcome these dilemmas.

In the broader healthcare context, workforce development projects aimed at primary healthcare providers have acknowledged the effect that negative attitudes can have on their willingness to intervene with clients who use both licit and illicit substances (see National Centre in Education and Training in Addiction (NCETA) 2006). In the associated NCETA training resource, healthcare staff members’ professional and personal attitudes are addressed due to the significant effect these have on their responses. Focusing on discriminatory attitudes the training resource aims to address

The dynamics of shame: navigating professional complexities when counselling in AOD settings

judgements of deservingness, in particular the extent to which drug users are perceived to deserve medical care in general, and whether they deserve high quality care. These judgements represent whether an individual believes a person’s situation or circumstances are just, fair and appropriate. Consequently, they have the potential to result in a patient being denied treatment, with the understanding that their presenting problem is their own fault and that they should live with the consequences. Ultimately, the background research highlights associations between these judgements and entitlement to the quality of healthcare provided by nurses towards people who use drugs, and provides insight into the ways in which notions of client responsibility can manifest in worker attitudes towards treatment dynamics (Skinner, Feather, Freeman & Roche 2007). It is therefore also possible that counsellors and AOD workers hold similarly implicit and negative attitudes, and that there are opportunities to improve current service provision by providing training that addresses these issues.

5.4 Conclusions In this chapter, I have outlined the various ways in which AOD use and problematic AOD use were conceptualised in the participant interviews and on AOD service website homepages. Through analysing the interview data, it became clear that while notions of drug use and ‘addiction’ were complex and diverse in participant accounts, there was a tendency for participants to remain tentative in their use of such definitions in their interactions with clients. Participant accounts were rich with reflections upon their own drug use or treatment histories and they had a tendency to empathise with their clients about entering treatment and undertaking counselling in relation to underlying issues. Given the emphasis on empathy in counselling, this is perhaps not surprising, however these accounts provide insights in to the various ways that an AOD setting can create facilitators or barriers to this empathy. Moreover, these excerpts demonstrate that a definition of addiction need not rigidly inform a treatment process. Participants in this study revealed the ways in which various values and conceptualisations can circulate alongside more tentative approaches to a presenting problem, and that ultimately clients have some scope to define their issues.

Consistent with previous research, participants’ accounts highlighted the importance of client motivation, or treatment readiness, to AOD treatment. In describing how best to

The dynamics of shame: navigating professional complexities when counselling in AOD settings

undertake counselling in an AOD setting, these professionals reflected upon the pre- existing challenges of engaging clients and motivating them to undertake an inherently difficult process. Imposing diagnoses or understandings of ‘addiction’ on clients was thought to diminish client autonomy and agency, and so participants articulated concerns that low levels of client motivation could be further reduced or disrupted. Participants were also concerned that using negative concepts of alcohol and drug use resulted in the victimisation of clients, who would be ‘torn to shreds’ or ‘brutalised’ through directive and punitive approaches.

Discussions of client motivation included reflections on the extent to which clients are prepared to take responsibility for their AOD issues. However, in assigning responsibility, participants also discussed the risks of forcing that responsibility on clients. This was seen to hinder counselling by engendering a therapeutic relationship that was built on a false compliance rather than an authentic evaluation by the client. The quality of the counselling relationship, therefore, was seen to be undermined and the potentially positive treatment outcomes for the client sabotaged. Significantly, despite the multitude of concepts that participants used in conceptualising AOD use, a recurring theme throughout was the need to remain respectful, tentative, and gentle in their work. This dynamic highlights the potential that counsellors have in acting as a buffer to the directive and dehumanising processes that a conceptual framing potentially instils on a treatment setting. It also demonstrates the potential benefits an “ethical” stance provides in enabling individual workers in navigating complex and contradictory medical arenas, for the benefit of the clients. These findings complement previous discussions on ethics in therapy by describing the importance of trust between client and practitioner. Ultimately, this research builds upon recent reports of the dynamics of responsibility, choice and client autonomy in other mental health sectors, specifically domestic violence programs and psychiatric clinics.

In this chapter, I have gained some insight in to the ways in which an AOD setting has the potential to affect counselling dynamics. In the chapter that follows, I focus on interview material that relates more closely to my original research question: how does shame prevent or enable the relational factors of counselling in AOD settings? I will build upon participants’ perceptions of the prevalence of trauma in client histories, and

The dynamics of shame: navigating professional complexities when counselling in AOD settings

how participants described the connection between shame and trauma. Finally, I will present excerpts that highlight the influence of stigmatisation in the AOD settings, and the negative impact of the labelling of addicts and alcoholics. Through presenting these themes, I will also show how stigma is entangled with shame, in participant accounts. This is an opportunity to contribute to earlier research that has described discrimination against AOD clients in the broader healthcare sector. As before, this will be examined as it relates to counselling in AOD treatment settings.

The dynamics of shame: navigating professional complexities when counselling in AOD settings

6. Navigating the dynamics of shame when counselling in AOD settings

In this chapter, I describe the recurring themes in participants’ accounts directly related to client shame, when counselling in AOD settings. I begin by exploring the ways in which participants conceptualised shame and show the similarities with previous research and what has not previously been reported. As a result I will be suggesting new directions for workforce development. Participant insights will also be used to describe how they experience the relational barriers that client shame creates in the therapeutic relationship. Participants describe their strategies for managing client shame and in some cases how they use shame as evidence of an authentic or motivated recovery process. Of particular note here are the different definitions of shame that interviewees employed to describe their experience of shame in AOD settings. These different definitions included: moderate shame as a tool for ascertaining violated boundaries or a sense of wrong doing; chronic shame as connected to some traumatic event and as negative in its influence, as well as a pre-determinant of problematic AOD use; shaming of the client by the professional, whether accidentally or deliberately; and finally, shamelessness which was thought to indicate chronic shame rather than a lack of shame. This list of definitions is not exhaustive but captures the main versions of “shame” described by interviewees. It should also be noted that these participants did not articulate a complete or static definition of shame, and often changed their definition or added to it as they grappled with what it means and how it plays out in counselling.

In keeping with observations outlined in the previous chapter, client shame was often connected to traumatic histories and experiences, and these were seen as “underlying issues” for AOD problems. As such, shame was incorporated in to the notion of trauma and participants explained that this trauma needs to be addressed in counselling so that shame can be managed and recovery can be effective and sustainable. Participant narratives held many reflections about the connection between shame and trauma, and often these words were used interchangeably. This study, therefore, will contribute to what is known about trauma by providing professional accounts of the association between shame, trauma and problematic AOD use.

The dynamics of shame: navigating professional complexities when counselling in AOD settings

Another recurring theme that emerged from these interviews was the perceived ubiquity of stigma that was related to clients’ AOD use, especially illicit substances. The shame of attending an AOD service and the acknowledgment that alcohol and other drug use had become problematic was thought to be coupled with a sense that the client would be negatively labelled and stigmatised. Presumably associated with the negative social and community views of AOD use, this stigma was viewed as a significant treatment barrier and participants described incidents where clients feared being stigmatised and discriminated against. In some cases these professionals described the discrimination that their clients were subjected to, and as such described the additional strategies they needed to incorporate into their work to help their clients manage these negative events. This chapter will include these insights and complement previous research that outlines the negative attitudes of professionals in broader healthcare contexts. I will present excerpts that outline the varying degrees of stigma that relate to different substances and practices, and demonstrate how client shame is thought to be compounded by internalised stigma. In this way, I outline how shame and stigma were intermingled in participant accounts and describe the strategies these professionals use to overcome these challenges. In describing these strategies, I articulate the possible barriers that counsellors face in developing a therapeutic relationship when working on shame with their clients. I also indicate the role that the AOD setting plays in facilitating counselling around shame issues, and how it hinders this.

This chapter has been organised in four sections. The first explores shame as a common issue for clients presenting with AOD issues. The second describes the perception that shame is connected to trauma in the client’s life experiences. The third examines how stigmatisation occurs for clients, and becomes entangled with shame, and the fourth will present participants’ descriptions of strategies they use for clients who have been negatively labelled due to their association with alcohol and other drug use.

The dynamics of shame: navigating professional complexities when counselling in AOD settings

6.1 The ubiquity of client shame when counselling in alcohol and other drug settings This section outlines participants’ perceptions of client shame and the ways in which this was thought to play out in therapeutic interactions in AOD settings. I will also consider the ways in which these accounts were aligned with, or departed from, previous literature in the field. These observations will be expanded upon in the conclusion chapter, with suggested options for future research and implications for practice.

Consistent with previous research, study participants perceived shame to be a common issue for clients attending AOD services (Stuewig and Tangney 2007; Dearing, Stuewig & Tangney 2005; Tangney and Dearing 2004; Potter-Efron 1989). Some participants were particularly vehement in their insistence upon this. For example, Kristine (psychologist, residential community AOD service) stated that shame is “pretty much guaranteed” among her client group. Participants would often describe how shame affected their clients in empathetic and connected terms. When asked why she thought shame was such a common phenomenon for AOD clients, Joanne said:

The humiliation, and stuff that’s happened to them, so shame is very profound in most people … everyone … and because of all of that they’ve done in their life, they see it all falling apart. It’s like: “how bad is that?” […] so, you would do a lot of talking around shame. (Joanne, counsellor, residential private AOD service)

Joanne perceived shame as a profound and universal human emotion. Where shame is different for AOD clients, is the sense that negative behaviours associated with problematic use were perceived to intensify this universal shame. The high degree of empathising with clients about the shame experience is not surprising given the importance that person centred counselling philosophy places on ‘walking in the clients shoes’. Moreover, it is not unusual for authors’ of clinical literatures on shame to reflect on their own experiences of shame (see Pattison 2000).

The dynamics of shame: navigating professional complexities when counselling in AOD settings

As has been documented in previous literature that explores shame in counselling contexts, participants also believed that clients would typically describe themselves as ‘useless’ or ‘no good’. Again, participants reflected on this with empathy and described their own experiences of shame, and the different degrees and causes of this shame. Shame was often described as a ‘bad’ feeling and one that was triggered by a sense of wrongdoing, for example: “anything that I might do wrong subsequently, could trigger that feeling of being bad” (Robert, counsellor, private bereavement service).

However, previous research has perhaps inadequately accounted for the emotional intensity of listening to narratives about shame, especially as it relates to the frequency of these narratives, and the challenges that face counsellors who work with clients with shame issues. It is possible to surmise that this poses additional professional burdens on counsellors who must find ways to manage these uncomfortable feelings without their being adequately recognised. This is a particularly salient point given that participants were describing clients who voluntarily raised shame issues in counselling, presumably because they hoped it would lead to the resolution of an issue. For example, Sarah described the strong reaction that one client had experienced when addressing her shame:

I remember a particular process with a client where we would go over significant periods in her life. […] So, between the first session and the second session there had been a horror week for this lady. And she told me about it later and we talked through all of that – how it had been, how she coped – but that’s beside the point. The second session we got into the subject matter and she had to go off to the toilet. She came back later and she told me it had made her physically sick. She had to go and throw up because talking about all these things and how badly she would have felt about it. (Sarah, psychologist, work in residential AOD setting)

The client shame that participants described was akin to what theorists have described as chronic shame, a distressing, overwhelming emotion synonymous with self-loathing. In contrast to previous texts, participants in this study tended not to describe shame as a potentially moderate or healthy emotion that could inform or produce appropriately

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relational behaviours (see Potter-Efron and colleagues 1988; 1989). Potter-Efron makes the connection between relationship function and shame/shamelessness using the metaphor of the shame continuum. For example, the ability to feel moderate levels of shame is associated with humility and a balanced sense of self. Through experiencing moderate shame and humility, an individual is able to relate to others more effectively. Humility and moderate shame are seen as the middle ground between chronic shame and shamelessness. The chronically shamed individual cannot easily relate as they see themselves as contemptible in the eyes of others. A shameless person lacks a sense of her/his own flaws, and therefore treats others with contempt.

Study participants viewed shamelessness as a barrier to an effective therapeutic relationship, as it was seen as a cover for intense feelings of shame. This was thought to signify that individuals would not be willing to work on their shame issues. During the course of the interviews, I would ask participants to reflect on what they thought of clients presenting as “shameless”, in response they typically described this as a lack of appropriate boundaries or an avoidance of therapeutic narratives about shame. For example, Isobella described a client who had attended a private residential service:

I’m gonna think of one person in particular, who was loud and their boundaries were pretty shaky around how friendly and demonstrative they were […] making close connections and friendships, or engaging in sexual behaviour on the premises. And then they’d leave and be back in within a week. But there are a lot of people who would behave in outrageous ways, in there, to prevent themselves from having to deal with the shame. (Isobella, counsellor, private residential service)

So when presented with shameless client behaviour, participants viewed this as a cover for chronic shame, rather than evidence of an apparent lack of beneficial shame. As a result, AOD counselling was approached with an expectation that AOD clients would be experiencing a burdensome level of shame, whether as a result of traumatic events in their family of origin, regrettable past actions, or remorse at their own behaviour while intoxicated. As Mary (a counsellor who worked in a residential community AOD service) said: “I have never seen anybody come in here whose totally shameless and,

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you know, the ones who are shameless usually are hiding a lot of shame”. Shamelessness was also described as avoidant behaviour that might appear as bravado or false confidence. So it appeared that for these participants, a perceived lack of shame in client narratives was basically evidence that their clients were resisting becoming engaged in the counselling process. Being shameless was therefore viewed as a process of denial or an attempt to deflect attention away from shame.

While this is not consistent with Potter-Efron’s shame continuum, it does provide insight in to the ways these professionals understood clients’ manifestations of shame, and the ubiquity of destructive levels of shame as a hurdle to the therapeutic relationship. I do not assume here that Potter-Efron wrote about the shame continuum with an expectation that counsellors would apply it to clients in a rigid way. There are gaps, however, in participant accounts about shame being connected to contemptibility and contempt, and this provides information about the additional training that could benefit AOD counsellors.

Participants tended not to describe shame as moderate or healthy. This may be due to the fact that they more commonly experience shame in AOD clients as a destructive and unpleasant emotion. Nevertheless, understanding shame as a moderate and relational emotion provides options for new directions in the therapeutic dialogue and this understanding was underrepresented among these professionals. As discussed in the previous chapter, treatment readiness and motivation to change were connected to a willingness to accept responsibility, and this creates a culture where a lack of shame is considered synonymous with a lack of engagement in the process.

Consistent with previous literature, problematic alcohol and other drug use was interpreted as a coping strategy for managing shame, a way of: “drinking the problem away” (James, psychologist, generalist counselling clinic). This was understood to be a cyclical process, similar to Potter-Efron’s shame spiral, where people are seen to use drugs to avoid an issue, which then increases the shame burden as they begin remembering the negative behaviours they engaged in while intoxicated, and so on. Later in her interview, Sarah reflected upon her client that had been physically sick when talking about shameful episodes in her life. She added:

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So it can … the psychological experience of shame promoting purely physiological reactions. You know? And if you have that type of reaction well, and you’re a drug user, well I know what drugs will help you with that. […] If you’re always feeling that feeling, I’d probably want to use drugs too. (Sarah, counselling psychologist, work in residential AOD setting)

Other participants described the relationship between shame and problematic drug use as a way of avoiding the distressing emotions that accompany high levels of shame. Alcohol and other drugs were thought to soothe the physical and psychological distress of shame. However, this soothing may lead to individuals avoiding their issues. Ironically, James felt that without alcohol and other drugs it would be impossible to live with high levels of shame while simultaneously avoiding dealing with these feelings:

[To use drink or drugs is] the only way you could actually keep going and not be eaten up by the shame. And then you feel another shame when you’d feel shameful that you tried to block the shame. So you get more shameful and therefore you have more addiction. So it actually could spiral like really quickly. (James, generalist counsellor, private counselling clinic)

Like James’s, Kristine’s description of ongoing and destructive AOD use was resonant of Potter-Efron’s shame spiral. She understood her role as raising awareness of this spiral to her clients. As such, she understood AOD counselling as a process of facing the distressing emotions associated with remorse:

Some of it, you know, they should be guilty about. Well not should be but, you know, the way I work with them is acknowledging that and saying that: “Yeah, it is okay to have a little bit of guilt about it but if you beat yourself up you’re then gonna drink and drug, and then that’s gonna lead to more, and then that’s gonna lead to more drinking and drugging.” And just showing them that cycle of, yeah, it’s not about letting yourself off the hook 100%. (Kristine, psychologist, residential AOD service)

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Given the extreme reactions to shame that participants have described in their clients, it is possible that Kristine has not accounted for the potentially overwhelming emotions that might result from this strategy. In this excerpt, Kristine is highlighting the potential use of guilt in her clients’ sessions. It was described as an opportunity to acknowledge the outcomes of different behaviours by moderating emotional reactions. There is, however, a risk that encouraging this guilt might be experienced as shaming by clients, which might inspire a greater need for substances, rather than reducing that need. In some cases, there was a conflation between shame and guilt, and consequently being and doing. These are often separated in texts that theorise shame. Potter-Efron (1989) describes shame as being related to how we see ourselves, our ‘being’, while guilt is related to our actions, our ‘doing’. It is a theory that has been supported by empirical research across multiple cohorts (see Dearing and Tangney 2004).

When shame and guilt were differentiated in participant accounts, shame was described as being worse than guilt: it was seen as a stronger, deeper experience which was more closely related to the person’s identity. For example, James (psychologist, generalist counselling clinic) described shame as different from guilt in its intensity:

I think [shame] it would be awful ... because it’s different from guilt. There’s almost like another layer to it. It could be a grey area in-between but yeah, there’s definitely a difference between guilt and shame.

Similarly, Sally thought of shame as being more intense than guilt despite acknowledging that guilt was more aligned with what the person has done:

I think shame is quite strong because it’s almost a rejection of yourself [...] well, this is my own interpretation of shame: like if you’re, if you have shame, it’s worse than just guilt, because guilt is almost like you feel bad about what you’ve done but it’s not necessarily a reflection of who you are; it’s more what you’ve done. Whereas I think shame is very much like you are more, it’s more about you’re ashamed of what you’ve done and who you are, and … and

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possibly even a rejection of yourself. And I think it takes a lot more sort of self- loathing to get to the point where you say, “I’m ashamed.” (Sally, psychologist, AOD service)

As with previous concepts of chronic shame, some participants described shame as being connected to the person’s sense of self, rather than their actions. However, it was the intensity of the emotion that was thought to characterise it, rather than its connection to ‘being’. Potter-Efron also suggested that shame and guilt are often simultaneously experienced and therefore hard to differentiate. Despite this, chronic shame and chronic guilt require different strategies, given the different focus of distress. While shame and guilt were articulated differently in some participant accounts, different therapeutic strategies were not described. It is therefore possible to surmise that additional training would be beneficial to counsellors and AOD workers, to remind them of the different strategies available for dealing with client shame and chronic shame. Moreover, given the emphasis on separating the person from their diagnosis, in the previous chapter, such tools may complement the strategies that these counsellors and AOD workers are currently using.

Similar to Potter-Efron’s concept of the shame spiral, shame was linked to the memory of behaviours and acts engaged in before sobriety was attained. This included intoxication itself, as well as the practices undertaken to acquire illicit drugs, such as sex work and theft. Significantly, Dearing and Tangney’s (2004) large scale studies revealed positive outcomes for therapeutic activities that focus on shame that relate to behaviours while intoxicated, or acquiring drugs. These outcomes included improved drug use regulation and a reduction of relapse rates over time. Participants in this study described clients’ memories of negative behaviours as increasing shame to destructive levels and the therapeutic goals they described focused on facilitating a space where clients could overcome self-loathing and their lack of self-forgiveness. While they could see the benefit of working on these types of shame, their focus was on the need to be tentative so as not to jeopardise recovery by triggering destructive levels of shame related behaviour. Mostly, participants described the complexity of this work. In reflecting upon how this relates to AOD treatment, John said:

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So, if the goal is to stop using then, you know, some alleviation around the history [is required]…and that becomes complicated too because there’s shame around, associated with, just the practice of injecting drug use…but then there are probably more appropriate instances of shame connected to a lot of the shitty stuff that people have had to do to maintain a habit. So, you’ve got a double whammy. (John, AOD worker, community health centre)

In another example, when Sarah was asked if she thought shame was an issue for clients in AOD services, she said:

My understanding of shame is you’ve done something, or something has happened to you, or you have done something that you later wish you hadn't and can’t forgive yourself. So for example, let’s say I use drugs and to use the drugs I would have to become a prostitute. And let’s say I was able to go to rehab and in, in a clean head look at what I did to get those drugs and feel shame for doing that in a way that I couldn’t forgive myself for doing what I did to get the drugs. I don't know … it’s a messy picture. But basically actions that you’ve done that you wish you hadn't and feel bad for. And you can’t forgive. That’s how I see shame. (Sarah, psychologist, women’s residential AOD service)

Client narratives around shame were perceived as being replete with the ‘unforgiveable’ and with a range of stories about regret. Shame was understood to be a destructive emotion here, and overwhelming. Such descriptions articulate how perceptions of shame can come to overlay guilt, regret and disgrace. Nevertheless, counselling around shame can be seen to provide a means of self-forgiveness.

Participant accounts of the relationship between shame and problematic AOD use support previous findings that shame is an intense and overwhelming emotion that can fuel drug and alcohol dependence, in order to suppress those negative feelings. Such was the expectation among these participants that clients would always present with shame issues that even the performance of shamelessness was seen to be a cover for

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shame rather than a genuine lack of shame. In describing how they understood the dynamics between shame and AOD use, participants provided insight in to the potential areas of workforce development that focus on the capacity to work with shame, guilt, identity and behaviours. These interviews also indicate the potential distress that workers experience in relation to counselling clients around shame given the intensity and discomfort of the client narratives that they were describing.

6.2 Managing shame and trauma when counselling in AOD treatment settings In this section, I build upon the insights about the perceived ubiquity of client shame in AOD settings, by examining participants’ perceptions of the aetiology of problematic drug use, such as trauma. The following interview excerpts build on the recurring statements which describe problematic drug use as indicative of an underlying issue, and demonstrate how shame is imbricated with problematic drug use and underlying issues through traumatic histories.

To recap, participants understood the role of counselling as an opportunity to address underlying issues, which were commonly viewed as the determinants of problematic AOD use. Underlying issues included unresolved trauma, such as family or interpersonal violence, singular episodes of assault, or abuse and neglect in the family of origin. For example, Joanne said: “I haven’t met an addict yet that didn’t have significant trauma somewhere in their life”. Shame was understood to be a reaction to the trauma of these events and therefore the two were often combined. I have also described the elements of the interviews that positioned unresolved trauma at the core of much AOD counselling work, and will now explore participant accounts of shame as a critical manifestation of this trauma.

When describing her experience of working in an AOD setting, Isobella described her focus as the trauma that led to the client’s sense of shame, and not the problematic drug use as such:

The amount of work that they did around shame was. It was sort of one of the main focuses. So they would do like...they would have groups every day and

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they would go through a process and do a trauma [intervention]. And look at all the different traumas and everything like that, and the shame attached to that. (Isobella, counsellor, private residential service)

Joanne (counsellor, private residential AOD setting) also believed that her AOD clients were likely to have traumatic histories. She felt that manifestations of shame and problematic drug use were directly related to this trauma. When asked what led her to believe she was often working with shame, she said:

Well, it could be obvious... because the knowledge that a lot of people are very shame-bound who are, you know, addicts and stuff … so, that’s kind of known. And especially if they’re narcissistic, you know? There would be massive shame in there somewhere, of the humiliation of the early trauma…which is why they create a grandiose self, because they just can’t bear it… and generally that’s extreme shame. Usually.

In addition to the difficulty they had in enabling clients to address shame issues, due to the anxiety provoking and alienating features of the shame experience, participants described the dilemma for clients given the difficulty they may have in recounting traumatic experiences. The long term and isolated nature of a residential setting was viewed as appropriate for providing a counselling space through which clients could work on their shame and trauma. This suggests that the setting or context is important in affecting how people deal with trauma and shame, and that AOD treatment settings can offer an opportunity to work on previously unresolved trauma. Indeed, participants recounted with some sadness the tragedies that some of their clients had endured and, therefore, placed importance on building trust and safety in the therapeutic relationship in order to foster a willingness in the clients to talk:

[When] they feel ready to talk about something big...the body language [changes], like you often find that they struggle to keep eye contact with you or just that they get overwhelmed with emotion. That sadness like; “I have to let go of this,” or, “I’m about to talk about this with someone.” And you know, to

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have that privilege of they trust you enough to, to go there, it’s pretty special, I guess. (Charlie, counsellor, residential community AOD service)

When counselling clients who are tentatively addressing their trauma histories, the participants explained that the work should be undertaken at the client’s pace and that it is important to monitor the emotional reactions through body language, or through knowledge of previous conversations in counselling sessions. These reactions could be similar to a shame reaction. For both reasons, participants explained that it was important for the counselling approach be gentle:

When they talk about shame-based stuff, I can pull in other things about their life… And I’ve just got that gentle [approach], you know? Where they’ll open up and talk about … Like lots of residents have been sexually assaulted and abused as children… like every day, basically when you’re in counselling, you’re talking about really sensitive, vulnerable issues, yeah, with vulnerable people. (Mary, counsellor, residential community AOD service)

When I asked Mary to spell out exactly how she undertook a gentle approach in counselling, she said:

They might make a comment, “Oh my dad does that” and you can see the body language, so, you pick on that. You know? [And sometimes they don’t] want to talk about that...and that gives me a clue; okay, that’s an issue she doesn’t want to go near so it’s an issue for her. And then like we’ll go along and if it’s like weeks and weeks have passed, and then she’s not getting into that, I’ll just say, “Look, I’ve observed here that we’ve been talking for weeks now and I just think every time your dad comes up you want to skip past it. Like, do you have issues?” “I have issues but I don’t want to talk about them.” And that’s fair enough: “But maybe if you want to get the best out of this recovery and being here, maybe you want to touch on it.” (Mary, counsellor, residential community AOD service)

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Given that many of the participants’ statements described clients as vulnerable, the model of treatment that was preferred was one that is empathic, gentle and based on the principles of invitation and person-centred counselling. In this way, trust can be developed that will hopefully enable clients to address the unresolved issues behind the problematic drug use, should they choose to. In Trauma, drug misuse and transforming identities: A life story approach (2008), Etherington explains that recovery, healing and transformation can only take place when the person feels strong enough to deal with the process and finds a safe enough environment to begin to pay attention to the messages carried by the body that tell of past hurts. This approach is, however, potentially at odds with service mandates that compel clients to relinquish AOD use and which promote facing up to negative past behaviours. In reflecting upon her own practice in AOD counselling through client narratives of their trauma, Etherington acknowledged the depth and vulnerability that shame and trauma inspire. As such, key findings in this study complement Etherington’s text by providing additional accounts of the challenges of this work, in particular challenges that relate to conducting this work in AOD services.

Similar to previous literature that recommends a family-therapy approach for AOD clients (Fossum & Mason 1989), study participants tended to conceptualise shame as a core issue, usually emanating from their family of origin experiences. It was expected that feelings of shame and other intense emotions would emerge during treatment, and that this would be a difficult and painful experience for clients, particularly when linked to being shamed by family and friends. Kristine said:

Shame, lack of self-worth resulting from shame, guilt that’s often put on them by not only people they don’t know but family members or partners, goes pretty much hand in hand with drinking or drugging. The drugs and alcohol are a really good way not to have to deal with the shame or guilt. They’re also a really good way of self-harm, so that they know that they’re hurting themselves because they’re not worth anything better than that because they’ve got all this shame or guilt, you know, that other people have put onto them. (Kristine, psychologist, residential community AOD service)

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As has been reported elsewhere, when living with the horror of shame associated with traumatic past experiences, alcohol and other drugs can offer some relief. However, when these substances come to affect the way people see themselves to the degree that they once again feel despairing, the task of counselling not only becomes a transformation of behaviours, but requires a fundamental shift in their beliefs and the way they see themselves and others (Etherington 2008). This transformation may be undertaken while ongoing shame experiences and traumatic incidents continue to occur. Given the regularity with which clients had been rejected by significant others and relatives, one of the aims of treatment might be to facilitate re-connecting with family, once shame is able to be moderated or tolerated:

The shame, the embarrassment...how it impacts on their family is another big hurdle… because, you see, some people, they’ve been using for, you know, 15 years, and they don’t have that contact with their family anymore. And they wouldn’t know about how to go about sort of initiating it because that sense of shame is so strong for them. (Deirdre, psychologist, community health service)

In these excerpts, participants express their understanding of trauma and shame as a pre-determinant of problematic drug use, which is then compounded by additional experiences of rejection and feelings of shame that are related to this drug use. Study participant descriptions were underscored by a conceptualisation of shame as a profound experience which at problematic levels, could negatively impact on relationships. This included rejection from family members, or at least a perception of these relationships being disrupted. When shame was described as resulting from shaming by significant others, participants described this as being connected to clients being rejected, ostracised, even singled out. As Sally (psychologist, community AOD service) said: “especially clients who may be the only one in their family who has any drug or alcohol issues, or you know, have been sort of ostracised from their family because of what they’ve done”.

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Thus, a recurring theme, in participant accounts of shame and drug use, was a convergence between rejection, trauma and shame and problematic drug use. Other participants described the shame that relates to family ostracism as something that was important for clients to address in their recovery process. As with Deirdre’s quote, participants often understood treatment as enabling contact between these family members, and potentially facilitating the restoration of relationships, including with clients’ own children. In those cases, clients were seen also to need to address the shame they may feel about their own abusive or neglectful parenting styles, and the shame, grief and stigma which might have resulted from the formal removal of their own children.

Shame was quite often described as emerging from negative experiences in the family of origin, and also by parents who taught these clients when they were children to be ashamed, sometimes because of the parents’ own issues with problematic AOD use:

In terms of demographics of the profile, you know, if there have been instances of abuse or even just parents who are illicit drugs users themselves in a really overt way… that would explain why shame might already be part of the kind of triggers for their use in the first place. (John, AOD worker, community health service)

This demonstrates how significant it was to these participants to describe shame as closely related to relationships and attachments, and to how clients were themselves parented and how they parent their own children. The cycle of shame was viewed as being related to problematic drug use which in turn led to problematic drug use in their families, which added yet another layer of shame. Other descriptions of shame were reliant upon concepts relating to attachment concepts, with shame understood as a corollary of exposed needs. Josie said:

I think people with substance use generally: it’s an issue about needs [...] I think shame is about that as well. Shame is about this kind of discrepancy between how you see yourself and how you actually think you measure up. And you don’t quite achieve those expectations that you have on yourself, and you feel

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somehow … I don’t know. You can feel quite easily shamed, I suppose, by that. And I think that is tied a lot in with neediness and intimacy, and closeness. I guess shame comes out of, you know, that whole period that Erikson talks about, about self-control and being a separate human being [...] that ability to be close to someone and attached to someone but also a separate individual. That’s a very difficult thing to negotiate. (Josie, counsellor, private practice)

Josie’s description of shame here deepens the implications of negative appraisal, in that the fear of rejection is exacerbated by the potential shame of this unmet need being exposed. The axis of attachment-need-shame is being viewed here but as a universal human phenomenon, not as a ‘trait’ specific to AOD clients. Rather shame is seen as universal human experience and drug use as a self-soothing mechanism that in some ways makes perfect sense. Unfortunately, however, the stigma attached to AOD use can intensify that shame if use becomes problematic. This supports previous literature that describes AOD issues as cyclical (Potter-Efron 1989, Dearing, Stuewig & Tangney 2005), and a dynamic, moving between people, inter-generationally, sometimes even being imposed on individuals by family members.

This recurring idea of shame being related to unmet attachment needs is perhaps unsurprising given the number of family-therapy-trained participants in the data set. While it is important to expect that training in the family therapy discipline and the reading of these literatures could account for the way in which these participants have conceptualised shame, these perspectives were also offered by counsellors and AOD workers who had not trained in family therapy frameworks and had not worked in settings that use Systemic principles. That is, a style of therapy which understands the individual client as part of a system. The system affects the individual and the individual affects the system. A system can be a couple, a family, a professional group or a community. This style of counselling is often used in couples counselling and for family therapy. This speaks to the ubiquity of family therapy concepts in AOD settings and perhaps also points to the broad range of psychological fields and constructs that AOD counselling makes use of.

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In order to prevent the ongoing cycle of relapse and shame, participants suggested that treatment needed to involve creating a safe space where the client could talk about these issues, in particular, unresolved trauma. Some of the participants described this as a life-long process that would require ongoing therapeutic support. Thus, brief interventions were seen as inadequate as they could not touch on these deeper issues. For this reason, Josie felt that most rehabilitation programs were too short. She also expressed a reluctance to use short term Cognitive Behavioural Therapy or Motivational Interviewing that focused on behaviour patterns. Building on the point she made earlier in her interview, which was addressed in the last chapter, she said:

My experience is that all [treatment strategies are] valuable in the short-term but for most of the people [...] the issues of substance abuse touch deeper, personal issues for mostly everybody. And that goes back to family issues and early childhood, and attachment problems and issues of, you know, neglect. And things that can’t, I mean let’s face it, you can’t resolve [those issues] in a short period of time. You know? These are things that people struggle with lifelong. (Josie, counsellor, private practice)

Josie’s quote provides insight in to how sustaining these professionals view AOD treatment to be. As such, she hints at the possible fluctuations in motivation they have in relation to their work when compelled to use interventions that are brief but unsustaining. It is probable that such an opinion is inspired by her personal recovery and that she has experienced this as an ongoing issue. Whether or not problems with alcohol and other drugs are related to clients’ traumatic histories or a lifelong issue, such an opinion has the potential to imbue directive and brief counselling practice with a sense of futility, and it is possible that worker morale can be negatively affected.

When counsellors and other AOD workers described their role in treatment as an opportunity to support clients in addressing the trauma they experienced at the hands of family and significant others, and/or making restitution with the victims for their negative behaviours, these workers are potentially adopting a professional approach that sits outside the philosophical mission of many treatment settings. As such, it is probable that counsellors working with clients around trauma face additional tension

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and work related burdens at navigating the forceful approach that some services apply to AOD treatment. Indeed, they are less likely to receive appropriate managerial or supervisory support when undertaking a process that is not endorsed by the local policy structures, despite their appraisal of what is best for the client’s process. In which case, a shift in AOD treatment culture may also be required in order to help support and sustain counselling practice that addresses clients who present with trauma and underlying issues. While the impact that such professional implications have on workers will be explored in greater detail in the next chapter, it is important to note here that some approaches to AOD treatment and counselling practice were seen as failing to address the underlying issues of shame, and at times participants perceived brief therapy to be futile in addressing AOD issues effectively.

To recap, shame was described as uncomfortable and akin to self-loathing. It was perceived as hard to distinguish from guilt but more intense than guilt. Shame was articulated as an internal experience, which could be the result of deliberate shaming and was often experienced alongside rejection by significant others. Many of the participants understood shame as something that might be taught in the family of origin, and could be perpetuated along generational lines. When asked if shame was an issue for AOD clients, participants described shame as a trigger for problematic drug use and, thus, a key role in counselling would be to raise awareness of this cycle and to provide strategies to disrupt it. Further, as suggested in Chapter Five, the connection between shame and other core emotions, like grief and loss, render brief interventions inadequate. Failure to work on these issues was believed to result in further episodes of problematic drug use which would then be repeated across the life course. Ultimately, shame was connected to traumatic experiences and so when approaching shame with counselling clients, participants were mindful not to re-traumatise clients and to be tentative and gentle. In reflecting upon these excerpts, my own personal experience of shame, and my professional experiences of counselling clients with shame, it seems that high levels of shame are themselves potentially traumatising. Consequently, this study sheds light on the ways shame and trauma can become imbricated through AOD treatment. In the next section, I will build upon these conceptualisations of shame, trauma and problematic drug use by exploring the theme of stigmatisation of clients in the AOD sector, through the negative labelling of ‘addicts’ and ‘alcoholics’.

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6.3 The dynamics of shame and stigma when counselling in AOD settings Throughout the interviews, participants often returned to their earlier definitions of shame in response to new questions and the ongoing dialogue that unfolded during the interview. Their original definitions might shift to incorporate new understandings that included additional memories of previous clinical work, previous clients, or their own life experience. These participants also speculated about the effect that social attitudes to alcohol and other drug use might have on client experiences of shame. Therefore, the following excerpts now focus on the descriptions that provide examples with a more social frame.

When examining the relationship between shame and the AOD treatment setting, participants explained that entering AOD treatment was potentially shaming. Mary described intake procedures at the residential rehab she worked at:

I mean it must be so overwhelming to leave, pack up everything and come into a place like this. And I think we’ve always struggled…because they walk in the door and they have to pee in a jar! […] Like that is shaming in itself. You know?! Search through all their belongings as if they’re a criminal or something. (Mary, counsellor, residential AOD service)

Study participants described shame as being compounded by social, institutional and community attitudes, and so as well as being implicated in relational dynamics, the self was seen to be subject to negative stereotypes. Elizabeth described her understanding of shame as something that is socially driven:

Shame: I guess it’s because the person…I think that that’s projected from our society […] it’s sort of like homelessness, they’re homeless from their own misfortunes and it’s their own fault. So there’s a lot of shame […] I think people can feel it. Looking at that person and saying: “you’re just a junkie” There’s a sense of shame. (Elizabeth, counsellor, community AOD service)

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Elizabeth described the perceived negative appraisals based on social discourses of drug users as potentially shaming. This sense of negative appraisal was partly responsible for AOD clients being marginalised, and this marginalisation was thought to compound the isolating factors associated with clients pre-existing shame. Due to this, Elizabeth expressed surprise that her clients opened up to her in counselling:

I just feel so privileged to have a client open up to me and tell me their life, about their life […] and they’re a marginalised community. People look down on them. People think they’re shit. They just get treated disgracefully. And they have stories and problems. (Elizabeth, counsellor, community AOD service)

In this quote, Elizabeth acknowledged the difficulty a client may have in engaging in counselling as a result being treated badly due to their stigmatised identity. As such, she provides insight in to the barriers her clients need to overcome in order to engage in counselling, and the additional barriers she faces in building rapport with, and gaining trust from, a client managing a stigmatised identity.

Robert (grief counsellor for a private service) reflected on the social dimensions of shame and connected this to the concept of rule-breaking. In addition to descriptions of ‘shaming’ by significant others in the previous section, or clients’ experiences of shame connected to perceived negative social discourses, Robert explained that shame might be connected to an individual’s sense of failure to achieve:

The thing about the shame is that it’s…the breaking of rules if you live in a particular culture that’s got a lot of rules … it’s also a failing to achieve. (Robert, counsellor, private bereavement service)

Similarly, John understood shame as both a deeply personal emotion, and a social emotion. He reflected at length about the ways in which social norms are incorporated into the person’s sense of self:

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To be socialised, I think, is to internalise a kind of repertoire of emotions, and one of them is shame. And we learn this kind of complex matrix of identifying emotions with events and actions or practices. And injecting drug use is one of those practices which is kind of incredibly kind of laden with meaning … they’re all pejorative. It’s all around, it’s prohibition, it’s … wrongness, it’s, I guess even, pathological nature. So, it doesn’t take a huge leap to work out why people feel kind of shameful. (John, AOD worker, community health service)

In these accounts, shame is described as a complex phenomenon that is internal, related to core emotions, grounded in the sense of rejection and an external dynamic related to stereotypes and a sense of failure. Shame can be an internal and external dynamic, and it can be internal and external at one and the same time.

Participants again explored these ideas in relation to their own experiences, including experiences of stigma. Brett, an AOD worker who worked across a number of community residential treatment settings, reflected on his own personal experience with labels, and how he understood shame as related to stereotypes:

Part of being ashamed of what I was doing wasn’t coming from me; it was from society, of being shamed by society for being an ‘addict’ or a ‘junkie’… And you get all those connotations and stereotypes of what a junkie is, and all that. (Brett, AOD worker, community AOD service)

In this quote, Brett reflected upon his personal experience as an injecting drug user and explained that the stigmatisation of illicit drug use can be experienced as shaming. In writing about shame in the therapeutic space, Pattison contends that descriptions and visualisations of shame are replete with notions of defilement, pollution and stain (Pattison 2000, p. 88). So that while shame tends to be described as a deeply individual and emotional experience, the result of innate attributions (internal shame) and the internal processing of external and social cues (external shame), it has much in common with the concept of ‘stigma’. Stigma is characterised as being a mark of pollution and exclusion. It is also enduring and difficult to separate from the person. In

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contrast, guilt is characterised as an offence, but involves the assignment of reparation debts, which can be settled and thus allows the individual to be reintegrated into society. Presumably, counselling in a stigmatised arena is further challenged by the attribution of social notions of wrongness, and further hindered by the internalisation of this sense of wrongness. Consistent with this, Kristine described shame as emanating from a sense of embarrassment about the acknowledgement that drug use has become problematic by using language that is framed by negative relational conduct:

So, most of them won’t have a lot of shame about the beginning part of their drinking. It’s when they start hiding it or start lying to people. It comes back to social morals and the values that we’re taught. (Kristine, psychologist, residential community AOD service)

Similarly, Brett (counsellor who worked at a community AOD service), perceived stigma as an additional burden experienced by people affected by AOD issues, who are already burdened with shame and guilt: “The stigma of being an addict [is an issue] for a start. [These clients have] a lot of guilt. Not living up to other standards, you know?” In describing shame in relation to AOD treatment, Elizabeth, Brett, Robert, John and Kristine described the influence of social discourses around drug use, or the behaviours associated with accessing alcohol or other drugs, which have imbued it with a sense of wrongness. This socialisation of shame need not, however, imply a kind of high level public exposure. Indeed many examples from the interviews focused on the domestic or private spaces of life as imbued with shaming experiences. In this sense, stigma and shame are intimately entangled. John (community AOD worker) said:

[Shame has] got to be understood as a kind of thoroughly socialised emotion. That it has to have a context. It usually has to have a history. And it usually involves other people … It implies an audience. But that doesn’t mean that there literally has to be other people involved in the knowledge of an action in order for you to feel shame about it. So in other words, there’s such a powerful discourse in our society about the wrongness of injecting drug use that it doesn’t, you don’t have to be kind of having a sneaky shot in your bedroom and your mum walk in to feel shame. You can feel shame quite independently.

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John’s account of shame describes the internalisation of the audience and hints at the additional ‘wrongness’ of illicit drugs. If we follow Goffman, who provided in his theories of modern life the notion of humans as social actors, interactions are largely governed by performance. This can then create anxiety as each individual experiences her/himself as constantly on stage, trying to improvise the correct performance of a role (Goffman 1971). Such notions are reminiscent of the metaphors of shame, from earlier in this chapter, in that failure to perform credibly leads to a sense of inadequacy on a social front, and thus a sense of failure and exposure on a personal level. As a result, contemporary theorists have described therapy and counselling as having a crucial role in narrating the self through self-observation that reduces anxiety and enhances self- empowerment (Pattison 2000, Giddens 1992, Giddens 1991, McLeod 1997).

In another example, Kristine (counselling psychologist at a Women’s residential AOD service) described shame as shaped by this illicit discourse. Because different drugs are sanctioned and scorned differently in various historical contexts, shame is likely to be experienced in relation to those different substances in various ways also. As such, shame and stigma may be internalised to varying degrees accordingly. This can then combine with family ideals, or even extend beyond them:

Illicit drugs: most people have a lot of shame about that because it’s illicit. It’s not legal. It’s not okay by society. And society’s norms I think play a large role to where people’s shame sits at […] But yeah, I think there is a difference between [this and] peoples’ level of shame about their alcohol use. (Kristine, psychologist, residential AOD service)

Thus, a person who is stigmatised is perceived to deviate from the expected norm of the social unit, which results in the individual being discredited. Stigma is viewed here as a relationship between attribute and stereotype that links a person to undesirable characteristics, which are then manifested in social interactions (Goffman 1963). In line with this, some participants reflected on the stigma that might occur through a client having her/his sense of self shaped and her/his relationships affected by assumptions of criminality and illegality.

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Participant accounts also provided insights into how the stigma of drug use can alienate (through disrupted relationships) and marginalise (through rejection by significant others, as well as the broader community) AOD clients, and the effect that this can have on pre-existing shame issues. This sense of alienation manifests in the clients’ sense of self and in their relationships and social standing, and vice versa. For example, John describes his understanding of the shame that relates to injecting drug use:

It’s the shame around the injecting drug use […] that doesn’t need to be there. Or at least that’s one of the things that fosters a sense of alienation from self and others. And marginalisation and stigmatisation that people feel. (John, AOD worker, community health service)

In relation to illicit drugs in particular, a client’s sense of shame was viewed as being compounded by the stigma of using, and by the sense of illegality attached to different drugs. The interviews presented in this study also build upon accounts presented in the previous chapter, and the value laden nature of illicit drug use in Australian society. In this way, this study contributes to other accounts of the stigma of illicit drug use, how it serves to increase treatment barriers (Buchanan & Young 2000), and the various and complex ways that these can interplay with a clients’ sense of identity and intra-psychic wellbeing.

When describing the dynamics of stigma for people with a mental health illness, Byrne (1997) suggested that an awareness of social stigma creates a sense of shame and difference within the individual, and a sense that they might “stick out”. This may be provoked by experiences that call into question an individual’s preconception of self, through the eyes of the perceived onlooker. As such, alongside client narratives that incorporate the intra-psychic aspects of shame, counsellors need to work with clients’ internalised stigma and social identity in recovery settings. However, attending a stigmatised treatment setting was not always understood to be a wholly negative experience. When asked what it might be like for someone entering residential rehabilitation, Isobella, said it would be frightening. When asked why, she explained:

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They think: “Am I gonna be in a room full of junkies that have got track marks and everything?” I think people relax a lot when they realise that often it’s...people at every end of the scale. (Isobella, counselling psychologist, private residential setting)

Given the stigmatisation of people who engage in AOD treatment, entering a program could be imbued with a sense of fear about other clients who might be viewed negatively by the client. This would be alleviated somewhat by interacting with a diverse community of fellow drug users who can be identified with. Crocker and Major (1989) argued that stigma need not exacerbate low self-esteem, as membership of a stigmatised group can buffer individual manifestations of stigma, through placing the negative responsibility on the discriminating individual or group. In articulating the potential relationships clients have with peers and the positive effect these relationships have on individual stigma and shame, these interviews provide examples of how treatment has the potential to buffer rather than add to client shame. Later in her interview, Isobella reflected on work she had done at other – non AOD – services:

I guess there’s this, the shameful stigma of being an alcoholic or a drug addict is, is lifted somewhat because everyone’s in there for the same reason. And going in there you know that that’s what’s going to be talked about and that’s what you’re there for. And so it’s okay to actually talk about it for once, whereas maybe if someone say came to me at the family therapy clinic I worked at, who was using, they may be far more cautious and not even be able to reveal that behaviour, until a rapport was built, and trust [developed]. (Isobella, counsellor, private residential service)

This suggests that the normalising potential of feeling part of a stigmatised group also provides opportunities through which an AOD setting might enable a reduction in a client’s sense of shame or internalised stigma. Therefore, while AOD related shame and stigma was largely described as a hindrance to counselling in AOD settings, participants also recounted incidents where the AOD setting provided a level of camaraderie that supported rapport building and thus increased engagement in

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treatment. Josie, who held a number of counselling roles including private practice, explained that she had experienced this process personally:

You identify a lot as a recovered person and that has some limits as well. So there’s a point at which you have to stop looking at yourself as being a recovered person; you have to start looking at yourself as being normal. (Josie, counsellor, private practice)

In this excerpt, Josie elaborates on her experience of the process of transformation. This began when she adopted the social identity of an ‘AOD client’ through treatment intake, to a ‘recovered person’ at program completion, and finally as a person beyond her ‘drinking’ identity. Josie’s comment showed how a professional might also feel obliged to refrain from revealing her own status as someone in recovery. In doing so, she also described her personal evolution beyond the label of ‘recovered’ and concluded that labels are so inherently limited that to be in the professional realm she had to split, or ‘pass’ (see Goffman 1963). She described this process as involving a re- evaluation of her own sense of self. In doing so, she was able to recapture her subjectivity and shake off the negative labels that she felt had plagued her for twenty years. As such, this study supports other recent research which highlights the complexity and multi-faceted nature of stigma (Simmonds & Coomber 2009). Link & Phelan (2001) described stigma as a combination of labelling, stereotyping, separation, status loss and discrimination. Stigma should be understood from the unequal (social) power relations from within the context it operates, and thus shift the focus from the stigmatised individual, and incorporate additional understandings of who is responsible for the problem of stigma (Sayce 1998).

In the excerpts presented so far, shame and stigma were entangled through the association of being an addict or alcoholic. Additionally, AOD clients might experience shame that is connected to the stigmatisation of other practices and actions such as the formal removal of children, to poverty and homelessness or to mental illness. One such example was provided by Sally, who was obliged to refer her clients to other services as part of a treatment plan. She described the discomfort with which her clients would receive these referrals to mental health services or AOD services:

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A lot of clients are more comfortable going to a hospital than they are going to a drug and alcohol setting [...] For them to go to somewhere like the mental health unit, which is the other location, they hang out, you know, the ‘bupe’ clinic’s there, the MERIT services are there, drug court services are there. So they sit in the waiting room with what they term “junkies” and a lot of dealing probably even goes on around there, you know? (Sally, psychologist, AOD health service)

Sally described stigma as being internalised through an association of attending an AOD service or allied contexts, such as a community mental health setting or a psychiatric ward. However, she also described her clients’ externalisation of this stigma, through stigmatising other clients. Garfinkel (1956) commented on stigmatisation within the drug using community as early as the 1950s, and recent research (Simmonds & Coomber 2009) has added descriptions of the ways in which stigma operates both against and within the community, and that there are levels and layers of stigmatisation (for example, increased derogation is directed at homeless people who inject drugs). It also adds to a more complex understanding of the ways in which the negative implications of stigma can lead to individuals rejecting a service in order to avoid, not just exposure, but the embarrassment of drug use activities (for example, needle and syringe exchanges). In the section that follows, I continue to explore these issues by focusing on power differentials in AOD treatment settings and describe the therapeutic strategies that study participants use with their clients to navigate these complexities.

6.4 Interrogating negative labels when counselling in AOD settings Study participants described counselling as a space that would be required to help clients manage the shame they experience in being labelled a ‘drug user’ while also managing the stigma of other phenomena like mental illness, and the fear they have at being compelled to associate with community members who have a mental illness or use different and more demonised substances. Scheff (1966) wrote that when an individual is given a label, such as ‘mentally ill’, the reactions of others and the person’s self-perceptions are changed forever. The identity of being ‘schizophrenic’

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becomes an overriding status. If the individual accepts the diagnosis totally, they begin to internalise the attributes (stigma) associated with it. Similarly, Paula perceived such stigma to be socially pervasive:

It’s a bit like that Rosenhan study: being sane in insane places…once you get labelled, you get shaped by this label…we tend to do that…we’re like cognitive misers, like: ‘oh, that fits into that box’ […] and once people start to get that view of themselves, it’s pretty difficult for them to see any other way. I guess [in counselling] you’re trying to open up new possibilities. (Paula, psychotherapist, community health service)

Here Paula refers to Rosenhan’s Being sane in insane places which is the classic scientific experiment on the validity and reliability (and lack thereof) of psychiatric diagnoses (see Rosenhan 1973). Paula refers to the study to illustrate her point that clinicians should be mindful that a diagnosis and label of ‘insane’ can be deterministic and incorrect. As with the terms associated with mental health issues, she understood the process of counselling to be a process which reached beyond the determinism of stigma and stereotypes, and to create new possible ways of thinking and being. The idea that a diagnosis is potentially deterministic and paternalistic has been widely theorised, however, this study provides previously under-reported professional accounts of the additional challenges that counselling practitioners face in light of these labels and diagnoses.

Moreover, as Paula’s metaphor highlights, these labels can be imposed due to the inherent power differentials between workers and clients, and so the terms that professionals use have the potential to affect a client’s sense of self as well as impact on treatment dynamics. Consequently, stigmatisation has been articulated through the concept of discrimination, a corollary of stigma (Link and Phelan 2001). For example, being labelled an ‘addict’ was thought to have ramifications on relationships and career prospects and such exposure was not just shaming but could lead to discrimination. While counsellors attempted to address the intra-psychic and potentially triggering aspects of client chronic shame, they described the need to manage the additional

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challenges of stigmatisation and discrimination. This was also the case for clients who did not present with high levels of pre-existing shame:

Say they don’t have an addiction but they’ve been caught [using drugs] and then they’ve got that criminal sort of association with them. So they’ve come in contact with the legal system because of their drug use. And then I think there’s a lot of shame associated with how their family’s gonna see them, the impact it’s gonna have on their work prospects, all that sort of thing. (Deirdre, psychologist, community health service)

This comment complements the work of Wodak and Moore (2002), which focuses on policies for illicit drugs. They argue that a prohibitive rather than social or health approach has the potential to endanger citizens, rather than protect or support them. In other words, an otherwise law-abiding citizen who engages in relatively infrequent use of recreational drugs may experience a series of negative outcomes when found in possession of an illicit substance. A moral or criminal justice approach, that is pivotal to policies designed to compel the community to cease drug use, has the potential to disrupt supportive approaches like harm reduction programs. These programs rely on individuals adopting risk management strategies that relate to drug use, such as blood borne viruses or negative health consequences like overdose, but policing and punishing drug use presents significant barriers to clients attending these services due to fears of recrimination that result from being associated with these programs.

Moreover, a health or social approach enables these harm reduction programs to engage potential clients, through constructing a trusting relationship through ongoing supportive dialogue, should their use become problematic at a later date. Thus, drugs services that do not provide treatment are considered a pathway to treatment for clients not ready to consider behaviour change. However, current Australian drug policies tend to favour funding criminal justice departments, leaving treatment programs under- resourced. As a result, it is easier to obtain illicit drugs than it is to gain access to AOD treatment. Wodak and Moore therefore build a ten-point action plan that is designed around reducing the punitive approach to illicit drug users and enhancing strategies that attract clients to AOD services (2002, p.75). The comments provided by this study

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provide additional support for the argument that the stigmatisation (and shaming) of people who use illicit drugs creates a wide range of treatment barriers, and these often pre-date clients seeking and attending treatment. The excerpts provided here help to outline the role that shame plays in relation to drug use, regardless of whether this use is problematic.

Given that the shaming and stigmatisation of clients can result from infrequent or recreational use of substances, the shame and stigma of addiction is not limited to AOD settings. It is, therefore, also probable that varying degrees of shame and stigma are related to different substances. Note that participants were aware that different substances carry different degrees of stigma, which in turn had the potential to exacerbate client shame about their AOD issues. Alcohol and marijuana use might be viewed as less shameful or stigmatising, for example, while injecting drug use or illicit hard drugs were thought to lead to a higher degree of demonising. As has been reported in the healthcare sector, stigma was viewed as synonymous with injecting drug use. Consequently participants described the role of counselling as a means through which to interrogate these meanings and separate alcohol or other drug use behaviours from the client’s identity.

If practices associated with illicit drug use (and to some extent legal substances) become aligned with the person’s identity, counselling around shame was considered an opportunity to re-author the story of the self. Isobella, (counselling psychologist, private residential service), proposed that the process of recovery could involve an acknowledgement of negative feelings that trigger problematic behaviours, and a separation of the negative appraisals from a client’s sense of self:

It’s looking at their behaviour [...] when people are ready, [we might look] at what it is that they were unable to feel, that they had to use for. So that could mean re-telling your story or having your story re-told in a more positive way, of their life, so there isn’t so much shame attached to it. (Isobella, counsellor, private residential service)

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Similarly Deirdre, who was reflecting on why she preferred to use a ‘behavioural’ treatment approach in AOD settings, thought the role of counselling was to offer greater scope to allow a client to see her/himself as separate from their drug use:

[A behavioural approach] separates the person from the drug and alcohol use […] saying to the person: “Well, how are you apart from it?” you know? “What other aspects of your identity are there?” and kind of teasing them out. I mean, I suppose in some ways it’s similar to a strengths-based approach... seeing it as something that’s acting on them rather than something that’s inherent to them, is also useful. (Deirdre, psychologist, community health service)

In thinking about drug use as an identity issue, participants understood their counselling role to be to help a client to view drug-using practice as one aspect of her/his life rather than something inherent in it. Consequently, they felt they were better able to tease out alternative behaviours and identities and capitalise on these. As suggested above, however, participants also described some of the positive effects that drug use may have provided the clients. Drug use was not understood as wholly problematic but also as potentially positive. Drug use could therefore be understood as pleasurable and strategic, as well as soothing or destructive. Presumably, a behavioural approach was seen as more in line with a therapeutic working alliance due to its withdrawal of the shameful aspects inherent to a labelling or stigmatising approach.

Those participants who described their work as informed by a ‘harm reduction’ model tended to be keen to separate themselves from models that conceptualised alcohol and drugs as wholly negative. In their view, as with descriptions of counselling that focus on teasing out the underlying issues given above, counselling operated to separate the person from the problematic behaviours and ‘negative’ drug use from ‘harmless’ use. For example, Paula felt that her therapeutic framework was at odds with services that adopted an abstinence-based model:

[The AOD sector] is very abstinence-based. See, I don’t work from an abstinence-based model. I work from a harm-reduction model...when we’d be

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setting up a therapy group, we’d be saying: “Look, whatever your goal is for coming here, that might shift over time, but if you want to just come back or, you know, maybe not … Just do the, just be where you’re at.”...just taking that pressure off, some people can...review things for themselves, and decide... (Paula, psychotherapist, community health service)

In Paula’s description of her work, she makes a distinction between a harm reduction model and other services that are abstinence based. She described her role as working with the client along the motivational continuum and thus acknowledging diversity in clients’ motivations and goals in therapy. Therefore, study participants described their goal as avoiding an appraisal of AOD use as problematic or recreational. Presumably a mandated client who does not view their use as problematic would be less motivated to engage in counselling and treatment than a self-referring client who does. Wodak and Moore (2002) prioritise the role of AOD services as attracting people who use drugs into treatment. The professional accounts describe the strategies currently used by frontline workers to canvass clients whether this takes place during the current clinical encounter, or for future reference, should their lives become problematic as a result of this use.

Fundamental to this approach was that illicit drug use should not be considered shameful or defined as wholly negative nor did they adopt a wholly positive attitude. Indeed, John hypothesised that drug use need not be shameful at all:

It’s impossible to have a kind of conscience outside of context but – whether there are actions that elicit shame regardless of what kind of context or social history, you know? … I guess what I’m trying to argue is...like, I can’t see how a meaning is ever inscribed within a practice itself. So, in theory it would be quite possible to inject drugs and feel no shame at all. (John, AOD worker, community health service)

In line with this, many of the other counsellors and AOD workers in this study described their work as grounded in the desire to develop new ways of being in the world that were not shameful or distressed. However, this was typically accompanied

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by examples of the shaming labels that are typically attributed to people who have experienced problems with alcohol and other drug use, particularly ‘addict’ and ‘junkie’. Terry, a family therapist, described counselling as a process through which the clients could think about how these and similar kinds of negative labels might have become internalised overtime, but can equally be challenged and abandoned:

The labels are the stories: “You’re a bloody difficult kid. You’ve always been a difficult kid,” and “thank God we’re over that time now, you always were bad- tempered!” The stories, the things we tell each other and our children, are the things that … we just wear them. We don’t ever challenge them. And I think that counselling is a place where those labels can stay there. They can just be exaggerated on [...] and all these labels and stuff come out. They come out. And the job of the therapist, if you like, is to actually get rid of the labels. (Terry, counsellor, family therapy service)

Paula, however, also viewed labels as affecting a clients’ perception of their ability to change, and viewed her job as challenging that idea. Indeed she described working with clients as an opportunity to interrogate the labels together and to challenge the purpose they might serve. By deconstructing a label in this way, Paula saw her role as empowering a client:

Yeah, [the way I work is to see] people as active agents of change. I think that’s, rather than passive recipients where someone’s kind of categorised or labelled in a particular way…you know, [a label] can be kind of useful and serving a purpose too. I’d be exploiting it and taking on that label, you know? What might that offer you? (Paula, psychotherapist, community health service)

Through deconstructing a label in this way, Paula would be working to engender a client’s agency to achieve recovery and then maintain it, and this might include embracing the label as a process of re-appropriation. This is resonant of excerpts presented in the previous chapter which highlight the power differentials and treatment barriers inherent to a diagnosis, a label and mandated therapy.

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While labelling is a process that is akin to stereotyping, the descriptions of labelling in these excerpts incorporated the notion of a choice that signifies a transition in AOD treatment. This choice can be presented to or adopted by the individual, who can interrogate the label for both positive and negative potential. Significantly, counselling clients around shame issues was thought to be hindered by the stigma and discrimination that AOD clients experience, but these associated and negative labels could be plundered for opportunities for clients to re-evaluate their sense of self and identity. In addition to a process of self-evaluation, interrogating the label was also tied to evaluations around personal practice and behaviour change. Thus, in discussing the dynamics of shame, these professionals explain that shame and internalised stigma can both hinder therapeutic dialogue, and the very site of transformation. By interrogating negative labels that accompany AOD use, and locating the origin of these labels, study participants felt that counselling could be used as a space to workshop reactions and responses to the stigma of ‘addiction’, thereby facilitating a more in-depth and sustaining recovery.

In his 2002 article “Addressing personal failure”, White draws upon Foucaldian notions of power to offer additional explanations for the interface between power relationships and identity issues. He presents a range of counselling implications relating to ‘modern power’ and therapeutic practice, but most relevant here is that modern power is insidious in that it recruits people’s active participation in the fashioning of their own lives, their relationships, and their identities, according to the constructed norms of culture. Counsellors, clients and other citizens are seen from this perspective as a consequence of power and a vehicle of it. In contrast to modern power, traditional forms of power use overt structures and institutions to oppress, repress, limit, prohibit, compel and to coerce. By contrasts modern power operates through the uptake of self- and relationship-forming practices - first developed at the local level of culture (the family, the clinic) - these operations were then professionalised through psychology, social work and criminology disciplines, which have played a key role in the technology of modern power.

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White’s aim in counselling (he is a proponent of Narrative Therapy) is to unsettle what is taken for granted, by analysing the operations of modern power with his clients, through challenging the dispositions and habits of their lives, and reconstruct identities that do not necessarily reproduce the constructed norms of culture. The excerpts presented here help to articulate the challenges that face these professionals as they attempt to undertake comparable processes of defamiliarisation with their clients. They provide insights into the various forms of power, both traditional power, through institutional policy and treatment procedures, and modern power, through navigating the dynamics of shame and internalised stigma with their clients. These clients must interrogate imposed labels in reconstructing their identity, while they are influenced by the constructed norms of achievement and failure. These professionals also provided many examples of ‘resistance’ to the dominant and potentially stigmatising discourses of ‘addiction’ and ‘alcoholism’. This complements Etherington’s (2008) accounts of client transformation, by highlighting the different qualities and experiences that invite us to think in terms of how a person’s self and identity is shaped within contexts, discourses and relationships, and the potential for that person’s idea of who they are to shift and evolve in relationships.

6.5 Conclusions Congruent with previous research, study participants described shame as a common issue for clients who attend AOD treatment services. This presumption of the inevitability of shame could signify to participants that a lack of shame in client narratives was tantamount to a lack of engagement in the counselling process and a block to the therapeutic relationship. As such, shamelessness was sometimes perceived here to be a cover for chronic shame, rather than a lack of shame. In contrast to previous literature, which described the differences between shame and guilt, participants did not describe using different therapeutic strategies to address these emotions. Shame was typically described as being worse than guilt: a stronger, deeper experience which was closely related to the person’s identity. While participants described shame as intimately connected to the person’s sense of self, rather than their actions, it was the intensity of the emotion that was thought to characterise it, rather than its connection to ‘being’. Shame was also described as a powerful, core emotion that is often simultaneously experienced with trauma, grief and loss. In terms of the

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therapeutic relationship, therefore, shame was understood to be a barrier to dialogue. Rather than silencing a client, study participants viewed the clients as unlikely to talk about shame experiences or emotions and this was due to a lack of engagement with the AOD treatment process.

Another recurring theme that emerged from these interviews was the perceived ubiquity of stigma related to clients’ AOD use, especially illicit substances. The shame of attending an AOD service and the acknowledgement that alcohol and other drug use had become problematic was thought to be coupled with a sense that the client would be negatively labelled and stigmatised. This was viewed as a significant treatment barrier and participants described incidents where clients feared being stigmatised and discriminated against. In some cases these professionals described the discrimination that their clients were subjected to, and identified additional strategies they needed to incorporate into their work to help their clients manage these negative events. This chapter included insights that complement previous research about the negative attitudes of professionals in broader healthcare contexts. Interview excerpts outlined the varying degrees of stigma that relate to different substances and practices, and demonstrate how client shame is thought to be compounded by internalised stigma accordingly. In this way I outlined how shame and stigma were intermingled in participant accounts and described the strategies these professionals use to overcome these challenges. In describing these strategies, I illuminated the possible barriers that counsellors face in developing a therapeutic relationship when working on shame with their clients. I also indicated the role that the AOD setting plays in facilitating counselling around shame issues, and how it hinders this.

This study provides additional findings to support the literature that describes shame as a pre-determinant factor to problematic drug use. This was recurringly described in relation to trauma, which is then compounded by additional experiences of rejection and feelings of shame related to this drug use. Given the regularity with which participants’ clients had been rejected by significant others and relatives, a common treatment goal was to attempt re-connecting clients with family once the shame manifestations were moderated, and the relationship features of shame better managed. This might include the clients’ relationships with their own children, in which case,

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they may also need to address their own shame about their abusive or neglectful parenting styles, connected to the grief which results from the formal removal of their own children.

A client’s sense of shame was understood to be compounded by the stigma of addiction and alcoholism, and by the illegality attached to different substances. The interviews presented in this study help to highlight the value-laden nature of alcohol and other drug use and the various and complex ways that these can interplay with a clients’ sense of identity. It is therefore suggested that alongside the client narratives that incorporate the personal and identity driven aspects of shame, counsellors have the opportunity to work with clients’ internalised stigma and social identity. In building upon themes presented in Chapter Five, these findings raise additional questions about the goals of AOD treatment: what is the presenting problem? In contrast to treatment strategies that force individuals to permanently relinquish their drug use, these counsellors and AOD workers describe their role as using treatment as an opportunity to support clients in addressing destructive levels of shame, as well as the shame that relates to underlying issues and unresolved trauma.

Additionally, this study contributes to complex understandings of the ways in which the negative implications of stigma can lead to individuals rejecting a service in order to avoid, not just exposure, but the embarrassment of drug use activities. Research to date has led commentators to recommend that professionals remain mindful of the effect that their attitudes might have on the way they work with clients and their recovery (Wahl & Aroesty-Cohen 2010, Palm 2006), and has demonstrated the ways in which the combination of mental illness, illicit drug issues and stigma and discrimination contribute to a vicious circle of social marginalisation and exclusion, where each factor can be both a consequence and a cause of other factors (Welbel et al. 2012).

Key findings in this study uncover a number of potential areas for workplace development. Given the growing body of work which guides counsellors with clients presenting with shame, future training initiatives would be advised to incorporate information to address gaps in practitioner knowledge, in particular the dilemmas they face in working on client shame in a shaming environment. By building upon the

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current therapeutic strategies that professionals employ in relation to shame and trauma, they increase opportunities that contribute to their clients recovering from problematic drug use. Further, this study outlines the ways in which stigma potentially compounds shame issues for AOD clients. However, the stigma of addiction was not considered to be an overriding barrier in AOD treatment. Indeed, in articulating the potential relationships that clients have with peers and the potential of counselling to unpack negative labels attributed to them, these interviews provide a few examples of how treatment has the potential to buffer rather than add to client shame. In describing their approach, some study participants suggested interrogating these socially imposed labels with each client. This suggests that AOD counselling has the potential to be a process through which to reach beyond the determinism of negative labels, stigma and stereotypes, and to create new ways of thinking that is generated by each client, rather than imposing an external morality.

In the chapter that follows, I will present the interview excerpts which describe the potentially negative impact of this tension on professionals, through participant accounts of their work. In particular, how they understand their role in relation to clients given the perceived prevalence of shame and trauma in relation to counselling clients in AOD settings. Through this process, the research questions: how does shame prevent or enable the relational factors of counselling in AOD settings? and: how does the AOD setting affect counselling around shame? will be examined in greater detail.

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7. Dynamics of shame: workforce issues for counsellors in alcohol and other drug settings

Until now, I have outlined participant accounts of the ways in which shame, stigma, and conceptualisations of ‘addiction’ affect counselling dynamics in AOD settings. This chapter will build on these insights by focusing more explicitly on interview material which describes the participants’ perceptions of the workforce issues and challenges they face when counselling in AOD settings. By exploring the effect of treatment styles and workplace policies on staff, this approach also permits an examination of professional perspectives on the barriers and facilitators of AOD treatment for attending clients presenting with shame issues. In addition to the challenges of counselling AOD clients, and the complexity of working on shame issues, participants described the difficulties they face in AOD settings, such as poor resourcing and inadequate facilities. At times, these professionals gave accounts of workplace conflict, undue pressure on individual counsellors, and the forced positioning of counsellors who resisted the shaming of clients as ‘maverick workers’. This thesis outlines and discusses these issues 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.

The key findings are presented in this chapter in the following way: first, the challenges of counselling in AOD settings; second, the effect of different ways of working with shame and addiction; and third, the personal impact of working in AOD settings. These issues are examined by focusing on the ethical dilemmas that individual workers face, and the potential these have for disrupting collegial relationships and intensifying worker isolation.

7.1 The professional challenges of counselling in AOD settings Consistent with published research, participants described shame as a barrier to the provision of talking therapies for AOD clients (Stuewig and Tangney 2007; Dearing, Stuewig & Tangney 2005; Tangney and Dearing 2004; Potter-Efron 1988). Shame was perceived to be difficult to work on as it is potentially mortifying for clients and hard to articulate, but shame was also seen as hindering the counselling process because

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counselling could itself be shaming. Consequently, the presence of shame was described by participants as inspiring a therapeutic dilemma. This was due to a sense that it is imperative to ‘name the shame’ to raise awareness among clients – and prevent further triggers to relapse – while it is also important for clients to word the emotional experience in a way that fits for them. As Kristine put it:

A lot of them don’t have a name for it. They don’t really know what all that feeling and that thought that’s going on inside them. And they’re embarrassed to actually come out and say that they, you know, have shame about this or they’re guilty about that. A lot of them are quite embarrassed to come out with that. And it’s also a level of vulnerability that they’re not willing to give you unless … But they’re waiting for you to throw a life-line. (Kristine, psychologist, residential community AOD service)

This therapeutic dilemma has received some attention in the clinical literature. Robert Lee and Gordon Wheeler’s (2003) collection of essays on shame in Gestalt psychotherapy highlight the complexity of shame in therapy. In particular, professionals need to be aware of shame on two levels: the shame-experience itself, and second order shame that relates to having such feelings (see editors’ preface). Lewis (1987, p. 25) also wrote that practitioners need to be mindful about naming ‘shame’ in therapy, as this can be shaming in itself. Failure to indicate the presence of shame in client dialogue or behaviour, however, could mean missing an opportunity to work through the emotional experience, thereby potentially hindering a client’s therapeutic process. Balancing these dilemmas is challenging to counsellors, and more so in environments that are considered shaming and stigmatising. It is therefore likely to increase the professional burden of workers in the AOD field.

To ‘identify and acknowledge’ shame was described by Brett as an ‘inevitable’ aspect of any therapeutic process. Treatment was intended to help clients acknowledge shame, and then to normalise these feelings through peer connections or formal interventions, like programs or visual aids: “pictures were used to normalise feeling that shame […] and workers chose to look at it deliberately” (Isobella, counsellor, private residential service). Accordingly, unaddressed shame issues in clients with low self-esteem might

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lead to their thinking that they do not deserve treatment or to live a life that is free of the distressing and negative aspects of problematic drug use:

You start looking at why did they, why did they use drugs or alcohol? Like [their] level of self-esteem has to be quite low for them to abuse it for that length of time, to not think that they deserve anything better. Charlie (counsellor, residential AOD service)

This phenomenon was conceptualised as a treatment barrier in a number of key ways. It was seen to discourage an individual from initiating treatment, in that the client might be obliged to experience the uncomfortable levels of shame that drug use had been masking. Awareness of this might lead to a sense of avoidance and a further reluctance to relinquish the soothing properties of drugs. This sense of shame could result in the client perceiving that they do not deserve to feel better, or to experience a more comfortable existence. Thus, participants understood their role to be one of working to engage clients in talking about this uncomfortable material in order to get to the root of the problematic AOD use issue. Participants provided insights into the challenges that characterise this work, and the professional tensions they experience as a result. These tensions are outlined here and at greater length in previous chapters, and help to elucidate the difficulty of working on sensitive issues with potentially recalcitrant clients, and then being further hindered in this process when working in professional environments imbued with a coercive or shameful tone.

In addressing the sensitive nature of this work, however, participants were mindful of the danger treatment approaches may pose for re-traumatising or shaming the clients. Brett (AOD worker, residential community AOD service) suggested that counselling around shame was a process that could not be forced. He felt that a counsellor or AOD worker should approach this tentatively: “It’s to be evaluated on an individual basis. Some people just aren’t ready to go there. But I think it is very advantageous if they do”. Other participants, who preferred to ‘name shame’, still felt it important to tread carefully to avoid inadvertently shaming clients through this process. For example, Paula, a counsellor who had worked at a dual diagnosis health setting, said: “I name it ... [but] people need to feel safe and respected to talk about their deepest, darkest”.

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Participants understood shame as challenging in AOD counselling because it requires an approach that is tentative, slow and gentle. It is surmised that this is a more challenging position to hold in workplaces that propose adopting a hard and forceful approach. At stake are the client’s dignity and equilibrium, which are in jeopardy even when they are working with staff members who have the best intentions.

In other descriptions, Paula perceived this shaming process as a way of understanding how other colleagues or peer workers might be handling a situation, often not very well:

[At another service, I was observing a group process] and people were talking about sexual abuse and I just … I don’t know; it felt like more shaming actually. It didn’t seem to be that therapeutic. I was kind of just shocked at the way someone handled it. I think it’s huge and I think that the people they encounter can really make or break the situation because people are fronting up with their own internalised shame. (Paula, psychotherapist, community health service)

This suggests that accidental shaming might occur due to unforeseen reactions to regular interventions or therapeutic exercises. Accidental shaming might also occur due to a lack of awareness on the part of a professional or be witnessed as such by colleagues engaged in different ways of working. This is in addition to previous accounts where participants indicated that clients may experience shame just by entering an AOD service. It is probable that witnessing such an occurrence was uncomfortable for Paula. In describing the shock she felt at witnessing a colleague mishandling an intervention, Paula voiced the discomfort, and potential distress, that frontline workers experience when observing clients being shamed, whether intentionally or by accident. Given Paula’s professional position of being respectful to clients, as outlined here and in the previous chapters, it is possible that she may experience additional distress and frustration when confronted with professional processes that negate the client’s dignity and that run counter to her strengths-based position. The focus of this section will now build on this to incorporate participant accounts of the challenges of working in the AOD sector more broadly.

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Participants described counselling in AOD treatment settings as both challenging and rewarding. Elizabeth (counsellor, community AOD service) was looking for a job outside of the AOD sector at the time of her interview. In reflecting upon her five years in the sector, she expressed some ambivalence about her resignation: “I just feel so privileged to have had these clients open up to me and tell me their life”. Indeed, those who had left counselling positions in AOD services described their previous roles as so challenging that it had compelled them to find work outside the AOD sector. I asked Joanne to describe her previous experience of working in a private AOD residential service and she said: “Yeah, it was always intense… but dynamic. I wouldn’t say it was always challenging but it was always intense”.

The intensity and slow pace of the process was seen as fundamental to good quality AOD counselling, in particular around shame issues. However, participants also described their varying motivation in working with clients for whom therapy was moving so slowly. Counsellors also understood that clients may attend treatment but be unable to abstain from problematic drug use. This was described as frustrating for counsellors at times. Sally (psychologist, AOD health setting) said: “sometimes you just want to tell them ‘Stop doing that!’” Joanne understood the recovery process as unique for each individual. She asserted that treatment episodes should not be characterised as successful or failed, based only on the length of a client’s abstinence, but that there was learning for the client in each stage of recovery. When asked how she maintained this way of being, given the potentially frustrating nature of the work, she replied:

I think you need to have good training or have… you need to have empathy or some kind of life experience so that you can understand how significant and important it is for them. As opposed to: “Oh well, just get over it,” you know? Or “Get on with it!” (Joanne, counsellor, residential private AOD service)

Significantly, the majority of participants in this study were under-trained, in that they had not finished their counselling training at the time of their interview despite the fact

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that they were working with AOD clients. In saying this, I do not suggest that they were unskilled or incompetent but this excerpt may highlight some of the risks that inexperience can pose for staff attempting to maintain an empathetic approach to clients.

The participants who did not work in an AOD setting described the ways in which clients presented with issues of problematic drug use in their work place. The motivation of clients entering a family therapy service was seen to affect their willingness to work on issues of problematic drug use, even if these issues may emerge in counselling sessions. When asked how he might imagine an ideal scenario for alcohol and other drug services, James, who had recently worked in a family therapy clinic, said:

I would change the name or change the focus. To not have a particular focus [...] it’s hardly a collaborative thing if they don’t actually want it. They want change but not actually about themselves. Or maybe they’ll say, “You fix my teenager first and then I’ll look at my stuff,” because they’ll say, “Well, the reason why I’m drinking so much is because my teenager’s driving me bonkers! [...] If I’m still drinking after you’ve fixed him, then I’ll know”. (James, psychologist, generalist counselling clinic)

In this way, participants spell out the potential difficulties that professionals may experience in relation to the slow pace of the therapeutic process with clients who may relapse or be unmotivated. Despite the concerns participants voiced in relation to treatment motivation and the challenges these present, this was not seen to be an insurmountable barrier to building a therapeutic alliance with clients, or to addressing relevant trauma memories. Earlier in her interview, Charlie stated that feelings of shame could create a barrier to clients addressing these issues. In the following excerpt, she describes the shift in this attitude, which she believed ultimately relied on the person staying in treatment long enough to appreciate the potential benefits of the process or building a rapport with their counsellor:

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I mean you get some women that come in and they’ll tell you to your face that they’re fine. Like some women are coerced to be here, whether it’s by a partner, by the law or by D.o.C.S. [the child protection department]. Most of them have some level of coercion. But if they stay here long enough and they start to actually get into some of that stuff, and they start to become aware of their level of shame and that they might be just putting on a front to begin with. (Charlie, counsellor, residential community AOD service)

Thus, participant accounts provide insights into the issues that influence client avoidance of treatment and the attrition rates of these services. These accounts help to illuminate the investment that workers make in their clients’ progress. Presumably, these professionals may experience a sense of loss, should the client leave prematurely or be ejected from the service, given that their hard work did not come to fruition.

The intense and potentially distressing nature of the counselling work was also seen to be hindered by the ongoing challenges of working in various AOD services, such as inadequate facilities or the financial pressure to accept clients who may not be appropriate for a particular setting. Given the effort put into engaging clients to the process, additional funding-related barriers were described with frustration and at times dismay. For example, Elizabeth complained that she felt awkward when orienting clients at intake due to the shabby facilities and lack of blankets and bedding. Similarly, Jackie worked in a non-government residential service and she perceived these issues as adding to the risk of client relapse:

We’ve had to cope with the traumas of an old building. You know, the toilets breaking down. Lizards coming in, we get rats sometimes, you know? And they just add to the triggers, you know? (Jackie, counsellor, residential community AOD service)

In previous chapters, I have presented excerpts which demonstrate the connection that these professionals made between stress and problematic AOD use. In these accounts, participants described the additional stress that poor structural resourcing may place on clients, thereby increasing the risk of relapse. These professionals were also

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embarrassed at bringing new clients into the service. They were even distressed that their clients might be cold, uncomfortable and stressed-out which was seen to add additional layers of complexity and challenge to their work. Moreover, working in these places was probably uncomfortable for the professionals interviewed here.

In addition to uncomfortable physical spaces, some participants recounted the distress that their colleagues were under due to new, inadequate, intake screening procedures. There was a fear that these changes were based on financial considerations, rather than therapeutic criteria. Isobella described some of the pressures her colleagues were under:

At the time, the staff who worked there were … [intake] was selective in terms of who they would allow and who they wouldn’t in terms of serious mental illness and things like that. And it wasn’t solely based around making money. I think the culture has changed a bit now. And they’re letting anyone and everyone in, and the mix is making things really difficult there. (Isobella, counsellor, private residential service)

Limited resources and inappropriate intake policies were thought to affect the therapeutic climate negatively, which in turn impacted on staff morale. These factors could jeopardise client treatment by adding further undue pressure and creating extra burdens for the workforce who need to manage these issues alongside their complex work in navigating shame issues in AOD counselling. Stilson and Katz (2008) wrote that more attention needs to be paid to burnout rates among counsellors working in AOD treatment. This study supports their work by providing professional accounts of the connection between the challenges of working in the sector, such as elusive client outcomes, low client motivation, counter-transference, and low resourcing. In offering a group supervision model to buffer against counsellor burnout, Stilson and Katz highlight the function that positive team functioning can play in supporting individual workers. However, the next section outlines the interview material which describes participants’ experiences of working in teams where the collegial climate was fractious and even hostile. In these excerpts, participants described working with colleagues with divergent concepts of treatment, AOD use and relating to clients. In this way,

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participants add to what is known about the various and complex ways in which professionals can be both hindered in their work and personally affected by it.

7.2 Different ways of working with shame and ‘addiction’ During the interviews, participants were asked to describe how they experience counselling practice in AOD settings. They were also asked how they prefer to work with clients and what suggestions they would make for enhancing counselling practice in relation to AOD issues. In addition to that which has already been presented these questions elicited descriptions of the professional dilemmas participants faced as counsellors as they were often working from different positions from their workplace colleagues. They described the complexity of working in a team that is philosophically conflicted, and the effect this has on the climate of the therapeutic setting, especially when feeling compelled to work to a prescribed model or policy that does not fit with their own professional ethics. Ongoing discussion in these interviews revealed how significant it was to these participants to achieve a productive therapeutic relationship between the counsellor and client. Indeed the quality of the relationship was thought to be tantamount to achieving effective treatment outcomes. Recurring themes emerged in relation to therapeutic strategies which were deemed ‘gentle’ and those deemed ‘harsh’. This section outlines the dialogue of participants that described the relational dynamics seen to be central to counselling and how this is impacted by working with alcohol and other drug clients.

In accordance with the tenets of counselling presented in the literature review, which prioritise the engagement of the client to the therapeutic alliance, Mary (counsellor, community residential AOD service) described the benefits of working in a residential setting as providing an opportunity to build rapport with her clients:

We have such a long time here. You don’t have time to build up rapport in other [services] where you’re only seeing them once a week. But we see them here all day, every day.

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Similarly, Sarah prioritised the relationship the worker has with the client over the prescribed framework of the setting, describing this as being with someone when they are vulnerable:

It’s probably less important about the…framework of the therapy. The whole, the fact that they were getting something, I think, at that stage in their addiction... [What do you think they were getting?] A relationship. [Uh-huh?] Time, somebody to be with them. Someone they could trust so that if they broke down into a crying mess, somebody is there to try and help them pick up some of those pieces. (Sarah, psychologist, women’s residential AOD service)

As with the previously outlined themes relating to the inadequacy of short time frames for dealing with shame issues, the idea of longer timeframes was emphasised here as providing an opportunity for counsellors to better engage with clients, and was seen as fundamental for building a therapeutic relationship. Brett concurs with Mary in relation to rapport building and in addition highlights that he prefers to work from a platform of mutual respect:

My main thing is in the relationship, the relationship with the client and building a rapport with them. Giving them respect and making sure they respect me as well. That's the bottom line. That’s what I just focus on...If you’ve got a good rapport with them and you’ve got respect for them and respect from them, I mean a lot of [the theories and models are] sort of, semantics really. (Brett, AOD worker, residential community AOD service)

In prioritising the relationship, participants echoed the client-centred processes outlined in counselling guidelines presented in the literature review. This is not new. In describing how they prioritise this relationship, however, they also highlighted the barriers that counsellors might encounter in adopting this approach. Similar to Sarah’s comment above, Josie recalled her internship in the AOD sector and how she saw the relationship between client and practitioner. She considered the most important factor

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in this relationship is the counsellor working in a way that the client accepts as reliable and trustworthy:

I have this sense that all these models, they all promise the world. I run into younger psychologists that still seem quite enthusiastic about learning this model and I feel quite cynical about it all. In a way I feel like there’s a whole industry built around promises to people. And in a way, whatever model you use, I’m beginning to think more and more that it is about the relationship between the counsellor and the client. And that is fundamental. And if that is one that kind of goes back to a very basic, caring relationship of trying to establish trust and expose yourself, and look at yourself, and have someone hang in there with you no matter how hard it gets, [that] is the primary healing. (Josie, counsellor, private practice)

Josie seems to be suggesting that with greater professional experience comes an increased appreciation of the role of the relationship between worker and client, in attempting to skilfully help someone, in this case to heal. John also understood the relationship that he built with his clients as the most important factor, in achieving therapeutic goals:

Like the way clients form relationships it’s...it’s with the person first and foremost, not the title. Some of the best relationships people had say at my place were often with staff that work behind the front desk […] and they’re not supposed to be doing any therapeutic work. But clients just don’t care about that stuff, to some extent. (John, AOD worker, community health service)

James described his perception of the dangers of having to work within a particular model of counselling or treatment. He suggested that while a conceptual framework could enable structure and process, it could also restrict the authenticity of the relationship with the client and prevent the spontaneity which enables a counsellor to attend to what the clients might need at any particular time:

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It is nice to have a model. It can almost be a philosophy, in a way. A general way of, sort of, seeing things. And it’s nice to kind of have that as a sort of a solid grounding. [...] But then the downside is that you could end up having a really, really solid base and you never build on top. So all you’ve got, instead of having a house, all you’ve got is the fantastic foundations. So … yeah, in one way I think it could be really, give you like a freedom, but also be very restrictive. (James, psychologist, generalist counselling clinic)

When researching the effects of counselling practice, international studies have reported that the quality of the alliance between the counsellor and the client is a better predictor of outcome than modalities or elements of therapy (Fonagy and Paris 2008, p.107). Thus, evidence exists as to the importance of the therapeutic relationship in achieving positive outcomes for clients. This study provides some supporting evidence of this practice implication through participant accounts of their work. It also provides some additional issues to consider in relation to the importance of the therapeutic alliance. For example, when expanding on the dangers of being ‘married to a model’ at the expense of the therapeutic relationship, James reflected on his perceptions of the clients’ experience:

Also some clients will just need different models and different ways of working with them. So to keep blundering down the same model that’s blatantly not working just is ridiculous. They probably feel stuck, or the [client] might feel to blame. (James, psychologist, generalist counselling clinic)

As James points out, clients will be unaware of the model or policy considerations that a counsellor or professional may be struggling to follow. Indeed, the focus for the client is more likely to be centred on what works. This is further problematised when clients are embarking on a treatment program in which they feel disempowered by directives or coercive treatment strategies. They may feel unable to question an approach that is characterised by the expert positioning of the professional. Nielsen (1988) considered professional boundaries and ethics as crucial in exploring the dynamics of shame.

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There are a number of relevant issues to consider in relation to this. The experience of shame is an inherent consequence of boundary violation, regardless of the nature of the relationship or the severity of the violation. However, when the violator is someone in an authoritative role, the intensity of the shame increases, and the victim is more likely to blame him/herself. These issues are especially relevant for counsellors, as the therapeutic relationship influences the restructuring of boundaries or the reinforcement of existing relational patterns (Nielsen 1988, p.110).

John, for example, reflected on non-shaming approaches to clinical procedures that he had witnessed at the community health setting in which he worked. He felt it was important to prioritise the respectful relationship that a professional can form with a client rather than being committed to a model that might use shame accidentally or deliberately as part of the process:

I have countless examples or illustrations of where a non-judgmental, supportive, accepting attitude worked, and no examples of instances where guilt and shame were in any way useful, if not downright counter-productive. (John, AOD worker, community health service)

John located the ownership for this non-shaming approach with the individual workers, rather than at a service or policy level. He continued to reflect on how this played out when workers enter settings that are structured by opposite approaches. Later in his interview, John said:

I think the capacity to judge or not judge as an AOD worker is to some extent informed by the professional context in which you’re working, in the sense that if you, if you feel very strongly about the role of non-judgemental-ness and therefore by default non-shaming in your work, then you’re unlikely to choose to work in a very morally laden kind of [...] service because you’re gonna be constantly at odds with the professional environment you find yourself in… yeah, I was gonna say I think you can be a non-judgemental person regardless of what institutional framework you find yourself working in. But I think that

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particular services kind of, you know, work as a barrier to or facilitate being more or less non-judgmental. (John, AOD worker, community health service)

John’s quote elaborates on findings reported in a Norwegian survey-driven study that explored the attitudes of staff working in opiate maintenance programs and associated outcomes (Gjersing, Waal, Caplehorn, Gossop & Clausen 2010). That study found that program policies affected service providers’ attitudes, which in turn affected termination rates in clients. While case load intensity and other factors were considered, Gjersing and associates highlighted the impact of program policy in adversely affecting client outcomes. John’s comments, as well as those of other participants below, add to these understandings by demonstrating some of the consideration that goes into managing these issues. They illustrate how these tensions have the potential to influence services, and how staff members manage the incorporation of program policies and workplace culture into their practice.

Similarly, Deirdre (psychologist, community health setting) did not place importance on the model a particular worker might use. Instead she described the type of relationship that characterises a therapeutic alliance. This included building trust and creating a relationship with a client where they could be comfortable:

I think sometimes when you’re doing counselling and you can slip out of that [modality] into having a chat or whatever, I think that’s okay. I know some people do get concerned about it but I think it’s a human relationship as much as everything else.

The excerpts presented in this section emphasise the importance that participants placed on the style of the relationship between a worker and a client. The qualities prioritised were rapport, trust, authenticity, congruence and a demonstration of their humanity. These quotes help to paint a picture of a relationship of greater mutual respect and positive regard, compared with the directive or forceful AOD treatment episodes described earlier. They also build on Nielsen’s points by demonstrating that motivating professionals to negotiate ethical and respectful boundaries with their clients is only

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half the task. The other half involves initiating and maintaining this action in contexts that might propose a more coercive approach. Presumably, being expected to work outside of one’s professional training and ethical position, or from a platform that one considers inadequate, have the potential to create tension for individual workers.

In Becoming Ethical, which provides clinical suggestions to counsellors working in punitive environments, such as domestic violence programs, Jenkins (2009) recommends a process of ethical discovery together with his clients throughout the therapeutic relationship. Rather than imposing a moral stance, an invitational exploration of ethics provokes the discovery of ethical ways of living and relating, of preferences that are respectful to each person’s strivings. The exploration of personal ethics in counselling can provide a reference point for challenging the restraining influences thereby freeing up a capacity to engage creatively with life (Jenkins 2009). Ethics in counselling is concerned with outlining how counsellors should behave towards clients and colleagues in order to prevent harm and avoid boundary violation. Being an ethical counsellor, however, is also integrated into the therapeutic relationship, and many practitioner/researchers have written about the importance of modelling a sound ethical stance in order to positively influence clients. Often called “walking the talk”, being ethical is understood to imbue the counselling process with trust and authenticity, and prevent the divisive and destructive influence of hypocrisy and corruption. In the following section, I use participant accounts to demonstrate how these various tensions have the potential to impact negatively on workers in a personal capacity.

7.3 Managing the maverick: the personal impact of counselling in AOD settings Given the importance that participants placed on their relationship with clients, it is perhaps not surprising that they also reflected on the effect this relationship has on them personally. Paula (psychotherapist, community health service) felt that it was not possible to separate the person from her/his role: “I really believe that the person is the professional and the professional is the person.” As an example of this, Sally described the tension of working with a client, with whom she had built a relationship, and whom she had to refer to another service when she/he no longer had an issue with alcohol or other drugs:

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I guess the difficulty is though once you develop rapport and they get comfortable in that setting, then to pass them off is sometimes seen as punishing them for doing that. Does that make sense? Sort of like they think: “If I was still using and still, you know, showing severe mental health symptoms or whatever, you’d still be hanging onto me and I wouldn’t be referred off to a different clinic for support. Whereas because I’m doing well, I’m putting in the hard yards, I’m practising what you’re telling me, then I’m gonna be [referred on]”. I guess it’s a difficult thing. (Sally, psychologist, AOD health service)

As outlined in previous chapters, the participants reflected upon clients’ varying motivation levels. In this excerpt, however, Sally described her fear that clients would feel less motivated to recover if they were separated from a counsellor with whom they had built a therapeutic relationship. She also expressed her discomfort at referring clients on. Rather than celebrating the clients’ transformation and her role in it, she might experience sadness or even a sense of betrayal at closing a treatment episode.

Forming therapeutic relationships with clients was typically complicated by dilemmas around being available, respectful and present, while simultaneously knowing when to be professional, removed and able to cease the therapeutic relationship at a time when this is beneficial to a client. Joanne reflected upon this bittersweet aspect of counselling through the concept of solid boundaries. She explained that counselling in AOD settings require a combination of firmness and softness:

It’s like a twofold process. And it’s hard. You have to be tough. You’ve gotta be tough with them. And there’s a lot of people who can work really well with addicts. But I personally think that if you are a recovered addict you’re the best […] and they know what they need. And they also know how to be with them. And they can easily be really tough with them but at the same time be very compassionate and empathic. (Joanne, couples counsellor, worked in a private residential AOD setting)

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Josie suggested that it was difficult to know when to use a soft approach as opposed to challenging the client. She too felt the pressure of working within teams where respected colleagues might be more confrontational in their style. Building upon her earlier point about the potential victimisation of clients in the AOD sector, she reflected on her own experience as a client of counselling:

I’ve always leaned towards psychodynamic models, and maybe that’s believing in recovery very early that it was very important to kind of – for want of a better term – work on yourself in a much deeper way than simply going to meetings and following messages in the program and living the right kind of life. I always craved something deeper in terms of understanding why I was like I was. And so in my own journey, throughout, I obviously used that and valued that depth of understanding and insight in my work with other people. I’ve always found models such as CBT limited. (Josie, counsellor, private practice)

In this quote, Josie outlined her craving for AOD treatment to be deep and located opportunities for this depth in counselling or psychotherapy. It is probable that as a professional she may experience frustration at having to work to a model that she finds shallow or limited due to her personal experience as well as her professional experience. A particular concern for her was the inherent imbalance of power in the therapeutic relationship regarding who chooses how to conduct the work, and moreover, how this might engender shame in the client:

I mean my biggest struggle with psychodynamic or analytic models is the imbalance of power, I suppose, in the relationship. And how that might contribute to, you know, a shaming process as well. (Josie, counsellor, private practice)

As shown in excerpts offered in the previous sections, a major source of tension for participants was the danger of shaming clients in AOD treatment or through counselling processes. The pressure to work to policies and procedures that are at odds with their own preferences made it difficult to remain authentic in the therapeutic

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relationship. For example, Mary reflected on the importance of establishing authenticity towards clients, and felt uncomfortable when colleagues talked derogatively about them. While she appreciated that colleagues may use negative descriptions due to stress, she preferred to remain respectful about her clients. I asked Mary what she thought might happen if the staff member were to speak in front of clients in this way:

That would just shame the person and they would totally shut up. You know, like shut off. Not open up to you anymore. The client/counsellor relationship would just...it would be damaged, because sometimes we’ve all got frustrations. We’re only human too. (Mary, counsellor, residential community AOD service)

This comment by Mary raises a significant point that relates to the potential of shame to silence clients. Silence can be a form of resistance on the part of the client. Whereas previous research on shame has described shame-silence to be the result of internal distress and mortification on the part of the client, Mary’s account describes a more relational form of silence. In describing the politics of silence at community level, Ferguson (2003) warned that silence is not simply an expression of acquiescence or passivity, nor of malfunction. Silence can be a form of resistance and an expression of identity. It is important to acknowledge that individuals can be powerful and powerless at various times, and at one and the same time. As such, shame and silence are affected by power and can be a form of power and identity. Rather than simply a violation that manifests as passivity, some clients might act upon this violation and opt out of talking therapies as this refusal to participate is their only form of resistance.

Mary described the potential damage that professionals might do to their relationships with clients by being flawed human beings and making mistakes, and in doing so indicated the pressure that these counsellors may be under to maintain these relationships. In the previous chapter Paula talked about her discomfort in unintentionally shaming clients. She also problematised more common notions of client silence that is inspired by shame or neuroses, by acknowledging client silence as a form of resistance to disrespectful or ineffective treatment approaches. Such accounts are

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scarce in the clinical literature and this scarcity perhaps shows the failure of previous research on shame-counselling to recognise low client motivation as a sign that treatment is poorly framed and managed. Future research on shame in coercive contexts would be advised to incorporate notions of silence as resistance due to unethical approaches to counselling, rather than low-treatment-readiness on the part of the client.

In addition to the tension created by listening to colleagues using disrespectful language about clients, other participants reflected upon the negative feelings associated with working with a stigmatised client community. They described their anger and frustration at hearing people outside the AOD industry stereotype their clients. In this way, participants describe the deleterious effect that working within a stigmatised arena has on them:

Like I get quite cross, when I say I work in drug and alcohol, someone will say, “You’re working with very messed-up people,” or whatever. [...] And you know, they’re quite naïve opinions too. But then it’s also, you know: why can’t people spend a little bit of time thinking about why? It’s not that they’ve been unlucky enough to have stuff happen to them that … some stories clients tell you are just, are just unbelievable. And you think it’s amazing that they’re sitting there in the room. And so I think that say if people were more sort of willing to reflect on why someone’s got like that… [rather than] putting them in a heap as ‘useless people who aren’t contributing to the world, blah, blah, blah, are just wasting resources’, I think that would be helpful. (Deirdre, psychologist, community health service)

When one reviews the literature that explores stigma, one realises that Deirdre’s concerns are not unfounded. Recent research, both in Australia and internationally, has revealed the multiple and complex ways in which stigma can create barriers to healthcare for people who engage in problematic drug use (Luoma et al. 2010). In particular, injecting drug use is a highly stigmatised behaviour that is viewed as socially unacceptable (Capitanio & Herek 1999). Seeking healthcare that relates to this activity, or becoming a needle and syringe program client, requires a person to identify

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as a current or potential injecting drug user, and such status brings with it the potential of increased visibility and stigma (Brener, Spooner & Treloar 2010). In the broader healthcare context, recent research has shown that healthcare professionals perceive drug use as within the control of the individual, that they are to blame for their condition (Holzinger, Matschinger, Lucht, & Angermeyer 2010; Brener, von Hippel, Kippax and Preacher 2010; Crocker, Major & Steele 1998); and that they should disclose unrelated conditions, such as hepatitis C (Brener, von Hippel, Kippax & Preacher 2010). Ultimately, AOD clients, particularly people who inject drugs, are more likely to receive poor healthcare, and be rejected by health professionals (Ronzani 2009; Brener, Von Hippel & Kippax 2007). A study that tested the effect of terms used to address drug-using clients, in referral processes between health agencies, found that individuals referred to as ‘substance abuser’ were more likely to be viewed as personally culpable for their condition and that punitive measures should be taken against them (Kelly & Westerhoff 2010). Clearly, being identified as a drug user can lead to various healthcare barriers. These may arise internally, through the perceived stigma in the mind of the client, or externally, through enacted stigma by the healthcare professional. Indeed, such dynamics may also negatively impact on the healthcare professionals who are attempting to engage and consult with these clients, and to work alongside other workers who hold negative views of their clients. An Australian study that explored the experiences of nurses who encounter clients with AOD issues found that due to the stigmatisation of drug users, nurses were required to advocate for these clients to prevent inappropriate judgements, and ensure that professional conduct was upheld at all times (Lovi & Barr 2009). It is therefore probable that the stigmatisation of service users can further disrupt treatment, through an increased burden on some healthcare professionals, and allied workers like counsellors.

Additionally, there is the potential for counsellors to be frustrated in their professional tasks and this may lead to increased levels of distress due to the relational nature of counselling work. As well as experiencing anger on the part of clients, some participants stated that they often spent time advocating on behalf of their clients:

Because you’re kind of having to advocate for clients, and that’s where your language-ing is a little different. And the ways that you think about and work

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with people, and talk about people in case meetings. For instance, I remember bringing a client’s issues to a case meeting with doctors. Multidisciplinary case, you know? And for instance, the way we worked, is to ask that client if it would it be okay if I talk about this stuff that we’ve talked about in therapy and take it to this thing. Getting permission as a respectful form of [working]… (Paula, psychotherapist, community health service)

In addition to the ongoing dilemmas of maintaining a client-centred approach in a field characterised by paternalism and coercion, participants commented on the additional burden of working to structures that might violate the clients’ boundaries and sense of self. This, and the need to manage emotional and ethical challenges – a situation that one might argue is inherent to any counselling relationship – creates a situation where such challenges actually add to the workload burden of these professionals.

A recurring theme in the interviews collected for this study was based on participant doubts that working respectfully with clients would be possible in certain workplaces. In a few instances, participants stated that they feared being ostracised by colleagues for going against the grain. For example, in his interview, John described his aim of working in environments that do not judge or dehumanise clients. Later in his interview, he talked about the perceived threat of ostracism should he work at services that did not support his non-judgemental stance:

So, I think I found myself working in environments that fostered my commitment to non-judgmental-ness, if you like. That I didn’t feel like I was at odds with … I didn’t feel like I was gonna be marginalised or frowned upon, or somehow heretical in that sort of context. Whereas maybe there are other contexts in which you would feel like you’re constantly pushing against the stream. That in fact it’s seen as part of your therapeutic practice to moralise, you know? (John, AOD worker, community health service)

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required to work in the AOD field, such as coping with the intensity of client narratives and low resourcing, a lack of support from colleagues who may disapprove of a particular professional approach could be a further drain on the worker’s energy. Worryingly, John’s interview also demonstrates the potential danger that client-centred professionals might avoid taking positions in coercive environments to prevent personal harm to themselves. This study complements previous research on AOD settings which has highlighted the potential for negative effects of program policies and low resourcing on client outcomes (Palm 2004). It also illuminates the additional issues for AOD clients who are experiencing chronic levels of shame, by demonstrating that such settings will fail to attract and retain staff that able to build a rapport with new clients and help them engage with their treatment.

Worse still, some participants said they had experienced hostility from other health workers, and Elizabeth (counsellor, community AOD service) said that she had been bullied by colleagues at her place of work. Mary reflected on her clinical dilemmas and described how the rigidity of externally placed rules had the potential to position her as ‘against the team’:

I mean it’s not a shame-based one but my own dilemma, where we have these rigid rules. And do they apply all the time? You know? Because sometimes it just, it goes against my own personal thing to enforce the rules. And I’m always debating that because you don’t want to minimise those rules or undermine the rest of the team, or anything like that. So … It’s always a hard one. (Mary, counsellor, residential community AOD service)

In this excerpt Mary hints at the philosophical isolation she experiences in her work, and this is perceived to create fissures with the team members she is dependent upon for support and supervision. Later in her interview, she described in more detail what happened when she maintained a gentle approach while working within a team that preferred to use more confrontational methods:

And then there’s other times where because I have a one-on-one [session with a

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client] and she’s opening up to me, and she’s not opening up to the rest of the community, and then [my colleagues say]: “You need to be really hard on her... she’s not opening up, she’s not talking about things.” And I think, “Well with me she really is.” And if we’re hard on her that’s gonna cut that off and she’s not gonna open up. So, I could try to express that, you know? And that’s where the culture and the whole community… And it comes down to an individual thing. Well you know, my boss says, “You need to be really hard on her,” but I personally think, “No, I don’t need to be hard on her.” So I thought: “You can be hard on her when you have your interactions with her and I’ll deal with whatever comes from that.” (Mary, counsellor, residential community AOD service)

In this instance, it seems Mary was able to avoid being ostracised by her colleagues. She was, however, put under overt pressure to adjust her approach and be harder on her client. While she was able to resist, she was also faced with the probability that she would have to work with her client to manage, perhaps even soothe, the detrimental effect of being confronted by some workers. At stake was Mary’s relationship with her team members, her relationship with her client and ultimately the treatment prospects of the client.

Sally said the team at her workplace struggle as a whole to reconcile their client-centred training with the more directive approach they were sometimes asked to undertake:

Because we’re so used to being non-judgemental, non-directive, we found it quite difficult working in this inpatient setting because it was very important to have the unconditional positive regard and that sort of stuff… we felt like it was being judgmental to tell them what to do. But we had to really figure out the distinction between creating boundaries and things like that, which is still not judging them. And I guess we were scared that it would ruin rapport to take away decisions for them, which is normally free-will. Mandated clients, they have to be there. And so it’s a completely different ball game: without judging them but still being that sort of disciplinarian, which was in interesting sort of thing to come out when you’re very much from that sort of, you know,

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Rogerian kind of model, I guess. (Sally, psychologist, AOD health service)

During interviews, participants would often use examples of ineffective treatment to elucidate why counselling should be undertaken in a way that was client-paced, tentative and empathic. In articulating this position, participants contrasted their work with that of other services or their colleagues. These other services were understood to exemplify negative or shaming treatment patterns. This was seen as something to avoid in counselling clients, in general, but in particular for those clients presenting with shame issues. Indeed, participants perceived that working in a prescriptive environment was to be avoided, as this scenario would compel counsellors to undertake processes that were at odds with their training and professional aims:

I haven’t worked in any of those kinds of [prescriptive] environments. And I suppose I stand back from them ...because where I worked it was quite…it was an integrated process, so it was holistic. And that makes sense to me, you know? That if you’re not looking at the whole person, and being able to accept where they’re at or their experience, then I don’t really feel that you’re going to work very well with them because that’s what I seem to find with addicts. (Joanne, counsellor, residential private AOD service)

Inherent in this statement is the perceived complexity of power relations that affect the treatment settings for AOD clients and the additional burden it places on clients and counsellors. When asked if he saw any connection between addiction, shame and counselling, James said:

Counselling can be used for good or evil. [...] whether knowingly or unknowingly, counselling could be more of the same, making them feel more ashamed. And the more ashamed they become, the more it could...lead to greater addiction, lead to greater shame. And so you get, the counselling could actually just perpetuate the cycle. It could help them to see things in a different way. Or to use the shame in a more positive way. Because the shame in itself

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isn’t necessarily a bad thing so like shame’s got a bit of bad press. But it is actually a good thing: you’re supposed to feel shame. (James, psychologist, generalist counselling clinic)

James’s quote articulates participants’ perceptions of the benefits of working on shame, in order to achieve a robust recovery. However, this work was also described as best undertaken carefully and slowly, at the client’s pace, themes that have been described in each of the findings chapters. Nevertheless, these intentions were not always appropriate given the inexperience of themselves or fellow workers, or the forceful tone of the service. Participants also indicated doubts as to the possibility of equalising the relationship between clients and professionals, and in some cases there was an acknowledgement that the client was unlikely to be the person to assess the quality of their recovery or their therapeutic course of action. As indicated in the literature review for this study, this poses significant ethical issues that relate to client centred practice and raises questions around the role of counselling in such directive and punitive contexts.

It is significant that participants did not mention protesting to colleagues or supervisors about this approach. Indeed, participants were more likely to describe seeking out contexts where that attitude was not permissible, and looking for employment with like-minded supervisors and colleagues. In addition to the mortification and denial that permeates shame experiences in the process of counselling clients, I surmised that participants in this study have also suffered, or fear, their own shaming by colleagues and supervisors. It is perhaps not surprising that participants reported incidents of workplace bullying and the negative use of power by supervisors and line-managers, and I doubt that this finding is isolated to counsellors or other workers based in AOD settings. The uniquely personal and intimate therapeutic relationship of counselling, however, requires that the personal and the professional maintain a reasonable level of congruence so that mental health and group functioning can be achieved for everyone involved. Professional dilemmas and ethical issues have the potential to confront counsellors daily, for they are part of the complex system of interaction in counselling settings. The uniquely value-laden and confrontational climate of AOD treatment, however, seems to add to this burden, and as a result, supervision structures designed to

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support counsellors to maintain functional professional boundaries can be seen as a negative influence here. In some instances this even resulted in the silencing of participant protests.

Jenkins (2009) wrote that there is a fine line between accountable and responsible forms of coercion and acts of violence which do harm, a distinction that is easily lost in the process of attempting to act in the service of a just cause. When working within a coercive setting, therefore, it is important for counsellors to maximise their accountability and understand clearly how an action is justified and what criteria are used to motivate an action ‘in the client’s best interests’. Jenkins asks: “How might counsellors develop ways to consider and monitor the potential for harm? How might counsellors minimise the use of coercion in their own practices? How might counsellors recognise violence? How might counsellors stay accountable for the violence in their practices?” This study provides some answers to these questions by displaying the strategies professionals use for navigating these complexities. It also provides insights into the measures that professionals take for self-preservation, including avoidance, and the potential that additional training might have on educating professionals to adopt a more transparent and respectful approach to AOD treatment which would have the potential to improve the outcomes of counselling for shame issues, as well as more generally.

Jenkins (2009) added that while boundary violation is ubiquitous in relationships and communities, not all violence is abusive. However, boundary violation does have the potential to be abusive when the person who enacts it possesses a significant advantage through conferred power, when they experience a sense of entitlement, and when they are in a position to abdicate responsibility for the well-being of the other. The most common sites of abusive behaviour are aligned with dominant and institutionalised cultural hierarchies of power. Interventions in these settings, therefore, require recognition of differentials in power and practices which address problematic behaviour in a context of safety and accountability. Citing Deleuze and Foucault, Jenkins prefaced his clinical suggestions by theorising that any context is political and concerns a wealth of intersecting and interconnecting power relations and practices which are hidden or invisible to participants (Jenkins 2009, p7). In accordance with

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Foucault’s understandings of power relations, dominant cultural interests provoke, and are determined by, ongoing practices of complicity and resistance. Ethical positions and practices arise from changing states generated by complicity and resistance.

While all coercion has the potential to cause harm, not all forms produce harmful violation or lead to disrespect of individuals, particularly when enacted within an accountable context where this potential is considered and the nature and effects of coercion are monitored. For example, police action to prevent a person causing harm to others can be considered respectful to all individuals concerned, and to the broader community. Justice processes which mandate therapeutic intervention when men act abusively can promote safety and respect and does not necessarily violate the integrity of those men. It remains helpful, however, to regard all forms of coercion as potentially violent. To recognise this potential can maximise accountability and minimise harm (Jenkins 2009). This study provides accounts of professionals who, despite their best intentions, have violated clients, and have witnessed colleagues abusing clients in the name of therapy, both in the AOD sector and outside it. In drawing attention to these factors, my study outlines new training opportunities through the potential cross- fertilisation of concepts and reflexive dialogue between the domestic violence field and the AOD sector – two industries comparable due to the tension that counsellors face in maintaining a client-centred and ethical stance in a field marked by punitive and coercive approaches.

7.4 Conclusions The prevalence of shame narratives that clients bring to counselling was described by participants as raising clinical dilemmas that required experience and supervisory support, in order to prevent the depletion of professional energy and commitment. Burn out and counsellor distress were felt to be common and several participants stated that they would not be able to continue their work indefinitely and were planning on leaving the field. This finding supports recent local workforce surveys conducted since the time of the interviews.

Participants also understood that motivational factors for seeking treatment could be particularly complex and suggested that working with clients, who had low motivation

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to address pertinent issues, could be frustrating and demoralising. The AOD field was thought to be marked by divergent understandings of what constitutes problematic drug use and, in building upon points made in Chapter Five this could lead to a lack of consensus between team members on how to best treat clients. Participants described workplace incidents where tension had built between staff members who understood treatment as a confrontational exercise and those workers who preferred a gentler approach.

In addition, participant interviews included the perception that material resources and staffing levels were inadequate for the work at hand, due to a general lack of funding. This was believed to lead to considerable impact on the AOD personnel and to have a negative effect on treatment outcomes and increased attrition rates. Study participants emphasised the difficulty of maintaining staff levels due to the demanding nature of the work. Those participants who had not worked in AOD settings also concurred with the demanding nature of counselling practice. These participants, however, did not report the same levels of discomfort and did not describe incidents where they had been expected to undertake interventions with which they did not agree philosophically. In short, attempting to maintain the ethical position of counselling practice meant that participants potentially had to work outside management requests or team structures and protocols, which positioned them as ‘maverick’ workers. In doing so, they were potentially denied collegial support or were forced to reconsider their ongoing employment.

On reflecting upon my original research questions that were concerned with the potential of shame to affect the counselling relationship, and the potential of the AOD setting to hinder counselling around problematic levels of client shame, it is clear that research on these issues requires a broad analytic frame that incorporates social and cultural influences. The original focus, the dynamics of shame, which refers to shame that is caused by a practitioner and is generally unhelpful, were viewed in relation to broader issues relating to workplace culture and social attitudes towards AOD clients. These professionals asserted that they were unable to consistently engage in robust client-centred practice to support clients in overcoming problematic shame and thereby explore the core issues that determined their AOD issues. Instead their accounts were

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more often concerned with managing the external influences and pressures that prevented them from continuing their work. The ‘dynamics of shame’ in this study evolved to be less about the therapeutic dilemmas described by Potter-Efron and more about the systems of power and discrimination that can disrupt the clients’ potential journeys of transformation. In short, before counsellors can work on problematic shame with clients presenting with AOD issues they will probably be required to navigate the complex and highly stigmatised arena of addiction in AOD services. In the final and concluding chapter, I draw from participant accounts to consolidate the implications these issues have for practice, and outline recommendations for counselling practice in alcohol and other drug settings.

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8. Summary, conclusions and implications

The aim of this study was to gain a deeper understanding of the dynamics of shame when counselling in AOD settings, with a particular emphasis on increasing awareness of these issues through the perceptions and experiences of counsellors and other frontline workers. Throughout this exploration, consideration was given to participants’ understandings of counselling, problematic alcohol and other drug use, shame, and finally how clients experience treatment in AOD settings. Space was also given to participants’ views on counselling in other sectors of healthcare or therapeutic endeavour. These insights were used to draw attention to the aspects of the drug and alcohol field that contribute most to the professional dilemmas that counsellors and other AOD workers face in their everyday working lives.

This final chapter will summarise the preceding chapters by responding to findings in relation to the research questions, before outlining how study findings might be used to inform counselling practice, and possible directions for future research. In each case, I begin by adding to the discussion in the literature review, by focusing on what is new and significant. This chapter, therefore, highlights the ways in which this research extends what is currently known about effects of shame on counselling practice in alcohol and other drug settings, especially relational factors, and how the setting further influences this process. In examining the implications of these findings for AOD treatment and future research, the significance of this study is identified. Finally, any limitations of the study are also acknowledged.

8.1 Summary To recap, study participants, described counselling AOD clients around shame to be affected in three ways: first, through the fractured and contentious understandings of what constitutes problematic drug use; second, through what constitutes appropriate AOD treatment; third, through the effect of stigma and the negative labelling of clients; and ultimately through the undue pressure these unresolved influences place on individual workers, attempting to navigate these issues.

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In reflecting on the original research question, this thesis demonstrates the complexity inherent in counselling AOD clients around shame. New questions are generated around the extent to which counsellors incorporate research findings into their work and the dangers of assuming that clients are presenting with shame, and conflating shame with manifestations of guilt, stigma and trauma. In describing their professional experiences, participants reflected on their views about what constitutes alcohol and other drug use, and the potential of this to determine their appraisal of the client’s ability to change. In doing so, they also questioned the ability of residential rehabilitation and AOD treatment to address adequately the numerous, and sometimes intense, issues that are part of the client community’s presenting problems. Indeed, this study provides some answers to the question: to what extent does the treatment setting actually add to the shame burden and stigma of being an AOD client? While study participants did not aim to contribute to client shame, and some were actively against it, they were aware that this is a pertinent issue for clients presenting at AOD settings. Therefore, conclusions in this thesis highlight unforeseen treatment barriers for clients, and the detrimental effect this can have on the workforce. The conclusions also draw upon the valuable insights provided by the participants and these have been collated into practice implications which might enable other practitioners to be better informed, thereby increasing opportunities to support clients attempting the formidable task of recovery from problematic alcohol and other drug use.

In one sense, this study has created a window through which to view the ways in which these professionals approach their counselling practice, and how they manage this complex and sensitive work in an arena which is influenced by differing codes of conduct, imposed policy dictates, fluctuating funding, shifting public opinion and working styles which may be at odds with their professional ethics. Therefore, through participant insights I am able to contribute to knowledge about the challenges that the AOD sector poses to the workforce in New South Wales, Australia. I am also able to give voice to the impact these issues have on personnel, as well as providing recommendations drawn from their experience and expertise.

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8.2 Conclusions about the research question: implications for practice As the term ‘implications’ suggests, I do not aim to provide definitive answers to counselling dilemmas. In keeping with qualitative research methods (see Scott 2004), I avoided the global question: “do AOD treatments work?” and instead aimed to contribute to knowledge about AOD counselling by exploring the question: “Which factors enable or inhibit counselling in AOD treatment?” Therefore, in this section I pull together the themes described in this study to think about how these might inform current counselling practice in AOD settings, with particular reference to the dynamics of shame, by raising awareness of issues that are not currently reported elsewhere, thereby complementing existing clinical suggestions with additional areas of consideration.

A review of the research field reveals client shame to be a well-documented issue for counsellors. There is also a substantial body of work that highlights the connection between shame and the problematic use of alcohol and other drugs. The existing clinical literature that offers guidelines for practitioners does not, however, provide insights into how counsellors working in the community might incorporate suggestions. Also, little is known about the extent to which this research has filtered into the clinical field and there is no evidence that such knowledge affects current practice, or policy manuals. Indeed, workforce development in the AOD sector has described the challenges of research knowledge to be better translated and transferred to service provision (Roche 2012), while the broader counselling field has been criticised for failing to incorporate research findings (see Cooper 2004, Murray and Welch, 2010), and practising within an information vacuum (Maiuro and Eberle, 2008; Bogard and Mederos, 1999; and Jacobson and Gottman, 1998). In this study, perceptions of shame, and its connection to problematic AOD use, were articulated as good counselling practice in AOD settings and in other sectors. However, participants also described the various hindrances to counselling around shame. Therefore, these practice implications will focus on situations where participants felt the contextual factors hindered AOD counselling around shame and how participants manage these dilemmas.

This study supports previous findings by showing how shame has the potential to create a barrier to therapeutic engagement and process. Participants described shame as an

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inevitable emotion for the vast majority of their clients. As a result, the ‘inevitability of shame’ meant that a lack of shame or ‘shamelessness’ in client narratives signified a lack of engagement in the therapeutic process. In other words, the participants would expect to work on shame and if shame did not arise as a topic or emotion in counselling sessions, they might assume that the client was not properly engaging in her/his recovery. Therefore, I surmised here that there is a danger that making assumptions about the prevalence of shame in client narratives as this might engender therapeutic determinism in treatment strategies. As such it is suggested that counsellors remain mindful of the presence of shame while demonstrating awareness that clients may be manifesting other core emotions, like grief and loss.

Unlike seminal texts on shame and guilt, study participants did not view the two states of shame and guilt as requiring different strategies. Shame was described as being hard to distinguish from guilt and possibly increased by feelings of guilt. However, previous research has described the different strategies required when working on chronic shame and guilt, given the different focus of distress. Therefore, possible workforce development avenues exist that include revisiting the literature on shame and guilt and disseminating information about the alternate strategies that these states require. It is recommended that ongoing workforce development incorporate evidence-based practice suggestions that relate to working on shame and guilt.

Having said that, participants also described the ways in which they remained tentative in their use of shame language, and how they deliberately avoided relying upon definitive categories to prevent generalising the clients’ experiences and determining their response. This echoes other research which articulates the professional dilemma of ‘naming shame’ to raise awareness in the client, which could potentially shame the client as opposed to the benefits of allowing the client to describe her/his own experience, while potentially missing a therapeutic opportunity which might jeopardise her/his recovery or clinical episode (Lewis 1987). In any case, participants were doubtful that shame could be separated from trauma manifestations or core emotions. In this way, participant accounts in this study provide fresh insights in to the challenges of undertaking therapeutic dialogue on shame and guilt, and contribute to clinical

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debates by providing alternative approaches that are better aligned with AOD treatment contexts.

This study also provides new insights into the dynamics between shame and stigma. Study participants reflected on the potential of treatment to be shaming, which might occur through intake procedures, ‘confronting’ therapeutic exercises or punitive and ‘moral’ approaches to recovery. However, participants also conflated shame and stigma in their accounts of client shame, and in some interviews the terms were used synonymously. Entering an AOD service was described as both shaming and stigmatising, and holding the potential to expose clients to labels like: ‘alcoholic’ or ‘addict’. Participants described labels as socially pervasive and destructive in that they could affect clients’ perceptions of their ability or motivation to change. This thesis contributes to contemporary research on the effect of stigma or shame for AOD clients and contributes to the growing body of research on client motivation and change factors in relation to AOD treatment, and how these play out in counselling processes.

Participants in this study also articulated shame as a social emotion that is affected by social norms, morals and attitudes towards various drugs. This was viewed as manifesting in attitudes, behaviours and emotions and through the lived experience of being socially alienated and marginalised. It is therefore proposed that alongside the client narratives that incorporate the personal and identity-driven aspects of shame, counsellors need to work very closely with clients’ sense of internalised stigma and marked social identity.

In accordance with clinical literature, participants felt it was crucial not to shame clients. This was seen as being intrusive, or cruel, and possibly as repeating experiences from an abusive family-of-origin environment. Participants, however, also described shame and stigma as potentially fruitful areas of therapeutic focus. The counsellor’s role might involve acknowledging the presence of shame and stigma in AOD recovery, and then supporting clients through the experience by demonstrating empathy and trust. This restates the centrality of client-centred practice in AOD treatment. It is important to consult with clients about the process, to inform them of the steps in the process and to gain permission to initiate the process in order to avoid violating any therapeutic

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boundaries. Participants in this study described the importance of counsellors assessing the appropriateness of this work on an individual basis. Where clients demonstrated reluctance towards engaging in this work, participants felt that it was inappropriate to push or force the approach. Therefore, this study contributes to clinical debates about the dynamics of shame, in describing the participants’ approach to goal setting with clients through the therapeutic working alliance, and points to opportunities for developing clearer guidelines around navigating those dynamics in AOD settings.

Given the conflation of shame and stigma in participant accounts, this study provides insights into ways for counsellors and other frontline workers make sense of the intermingling of the internal features of shame with the external components of identity assignation. Counselling was described by study participants as a process through which to reach beyond determinate labels of stigma and stereotypes, and to create new ways of thinking and being. The participants saw it as their job to challenge these labels, to interrogate them and unpack any purpose they might serve. Through deconstructing a label in this way, participants described their work as improving a client’s agency to achieve recovery and maintain it. This study highlights opportunities that AOD professionals acquire to incorporate concepts from other therapeutic sectors that highlight the dehumanising action of a label and the transformative effect of externalising that label. A recommendation that relates to workforce development would be to incorporate more Narrative approaches to AOD treatment, as outlined in references to the work of Michael White (2002; 1990) and Alan Jenkins (2009; 2001). Narrative Therapy aims to externalise the problematic behaviours from individuals in order to reframe their identities, and this may offer productive opportunities to challenge stigma (see also Etherington 2008; 2006).

Similar to case study presentations in clinical literature about shame and problematic alcohol use, study participants described chronic shame as emanating from the family- of-origin and reflected on the connection between childhood trauma and shame, and how these experiences might be a pre-determinant to problematic alcohol and other drug use. This is not to say that AOD use was viewed as wholly problematic nor that abstinence was seen as the most appropriate goal of counselling. Participants described AOD use variously as: a coping strategy; pleasurable or recreational; destructive and

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overwhelming; and a way of gaining access to a social group or sub-culture. Differentiating between problematic and recreational AOD use does not mean that participants believed there were always benefits to a client being diagnosed within a singular category. Indeed, it was more commonly understood that a client could use drugs for some or all these reasons, simultaneously, and that AOD use was perceived as having a complex and at times paradoxical impetus. With this in mind, AOD treatment was viewed as an opportunity to address problematic drug use alongside the manifestations of trauma, and accompanying chronic shame, and the guilt or remorse that results from the recollection of abhorrent actions undertaken while intoxicated, or in order to gain illicit drugs. However, abstinence from drug use was not unanimously recommended by participants, who reflected on the benefits of separating recreational drug use from that which is overwhelming and harmful. This study contributes to research in the harm reduction field by providing examples from interviews with professionals working in the field of the ways in which a moral and totalising definition of drug use has the potential to hinder AOD treatment. In contrast, I am arguing that a more post-structural account of drug use has the potential to enable therapeutic dialogue which more readily embraces the pleasurable or positive aspects of AOD use, the complex range of determinants of harmful use, and the individual client’s modified understanding in relation to their various uses. In this way I raise questions about the possibilities for counsellors and clients to discuss drug use in various ways, since the AOD treatment sector can be enforceable, coercive and even brutal.

Shame has been described here as a profound and crippling experience with the potential to impact negatively on relationships. This supports previous research that evidences the anti-social aspects of chronic shame (Dearing and Tangney 2004). Participants in this study, however, rarely described shame in moderate amounts, nor as a positive dynamic in relationships. This study highlights other gaps in the knowledge of local frontline workers and indicates further avenues for workforce development. These avenues might include information about the positive functions of shame in relationships and emotional functioning, and how working on shame might be an addition to trauma-work, rather than attempting a convergence of the terms.

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Participants also voiced their frustrations about having to work within the short time frames and rigid structures of some treatment programs. They note the failure of existing AOD programs to treat clients who present with underlining issues, like childhood abuse and trauma, adequately. These issues were perceived to be common precursors of problematic alcohol and other drug use. This study thus contributes to knowledge about good practice principles for AOD treatment and raises additional questions about the best timeframes for working with one cohort of the client community, namely those people presenting with issues of trauma that relate to family violence and childhood trauma.

My analysis outlines the multitude of different definitions that participants used to describe problematic alcohol and other drug use, and how such definitions were inspired by complex influences like personal experience, clinical training, and workplace culture. Significantly, participants used multiple, and at times contradictory, definitions and these definitions could alter during the discussion. Participants often stated that they had not considered which definitions they used in their practice or the effect of these various understandings. Therefore, the conceptualisations of problematic AOD use in the interviews gathered in this study were potentially contradictory. Also, certain definitions may be loaded with values that influenced how the participant viewed the client and the possible outcomes of treatment. For example, those participants who understood addiction as being genetic or fixed were more likely to view treatment as teaching the client how to manage this lifelong affliction, whereas those participants who viewed drug use as dynamic or a coping strategy were more likely to view counselling as a process through which to facilitate the uptake of alternative coping strategies or behaviours. It is therefore suggested that supervision strategies be devised to generate discussion, especially between team members, about what constitutes problematic AOD use, and how counselling is to be undertaken in light of these definitions.

Key findings from this study suggest that the AOD field is marked by diverse and complex understandings of what constitutes problematic drug use. Participants described some definitions of problematic drug use as being value-laden and as potentially leading to clients being subject to contradictory treatment strategies and

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moralising understandings of responsibility and blame. As reported elsewhere, participants often described problematic drug AOD as connected to shame and unresolved trauma. The combination of perceived trauma in client life-histories and the use of punitive treatments, often adopted in AOD settings, were seen to be problematic. Through participant accounts, this study demonstrates the possible lack of awareness that counsellors and frontline workers harbour in relation to understandings of addiction, alcoholism and AOD use. Therefore, this study provides insights into how frontline workers perceive addiction and AOD counselling, and how this informs the construction of therapeutic goals and treatment dynamics. It is possible to surmise that nascent understandings of addiction might imbue a counselling session with language or attitudes that shame attending clients. Thus, new avenues of inquiry around shame and counselling are highlighted here.

Participant accounts highlight the potential of counselling in the AOD field to be demanding, intense and poorly supervised. In doing so, this study provides insight in to how counsellors perceive the AOD treatment sector as performing in relation to both treatment goals and workforce engagement. The participants also reflected on the difficulty in maintaining staff levels due to their own resignations from the field. Burn- out and professional distress were felt to be common in AOD-related work and many of the participants in this study discussed their intention to leave the field or gave reasons why they had done so already. Those who had not worked in the AOD field specifically also reflected on the demanding nature of counselling practice and stated that a lack of funding and poor staffing levels had a detrimental effect on the service offered. These participants did not, however, describe incidences where they were expected to undertake interventions they did not philosophically agree with, or to undertake coercive treatment strategies. These issues were under-represented in the international research field at the time of writing but local research, by the National Centre for Education and Training on Addiction (NCETA) at Flinders University, has since begun to explore these issues in relation to workforce development and retention. The findings of this study complement this work by providing additional professional accounts that outline concerns for career pathways and areas of professional development.

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As outlined in the background section of this thesis (the Introduction), I witnessed practices when working in this area of counselling that could be viewed as directive, and at times punitive. I was compelled to adhere to policy and procedural guidelines that contravened what I believed to be the ethical remits of counselling practice, and I was concerned that attempts to maintain my professional integrity would alienate me from my professional team members. Participants in this study also witnessed and experienced these dilemmas and yet, little is known about how a coercive clinical setting impacts on counselling around shame, and how these challenges are understood by frontline workers. I surmised that the treatment barriers for shame-counselling are compounded when the therapeutic space is cultured by a coercive or judgemental approach. Significantly, this study has outlined the ways in which these factors have the potential to negatively affect frontline workers and begins to describe the ways in which participants were hindered in their work, sometimes to the detriment of clients. This study contributes to the research field by voicing the experiences and perceptions of counsellors and frontline workers of AOD treatment settings, and provides indicators for workforce support and supervision and possible avenues for future research by more clearly enunciating new research questions.

On reflecting upon my original research question, I aimed to consolidate the nascent issues this study highlights around counselling and the dynamics of shame in AOD settings. The implications outlined here focus on the barriers and facilitators that participants described in their interviews, and point to possible ways of addressing issues that cannot be resolved by individual workers, like workplace policy dictates and the working styles of colleagues and supervisors. In these situations, I suggest that counsellors and AOD workers discuss the existence of such limits to the therapeutic relationship with their clients to avoid either party inadvertently internalising these limits, or confusing the intention of certain interventions, which has the potential to disrupt the trust that needs to be built between client and counsellor. In navigating the different styles of AOD treatment, counsellors can be empowered by considering which interventions might be of benefit to clients in certain situations, and which should be avoided, a consideration which can be shared with the client.

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Counsellors may be encouraged, therefore, to adopt a more political, or existential, stance and to use incidents of potential coercion as an opportunity to test possible courses of action in conjunction with their clients, and to make more lucid decisions about which consequences to accept and which benefits to seek. In this way, a counsellor might work with a client to practice possible responses to a situation, given that coercive and discriminatory acts are unlikely to stop for a client once they have left treatment. In reflecting upon my own work, I share the views of John and Josie who perceived an equal relationship between a client and counsellor in AOD counselling to be an unlikely occurrence. I am, however, also buoyed by the input of Paula (and narrative practitioners more broadly) who described a process that aims to equalise the relationship as much as possible. In this way, counsellors can facilitate a collaborative approach about how the client would like to live, and the place of alcohol and drugs within this imagined scenario.

8.3 Limitations of the research project This study is a localised research project which contributes to the knowledge of counselling in AOD treatment settings in New South Wales, Australia. It represents the perspectives of a range of professionals who were largely trained in psychological methods, who in some cases had not finished their counselling training at the time of their input, and who mostly identified as Anglo-Australian. Therefore, this study does not include perspectives from members of the Aboriginal or Torres Strait Islander communities of Australia. Further, this project cannot speak to the perspectives or experiences of frontline workers in sectors characterised by cultural diversity or racial discrimination.

In addition to limitations around the participant profile as set out in the methods section, this study is limited in that it provides the perspectives of professionals working in the field and does not incorporate client perspectives. While some of the participants incorporated their experience as clients in their interviews, these participants were trained as counsellors. As a result, the findings from these client interviews can be accounted for by their counselling training, and an allegiance effect, namely that they may be biased towards the model of counselling they were trained in. Given my training, it is also possible that my analysis and interpretation of their

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accounts has favoured a particular model, which is a humanistic and client-centred approach.

Despite these limitations, this study has provided rare access to the professional lives of counsellors working with clients experiencing AOD issues. In a field dominated by quantitative and survey-driven evaluations that focus on the outcomes of treatment episodes, this qualitative, reflexive interview study provides discursive material to addresses a current gap in the research field. This study also provides feedback on how current procedures and policies play out in treatment settings, and therefore contributes to our understanding of what hinders and what enables the counselling of AOD clients. In broad terms, it takes the field forwards in understanding how AOD counsellors and other frontline workers think about and experience their work.

8.4 Suggestions for future research This thesis incorporates different, and disparate, fields of research that inform clinical governance, addictions treatment and the psychopathology of shame. Through the research axis of AOD counselling around shame, I explored what factors AOD counsellors and other frontline workers perceived as treatment barriers and what they perceived to be helpful in providing clients with therapeutic benefits. In exploring the various practice implications of my key findings, I have also developed new ideas about professional training and possible avenues for research around AOD counselling practice. In what follows, I will review these research questions in relation to what is known in the broader field of enquiry.

In a meta-analytic review of psychotherapeutic research, Cooper (2010) outlined what is known about the benefits of counselling. It is possible to prove that counselling helps to lessen client distress and is as effective as medication in the long term. Counselling and psychotherapy are cost effective forms of treatment and there are only small differences in the effectiveness between the different bona fide therapies. Clients’ involvement with therapy and their capacity to make use of it are strong predictors of outcomes, and as Rogers hypothesised, positive outcomes are associated with the therapist’s way of relating to clients, which is their ability to be collaborative, caring and empathic. However, research that focuses on the AOD field demonstrates poor

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outcomes with regard to attrition rates (United Nations 2002; Brunt 2002). Therefore, more research is needed to monitor client engagement, to test the benefits of a client- centred approach in engaging and motivating clients, as well as the various issues related to early cessation of treatment, including the role of counselling in this.

There has also been criticism of the research methods used to evaluate therapeutic models. The problem with previous research is that it largely tries to prove the merit of a particular model, and that levels of success can be accounted for by the allegiance effect (Cooper 2010). Thus, further research is needed on whether counselling effects change, the importance of practitioner characteristics on change, and whether outcomes vary according to the current definition of ‘successful recovery’.

The interviews for this study also reveal disagreement about how we might define a positive outcome and who decides what it is that a client needs to change, as well as the criteria for change. For example, a client’s moderate use of alcohol and other drugs might be viewed as a relapse in a model that prioritises abstinence. In a sense, this thesis examines practitioner perspectives of what characterises change in relation to the problematic use of alcohol and other drugs. As I pointed out, however, what constitutes the ‘practitioner’ is complex and how she/he defines the problem and change criteria is contentious. Also contentious is the extent to which practitioners and clients are able to negotiate goals of therapy and the means by which to realise these goals is affected by the context in which the work takes place. Participants described workplace conflict, undue pressure on individual counsellors and the forced positioning as ‘maverick workers’ who resisted the shaming of clients. These professionals said they were affected by this on two levels, first they were distressed when they witnessed their clients being treated in ways that were perceived to be disrespectful, shaming or harsh, and second, they felt torn when colleagues and supervisors encouraged them to adopt more confrontational approaches, for fear that they might themselves be alienated should they refuse to comply. More research is needed to examine the effect of the setting on change factors and how this plays out in relation to different models and broader cultural factors.

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Appendix One – Recruitment Flyers

Accompanying text to email request:

To whomever this may concern,

I am a social researcher and PhD candidate at the National Centre in HIV research at UNSW and I’m conducting a research project on counselling as a treatment option in AOD settings. I would appreciate it if you could disseminate the attached circular, to all staff who may be interested in participating.

Should you require any additional information, please feel free to contact me on the details below.

Kind Regards, REBECCA GRAY

Flyer:

Do you Counsel or work with AOD Clients?

Seeking interviews with workers of AOD services

Information for prospective participants

This research aims to gain a clearer understanding of the counselling process in an Alcohol and Other Drug (AOD) setting, targeting issues of shame in relation to problematic drug use. A better understanding of the experiences of workers can enhance services and policy and procedures.

The project is being conducted by the National Centre in HIV Social Research, UNSW, and aims to source workers’ perceptions of AOD settings and in particular for clients who present with shame issues. The research will communicate results in a variety of forums, including workforce development, counselling models and academic conferences. The project has approval from the University of NSW Human Research Ethics Committee. The interviews will be like an informal conversation and will take about one hour to complete. They will be audio recorded, with your permission, and are anonymous and confidential – all personal information recorded during the interview will be erased from the transcript, and names will be changed.

For more information or to arrange an interview, please contact: Rebecca Gray

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Second Flyer

Are you a counsellor or Psychotherapist? Seeking interviews with counsellors who have and have not worked in Alcohol & Other Drug or Dual Diagnosis services

Information for prospective participants This research aims to gain a clearer understanding of the counselling process, targeting issues of shame and stigma. A better understanding can enhance services and policy and procedures. We would like to hear your thoughts and experiences.

The project is being conducted by the National Centre in HIV Social Research, UNSW and aims to source worker’s perceptions. The research will communicate results in a variety of forums, including workforce development, counselling journals and academic conferences. The project has approval from the University of NSW Human Research Ethics Committee (07263)

The interviews will be like an informal conversation and will take about one hour to complete. They will be audio recorded, with your permission and are anonymous and confidential – all personal information recorded during the interview will be erased from the transcript, and names will be changed. A summarised version of the findings will be made available.

For information or to arrange an interview, contact:

Rebecca Gray 0422 536 761

[email protected]

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Appendix Two – Interview Guide

Engagement Section Inform the participant that the audio recorder is switched on Can you please confirm that you have undergone the consent process? How are you today? How was getting here for you today? Before we start, do you have any questions?

Background Information What led you to work in your current setting? Tell me about the counselling training and workplace experience you’ve had?

Understanding counselling practice Describe for me the counselling models you prefer to use? Are there models that are preferred by the service you work for? Describe for me the benefits of these models. Describe for me the barriers or limits of these models. What is your understanding of the setting in which you work? What is your understanding of the effect that setting has on your work? How do you understand the connection between counselling and setting?

Understanding alcohol and drug use How do you prefer to describe drug use? What is your understanding of this?

Understanding shame What is your understanding of shame? How do you understand the connection between [insert participants preferred term for drug use] and shame? How do you understand this in relation to counselling? Do you see any connection between [participant’s preferred term for drug use] and shame and your work setting? How do these connections play out for you?

Seeking suggestions for practice In an ideal world, how do you think treatment should be conducted for clients presenting with problematic drug use? What are the benefits of this depiction? What do you see to be the barriers to this depiction? How do you understand the role of counselling in this ideal world scenario? What changes might there be as the result of these hypothetical improvements?

Closing section Is there anything you would like to add? How do feel the interview went? Is there anything that you think I should do differently? Do you have any further questions or additional comments? Inform the participant that the audio recorder is being switched off.

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Appendix Three – Coding Framework

These categories were made up of recurring statements, ideas or described experiences that became apparent across the interviews. In order to begin the next stage of coding, these recurring statements were categorised into groups that would inform an overarching coding framework. This was not a fixed or isolated process and ongoing reading and re-reading of the transcripts and textual data. The international literature and subsequent interviews also helped to revise and clarify this analytic process. The labels and categories were presented alongside quotes to the project supervisors who, through a discussion process, verified the ongoing analysis. The following outline provides an indication of the diverse topics discussed in each of the first five interviews that relate to the axis of shame/counselling/problematic drug use, and provides the background to the subsequent thematic analysis. This open coding process was intended to provide potential labels by which to categorise and test the recurrence of various themes. The subsequent list does not indicate that these statements were given in every interview and some labels may indicate a single utterance only. However, most of the labels below were used by multiple participants and many times. Also, every attempt has been made to retain the participants’ words and to avoid imposing additional meaning through researcher interpretation. The open coding process provided the following categories and topics:

Shame is seen as a pre-determinant to alcohol and other drug issues: addiction is shameful; addiction is stigmatised; addiction is related to family of origin issues; shame is related to past behaviours when intoxicated; addiction may be related to trauma induced shame; alcohol and drugs may be a coping strategy for shame, trauma and stigma.

Shame manifestations: shame as an affect; shame-affect is anger; shame-affect is rage; shame is life-limiting; shame silences; shame is related to sexual practice; shame is related to the sexualised body; shame may look shameless; shame affects behaviour; shame has a precipitating event; shame makes the person feel dirty; shame affects self- esteem; shame affects the clients ability to set appropriate boundaries; shame affects a client’s sense of identity; shame may lead to outrageous behaviour; shame is intense; 208

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shame is dynamic; shame can be caught by the witness; shame manifestations can be experienced as a spiral; shame is pre-verbal.

Treatment is shaming: worker inexperience; worker being married to a program; counselling models and staff may label clients; shame is related to sexual practice; shame is related to moralising; worker lack of training; lack of funding to a service; worker shame; criminalisation of the clients; worker coercion of clients; formal removal of children as shaming; entering treatment as shaming; taking a urine sample is shaming; hard-line treatment is shaming; AOD issues are shameful; entering an AOD setting is shameful.

Shame and treatment suggestions: drug use may be a coping strategy; treatment is useful to normalise shame and stigma; treatment allows shame to be named; shame can be reintegrated rather than evaded; treatment allows congruence between event and reaction; non-judgemental treatment assists with shame affects; treatment should be client-centred; treatment should include positive regard; treatment should help client to self-actualise; treatment should include techniques that foster social inclusion for the clients; behaviour is not the person, thus should not label; focus on the therapeutic relationship; use empathy; work therapeutically on clients sense of accountability and responsibility; treatment prevents client hiding; treatment should be gentle; focus on communication skills; be directive; do not name shame; communication between staff members is important; be hard; be soft; counselling should work at depth; focus of duty of care; create a safe space in which to work; utilise role-modelling for the clients; be reflexive; avoid rigidity; be tentative; treatment should be dynamic; treatment should be holistic.

Treatment models: disease model; twelve step model; medical or health model; therapeutic community model; residential model; psycho-educational model; narrative model; spirituality.

Therapeutic power dynamics: therapeutic accountability; client responsibility; morality; power of staff over clients; active agents of recovery; passive agents of

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recovery; power of clients over other clients; treatment as difficult to navigate; bullying in treatment; power as hindering trust.

Worker impact: tension of using different models; tension of different practices used simultaneously; worker shame; shaming treatment as vicariously shaming; shaming treatment as vicariously traumatising; funding issues; lack of staff team cohesion; conflict between staff at work; conflict between clients at work; conflict between staff and clients at work; dual diagnosis as unmanageable; unclear policy; client group as complex; policy and practice always changing; lack of resources; low quality buildings; low pay; long hours.

From this initial labelling or open coding process, the following coding framework was constructed and then applied to the entire data set (outlined in table 2 in alphabetical order, with brief descriptors to clarify the codes):

Table 2 Coding label Description - Includes statements that refer to: Addiction / Problematic Drug Use Descriptions or definitions of client addiction or problematic drug use. Background / Biography Participants’ professional and personal background. Barriers Treatment barriers. Client Shame Participants’ perceptions of client shame, including both imagined and witnessed. Counselling Models Counselling models. Dynamics of shame Shame as a dynamic. This loosely means the movement of shame, within the individual, between participants in a group, or the changing or shifting of the shame experience. Moralism Negative use of morals in treatment. In particular, when the application of morality

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was seen to be mis-guided or over-applied. Participant Shame Research participants’ experience of shame. Power Experience or use of power. Research method Project method design or interview technique. Researcher shame My shame experiences. Shaming treatment Treatment as shaming. Stigma Stigma. Suggestions Direct or indirect suggestions about how AOD treatment should be undertaken. Triggers Clients being emotionally triggered and this resulting in relapse or recidivism. Worker impact Negative worker impact, as a result of their clinical work or administrative tasks.

Through the ongoing process of coding using the Nvivo software package, reports and analytic memos were used to track and monitor the relevance and appropriateness of these codes. The software also allowed for the categorising of statements through the manipulation of the data. Therefore, various other analytic devices were used to contrast and compare these statements in order to further clarify and ascertain the ensuing themes. The data was separated through educational background, gender, and workplace. However, no findings emerged in relation to this splitting and analysing. Also, through the use of this coding frame it became apparent that some codes were being under-utilized (less than three statements coded) or were being duplicated. Therefore, a number of the codes were discarded at the final stage of analysis. This included: participant shame; researcher shame; and research method.

Finally, a further three codes needed to be added to the coding framework, as ongoing analysis revealed gaps in the current analytic process. These were: “Ethics” (use of prescribed ethical conduct or descriptions of ethical dilemmas), “Policy” (prescribed policy and practice dictates), “Settings” (settings, locations, venues, services and contexts in which treatment takes place).

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