Alcoholism, Substance Abuse and Dependency CEUS - Chapter 7.2 - Counselor/Client Relationship and Self Awareness

Working with clients with depressive symptoms can be a frustrating and difficult experience for substance abuse counselors. However, helping someone emerge from personal darkness and hopelessness to the light of living well, renewed enjoyment of life, and hope for the future is also one of the most rewarding experiences for the counselor. This section discusses some of the challenges you will face in working with clients with depressive symptoms, and presents several techniques for preparing yourself to deal with these challenges. While the personal emotional reactions to clients with depressive symptoms can get in the way of effectively using the therapeutic techniques described in chapter 2, it should also be noted that understanding your emotional reaction to a particular client can assist you in helping your client. Your feelings toward the client may in fact reflect the client’s mood and/or feelings about himself or herself. In addition, acknowledging your own grief or depressive tendencies can help you form a more empathic connection with the client. Denying your emotional reactions to the client is likely to interfere with your role as a professional. Whatever your reactions, addressing them with your supervisor will help you sort out the reactions that are about you and those that are about the client.

Attitudes and Beliefs You May Bring to Your Work

Although you may have never dealt directly with depression in your clients, you have certainly encountered depressed clients in your work as a substance abuse counselor. As a result, you may have developed attitudes and beliefs that could interfere with your ability to effectively use the recommendations in this TIP. Some common attitudes and beliefs are given in Figure 1.5. The table contrasts these attitudes and beliefs with what is known about depression among people with substance use problems.

Transference and Countertransference

Transference (by the client) and countertransference (by the counselor) refer to the unconscious (underlying) use of past experience with similar individuals or in similar situations to shape reactions to a new person or social situation. Transference and counter-transference occur in all types of counseling—including counseling for substance abuse and for mental health issues—as well as in our everyday reactions to others. The positive aspect of transference and countertransference is that it helps you generalize from your past to better manage the present. The downside is that rarely are these generalizations completely accurate. You may remind the client of a teacher he or she had in school, and his or her initial feelings about you and reactions to you may be shaped as much by these feelings as they are shaped by what you do and say.

Just as the client applies what he or she knows (or believes) about similar people in understanding you, so you apply your knowledge (or beliefs) about people similar to the client in understanding him or her. If

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you are unaware that it is taking place, countertransference will almost always interfere with your work with the client. After all, the client is not your parent, son, or daughter, the kid you did not like in school, your scoutmaster, or someone you know who spent most of their life being depressed. Each client is a unique individual whose needs, beliefs, aspirations, fears, and desires you must come to understand.

Countertransference, if recognized, can be used productively in your work with the client.

It can facilitate:

Developing an empathic relationship with the client.

Understanding the thoughts and feelings you have in reaction to the client.

Understanding what your client is feeling by understanding your own reactions to your client (“Why am I feeling this way? Who am I to the client now?”).

Disentangling the web of your own feelings from those of the client.

It is difficult to manage counter-transferential reactions by yourself, even with extensive experience as a counselor. As a result, clinical supervision is an essential component of the counseling process. It is particularly important when you have a strong reaction to a client (positive or negative) that could potentially interfere with treatment. Most people have had powerful experiences in the past both with people with substance abuse problems and people who are depressed. They may not be consciously aware of those experiences in the presence of a client today, but those experiences can (and probably do) affect how they approach the person in their office, how they view the client’s potential for recovery, and how they feel about themselves in the client’s presence.

Countertransferential Reactions As You Work With Clients With Depressive Symptoms

Clients with depressive symptoms commonly paint a negative picture of themselves, either in words (expressing feelings of worthlessness, hopelessness, inability to cope, lack of competence) or through appearance and demeanor (lack of attention to grooming, listlessness, difficulty communicating). It is understandable that some substance abuse counselors may have an initial negative reaction to the client—for example, “This person is a loser.” Counselors working within the 12-Step tradition may refer to this as “taking the client’s inventory.” Rather than fall into the trap of blaming or judging, the substance abuse counselor can instead take a stance of curiosity and help clients verbalize their thoughts, feelings, and awareness. Such a stance can help in differentiating depressive symptoms from resistance and motivational problems. Additionally, as a counselor, you may fear that you are not equipped to help your client with depressive symptoms. Your own feelings of helplessness or inadequacy may also arise. Addressing these concerns in supervision will help you be more open and helpful to your client.

As a result of these feelings of helplessness or inadequacy, you may find yourself wanting to “fix” the client’s problems. This, in turn, may lead to overly directive behavior (e.g., “do this, change that”), “cheerleading” (e.g., “things aren’t really so bad”), or preaching. Wanting to “fix” the client’s problems is not by itself a problem. After all, you are in this profession to help clients with recovery. However, it is important to find a balance between your desire to protect the client from further harm because of poor choices or maladaptive behavior and the client’s need to develop autonomy, engage in his or her own recovery, and “walk the walk.” Depending on the stage of recovery and specific needs of the client, what may be helpful in one stage could be enabling in another. For example, advice and reassurance may be helpful at one stage while at another it may interfere with autonomy (Rosenthal, 2008). Miller and Rollnick’s (2002) motivational interviewing concept for wanting to “fix” the client is referred to as “the righting reflex,” the urge to “right” the “wrong” experienced or expressed by the client.

Although these reactions are common and understandable, they will prevent you from entering the world of the client and establishing a therapeutic alliance (a joint agreement and rapport between the client and the counselor to work together toward the client’s recovery). They may also reinforce the client’s belief that he or she is worthless, beyond help, and different from “normal” people.

Recovery from depression takes time, and sometimes clients seem to be “stuck” in a set of beliefs (e.g., the situation is hopeless; they are unable to change) to which they will continually return. This can be a frustrating experience for you and you may find that it brings up feelings similar to those that arise when you are working with a client who keeps relapsing.

Just being with someone who is depressed can be draining and at times can feel depressing. The feelings of hopelessness, despair, anger, or sadness experienced by people with depressive symptoms can sometimes feel quite toxic, even to an experienced counselor. In addition, the life challenges faced by the depressed client can be very real and difficult as illustrated particularly in vignette 1 in Part 1, chapter 2.

Emotional reactions may be particularly strong when working with clients who are suicidal, and additional support and supervision are indicated when working with clients who are at risk of harming or killing themselves. This is particularly true if the counselor has had major life experiences with his own suicidal intent or suicidal efforts of significant others. Special approaches to counselor self-support, such as good clinical supervision, ability to leave work at work, and a healthy lifestyle away from work, are important for the counselor to maintain.

You may have had experience with your own depression (or experience with depression of significant others) that may bias and/or improve your capabilities in working with people with depressive symptoms. Much as with a person recovering from a substance use disorder working in the addictions field, it is important for you to keep your own experiences separate from your professional role with clients. Many counselors who are constantly exposed to the stresses of their clients in early recovery find that they benefit from supportive psychotherapy. Psychotherapy improves one’s own life as well as one’s ability to help others.

In summary, therapeutic work with people with depressive symptoms is similar to therapeutic work with people who have substance use disorders—not only are specific skills needed, but also self-awareness and an ability to differentiate your life experience and needs from those of the client. It is important not only to be aware of and empathic to the client’s affects (i.e., sadness, anger, and anxiety), but also to be aware of how the client’s affects influence you.

Therefore, it is critical that you seek quality clinical supervision on a regular basis that employs the best-practices available. More information on the benefits and resources available through clinical supervision will be available in the forthcoming TIP, Supervision and the Professional Development of the Substance Abuse Counselor (CSAT, in development c).

Treating the Whole Person

Central to the concept of integrated treatment is viewing the client as a whole person. Everyone places people and things in categories. This is a natural tendency for humans and serves the useful purpose of bringing some order to the world. In thinking about your clients, you probably use categories such as their drug of abuse, their gender, their age, and so on. Thus, one might say, “Matt is a 25-year-old man who abuses cocaine” or “Janice is a 45-year-old female who is alcohol dependent.”

In reality, of course, Matt, Janice, and all your clients are complex individuals, each with a unique genetic makeup, a personal history, relationships with others, likes and dislikes, emotions, thoughts, attitudes, beliefs, hopes and desires, predispositions to think and behave in certain ways, and so on.

The norm of identifying oneself as an “alcoholic” or “addict” in 12-Step programs helps reduce isolation and shame and create a sense of belonging. Learning to “identify with the feelings,” rather than comparing oneself to others also helps normalize experiences and offer hope. This is a very important component of the self-help community—one that should be supported by substance abuse counselors. However, in treatment programs, professionals have the opportunity to address individual differences and complexities and complement the group mentality of self-help to provide the best possible chance for recovery.

Treating the whole person means recognizing that particular symptoms, whether of substance abuse, depression, or some other issue, are part of a system of biology, thoughts, beliefs, emotions, spiritual, and behavioral predispositions that make up the totality of the client (see the example below). The symptom cannot be addressed in isolation. Rather, its relationship to and interactions with all the other attributes of the client must be understood.

Interrelationships and Interactions

The Perspective of the Client With Depressive Symptoms

While people with substance use disorders generally tend to have a perspective that incorporates some of the thinking styles discussed in this section, the discussion focuses on the perspectives of people with depressive symptoms. Persons with depressive symptoms tend to have a negative view of themselves, their surroundings, and their relationships, and lack hope that things will get better. These pessimistic and self-defeating thoughts about the self, one’s experiences, and one’s future form the “cognitive triad” of Beck’s (1979) cognitive theory of depression. People with depressed mood tend to automatically interpret experience through a negative filter, making unrealistic negative attributions about self and others. The negative thoughts are automatic and are typically accepted without any awareness or scrutiny. For example, when people behave in ways that they experience as depressed, such as staying in bed, or not taking care of family responsibilities, their dysfunctional cognitive process reinforces negative attributions about the self such as, “I’m irresponsible” or “I’ll never amount to anything.”

The theory of depression from a cognitive–behavioral standpoint is that dysfunctional core beliefs and assumptions support distorted or maladaptive thinking, which then lead to altered affect and maladaptive behavior. So, changing the dysfunctional thinking should lead to improved mood and modification of beliefs and assumptions, to long-term improvement of mood with reduction in vulnerability to relapse.

The following examples of typical depressive thinking styles (adapted from Gilbert, 2000) provide insight into the experience of depression:

• Jumping to conclusions—People with depressive symptoms tend to jump to conclusions easily, particularly negative conclusions. For example, in vignette 2 in the next chapter, John’s friends don’t talk to him when he enters the room; he concludes that they don’t think he’s worth talking to. This is a negative self-attribution based in a dysfunctional belief.

• Emotional reasoning—Emotional reasoning is related to jumping to conclusions. People with depressive symptoms may assume that their emotions give them an accurate view of the world and do not test further. In the above example, John may not start up a conversation himself. He simply assumes his “gut reaction” is accurate.

• Discounting the positive—People with depressive symptoms tend to discount their positives; the glass is half-empty. Because of selective perception, they tend to not focus on what they do have, only what they don’t have. As a result, they may feel deprived or disappointed. Even when people who are depressed achieve something, they tend to discount it with the negative self-attribution that “anyone could do that.”

• Disbelieving others—It is very common for people with depressive symptoms to believe that others are being nice only because they want something, that they are being manipulative. People with depression often believe that individuals have one set of thoughts they express outwardly and a set of thoughts they keep private. They believe this in part because this is what they do (for instance, project happy feelings outward while feeling miserable inside). They worry that the private thoughts of people are very negative toward them—an example of negative attribution.

• Black and white thinking—Depressive symptoms makes it harder to think about life in complex ways. Thinking tends to become black and white and “either/or.” Either one is a success or a failure; either this relationship is good or it is a complete failure.

When combined with the sadness, inability to derive pleasure from life, and feelings of isolation that are characteristic of depression, these thinking patterns can lead to a dark and hopeless view of the world. To work effectively with clients with depressive symptoms, you will need to enter that world with as much understanding, empathy, and compassion as possible.

Only then can you guide clients in ways that will assist them in emerging from depressive symptoms and open the way to recovery from substance abuse.

mportant Ways in Which Clients Differ

Although each person is made up of a system of biology, thoughts, beliefs, emotions, and behavioral predispositions, specifics are what make us unique individuals. As has been discussed, depressed people tend to share certain characteristics in these spheres. However, there are some important differences of which you should be aware. The role of culture was discussed earlier. Following is a discussion of some other differences.

Attitudes toward substance abuse and mental health problems—People differ in their attitudes toward substance abuse and mental health problems and in seeking help for these problems. As noted in

Managing Depressive Symptoms: A Review of the Literature, Part 3, many people still view depression and other mental health issues as something to be ashamed of, a sign of weakness, and/or something to hide from others. Many people believe that problems should stay within the family and should not be discussed with outsiders, such as counselors. This can be particularly true of ethnic groups that face discrimination and racism.

Some people believe that counselors who have different ethnic backgrounds or have not had the same experiences cannot help them. These attitudes are similar to the attitudes that some people have concerning their substance abuse. In spite of the reality that substance use and mental disorders are beyond the reach of simple willpower, vast numbers of people in our greater culture still think that you should “pull yourself up by your bootstraps.” This widely held attitude is a common source of shame and stigma for our clients as they struggle with acknowledging substance abuse or depression. For some people, the 12 Steps can help them come to terms with their depression (see the section “The 12 Steps as a Tool”). For others, education about depression (as demonstrated in vignette 2 in chapter 2) may be needed to bring them to a point where depression can be acknowledged and addressed. A variation of this issue is when clients accept the idea that substance abuse or dependence is an illness, but feel that their depressive symptoms are a personal weakness.

Belief that substance abuse and mental health problems can be addressed—Although increasing numbers of Americans have come to view mental disorders as treatable, many still are skeptical of both “talk therapies” and medications. Your client with a substance use disorder may initially believe there is nothing you can do for his or her depressed feelings. As noted earlier, in some cases, you may hold this belief yourself. However, this TIP is predicated on the assumption that you can assist your clients with depressive symptoms during the course of their substance abuse treatment. Part of that help is communicating hope that things can get better.

Spirituality and religion—As a substance abuse counselor, you may understand the important role that spirituality plays in recovery. Spirituality and religion can be important resources for addressing depression for some people. Noted among the positive effects is the support provided by religious communities, the use of religious and spiritual concepts to help people understand and cope with life stresses, the strength some people draw from their religious or spiritual convictions, and the emphasis in many religions on moderation and healthy living.

On the other hand, some spiritual and religious beliefs and practices may contribute to increased feelings of guilt (especially pertaining to family conflict and child rearing), may discourage addressing interpersonal conflict directly, or may lead the depressed person to believe that he or she deserves to be depressed because of some transgression. In yet other cases, depression may be viewed as being caused by a character defect or seen as self-pity. People may even be discouraged from taking antidepressant medications. Clearly, with a good therapeutic alliance, you can explore your client’s specific religious and spiritual beliefs so as to better understand the role of these beliefs in either facilitating or inhibiting recovery from depressive symptoms.

Clients with active substance use disorders frequently behave in ways that harm others. However, depressed clients tend to over-interpret the harm they have done to others. Because guilty feelings can drive relapse, in early recovery it is often best to guide the client away from contemplating the harm he or she has done to others, until sobriety is well established. Later in recovery, when the client has better coping strategies, ethical guilt can begin to be approached in a calm and exploratory manner with the counselor. The client can then explore prior harmful behaviors, begin to address them with religious or spiritual involvement, and make amends through step-work or other means. However, guilt is also a symptom of depression and often clients suffer from inappropriate guilt, that is, the client assumes guilt inappropriately for imagined transgressions. Helping clients differentiate ethical guilt from inappropriate guilt can help alleviate suffering.

Learning styles—Like recovery from substance abuse, recovery from depressive symptoms requires learning new ways of viewing and dealing with self, others, and the world. For example, as part of their early work with you, it is important for the client with depressive symptoms to learn the facts about depression. Some of the interventions discussed earlier rely on your client’s learning new ways of thinking and behaving. People differ in the ways they learn most effectively. Some people learn best by reading, some by listening, some by watching others, and some by doing. Some people prefer to get information as a series of bullet points, whereas others are most comfortable when points are made in a story or example. As a general rule, adult learning occurs most rapidly and effectively when some combination of these methods is used. Effective counseling requires that you discover the ways your client learns best.

Some people understand their own learning styles and will ask you to provide information in a specific form (e.g., they will ask for a pamphlet or ask you to give examples). However, many people cannot tell you how they learn best. Hence, you must try out different methods and be aware of whether or not the client is “with you.” As time progresses, you will discover the methods that work best. Even when you have discovered the client’s preferred mode of learning, it is best to use more than one method to reinforce the information you want the client to learn.

Chapter 7.2 Counselor/Client Relationship and Self-Awareness

Preparing Yourself To Work With Clients With Depressive Symptoms