I have always been sceptical about the usefulness of providing trained counsellors to help those impacted by incidents of major trauma. It is almost commonplace, nowadays, to hear in news reports that trained counsellors have been drafted in to help deal with the emotional carnage following a major incident. Such considerations for those affected may indeed be well intentioned but that is not the point. I have often wondered if such decisions to draft in a cadre of specialists might actually be counter-productive for the resilience of those affected by such events.
I was interested, therefore, to hear the recent statements from the President of the Royal College of Psychiatrists when he cautioned against the automatic provision of crisis counselling interventions for those affected by major public incidents including the recent terrorist attacks in Manchester and London. Sir Simon Wessely, a specialist in the treatment of post-traumatic stress disorder (PTSD), believes that research has demonstrated that the routine screening of survivors as a way of seeking to find those most in need of psychological support has proven to be ineffective. The research indicates that a policy of implementing routine counselling could potentially traumatise those who would otherwise have recovered from their experiences. There was a wider risk of “professionalising distress”, he cautions, in encouraging those going through sadness or grief to think there was something wrong with them,
This reminded me of the time when I worked at a national charity, offering a telephone sign-posting service for people affected by problem gambling. Managers would offer a debriefing telephone consultation (which alarmingly usually involved one’s line manager providing the debriefing) immediately following a shift in the misguided belief that debriefing was an appropriate tool of self-care to support helpline advisors to cope with potentially difficult material. They would almost pressurise people to take advantage of the debriefing service and there was little awareness of the risks associated with such early interventions or that such support, if it is to be effective, should be voluntary.
Most people who have been affected by major incidents will benefit from a normal healing process whereby they learn to cope by using their own support networks. The research would appear to show that affected individuals mostly get better by talking to and sharing experiences with friends, family and colleagues. Sir Simon suggests that only a minority will need specialist help and such need will only become evident after a period of what he terms “watchful waiting” (which could be a period of up to 12 weeks when the needs of individuals are properly assessed).
The provision of early counselling for those affected by major public events may, of course, be well intentioned. However, early counselling risked overwhelming survivors as well as possibly interfering with psychological defence mechanisms, which aim to protect against too much reality and horror. There is also a risk of pathologising distress and potentially undermining the resilience of individuals, if there is a rush to intervene too early. Further, with the power of suggestion, there is a risk that individuals might experience possible ill-effects merely from the thought that they might occur.
The people who need reassurance might be those who have unresolved and unprocessed trauma from the past which gets triggered by witnessing major public incidents of disorder. The risk for such individuals is that they will feel unsafe and might seek to engage in unhealthy safety seeking behaviours as a way of avoiding the heightened feeling of threat. In such instances it is vital that these people have the support to go about their business in a normal way and help in dealing with their hyper-vigilance. Therapy can help with dealing with historical trauma, acknowledging cognitive distortions as well as helping to reconnect with an internal safe place. But crisis counselling should not be the first thing we think about for those who were unfortunate to witness the unpleasantness associated with major public incidents.
Have you heard of fidget spinners? If not, you might be surprised to hear then that they top the lists of the best-selling toys on Amazon UK. They are the latest craze amongst school children and are being hailed as a learning tool to help kids suffering from inattentive states of mind.
The marketers claim that the devices can be an aid to learning for those suffering from ADHD in the classroom as well as potentially relieving the symptoms of ADHD itself, autism and even post-traumatic stress disorder(PTSD). These are big claims.
However, there are no clinical research findings to support these views, at this stage of their usage. At best what could be said is that there might be anecdotal evidence to suggest that these devices may help inattentive kids to concentrate on their learning. However, it would be inaccurate to suggest that these devices support the learning capacity of such kids, particularly those suffering with symptoms associated with ADHD.
These spinner devices are visually distracting which could be their major drawback. Some of the devices have lights on them which could make them further distracting in addition to the whirr sounds. This could potentially act as a mitigating factor against their usefulness as a learning tool. Other fidget devices, which don’t have the visual distractions, could possibly be better gadgets as an aid to learning for kids suffering from inattention. Indeed, good old stress balls (with no visual distractions) would be more effective as an aid to learning for inattentive kids.
Riding a stationary bike whist reading would offer the potential for small and non-distracting motor movements. Fidget Spinners,however, don’t require gross body movement, which is needed for increasing the activity of the frontal and prefrontal parts of the brain that are responsible for sustaining attention.
Problem behaviour, as with any dependence on any gadget, is when negative consequences begin to occur in other aspects of the user’s life or when they act as barriers to communication. Addiction is the search for emotional satisfaction. It is worth asking what happens to the emotional regulation and mood when the device is not available. The key is that kids are taught how to use these devices appropriately so that they do not prove to be distracting to their learning but can be used in a constructive way.
If you are a parent and worried about your child potentially having ADHD it could be worth a consultation with your GP who will be able to direct you to the appropriate support services. See the NICE guidelines for more information on support for ADHD.
Yesterday I chatted with Dr Mary Deitch, President of SASH, about working with clients suffering with problematical sexual behaviour. I first heard Mary speak at the Farley Center when she presented on understanding the basics of problematical sexual behaviour. (See the slides for that presentation here). In the interview we discuss how to identify problematical sexual behaviour and the difference between what are sometimes termed lifestyle choices versus what is actually addictive behaviour. We also briefly discussed the disease model of recovery, attachment styles related to addiction and how useful clients can find attending meetings of 12 step fellowships, such as SA, SAA and SLAA.
For therapy to be successful I believe that it is essential that clients feel comfortable and safe with their therapist so that they can start an open and frank dialogue. Various researchfindings have indicated that the working alliance is as important as any other factor in successful therapeutic outcomes. John C. Norcross’s approach to integrative psychotherapy involves selecting models and methods from across orientations so that the client’s experience is best met and in context. He shows how meta-analyses demonstrates that tailoring therapy to the individual client enhances treatment effectiveness.
I sometimes wonder, however, whether integrative therapists debase some of the therapeutic approaches. When you look at various profiles on therapist directories, for instance, it is not uncommon to see practitioners describing themselves as analysts, gestaltists and CBT therapists. On closer inspection such profiles state that their psychotherapeutic training took place at generalist training institutes, usually integrative. Some profiles refer to offering ‘Jungian therapy’ as part of their counselling and psychotherapy private practice. In actual fact, what this means is that they had a few lectures on Jungian symbolism, at best. Their training was not in the Jungian approach, at depth, and they did not have analysis a few times weekly as part of their personal therapy (nor did they benefit from specific clinical supervision in the Jungian approach). The same is true of the Gestalt approach when integrative practitioners may have benefitted from a weekend of experiential work using some of the Gestalt tools and techniques in a very general way. However, they won’t have had any real thorough training in the Gestalt approach.As for CBT, it has been my experience that integrative training institutions are biased against the CBT approach and offer such a slimmed down version of it, as part of their core syllabus, that I wonder why they bother in the first place.
Of course, it is fine to say that as an integrative practitioner one can offer components of certain approaches as part of an overall psychotherapeutic offering, as a kind of generalist toolbox. Indeed, one can use continuing professional development (cpd) to expand one’s knowledge base in particular areas throughout one’s career. However, I find it disingenuous to talk about being an analyst in the absence of specific training in that approach.
Do you struggle with your boundaries and usually give too much to your partner without receiving back the love and respect you expect? Are you involved with an avoidant personality type and frustrated with the level of communication in the relationship. Do you see yourself as dedicated to the welfare of others? If these questions make you answer yes, then perhaps you might benefit from reading on.
Codependency is rooted in addiction. It is about over-functioning in someone else’s life but under-functioning in your own.To have a working understanding of codependency is to see a co-dependent as someone who cannot function from their innate self and whose thinking and behaviour is instead organised around another person, or even a process, or substance.
The term is located within a systemic framework. Codependency was originally a term used to describe a particular relationship dynamic where one partner had a substance abuse problem and the other didn’t. The individual who didn’t have the substance abuse issue became caught up in a cycle of excusing, tolerating, defending and even enabling the addiction of the other. In Alcoholics Anonymous (AA) the problem became known as an issue not solely with the addict, but also the family and friends who constitute a social network for the alcoholic. Al-Anon (the sister fellowship of AA) was formed in 1951, and holds the view that alcoholism is a family illness. Al-Anon is one of the earliest recognitions of codependency.
The term codependency is not universally accepted in the therapy world. For some clinicians codependence is over-diagnosed. For them, people could be helped with shorter-term treatments instead of potentially becoming dependent on long-term self-help programmes or therapy. Such treatment, they argue, can be theoretically misplaced as the direction of the treatment can follow the disease model of addiction. For others it is a healthy personality trait, albeit just taken to excess. The key in determining whether you have a problem yourself is to assess the extent of the under-functioning in your own life as a result of caring for another. Does your own life suffer as a consequence of your concentration on the needs of another.
Clients don’t often attend counselling and psychotherapy for codependency, or other addictions for that matter, but might present with problems associated with anxiety in their lives, for example, or relationship issues more generally. Once in the process of attending therapy sessions,however, they can become more conscious of their underlying codependency issues.
In order to understand codependency it is useful to gain insight into what kind of attachment style you operate from in relationships. We develop a style of attaching that affects our behaviour in close relationships throughout our adult life. One of our prime drives, after all, is to affiliate, just like our drive for survival. Our attachment style is largely dependent upon our mother’s behaviour, in addition to later experiences in childhood and other environmental and social factors. For more information on this see my article on attachment styles and recovery from codependency.
Recovery from codependency, like all addictions, involves the development of a healthy self and allowing for an expansion of consciousness. Healthy relationships are when each person can remain themselves and when the dynamic allows for change and flow. If you are in a codependent relationship a recovery path could be to detach with love, face illusions about your life and your relationship, set healthy boundaries and develop your spirituality.This can help build a healthy sense of self going forward when you learn to take care of your own needs and ultimately learn to be happy with your own company.
I often wonder how the whole field of counselling and psychotherapy could help to better address the needs of those who are essentially most in need of psychological support. Men, for instance, who suffer from depression often present as angry individuals but the anger is often hiding the pain of depression. Depression in men is so often difficult to identify as it can be accompanied by displays of angry behaviour in social situations. Men, in effect, can more easily end up in prison than in a therapist’s room.
The stigma for men surrounding not only drug use but also gay sex can act as a barrier for individuals who really need help accessing psychological support services. The drug-fuelled party lifestyle associated with chemsex can destabilise the mental health of those already suffering from pre-existing mental health problems. These issues will be presenting more and more in the coming years in counselling rooms with the advances in mobile telephony and hookup apps. But a prevalent culture of silence, secrecy and stigma in the chemsex world can keep individuals isolated from accessing services. Chemsex users perhaps need to be reassured, more than any other client group, that they will be understood, and not judged, if they do end up presenting for help.
Therapy can offer people a vital place of safety to unravel their story so that greater insight can be obtained for problem behaviour. It can be common for attachment issues to get played out in all forms of addiction, as well as past traumas and previous psychological wounding. Therapists need to be even more aware of their need to make personal connection with the presenting issues with such clients. An abstinence based approach might not always be appropriate for them, at least initially, as the thought of complete abstinence might make them run away. Harm reduction and psycho education could be useful areas to cover as well as the principles and ethos of motivational interviewing. These clients are often in a contemplative mode when assessing the options about their future intentions. Chemsex users are familiar with high adrenaline excitement as a means of mood regulation and will be easily frightened about slowing down and getting in touch with difficult personal material that might threaten their equilibrium.
Chemsex parties offer excitement and the apparent lure of social connection. However, for those vulnerable to psychological wounding the lifestyle can be a dangerous playground and chronic feelings of aloneness can persist. Addiction can be viewed as a search for emotional satisfaction, as a place of safety, balance and comfort. If the connection in the consulting room is robust the underlying psychological issues will get played out in a safe environment through projections and transferences.
Yesterday I appeared on the Insight programme on TRT World discussing online safety, with particular reference to young people, as part of Safer Internet Day 2017. Click on the link below to see the discussion.
When discussing the impact of the massive social change that has been underway for the past 25 years with the advent of the internet, it is worth remembering the accelerated change that has occurred only relatively recently with the increased speeds associated with mobile telephony. The first generation iphone came out in 2007, even though it would seem to have been around forever, and it is only very recently that we have seen the introduction of fast 4g superfast smartphones. As consumers we have incredible search capacity on these powerful multi media devices and with exciting apps we have never had it so good in terms of personal entertainment on the move. However, there is always downsides to everything that is good and young people in particular need to be aware of the risks associated with sharing personal information and engaging with others online.
See the links below for some useful lists of resources and further information about staying safe online. There is also a resource pack for parents on how to engage with their children and the digital world.
Today I had fun chatting to the Doha team of Aljazeera TV (Arabic)about internet addiction and specifically problem behaviour with social media. I was on a live feed in the London studio (based in the Shard) and my views were sought through a translator about the universal problem of overusing smartphones and social media apps.
I am often asked what constitutes problem behaviour around the internet and mobile telephony. You might have a problem when you can’t stop checking social media updates in spite of negative consequences in other parts of your life. It is not the number of devices you own but rather the amount of time on the devices and the negative consequences on other parts of your life. So, you may have a mobile phone, tablet, laptop and main computer in your possession but your life may well be better for it if you are using social media apps to further your career and social life. However, if you start to experience anxiety and depression from seeking emotional satisfaction through social media engagement then you find have a problem. Try setting time boundaries about your use of mobile devices and also set phone and non phone time in your day. See what happens? Do you panic at the thought of restricting your access?
Addicts tend to be ‘do it yourselfers’, to coin an expression, so will tend to be reluctant to seek help and if they do attend therapy they can stay in a very defended position. Asking an addict why they did something might risk a very long answer as addicts tend to have massive self-justification and rationalisation for everything they do. If you think you or a member of your family has a problem click on the links below.
See the attached link for the interview (scroll to 23:30 in the timeline).
Are you a therapist, counsellor or life coach and struggling with your journey in seeking to build a thriving private practice? This one day CPD event may well be for you. It is for therapists, counsellors and coaches who want to kick-start or develop their private practice.
The workshop will equip you with the knowledge to boost your private practice.
Specifically the event will cover the following:
building a successful online marketing strategy (website, social media and SEO)
fees and self-worth
how to write web optimized content and articles
building a successful business strategy
developing professional networks that result in referrals
practical advice on finance, ethics and administration
The workshop will be experiential and will allow participants to explore personal self-limiting beliefs. The workshop will be facilitated by myself and Louise Gulley.Louise is a change enabler, group facilitator and BACP accredited counsellor based in London and Kent and built a thriving practice within 6 months of graduating.
* An early bird discount applies until 30 January. See flyer for booking details.
An addiction disorder can be very distressing for an individual as well as their partner and family. Active addiction involves loss of ability to choose freely whether to stop or continue the behaviour (loss of control) and leads to experience of behaviour-related adverse consequences (Schneider & Irons, 2001).
The disease model of addiction underpins the enormous rehab industry whereby addicts get treated at the hands of so-called ‘experts’ at very expensive units, and often within residential retreats. The treatment team at such places invariably consists of medical experts (including psychiatrists) but also the burgeoning band of treatment personnel who report to them (a lot of whom are low paid staff or trainees on placement). The most common interventions are group process dynamics as this represents the most cost effective treatment plan. The success rate for these places in effectively treating addiction is poor as the rate of relapse amongst patrons is quite high. So, you might ask what is the theoretical foundations of their addiction treatment?
Addiction treatment is largely based on three broad categories that underpin addiction recovery treatment programmes. They overlap to some degree, but each model has unique implications for research, funding, and care, from the level of government policy to that of treatment options for individual sufferers. The three categories are:
1. The Brain disease model
Advocates of the disease model maintain that there is ample scientific evidence from PET scans to believe that the brain changes as a result of substance abuse and that because it changes it must, therefore, be evidence of disease.
The disease model of addiction is essentially a biological explanation for the causes of addiction. Drinkers and drug users follow a pathological road to destruction and have lost control as a result of their using. Proponents of this outlook see addiction affecting the brain in similar ways that physical illnesses produce changes to vital organs. For example, diabetes changes the way the pancreas works and hepatitis changes the way the liver functions and this is the same for alcoholism, in that it changes the manner in which the brain functions.
Alcoholism was officially designated an illness by the American Medical Association (AMA) in 1967. Seeing addiction in this way, rather than as a weakness by self-indulgent moral degenerates, has brought benefits to the medical community for it has stimulated research as well inspiring the development of useful medications that have helped ease the symptoms of withdrawal.
The disease concept of addiction has formed the basis of the 12 steps of recovery from Alcoholics Anonymous (AA) and Hazelden’s ‘Minnesota Model’ and contain key concepts of powerlessness around alcohol (and drugs) and personal unmanageability in life. These concepts form the bedrock for an abstinence based approach to treatment, for life, albeit one day at a time. AA’s 12 steps are a combination of cognitive and behavioural tools and techniques and have a concept of a mental and spiritual malady at its heart. AA’s founders Bill Wilson and Dr Bob Smith were heavily influenced by Carl Jungin embracing the idea of a higher power to stimulate personal and spiritual ‘recovery’. The 12 steps state that the chronic alcoholic must undergo an entire psychic change in order to recover from a seemingly hopeless state of mind. People attending AA meetings see themselves in perpetual ‘recovery’ from an illness and observe total abstinence for life.
search for emotional satisfaction – for a sense of security, a sense of being loved, even a sense of control over life
The Diagnostic Statistical Manual of mental Disorders (DSM), currently in its fifth iteration, is the psychiatric bible for clinicians and states the following: a “substance use disorder describes a problematic pattern of using alcohol or another substance that results in impairment in daily life or noticeable distress.” The present trend in psychiatry is to also classify gambling and even excessive internet use as disorders (as listed in DSM5), which others see as a vague term that overlaps with “disease”. Critics of the disease model ask where it will stop when defining symptoms of disease. They ask whether net surfing, hoarding, unrequited love and compulsive shopping might also be classed as diseases or disorders. Stanton Peele, a big critic of the 12 steps approach, argues in his book The Diseasing of America (1989) that addicts can recover without so called treatment, and that it is wrong to build into treatment the notion of character flaws (one of the steps in AA is to undertake a personal and moral inventory and to start with a form of confession in relation to the 7 deadly sins). Peele argues that numerous studies have demonstrated that people can drink socially again at a point in the future. He rejects the idea of personal powerlessness, opting instead for the concept of personal empowerment, as a more robust and positive approach to addiction treatment. For Peele addiction is the search for emotional satisfaction – for a sense of security, a sense of being loved, even a sense of control over life. Peele explains that addicts tend to display susceptibility to diverse addictions, in sequence or at the same time. However, the gratification turns out to be temporary and illusory and the addictive behaviour results in more and more self-disgust, reduced psychological security and a poorer ability to cope with stress. In the attached clip (below) Peele expands on his ideas about addiction with particular reference to the neuroscience of addiction.
Marc Lewis agrees with Peele in rejecting the disease model by pointing out that whilst the brain does indeed change in response to addiction, so the brain changes in response to falling in love. The brain will change in response to learning activity and, therefore, brain change itself should not be used as evidence of disease. He points out that the hippocampus of London cab drivers expands by learning The Knowledge Test (see Maguire and Woolett). Indeed, Lewis argues that advocates of the disease model need to prove that brain change in addiction goes beyond what would occur in response to normal learning and development. Rather than the 12 steps of recovery Lewis prefers the notion of motivated self-directionfor treating addicts, when the addict finds greater meaning and purpose in their life to sustain a healthier lifestyle. For Lewis addiction is motivated repetition that gives rise to deep learning as he explains in great detail in his recent book The Biology of Desire: Why Addiction is not a disease. Addiction can also be seen as recurrent desire towards a single goal. In the attached clip (below) Lewis expands on his ideas about addiction.
2. The Choice model
The choice model was the theoretical basis of the War on Drugs campaign and the popular slogan “Just Say No”. Users do not consider addiction a good choice, but they often consider it a rational choice, at least in the short term – as when the relief gained from the addiction outweighs other possible choices.
Gene Heyman, is his book Addiction – A disorder of Choice, argues against the conventional psychiatric view that addiction is a disease. For Heyman, addiction is entirely voluntary and he sets out to demonstrate that drug use, like all choices, is influenced by preferences and goals. In the attached clip (below) Heyman articulates his ideas on addiction.
The Choice Model explains why people suddenly stop being addicted in response to a change in environment. An example would be when Vietnam veterans suddenly stopped abusing heroin when they returned to their homes after the war. This idea builds on the Bruce Alexander “rat park” experiments which showed that rats did not consume drugs in controlled trials in response to an improved social environment. In the attached clip (below) Alexander expands on these ideas of the need for an improved social environment.
Proponents of this model point to economic and environmental factors beyond the addict’s control such as poverty and social isolation. However, when conditions change with time and circumstances, then so do choices. Users see a different outcome to their predicament and change their behaviour accordingly.
The choice model explains better than the disease model how addicts suddenly quit but advocates of this approach risk viewing addicts as selfish and self-indulgent moral degenerates.Rather than being victim of a biological condition they are personally responsible for bringing on their misfortune in life by bad choices.
Treatment in this model could involve reviewing one’s beliefs and changing one’s perspectives, using tools and techniques offered by cognitive behavioural therapy (CBT) and motivational interviewing. Treatment invariably proposes total abstinence.
3. Self-medication model
The self-medication model is not a coherent approach as it is grounded in developmental thinking and conflicts with the notion that addiction results from an allergy. As children and adolescents develop, emotional problems can erode their sense of well-being. Trauma, either social, psychological, or sexual, is a buzzword for early adversity and post-traumatic stress disorder (PTSD) is often found to underlie anxiety and depression. Researchers have found that substance abuse among those with PTSD is as high as 60-80% and the rate of PTSD among substance abusers is 40-60% (K. T. Brady and R. Shina, 2005).
Taking drugs and alcohol make you feel better until they don’t. A nasty side effect of addictive drugs is that the addiction itself becomes a source of stress.
Treatment, according to this model, stresses the need to protect people who are vulnerable to psychosocial pressures and to diagnose and treat underlying developmental issues that have predisposed someone to addiction. Gabor Mate in his book In the Realm of Hungry Ghosts skillfully made a case that addicts seek relief from drink and drugs in response to early bonding experiences that were difficult and painful. In the attached clip (below) Mate expands on these ideas on the power of addiction.
Treatment options cover a range of holistic tools and techniques including CBT, attachment theory, object relations theory, creative imagination and mindfulness for addiction can be viewed as a loss of connection, or meaning in life. It could also mean loss of soul in transpersonal terms. Counsellors and therapists in this theoretical model might advocate total abstinence but not necessarily so as working therapeutically on past trauma can potentially see a transformation that entails social drinking at some point in the future.