Studies have shown that roughly one in five of us will suffer from anxiety or depression at some point in our lives. There are, of course, many types of anxiety. For some anxiety might involve suffering the symptoms of Generalised Anxiety Disorder (GAD) to full blown panic attacks to obsessive compulsive disorder (OCD). In England, according to the Mental Health Foundation, women are almost twice as likely to be diagnosed with anxiety disorders as men.
Anxiety may be termed as a form of fear which may usually be associated with the thought of a threat or something going wrong in the future. However, it may also arise from something occurring in the present time and in the case of GAD there may not be any particular reason for feeling the fear.
Depression can affect individuals in very different ways and in varying degrees of severity. For some it can involve feeling blue and lacking in motivation whilst for others it can express itself in aggressive behaviour or even in suicidal thoughts. Depression is the predominant mental health problem worldwide, followed by anxiety, schizophrenia and bipolar disorder.
The massive increase in depression diagnosis since the 1950s can’t be put down entirely to a decrease in parenting skills. An increased neuro toxic environment in the modern world could be seen as gradually lowering the quality of brain health. See more on neurogenesis and improving brain health.
A mental health condition could be termed as suffering problems, especially over a period of time, with thinking, behaviour and or mood. See my article on Counselling Directory if you are considering treatment options and wondering about the following questions:
Professor Wendy Burn, from the Royal College of Psychiatrists, has been doing the media rounds over the weekend and has called the current waiting times a scandal when compared to the urgency when needing to see a cancer specialist. She is absolutely right to highlight the disparity of care and she is also right in seeking greater funding for mental health service provision in the NHS.
However, the uncomfortable truth for us in the West, particularly the UK, is that the bigger scandal over decades has been how rich developed countries such as the UK have consistently targeted low income countries to recruit medics, including psychiatric staff, to fill vacant posts in the NHS. There has been a form of brain drain of medics to the UK from parts of the world that are in even greater need of psychiatric services such as huge parts of Africa, the Indian sub-continent and places such as the Philippines. The numbers of doctors migrating into the four major destination countries (the UK is one, but also includes the USA, Canada and Australia) has steadily increased over the 10 years from 2004 (Siyam & Poz, 2014).
Whilst one in ten vacancies in the UK might seem like a scandal to us compared to physical health provision just consider this one statistic: there are currently approximately 250 psychiatrists practising in Nigeria, a West African country with a population of over 175 million. In the UK, the ratio of psychiatrists to the population served increased from 5.9/100000 in 2003 to 7.6/100000 in 2013. In Africa the equivalent ratio remained extremely low, just 0.1/100000 in 2014. One can only wonder how the local populations in these parts of the world have coped with this level of service provision. Just consider where someone goes when suffering a mental health crisis in such an environment, or the impact on their families for that matter.
The UK has in the past, through recruitment tools such as the International Fellowship Scheme, targeted low income countries for healthcare professionals and significant appointments were made to psychiatric posts (Goldberg, 2004 – The NHS International Fellowship Scheme for Consultant Psychiatrists. Newsletter of the Faculty of General and Community Psychiatry, 6 (Spring), 5-6.). Psychiatry had been a major beneficiary of the scheme, and had recruited more consultants than all the other specialties combined. According to the World Health Organisation (Atlas country profiles of mental health resources. Geneva: WHO, 2001), India, with a population of over one billion, had fewer than 3000 psychiatrists. This compares unfavourably with the UK with a difference of about 27 times. Despite this massive inequality, the NHS previously launched a scheme to recruit senior psychiatrists and other medical specialists from India and other developing countries.
The Department of Health claim that the UK has gradually engaged in more ethical recruitment of medics from source countries but the hard reality is that historical aggressive recruitment of such doctors has badly affected the provision of mental health services in the local populations of these source countries.
The global disparity in healthcare provision between rich and poor countries will not be easy to resolve and there are no quick fix solutions. Perhaps all countries, rich and poor, need to attract more doctors into psychiatry training, that’s for starters. Ways need to be found to address professional isolation, and to improve training and career prospects within the countries where doctors are migrating from. Gureje et al, 2009 showed that these issues are some of the key factors presently driving the emigration of mental health professionals. Ultimately, the partnerships between institutions in developed and developing countries are required to encourage doctors to return to their own countries where they are vitally needed.
In the interview we discussed her couples work and how it differs from individual 1-1 work. Laura explained how she initially got involved with the Gottman Institute and why she works online and why with couples amongst other topics.
My latest interview in my podcast series is with Louise Mazanti. She might be familiar to some viewers in the UK having been featured on Channel 5 as an expert for the factual entertainment show Make or Break.
Supervision is a term that often causes much debate within counselling and psychotherapy circles. It was once considered to be something you ‘got landed with’ by virtue of being the most experienced practitioner within an organisation. Implicit in this view was that therapy should be conducted in a right way and, therefore, not in a wrong way, and that supervision should be arranged and facilitated by the most senior and most experienced therapist, regardless of their competence, knowledge base, attitude or management skill. This hierarchical view of supervision is possibly reflected in working practices within organisational settings where managers are worried of things going wrong and being the subject of a claim or complaint. The NHS is a case in point whereby supervision is more likely to be for those further down the food chain. Consultants in the NHS are not routinely offered clinical supervision as part of their working arrangements. Whilst some might engage in loose forms of reflective practice listening with their colleagues there is no formal supervision arrangements, certainly not as psychotherapists would understand it.
Some therapists see supervision as a box filling exercise, and something which they are required to undertake, whilst others view it as an opportunity to merge with the person who they like and respect. I recall from my training days when certain trainees would choose their personal private supervisor on the basis that they were similar in outlook and where there was a great deal of deference and admiration. In such cases I was left wondering about the motivations of such individuals in their choice of supervisor.
Clients can also have differing views on how supervision could be defined and what the process entails although they rarely show much interest. When they do they sometimes wonder if their personal material will be discussed with a stranger and consequently if their privacy and confidentiality could be compromised and can, as a result, be defensive about the thought that the therapist is engaging in such a process.
So, how is clinical supervision defined by professional accrediting bodies?
The UKCP defines supervision as a reflective and evaluative process conducted within an articulated working relationship between a qualified or trainee psychotherapeutic practitioner and an appropriately knowledgeable supervisor. The BACP Ethical framework says the following: ‘A specialised form of mentoring provided for practitioners responsible for undertaking challenging work with people. Supervision is provided to ensure standards, enhance quality, advance learning, stimulate creativity, and support the sustainability and resilience of the work being undertaken.’ In Hawkins and Smith 2006 Professor Hawkins defined supervision as: “The process by which a Coach with the help of a Supervisor, can attend to understanding better both the Client system and themselves as part of the Client / Coach system, and by so doing transform their work and develop their craft.”
Clinical supervision is different to consultative supervision and informal reflective practice. Consultative supervision and reflective practice can potentially take place with anyone whereas clinical supervision might typically take place with another therapist who is appropriately qualified, and usually accredited (although a lot of supervision training is not associated with a formal accrediting body). Supervision is now a core component of continuing professional accreditation (cpd) and, indeed, is now viewed as a discipline in its own right with its own training route.
Supervisors should not follow outdated rulebooks
Supervision is not personal therapy. However, it would be naïve to think that the therapist’s personal material is not also relevant within the discussions in a supervision session. I recall from my training days a strict demarcation enforced by some supervisors between what was considered appropriate for the content of clinical supervision and what was considered personal material. I felt at the time that this demarcation to be a bit mechanical, as if the supervisor was following an outdated rulebook. It was almost like the supervisee could not refer in any way to any personal material possibly triggered by client material. Such material was considered to be something that should be taken to personal therapy. This approach, I feel, can be potentially shaming for the supervisee. It is my view that a good supervision session allows for a wide ranging airing of views and should not be restricted to strict mechanical ways of working. Supervisees should, of course, remain open-minded and inquisitive about other options when presented with a view about ways of working in supervision but should also avoid the temptation to hand their authority and accreditation away to others.
I wonder if the work of David Rennie on deference in the client therapist relationship could also be usefully applied to the supervisee–supervisor relationship. Indeed, I often muse if the word supervision almost unconsciously sets up the potential for a narcissist co-narcissist relationship. The supervisee can potentially be approaching the supervisor in the child ego state rather than entering into an adult to adult form of communication or as one professional to another.
Themes of control, management, hierarchy and power are often associated with the term supervision, particularly in periods of formal training. This ethos of deference is probably not that surprising since trainees need the supervisor to effectively approve them during periods of continuous assessment. However, the good trainees will be the ones who form their own opinions and learn to trust their own intuition rather than deferring to another.
Putting supervisors on pedestals is dangerous
Liking your supervisor is perhaps not an all together bad idea but putting them on pedestals is dangerous, as this is when narcissistic co-narcissistic relationships can take hold. The co-narcissist part of the relationship has the potential for an ego driven supervisor to feel boosted when in receipt of such admiration. When this happens the supervisor can fill the role of being a know-it-all.
A more mature approach to supervision might be to view the process as one professional exchanging unconscious material with another in an open-minded pursuit of different perspectives. In such an open-minded approach it can perhaps be useful to flirt with your hypothesis but not to marry it.
Parallel processing might result when the supervisor and supervisee re-enact in their relationship something that the client is not expressing. This form of projective identification might feel uncomfortable for the supervisee, and might not feel enjoyable, but could ultimately prove very useful for understanding the client better. An example of this might be a client who presents with historical shame and the therapist starts to connect with their own shame with the supervisor. This might be what Margaret Rioch referred to when she wrote about increased self-awareness for both parties. Feeling discomfort might actually be where the crux of the work might be residing rather than the apparent comfort zone when seeking to merge with the supervisor. Working in this way would be difficult if one party has been put on a pedestal by the other.
Role reversal can be useful, as the Gestaltist author Yontef suggests in the Handbook of Psychotherapy Supervision (Watkins, 1997 p158), in the exploration of counter-transference and gaining a different perspective. This can potentially involve the therapist playing the role of their client and acting in an ‘as if’ capacity. The therapist can act as if they are the client in the supervision setting and this way of working can be transformative in helping to realise unconscious material. This way of working might be difficult in a narcissist co-narcissist relationship.
Supervision should be like going on retreat
Rather than supervision, I prefer the terms ‘all vision’ or even ‘independent consultation’ as a process whereby the therapist can explore client material with a professional colleague. Supervisees should not feel like they need to justify their interventions with clients, or have to ponder too long as to whether they are ‘doing it right’. I don’t believe that the supervision consultation should be about right and wrong ways of working but for the exercise to have value it can offer the opportunity for the therapist to gain access to their own blind spots in their unconscious material and to consider other ways of working. Approaching the process in this manner will help protect against the risks associated with the creation of a narcissist co-narcissist relationship.
I like how Lady Diana Whitmore refers to supervision as akin to going on retreat where the therapist can explore client material in an uncensored way. This approach is very different to the tick box exercise when the therapist is required to fulfil professional accreditation and licensing requirements or to satisfy organisational demands. Supervisees attend sessions to stop and listen and to open their awareness. However, for the process to be effective it needs to be a two way process. The supervisor is providing the space for retreat, the holding for retreat and the transpersonal context for retreat, not sharing their own frustrations with their working day or the state of the profession. I like what Houston says (1995, p95) that the supervisor takes the supervisee forward at the right pace toward self-confidence based on reality and toward abundant motivations. This is when supervision is a containing and an enabling process rather than an educational or even neccessarily a therapeutic process.
Hawkins and Shohet devised the 7 eyed model of supervision. See my interview with Robin Shohet.
The 7 eyed model of supervision is:
Eye 1: Focus on the Client
Eye 2: Focus on Interventions
Eye 3: Focus on Client-Therapist Relationship
Eye 4: Focus on Therapist’s Process
Eye 5: Focus on Therapist-Supervisor Relationship
Eye 6: Focus on Supervisor’s Process
Eye 7: Focus on Wider Context
The austerity agenda over the last 7 years has severely impacted the budgets of mental health services and affected frontline services, so the news of additional funding was met with a bit of a fanfare in the news outlets. We know that not being able to access services invariably intensifies feelings of isolation, desperation, a sense of worthlessness and depression. Rejection can be routinely experienced in a personal way when patients can perceive there is something wrong with them when they can’t secure an appointment.
The unfortunate reality of access to talking therapy is that only about 16-17% of adults who need therapy are currently able to get it on the NHS. The additional funding, whilst very welcome, will only seek to increase this to 25% by 2020/21 (for children it will be 35%).
I would argue that quality means having enough therapists within the service to provide enough sessions and it means a choice of therapies for patients. Historically the NHS and NICE guidelines has been almost fixated on the CBT approach given their medical model of therapy services and their quest for an evidence base. This one size fits all approach does not, in my opinion, meet the diverse needs of patients. There is other evidence to suggest that the relationship and the therapeutic alliance is what heals, not manualised scripts. Improving quality means employing therapists trained to deal with the complexity of cases they face. Access and quality must, therefore, go hand in hand and waiting times need to be addressed.
I made these points on Sky News on Monday when interviewed with Dr Marc Bush of YoungMinds.
Parity of esteem between physical and mental health services is a laudable ambition that hasn’t been followed through in practice. Take the level of research funding, for example. Approximately £8 is invested in research per person affected by mental illness. To evaluate this rate of investment it is worth noting that 22 times more is spent on research into cancer, and 14 times more on dementia.
Mental health services in the NHS are being pressured by rising demand, historical underfunding, staff shortages, poor staff morale and the failure of funding to reach the frontline. Public health promotion campaigns, such as the Heads Together campaign, can do commendable work but they can also have the effect of increasing the pressure on existing resources by boosting demand.
The devil will be in the detail of how the extra funding is allocated and whether the additional funding makes the NHS more attractive as a potential employer for therapists. Delivering these new integrated services within primary care is critical to building care holistically around the needs of the person to improve their health outcomes and support them to achieve wellbeing.
What we might need to acknowledge is that whilst additional funding for mental health services is to be welcomed a lot of mental anguish might be inseparable from far deeper and wide ranging problems such as social fragmentation, poor housing, trauma, unstable employment and discrimination.
Today I was interviewed on Sky News about the risks posed by the Blue Whale game in the UK and about peer pressure facing teenagers. Blue Whale is an online game that originated in Russia and where it is claimed users are manipulated into self harming and ultimately encouraged to commit suicide. This has led some to refer to it as the suicide game. It is feared that up to 130 deaths in Russia are linked to the phenomenon. Also referred to as the “Blue Whale Challenge”, it encourages users to complete a series of tasks over a 50 day period. There are fears that the game’s contagion could spread to the UK with police and teaching bodies issuing warnings about the risks posed by the game.
Whilst not wanting to minimise the danger or to downplay the potential risks I would caution against getting too worried. The UK is not Russia. There is an absence of social mobility and economic opportunity amongst young Russians (particularly for those outside of elite circles) growing up in a post communist society, and perhaps living in a high rise block from the Soviet era in a grim part of middle Russia. British teenagers do not face anything as dismal in their lives. The suicide rate in Russia is high and Unicef reported in 2011 that the country has the third-highest teen suicide rate in the world. We can’t even be certain that the game actually caused the deaths or that these deaths would have occurred in the absence of the game.
The trouble with setting boundaries around technology more generally is that parents have knowledge of pre internet behaviour. Young people don’t have a baseline behaviour of something other than the internet, its as if it has always been here. Engagement with the internet is not optional for them. For them the internet and specifically social media engagement satisfies prime drives for survival and to affiliate. However, we wouldn’t allow children to go to a public park unsupervised but some teenagers are given unsupervised access to a smartphone, which is essentially a portal to the outside world with high potential for encountering inappropriate material. Most, however, will be fine and will have developed sufficient levels of resilience to cope with cyber bullying or inappropriate suggestibility from others. But just like with alcohol and food there will be a small proportion who will develop problem behaviour with technology and will be susceptible to manipulation.
Some people might wonder how someone could fall under the spell of something so ridiculous as following the commands of strangers to commit actual self harm. Indeed, others would say that all you need to do is switch off the computer if being bullied online. This is a little simplistic. The teenagers who are selected for cyber bullying are often vulnerable and are, therefore, at greater risk of being manipulated and exploited. Teenagers often worry about their appearance, their weight and whether they are cool and so can be vulnerable to being bullied. They often seek approval from others to satisfy their feelings of esteem. Children who suffered disorganised attachmentwhilst growing up are particularly vulnerable to exploitation.
The sinister aspect to the Blue Whale game is that other teenagers are also recruited by the gang leaders to select and recruit the most vulnerable users, called masterminders. The kids who create the peer pressure are often frightened and lost themselves and they seek strength in groups. We see this quite commonly as a feature of teenage gang violence in our cities. The even more sinister aspect is that some of the Russian gang leaders behind the game, and who referred to getting rid of ‘biological waste’, received love letters from teenagers after being locked up.
Whilst I have downplayed the risks associated with the Blue Whale game in the UK I would, nevertheless, suggest that parents remain vigilant about the risks presented by this and other online games. They can become more proactive in the active monitoring of their children’s web usage. Parents should keep lines of communication open with their children as they will need someone, who they can trust, to turn to if they encounter any problems online, or in the real world for that matter. The key is to try to help them achieve a balanced level of engagement with technology and to ensure that their activity takes place within a safe environment. They can learn to say no and to only share information and content that they are comfortable with. Try to agree terms and conditions with your child around appropriate device time and above all don’t allow devices in their bedroom.
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.