Defining behaviours as an addiction or a disorder can create lively debate in the therapy world. Take internet gaming. There are users out there, for sure, who overdo playing video games. But so what, you might say. Individuals overdo lots of stuff, after all, so what is so special about video games? And is it worth asking why we can’t have a general category called ‘behavioural addiction’ that can be applied to anything that people overdo.
The World Health Organisation International Classification of Diseases (ICD) will include the condition “gaming disorder” for the first time when its 11th iteration is due out later this year. The draft document, released a couple of months ago, describes it as a pattern of persistent or recurrent gaming behaviour so severe that it takes “precedence over other life interests”.
Others will have great difficulty in accepting a behavioural activity as a disorder resulting from brain change when there is no ingestion of substance. Brain change can occur from falling in love or learning a new language so should not be seen as concrete evidence of a disorder. Furthermore, some studies show that playing video games has benefits such as increased cognitive efforts and enhanced motivation to hit long-term goals, such as reaching multiple levels and ultimately winning the game, which is similar to the benefit children derive from participating in sports and clubs. Playing games and engaging in a gaming community (albeit online) has also been linked with better memory and improved hand-eye coordination.
The trouble with addiction treatment models is that individuals can potentially get lost in the labelling and people can become defined by their ‘condition’ which can restrict their potential. The risk is that they will assume the ‘addict’ label as a defining identity rather than the problem behaviour being one part of their whole self. There is also the issue of co-morbidities and if the gaming is causing problems per se or whether there are pre-existing problems which users are escaping from by gaming. For instance, is there underlying anxiety or depression or untreated trauma that leads to the behaviour becoming a form of self-medication.
Whether the term ‘behavioural addiction’ can be extended to more behaviours is largely dependent on one’s view of the nature of addiction which will also inform the appropriate treatment model. See my post on choice or disease addictionfor more on this lively debate.
I took part in a tv debate the other day on TRT World (Sky Channel 519 HD) which discussed some of these points. For me addiction is slavish attachment to pleasure in search of emotional satisfaction and security with negative consequences on other parts of one’s life. Enthusiastic gaming might be excessive in time consumption but would not meet the diagnostic criteria of the substance abuse treatment model.
The links below contain two interviews resulting from our meeting. The first one is a general discussion about the definition of codependency, how to recognise it and what to do about it. The second link had an audience of therapists in mind when discussing how to work with codependency in the consulting room.
This interview below covers Nancy’s initial interest in the topic of codependency, what her influences are, her definition of psychotherapeutic integration and how to work with codependency in the consulting room.
An independent review panel investigating the response to the Manchester Arena Attack, which saw 22 people tragically die, is requesting that Greater Manchester sign up to a ‘Charter for families bereaved through public tragedy’. The panel, chaired by Lord Bob Kerslake, published a progress report today and is recommending that all public bodies adopt the charter that was inspired by the Hillsborough families and proposed by The Right Reverend James Jones KBE in his recently published report. Read the full interim report here.
The role of some of the media outlets in seeking comments from bereaved families will form part of the review as will the function of social media when such events are unfolding and the impact on victims and their families.
It is also very important that statutory services, including crisis counselling, are provided for victims and their families so that they feel heard and have an opportunity to overcome their feelings of grief. Of course, a lot of people caught up in such events will prove to be resilient and won’t have any significant issues in recovering from the trauma. Sadness and grief will be felt but they will ultimately cope with the help of their social support network.
Routine screening for those who have been impacted by terrorist incidents, whilst very well intentioned, have been shown to be ineffective. Indeed, there are risks with the ‘power of suggestion’ that these people might suffer needless ill effects from being targeted for crisis counselling. They might feel like they should be feeling angry or overcome with grief when in actual fact they will resolve their difficult feelings organically. Crisis counselling should be offered for victims of such incidents, of course it should, but it should be offered for those who really need it and seek it.
Crisis counselling for those who have been impacted by terrorist incidents can help by assisting victims in feeling heard. Counselling can also help them to identify an internal ‘safe place’ when reexperiencing traumatic memories of the incident. It can be helpful to maintain a normal routine when the temptation might be to seek out an avoidance strategy. Engaging in avoidance strategies such as not leaving one’s house might compound the anxiety around the incident. The people who might really need crisis counselling are those who have historical unresolved and unprocessed trauma from their past. This can be when their anxiety is compounded by being triggered by discomforting memories from the past.
I spoke about these issues on Sky News today. See below for the link.
Are you worried about identity theft and staying safe online in an increasingly risky cyber environment? Click below for a recent panel discussion on how to avoid some obvious pitfalls in personal data protection. I participated on this Roundtable discussionon TRTWorld about the epidemic levels of identity theft, why someone is motivated in this criminal behaviour and how we can protect ourselves online.
TRT World is an English language news channel based in Istanbul and offers news and current affairs on television (available on Sky, channel 519) and online (including on mobile). This programme was recorded in its London studio. Other participants on the panel included Emma Mills, Chief Operating Officer at C6 Intelligence;Mary-Ann Russon, freelance technology journalist; and Professor David Stupples, director of the Centre for Cyber Security Studies at City University, London.
It has been reported that children in England will be seen by NHS mental health services within four weeks, as part of a Government pilot. The consultation on the preliminary paper will run for around 12 weeks and will see additional funding for mental health services (even though the increase in overall NHS spending is projected to be below inflation for the next two years), mental health leads in schools in addition to greater emphasis on reducing waiting times, and setting maximum waiting times for mild and less severe cases. There will be trailblazer sites and funding pressures mean it won’t be UK-wide until 2021. The new measures are part of a £300m investment by the Departments of Health and Education although it is not clear whether the 4 weeks target would be for assessment or for treatment. Mental health campaigners have been increasingly asking the government to commit to increased funding for child mental health services and for a greater focus on wellbeing in schools in the upcoming green paper on Child and Adolescent Mental Health Services (CAMHS).
There is more than one split going on within government at present. Whilst pro-Brexit and anti-Brexit ministers might be at loggerheads at the heart of government there is also a split about the level of additional funds to be allocated to public services such as the NHS.
The Health Secretary Jeremy Hunt is fighting a battle with the Treasury Department in seeking to secure additional funding for the NHS, and particularly for mental health services, and specifically for young people’s access to services. The Treasury are seeking assurances from Mr Hunt that the NHS is leaner and meaner in implementing efficiency savings before agreeing to additional taxpayer funds to meet increasing need.
Mr Hunt can point to savings already in estates management, workforce planning, more collaborative procurement and shared services, reduced agency nurse costs (producing around £800m in savings), greater use of generic drugs and other efficiencies in back office functions. These savings are re-directed back onto the front-line. Progress has also been made in making in-hospital care safer and dealing with infectious bugs for in-patients. The NHS is now viewed as a safe healthcare system by numerous health think tanks and watchdog bodies. However, mental health services are playing catch-up given the underfunding over the recent years and this is where the Health Secretary is facing an uphill task with the Treasury.
It is clear that awareness of the unmet needs of mental health is far more prominent now in political circles as well as in the NHS itself. The difficulty, however, for Mr Hunt is that demand is continuing to rise, and will only increase in response to stigma reducing campaigns such as the Heads Together campaign, and any increase in funding is difficult to notice on the ground.
Working with children involves combining medicine and therapies and an emphasis on multi-disciplinary working and involves a multi-agency approach. That is why their therapeutic journey often needs to start with a visit to their GP and then contact with secondary services. Psychotherapy might follow as part of a integrated treatment plan.
Young people are increasingly at risk of mental health disorders for a number of reasons but just consider some of the statistics for self-harm. Admissions to A&E departments are up 50% over the past 5 years for under-18s. About 77% of A & E, or hospital admissions, for self-harm were made by girls in the years 2010-16. The sobering statistics are that at least four young people in every secondary school class in England are now self-harming. The Children’s Commissioner Anne Longfield recently told the Commons Health Select Committee that children as young as 13 felt they could only access support from mental health services by attempting self-harm.
What’s needed in children’s mental health services?
Yes, there needs to be parity of esteem with physical health care but this requires a shift in thinking and priority. It takes a lot of courage for a young person to reach out for help, but too often that help is not immediately available. In a mental health service that is in crisis clinicians will prioritise those with diagnosable conditions for treatment. The indirect message for many young people presenting with problems has often been to effectively come back when sicker. We should be aiming to have higher clinical outcome measures for treating all mental health conditions, not just the most severe cases. It should also be appreciated, however, that emerging psychosis is harder to identify than cancers, for instance, so achieving 100% targets in mental health might be more difficult than in physical health. The reality is that it is harder for psychiatrists to get people into their clinic than it is for oncologists to get cancer patients into their clinics.
More above inflation funding is needed to account for ever rising demand and to compensate for years of underfunding. Demand in the NHS overall is variously described as rising by 4% annually yet funding increases next year is projected at 0.9% and neutral the year after. That level of funding will require massive increases in productivity in order to expand services. Additionally, mental health budgets need to be ring-fenced so that funds are not redirected by NHS Trusts to deal with crisis situations in local hospitals.
Early intervention targeted campaigns need to be boosted. It is thought that approximately 50% of all life-long mental health problems first appear by the age of 14. Early intervention is, therefore, critical as are school health promotion and well-being campaigns. Such early intervention campaigns will ultimately boost the economy and the longer term NHS budget by tackling lifelong conditions earlier, thereby making long term savings with better clinical outcomes.
Better statistics for mental health services are needed. It was in 2004 that witnessed the most recent comprehensive national prevalence study of children’s mental health. This was conducted at a time before the explosion in social media and mobile telephony. The authorities could agree to commission regular and comprehensive prevalence studies so that risk factors and trends can be identified.
The emphasis needs to be kept on quality and not necessarily on quantity. Seeing children quickly for assessment (which is a potentially easy target to hit) might risk losing focus on keeping the concentration on maintaining robust care for existing patients and achieving good clinical outcomes for young people. Achieving more assessments could look good politically but there is a danger that such an emphasis might impact on existing services given the crisis of current resourcing in mental health services.
Mental health staff need to be motivated to achieve good clinical outcomes and this should involve all members of multi-disciplinary teams from caterers and cleaners on wards to consultant psychiatrists. The patient journey requires a complete joined up approach. Pay is just part of that motivation but also staff satisfaction levels, monitoring stress levels and effective workload management. Expanding clinical services has to be balanced with the stark reality that pay takes up about 62% of all spend within the NHS. Perhaps everybody in the NHS, not just the paymasters in government, need to prove that safety and quality are paramount within the NHS and that means every surgery, ward, operating theatre and clinical team being committed to driving up outcome service levels.
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