FOBTs and the review of the Gambling Act 2005

Gambling disorderOften dubbed the ‘crack cocaine of gambling’, Fixed Odds Betting Terminals (FOBTs) are electromechanical devices most commonly found in UK betting shops and allow players to bet on the outcome of various games, of which the most common are roulette and blackjack, and events with fixed odds.They have been in betting shops since 2002.

The Government recently announced a review into the legislation governing gambling adverts and FOBTs, and,more broadly, the functioning of the Gambling Act 2005. Tracey Crouch, the sports minister, said the review would consider the maximum stakes and prizes for gaming machines and, in particular, FOBTs because of concerns that they can be addictive. The Gambling Act had allowed betting shops to increase the number of FOBT machines allowed in betting shops, up to four, depending on size of shop. The review will also investigate the impact of advertising of betting websites on daytime television.

The Gambling Commission, set up under the Gambling Act 2005, is the body that regulates commercial gambling in the UK in partnership with licensing authorities. Its latest statistics show that in the 12 months to March 2016 punters lost a record £1.8 billion on FOBTS. Interestingly, the figures also show that online gambling is now the largest gambling sector in the UK.

FOBTs are also known as ‘electronic morphine’, because of their highly addictive nature. It is true that journalists often seek to sensationalise the story with such descriptions but the words are probably a fair portrayal because repeat players will become addicted to this form electronic gambling more rapidly than other forms of gambling such as sports betting and card games (reference: Dow Schull, Addiction by Design: Machine Gambling in Las Vegas 2014 Princeton University Press). The devices allow punters to bet £100 every 20 seconds. There are proposals that could see the minimum stake reduced to £2, as in the case of Australia. They are banned from betting shops in Ireland.

The extent of problem gambling

The British Gambling Prevalence Survey 2010 was the last bespoke gambling prevalence survey commissioned by the Gambling Commission.   From 2013 the body has pursued a decoupled approach to the collection of adult gambling prevalence data (i.e. the separate collection of participation and problem gambling data) through the Health Survey for England and the Scottish Health Survey. The rate of problem gambling in the adult population for England is estimated to be 0.5% or  0.4%, depending on how it is measured.   The latest combined data shows the overall problem gambling rate to be 0.7% but this would appear to be consistent with combined data from 2012 (0.6%). However, it should be noted that these are indicative figures and the new Health Survey data is due to be published in early 2017.

Derek Webb, who provides funding for the Campaign for Fairer Gambling and the Stop the FOBTs Campaign, advocated in The Time’s Thunderer (“Lower the stake on betting machines for addicts’ sake“, Oct 7) that there should be such a minimum staking policy on FOBTs. He argues that whilst Ireland banned the machines, UK players can stake up to £100 per spin and this puts users are grave risk.

According to the Gambling Commission the problem gambling rate has increased from 0.4% in the year to June 2013 to 1.5% in year to June 2016 amongst the 16-24 age group (these are, however, indicative figures taken from quarterly short-form PGSI data, whereas the full health survey results will be released in 2017).

Views of the industry on FOBTs

The Association of British Bookmakers Ltd  (ABB) dispute the view that FOBTs cause gambling problems. They are also against cutting stakes on FOBTS as such a decision to potentially solve problem gambling would be akin, in their minds, to cutting the alcohol level in whisky in the hope that this might stop individuals from becoming alcoholics. The ABB disputes that there is any evidence to demonstrate that FOBTs create problem gambling. They claim that independent research clearly shows that most people who develop a problem with gambling use different types of products.  They also claim that the level of problem gambling in the UK have remained unchanged over the past 15 years.

I checked the ABB claims with the Gambling Commission who told me the following:

We do not have data collected to a consistent methodology covering the last 15 years. Our most robust estimates of problem gambling, based on the largest sample sizes and comparable to the BGPS 2007 and 2010, will be published next year (2017) in our combined report on gambling behaviour, where the data will be taken from the Health Survey for England 2015, the Scottish Health Survey 2015 and our own Welsh Problem Gambling Survey 2015”.

The industry might claim that they should not be held responsible for problem behaviour in the same way as licenced vintners should not have to restrict selling whisky in case a person becomes alcoholic. However, the Gambling Act 2005 places social responsibility requirements on UK based gambling operators who are also required to contribute to research, education and treatment of problem gamblers (the Act essentially enshrined the principle of ‘polluter pays’ regarding gambling treatment).

A view from the legislators

Carolyn Harris MP, chair of the FOBTs All-Party parliamentary Group (APPG), believes that there is evidence to suggest that reducing stakes on FOBTs can help to reduce instances of problem gambling and such steps should be implemented immediately.

There appears to be stand-off between the industry and legislators, however,  since the ABB failed to show up for the latest APPG meeting in November 2016 stating that it’s ‘nothing but a kangaroo court.’

Newham Council in London, has, along with many other local authorities,  proposed a £2 maximum stake under the terms of the Sustainable Communities Act.

The treatment of gambling addiction

The three most common models of addiction are disease, choice, and self-medication and the most effective recovery programmes are dependent on how addiction is viewed. The disease model is advocated by Gamblers Anonymous (an off shoot of Alcoholics Anonymous) and holds that ‘recovery’ must entail abstinence for good, albeit one day at a time. Dr David Sack, a leading advocate of the disease model, argues that addiction is a disease and needs to be treated as such. A big critic of the disease model for treating addictions is Marc Lewis and he argues that treatments based on this model are ineffective. The choice model takes the view that addiction is free choice and that treatment should address different choices. Vietnam vets stopped taking heroin when they returned to their families and to their safe environment, for example. Trauma is the root cause of the self-medication model. PTSD, depression and anxiety disorders all hinge on an overactive amygdala but drugs, booze, gambling and so forth take you out of yourself and calm the amygdala down.

According to the Royal College of Psychiatrists there is no medication that is licensed for the treatment of problem gambling in the UK. However, antidepressants can be prescribed to help with low mood. Cognitive Behavioural Therapy (CBT) has been cited by the College as showing some effectiveness in helping gamblers reduce the amount of time and money they spend gambling and once stopped to stay stopped. In therapy, the therapist can be the detoxifying agent for the gambler’s toxic mentations.

Psychiatrists, such as Dr Henrietta Bowden-Jones, lead psychiatrist of the NHS National problem Gambling Clinic, has called for all gambling treatment service provision to be integrated within the existing network of drug and alcohol treatment services since gambling disorder is now acknowledged as a valid psychiatric condition. She points to the particular vulnerability of young people to problem gambling. She believes that this could be due to later maturation of the prefrontal cortex which can lead to higher levels of impulsivity, poor decision-making and a preference for immediate gratification. Television gambling adverts, she claims, shown during sporting events could be seen as priming the brain of the young.

When Donald Winnicott said there was no such thing as an infant (a baby is his environment), perhaps there is no such thing as just a drug user. It could be fruitful to ask what is happening in the user’s world? Bion described drug addiction as a ‘hatred of reality‘ and I wonder if a similar description could be applied to gambling addiction. There is certainly a loss of connection when gamblers recount stories of feeling empty and lonely.

‘The zone’ has been described by Natasha Dow Schull, in her book Addiction by Design, which showed how an electronic slot machine random number generator provides a reinforcement schedule that keeps the user in a trance-like state.  She describes this state of mind in greater detail in the attached presentation below. The ‘zone’ is akin to nothingness where the user relies on the comfort that the machine is forever present.  Once in the zone, problem gamblers use the machines not necessarily to win but rather to keep playing, for as long as possible. They continue to stay in this state in spite of physical and financial exhaustion. In this state, users have described even forgetting the names of their children, such is the hypnotic-like environment in which they exist.  The machine and person enter a form of emotional intimacy where fear and worries appear to fade away.

Betting shop machines have been designed with the maths in mind and digital machines now offer multiple-line betting, unlike the traditional analogue gaming machines which did not offer such opportunities.  An FOBT random number generator provides a reinforcement schedule that keeps the user in ‘the zone’ as machine designers have worked out how to harness gaming productivity to the optimum.

It seems to me that an abstinence based approach should form part of a robust treatment plan for problem gambling regardless of one’s addiction model. Reconnecting to one’s creative and vibrant self could form the basis of one’s therapeutic journey.

The evidence to claim that FOBTs create problem gambling might not be conclusive. What is fair to say, in my opinion, is that there was no proper impact assessment carried out when the decisions were taken to allow the expansion of FOBTs in betting shops in 2005 (and for pre-watershed gambling television advertising). That is perhaps the core of the issue that the Government’s review will need to contend with. It will be interesting to see what the review comes up with.

See also my article on FOBTs and how they are the crack cocaine of gambling

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Making better decisions

making better decisionsI always find it interesting when people not trained in psychology adopt tools, techniques and insights from the field and start to practice them in their particular area. Sports coaches are increasingly using psychological insights to improve elite performance in individual and teams sports.  Another area is the investment sector to boost one’s ability to improve upon their decision making. Michael J. Mauboussin, an investment strategist, has written a well researched book entitled ‘Think Twice – Harnessing the Power of Counter Intuition’ and has produced an interesting set of statistics, case studies and self-help tips to help improve the way we make decisions.

The power of intuition was an influential theme running through my psychotherapy training.  But, intriguingly, whilst Mauboussin encourages us to trust our intuition in the decision making process, he also cautions against overly relying upon it.

We all make poor decisions in all aspects of our lives from time to time. Even the people with the finest brainpower regularly make mistakes. The 2008 financial crisis is a classic example of that. Nobody embarks upon their day with the intent of making poor decisions. Poor decisions can emanate from cognitive biases and a failure to spot when we are acting from a blind spot. So, how might a person prevent new distortions from arising and bring more awareness to their distorted thinking?

The business of decision making can be highly complex. However, by instigating a few simple, yet counterintuitive habits, we can position ourselves to make better decisions.  See my article on Counselling Directory for some ideas to help improve your capacity to make better decisions more often.

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Knowing your cognitive distortions to help with anxiety

cbtIt can be useful to bring awareness to your cognitive distortions especially in helping to cope with feelings of anxiety and depression. Cognitive Behavioural Therapy (CBT) can be very useful as a targeted approach to achieve balanced thinking.

CBT is flavour of the month in the NHS, and consequently can be downplayed by some within the psychotherapy profession, but I believe that it contains extremely useful tools and techniques for changing unhelpful thinking and behaviour. We owe a lot to Albert Ellis and Aaron Beck for helping us provide solutions to cognitive, emotional, and behavioral disturbances. See my article on identifying your cognitive distortions to help transform your relationships and better cope with anxiety and depression.

 

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Self-help management regime for Generalised Anxiety Disorder (GAD)

GADAre you worried about feeling anxious? Do you withdraw from meeting up and mixing with your family and friends?  Do you avoid social situations in order to not have feelings of worry and dread? Do you find it difficult to go to work and do you take time off sick? These actions can make you worry even more about yourself and diminish your feelings of hurt.

Generalised Anxiety Disorder (GAD) is defined by the Statistical Manual of Mental Disorders  (DSM 5) as an anxiety disorder.  Psychiatrists have defined GAD as a condition where worry is seen as uncontrollable and often irrational. Worry is also so excessive that it involves extreme apprehension about future events or activities.

If you have GAD, it may not always be clear what you are feeling anxious about. One of the most debilitating aspects about anxiety is the manner in which it occurs without any apparent identifiable cause.  Not knowing what triggers your anxiety can intensify it and you may start to worry that there is no solution to the way you are feeling.

The psychological symptoms of GAD (such as restlessness, feeling constantly ‘on edge’, a sense of dread, difficulties with concentration and irritability) can cause a change in your behaviour and the way you think and feel about things.

We all have worries as we encounter new challenges in the course of our everyday lives but if you have GAD you may take worrying to a different level, a more intense level.  The difference between what might be termed ‘normal’ worrying and generalised anxiety disorder is that the worrying involved in GAD could be termed excessive, intrusive, persistent and debilitating.

What helps you manage your symptoms?

The Royal College of Psychiatrists states that for the most effective management of GAD:

Firstly, psychological therapy and Cognitive Behavioural Therapy (CBT) is suggested, as per NICE guidelines. CBT is an approach that seeks to help you gain charge of your thought processes by identifying automatic negative thoughts and to change them to help you to manage your situation. Your CBT sessions focus on helping you to acquire specific skills to empower you to reacquaint yourself with those activities which you may have avoided because of your anxiety (the behavioural aspect of the approach). You can listen to my interview with Professor Windy Dryden who explains the effectiveness of CBT. Secondly, medication is the next most effective such as a course of SSRI prescription. Thirdly, self-help such as reading books based on the principles of CBT and implementing the suggestions.

However, whether you seek professional help or not, it is still of critical importance to practice a self-help management regime in your daily life.  Seeing a therapist will help but ultimately there is no magic wand.  You will still need to manage your feelings and behaviour on a daily basis between sessions.

Self-help management regime for anxiety

  1. Practice mindfulness and relaxation techniques

Try to become more mindful, there are many practical toolkits available online. My interview with Fr Laurence Freeman explains the benefits of regular meditation. You can also download for free some useful relaxation techniques from Helpguide. Here is a useful breathing exercise to help you relax:

In – on the in breath draw up the magnetism of the Earth through your body, feet and the palms of your hands faced downwards. Think of the Earth and yourself as two magnets – one giant, and one tiny. If you like you can visualise the Earth’s energy spiralling upwards in an anti-clockwise direction from your feet to your head.

Out – on the out breath you are releasing the distortions of your bodies – physical at the cellular level, as well as energetic and emotional. In releasing distortions and toxins back down into the Earth we can remember that it is a giant transformer, willingly able to take these from us.

  1. Review your attitude to worrying

Everybody worries and from time to time we all let worry take greater prominence in our lives than it should. Scott Peck starts his book The Road Less Travelled with the line ‘Life is difficult’. That is perhaps the reality of modern living, that life can be tricky at times.  However, if you’re focusing on “what if” scenarios all the time, your worrying has become unproductive.

  1. Do something different

When you feel anxious you may need to change the scenery and location of where you are.  If you are indoors and working on a computer try to go for a long walk in a park and take in your surroundings.  Leave your phone at home, if you can. You will have a more mindful experience if you are not focused on the receipt of phone messages.

  1. Avoid isolation

Try to join a group, however informally, as a way of containing your anxious feelings. Get in touch with friends and family who you feel comfortable speaking to. Isolating will only compound your anxious state.   See my resources list at the bottom of the page for links to self-help groups. This is the behavioural aspect of CBT.

  1. Review how you are living

Evaluate your way of living and assess whether you could change your diet so that you are concentrating on eating nutritional meals. Try to avoid too many sugary products.

Try to observe a healthy sleep hygiene regime. Research has shown that sleep deprivation can lead to anticipatory anxiety. Try to avoid looking at your phone, computer and television two hours before going to bed.

Do you leave sufficient time to prepare for going out or going to work?  Hurry and indecision can be detrimental to your sense of well-being. Try to leave plenty of time for the preparation of daily tasks and plan ahead.  It can be useful to pack your bag for work the night before so that you don’t end up rushing. Planning ahead will also reduce the potential for anticipatory anxiety.

  1. Accept your existential crisis

For the existentialists, psychological dysfunction results from the individual’s refusal or inability to deal with the normal existential anxiety that comes from confronting life’s ‘givens’: inevitability of death, isolation, freedom and search for meaning. These are deep issues but break them down to practical parts. We often refuse to consider these questions when we get caught up in the engagement of material pursuit but there can be benefit to adjusting ourselves to the realities of life so that we can be more in the moment.  Anxiety, for the existentialists, is derived from the realisation that our validation must come from within and not from others, or other things. Bring this mindful approach to your meditation and try to live in the moment.

From a transpersonal perspective, an existential crisis is witnessed as a loss of soul due to greater isolation we suffer in modern life from the advances of technology, pursuit of material possession and increased secularization. This all creates greater levels of anxiety as we search for more and more answers online when perhaps what we really need to do is to slow down and listen to our heartbeat in quiet periods of silent meditation.

If you think you are suffering from GAD it is important to speak to your GP, especially if you are experiencing physical symptoms. Your GP will know your personal history and should be well placed to help you.

Resources:

Anxiety Alliance: A charity committed to the support of individuals suffering from the condition of anxiety disorder. Their telephone helpline number is 0845 2967877.
Anxiety Care UK:  Runs mutual support groups.
Anxiety UK: A National charity founded by Harold Fisher, a sufferer of agoraphobia, for those affected by anxiety disorders. The charity provides resources to help reduce the impact of anxiety disorders. The Helpline number is 08444 775 774.
Anxiety in kids: how to turn it around
Helpguide.org: Treatment of GAD
NHS Choices: Treatment of GAD
NICE Guidelines on General Anxiety Disorder in Adults National Clinical Guideline 13
No Panic: A national organisation which provides support for those with phobias , anxiety and care. The Helpline number is 0800 138 8889.
Patient.co.uk: Information leaflet on GAD
Royal College of Psychiatrists: Information on anxieties, phobias and panic.

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My interview with Windy Dryden about CBT and integrative psychotherapy

Windy Dryden chats about CBT and integrative psychotherapy.

Windy Dryden chats about CBT and integrative psychotherapy.

I recently chatted with Windy Dryden about CBT and integrative psychotherapy. Windy was the first appointed professor of counselling studies at Goldsmiths College, University of London, in 1992.  In the interview we discuss the challenges of editing the Handbook on Individual Therapy, often viewed as essential reading for anyone wanting to know more about counselling and psychotherapy. We also discussed RECBT, IAPT in the NHS, the Albert Ellis Institute and what is uniting about the different approaches in counselling and psychotherapy.

To listen to the interview click here.

For more information on the UK CBT meetup group with live CBT demonstrations visit their website.

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Recovery from addiction (with a spiritual twist)

Recovery from addictionI came across 3-s therapy or Spiritual Self-Schema in my recent reading. This is a manual based therapy developed by Avants and Margolin. The chief objective of the therapy is to enable clients to develop, build upon and habitually activate a cognitive schema, which is what is referred to as the Spiritual self-schema. See the step by step guide here.

The therapy is a manual based approach compatible with drug abstinence, HIV preventive behaviour, and adherence to medical regimens. There is a great deal of common ground with CBT in the form of monitoring automatic negative thoughts, verbal disputing, noticing body sensations and observing behaviour patterns. There are obvious similarities with the 12 steps of recovery approach to the treatment of addiction too as the 12 steps employ a range of holistic tools and techniques to bring about personal transformation and heightened levels of consciousness.

Increased levels of consciousness could be viewed as the aim of all therapeutic approaches to recovery from addiction. The means to get there is often the point of dispute between the modalities. For the behavioural school the person should change their actions and their (reformed) feelings and thoughts, it is hoped, will follow and the addictive desire wlll lose its grip. The cognitive school will emphasise a new way of thinking to affect change so that you would feel a different way about your life. The analysts will delve into the past to seek to unearth a developmental rupture, often in psycho sexual development, as the reason for poor life choices. The existential school would explore one’s relationship to the givens of life and reassess one’s life choices in terms of meaning. For the transpersonalists, and here I am aware of being quite generalist, addiction is the result of loss of soul.  

Addiction is essentially a way of blocking your feelings. Feelings can not be contained or tolerated in their present form and, therefore, comfort is sought in the form of addictive behaviour.  I like this phrase: If it feels good get worse, if it feels bad get better. I take this to mean that anything pleasurable whereby I am seeking to escape from discomforting feelings will have a price attached to it. Whereas, if I do something less pleasurable but more healthy in the course of my recovery then in the long term I will get better. For example, I want to sit and eat chocolate and watch tv all day when i feel depressed whereas I could go out for a long cycle. The thought of sitting with chocolate might appear more comforting than getting ready to go cycling.

Addiction can also be seen as a devotion to oneself.  Whilst we may refer to our various vices, what we are really attached to, is ourselves, our desires, our wants, our resentments and our fantasies. Recuperation is another word for recovery, deriving from the Latin word “recupare” meaning “to regain.” Through transformation in the psycho spiritual journey, whether that is by cognitive and behavioural tools and techniques or by meditation, or by surrendering, we can regain consciousness and develop a greater level of peace within ourselves.

Active addiction is a loss of consciousness, as we become obsessed with ourselves. To recover, is to push back the border of our consciousness, to know more and to regain interests in relationships and in the flow of life. We begin to feel more present and happier in the here and now.

Metzner (2009) referred to consciousness as a spherical field of awareness that surrounded us and moved wherever we went. For Metzner, addiction is a narrowing of focus, a contracted state of consciousness that contrasts with transcendent states which involve a moment of attention and an expanded state of consciousness.

There has already been a number of clinicians and theorists who have theorised on the integration of Buddhist and western psychological principles and practices for a number of psychological issues. Avants and Margolin are not alone. These discussions have primarily focused on the potentially important role for “mindfulness” meditation in the conceptualization and implementation of treatment.

Rubin (1996) and Epstein (1995) have discussed how Buddhist thought and mindfulness experience can enrich a Freudian, psychoanalytic framework in the practice of psychotherapy. Segal and his colleagues provide a systematic mindfulness-based cognitive therapy for the treatment of depression (Segal,Williams, & Teasdale, 2002). More broadly, Rosenbaum (1999) describes how psychotherapists can enrich their work, their interactions with their clients, and, indeed, their lives, through the incorporation of mindfulness principles and practices of Zen Buddhism. With respect to the treatment of addictions, Ash (1993) has proposed a Zen Buddhist interpretation of the Alcoholics Anonymous, “12-step” framework.

The primary difference between the 3-s therapy or Spiritual Self-Schema approach and those cited above is their use of an information processing, cognitive self-schema theoretical framework. You might find their free tutorials of use by checking them out by clicking on the link below.

Resources

3-s therapy workbook

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CBT of little use in the treatment of schizophrenia

CBT and goal settingThe results of a recent study into the effectiveness of talking therapies and CBT as a treatment programme for schizophrenia show its usefulness is so minimal that it’s continued recommendation cannot be justified. Researchers at the University of Hertfordshire led by Prof Keith Laws found that CBT only had a “small therapeutic effect” on schizophrenic symptoms.

For years the National Institute for Health and Care Excellence (NICE) has argued that CBT is effective, and recommended it for all people with the disorder. CBT has been the standard dish on the menu in the NHS for talking therapy intervention so it will be interesting to see if there is any notice taken of this recent study. 

I do believe that CBT has a role to play when it comes to the successful engagement of clients in the process of therapy, as it can facilitate goal setting, especially in short term counselling. I often use behaviour change techniques such as anti-procrastination exercises and cognitive change techniques such as verbal disputing (and Beck’s ABC Model) in my integrative psychotherapeutic practice. But I also believe that healthcare commissioners need to take note of negative research findings particularly when so called evidence based approaches have gained priority over other approaches in the public sector.

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Reflections on two years of my psychotherapy training

Holiday time finds me reading books which I had failed to read throughout the year, such as I’m OK you’re OK as well as books which I want to read out of pure interest.  I also find myself reflecting on the last two years as I pass the mid point in my training. I recall what tutors said on the opening evening of the course. They said that we as students would develop as counsellors in our own unique way throughout our time at the Centre.  There was not a CCPE way to developing as a therapist but that we would grow in our own individual way and find our own truth.  I am reminded of this as I write.

As a result I find that I ask myself what is my way?  Have I read enough? What is my approach to counselling and psychotherapy?  What does it mean for me to be an integrative psychotherapist? These are questions that will be perhaps a constant line of questioning throughout my journey as a therapist.

My second year at CCPE has been a time when I have revisited early life issues and experiences. Indeed, Rosemary Cowan [1] points out that the developmental model that CCPE suggested was very helpful to her.  She notes that trainees in the first year were likened to wide-eyed, enthusiastic primary school children; in the second year, like pre-teens, they gain confidence and independence but may also be ‘know-alls’ who overstretch themselves; in the third year they reach the rebellious, argumentative, difficult teenager stage; in the fourth year, with increased maturity and stability, they become more rounded, finished characters.  I am not sure where I fit in with this model but it is an interesting theory.

 I became more conscious of the emotional effects of group-work

I learned a lot about my early childhood experiences and how I act in groups following 16 weeks of group process. Families are, after all, our first blueprint for how we act in groups. It became evident to me that my early experiences were constellating in my life as an adult. I like what Bion [2] said about experiential groups. When under attack it is far more beneficial to one’s own learning process to try to observe that one is being attacked, and take in what that experience really feels like, rather than reacting to the source of the attack.It was also interesting to sit with how I felt about those in the group who didn’t participate in the group’s discussions.

My placement gave me an insight into the limitations of psychotherapy.

I had been fortunate to secure a psychiatric observational placement at an NHS Mental Health Trust where medical students were also on placement. It proved to be an amazing experience from a learning point of view as there were many specialist services in the Trust.

I had been familiar with Cognitive Behavioural Therapy (CBT) before the start of my placement through my lectures and my own prior knowledge. However, I attended a team meeting in a sexual behaviour unit in a forensics unit and learned about the Dialectical behaviour therapy treatment programme.  It was welcome to see that Zen techniques have been incorporated into the treatment models, even in the NHS.

My placement gave me an insight into the limitations of psychotherapy.  Some patients are so ill they lack the capacity for insight and a pharmacological treatment plan is critical for their recovery.  I believe we need to proceed with great caution when working with clients with psychotic conditions as there is often an absence of a healthy ego.

Gestalt Psychotherapy proved to be one of the most powerful components of the course so far

I have enjoyed the second year lectures starting off with short term therapy.  I found the lecture on short term therapy to be very helpful from a practical point of view given that I see clients for an initial period of six weeks at Help Counselling.   One or two lectures (though thankfully the minority) were uninspiring and at times I wondered whether we were really on a postgraduate level course given the poor quality of discourse in the room.

We had a three day weekend on Gestalt Psychotherapy, which for me, proved to be one of the most powerful components of the course so far.  The word gestalt is used to describe a phenomenon/concept in which the ‘whole’ is considered as greater than the sum total of all its parts.  I found the empty chair technique to be a good technique for dialoguing with absent parents, friends or colleague, dealing with unfinished business.

I believe that in psychotherapy clients make theory rather than theory making therapy. I need, therefore, to remain open-minded and use early life theory as a map which might be helpful in the navigation rather than as a set of rules. Pattern recognition is essential to good therapy. The primary difference between talking to our friends or Aunt Dorris is that counsellors are trained to look for patterns.

I believe that transpersonal psychotherapy is not alone in encompassing spirituality into treatment. Indeed, other modalities allow for the spiritual in their therapeutic approach but transpersonal psychotherapy actively involves the spiritual element in the client work.

 

[1] Therapy Today July 2012
[2] What is a Group? A discussion of Bion’s Experiences in Groups Antony Froggett 2005
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At some point in a OCD patient’s recovery, it is important that people with OCD try CBT first

The OCD Action National Conference recently took place in London. Leading OCD charity, OCD Action, organises the annual OCD Action National Conference to help people with OCD develop their own support network and to give them the chance to hear from leading experts.

The World Health Organisation has listed OCD in their top ten of the most disabling illnesses, decided by lost earnings and diminished quality of life. However, the good news is that it is treatable. There is evidence that a form of cognitive behavioural therapy (CBT) called Exposure Response Prevention can help people with OCD and sufferers are learning to confront their worst fears and regain control of their lives.

In Overcoming OCD, reporter Judy Hobson investigates why people with OCD often don’t seek help until middle age.  This can be in spite of the condition usually first emerging in their childhood.

We in transpersonal psychotherapy try to improve a psychological condition by helping clients gain “insight” into their problems and through creative interventions seeking to produce a transformative experience by helping client’s get in touch with their essence. The medical experts suggest, however, that although this approach may be of benefit, at some point in a OCD patient’s recovery, it is important that people with OCD try Cognitive Behaviour Therapy (CBT) first, as this is the type of treatment that has been shown to be the most effective.

This screening test was designed as a guide to find out whether you show symptoms similar to those of Obsessive Compulsive Disorder (OCD).

It is worth noting that:

  • The questionnaire is meant for indicative purposes only. It does not mean you have OCD if you obtain a high score as a result of completing this questionnaire. It will be necessary to obtain a trained healthcare professional can diagnosis.
  • This test has 20 questions in Part A and 5 questions in Part B and should take about 5 minutes.
  • The test was developed by Professor Wayne Goodman of the University of Florida.

Shortly, the revised DSM5 will reclassify OCD into a new category with other OCD spectrum disorders such as BDD, skin picking disorder and hoarding disorder.

Are the medical experts correct with the assertion that at some point in a OCD patient’s recovery, it is important that people with OCD try CBT first? With other illnesses, my psychiatric placement gave me an insight into the limitations of psychotherapy.  Some patients are so ill they lack the capacity for insight and a pharmacological treatment plan is critical for their recovery.  I believe we need to proceed with great caution when working with clients with psychotic conditions as there is often an absence of a healthy ego.     For instance, critics of the transpersonal school argue that those with borderline personality or psychotic symptoms are not appropriate candidates for transpersonal therapy techniques because of the potential for ego defences to be overwhelmed. However, Linehan [1] argues that these conditions can be relative contraindications at best. She used mindfulness techniques and visualisation with borderline patients in Dialectical Behaviour Therapy and suggested that even patients with fragile or unstable ego functioning can benefit from such work. Does this apply to OCD clients? I believe that we need to pay attention to the evidence base but not be a slave to it.

[1] MARSHA M. LINEHAN, Ph.D. is the originator of Dialectical Behavior Therapy and is a professor in the Department of Psychology at the University of Washington

Additional Resources:

What is good CBT
Whats new in the treatment of OCD
Summary of NICE-recommended treatment approach for OCD  
The Treatment of OCD and BDD in the NHS Blog post
TOP UK triumph over phobia a UK registered charity which aims to help sufferers of phobias, obsessive compulsive disorder and other related anxiety to overcome their fears and become ex-sufferers.
The Centre for Anxiety Disorders and Trauma provides a national OCD/BDD service
Leaflets on OCD from the Royal College of Psychiatrists
OCD: A web guide for health professionals Contains useful links
Summary of NICE-recommended treatment approach for OCD Stepped care model for treatment of OCD
NICE Guideline: Obsessive compulsive disorder (OCD) and body dysmorphic disorder (BDD) (CG31)

If you are experiencing problems with OCD, refer to SW London and St Georges NHS Mental Health Trust OCD/BDD Clinic.

 

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Working with Trauma in Psychotherapy

I attended an amazing course today on how to work with Trauma, which was run by Mark Brayne.  Mark is a psychotherapist, journalist, and author. After a first career as a foreign correspondent,  when he worked as a BBC and Reuters foreign correspondent and editor, he qualified in psychotherapy and since 2002 has specialised in working with trauma. His enthusiasm for his work knows no bounds and his lectures and courses seem to end so soon – such is the level of engagement with the material.

I was the only trainee there, as most participants were experienced therapists. One had flown in from Dubai especially to attend the course, another from Switzerland and another had just returned from North America. I attended the course primarily because Mark had given a 90 minute lecture on trauma a few weeks back at my College but I wanted more.

This one day event offered an opportunity to explore the issues in greater depth than in a standard lecture. Trauma, it could be argued, is behind so much of the presenting issues that clients bring to therapy whether in the form of anxiety, depression or addictions and should be prioritised in psychotherapy training. Indeed, I would welcome a weekend or a week on treating trauma.

So what is trauma?

Trauma is any threat to life or identity, mostly unexpected and which overwhelms the defences.  There is extreme helplessness involving fear and horror. Trauma is the piercing of body and psyche defences and survival involves fight/flight/freeze.

Traumatic symptoms will invariably comprise of the following: Intrusion (the inability to keep memories of the event from returning), Avoidance (or numbing) (an attempt to avoid stimuli and triggers that may bring back those memories), Hyper Arousal (similar to jumpiness. It may include insomnia (trouble sleeping), a tendency to be easily startled, a constant feeling that danger or disaster is nearby, an inability to concentrate, extreme irritability, or even violent behaviour).

Part of the course involved watching videos of the Twin Towers attack from 2001 and the G8 Summit that took place in Genoa, when riot police dished out savage beatings to protesters on the streets of the Italian city.  We were asked to monitor our thinking processes, feelings and physical sensations whilst we watched the videos. The videos  showed graphic close up footage. I felt dizzy as I witnessed the Italian riot police pound their batons into the protesters who were dragged along the street like pieces of dirt. Therapists need to be able to survive the trauma brought by clients in order to create a safe containing space.

The course dealt with EMDR as a treatment model. EMDR, it was noted, should only be practiced by a qualified mental health professional – with additional accredited training in EMDR.  That professional will most usually incorporate the therapy into their usual practice such as a Cognitive Behavioural Psychotherapist who may include EMDR in their CBT practice, particularly when treating trauma.  So, if you are in training you will need to wait until at least two years following qualification before applying for EMDR licensing.

I have always been fascinated by the brain. Did you know that the Amygdala performs primary roles in the formation and storage of memories associated with emotional events. When assessing the role of the Amygdala think of it as the control desk in the brain.  It will flash red warning lights at perceived threats.However, sometimes an event occurs, such as a trauma, which is simply too large or difficult for the brain to process.

EMDR also has the potential to cause serious psychological damage by triggering extreme traumatic memories. It is, therefore,  not an appropriate approach for a self-help book. So, be careful about engaging with bilateral tapping on your own.

How EMDR works

EMDR therapy is only interested in feelings NOW. What is in the past is done with. During EMDR sessions you will remain in control, fully alert and wide-awake. This is not a form of hypnosis and you can stop the process at any time. It is possible to use EMDR as a stand-alone treatment, but most often this would be for treating the psychological consequences of single event traumas.

Think of the mind as being like a factory or a massively complicated control centre.  One of its jobs is to process life events so that they can become memories. Because the event isn’t processed, it is prevented from becoming a memory and, therefore, it remains a current problem, rather than one that’s in the past. Memory involves what happened, an image association, negative thought, feeling and physical sensation. What usually happens with an unprocessed event? We get ‘flashbacks’ when present day situations or events that remind us of the original trauma get triggered. During periods of distress, we tend to press the factory’s STOP button. We also avoid situations which are likely to trigger these ‘flashback’ experiences, reinforcing the lack of processing.

We need to expose ourselves to thinking about and imagining the traumatic event, and/or gradually exposing ourselves to real situations which we normally avoid – if we are to effectively treat the traumatic event so that our ‘factory’ can process them into memories.

This process will result in experiencing distress, but will also cause the factory to effectively process the traumatic event, which will greatly reduce the distress in the long-term.

When the brain is profoundly threatened it will imagine the worst. When wounded or injured it generates massive amounts of opiates.  Sometimes, people become adrenaline junkies. Do you know people who are almost addicted to the high they receive from engaging in extreme sports activities, or high risk sexual behaviour? This behaviour may well be covering up untreated trauma.

What helps recovery?

The most valuable recovery tool for anyone suffering from the effects of trauma is a support system of family and friends.  Most people will not need counselling after a traumatic event as they will heal through their own processes. Professor David Richards research from 1997 on the prevention of post-traumatic stress after armed robbery showed that 80% of those who witnessed an armed robbery will heal on their own.

I sense I will go on to research this area and will try to get more training in treating trauma, as it fascinates me.

I learned more about mirror neurons at the course

Attending courses such as the one I attended help you see things more clearly.  For instance, have you ever seen people working with corpses?  They can appear to be very matter of fact in how they deal with the body. This is possible if they don’t know any personal details of the dead person.  It would be harder if they knew the person. Furthermore, I learned more about mirror neurons during the course (or counter transference).  Researchers argue that mirror neurons may be important for understanding the actions of other people, and for learning new skills by imitation. Emergency services workers will try not to talk about their work to family at the end of a working day or they risk dragging loved ones into the circle of trauma.

What is NOT recommended for the treatment of trauma

  • Psychological debriefing: This risks retraumatizing people who might not have been directly affected by an event.
  • Ineffective psychological treatments
  • For PTSD, drug treatments NOT a first line treatment (different for depression)

What IS recommended

The aim of EMDR therapy is to normalise and validate and the therapist will do this by displaying empathy whilst focusing on the trauma.
If you are affected by any of these issues consult the links below for help.

Resources

DSM IV criteria for Post Traumatic Stress Disorder
The European Society for Traumatic Stress Studies (ESTSS)
The International Society for Traumatic Stress Studies (ISTSS)
The European Network for Traumatic Stress (TENTS)
United Kingdom Psychological Trauma Society (UKPTS)
The IES-R is a 22-item self-report measure that assesses subjective distress caused by traumatic events
The Master and his Emissary Iain McGilchrist is a psychiatrist and writer who works privately in London 
Mark Brayne is a psychotherapist specialising in trauma

 

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