Counselling, Supervision, Training, Research, Teaching, Writing. Providing therapeutic services to the people of East Lancashire and beyond.

Friday, 23 December 2011

Circles of Support and Accountability

Hanvey, S., Philpot, T. and Wilson, C. (2011) A Community Based Approach to the Reduction of Sexual Reoffending: Circles of Support and Accountability, London, Jessica Kingsley

This book introduces readers to a new and innovative approach to the management of sexual offenders in the community - Circles of Support and Accountability. It will appeal chiefly to those who have a professional interest in the supervision of sexual offenders; but it also provides a fascinating read for anyone interested in safeguarding children and adults at risk of sexual aggression.

The first Circle was set up in Canada in 1994 to manage a sexual offender released from prison without statutory supervision. In response to community concerns a group of volunteers gathered round the offender to support his rehabilitation, monitor his behaviour and help him to maintain an offence free lifestyle. The experiment was successful and the model was imported into the UK where it has been tested and developed.

The book begins with a history of the Circles approach, rooted in ideas of restorative justice. This is followed by chapters on sexual offending and the criminal justice framework built to manage sexual offenders in the UK. It’s clear that Circles can complement the resettlement work done by statutory agencies, offering emotional support and practical help at a time when offenders are at increased risk of reoffending. The role of the circle’s volunteers is not simply to support the offender; trained and risk aware, they monitor the offender for signs of increasing risk, report any concerns to statutory services and hold accountable the offender’s promise of “No more victims”.

At the heart of the book are two fascinating chapters containing interviews with sexual offenders and volunteers. Both groups describe their life experiences and the benefits that each derives from being part of a circle. The striking difference between the two groups is the amount of trauma experienced in early life by the offenders. The book goes on to evaluate the effectiveness of Circles, with preliminary results suggesting a very positive effect on reoffending rates.

The final chapter criticises the press for demonising sex offenders and strengthening the public’s mistaken perception that sex offenders are ‘monsters’ and ‘strangers’ that our children must simply avoid to stay safe. In fact most sexual offences are committed by trusted family members, friends and neighbours. The book’s positive message is that whilst sexual offending takes place within the community and causes much harm, the community can respond and sexual offenders can be successfully managed by the communities in which they live. The book is a highly readable, informative and welcome addition to the literature on sex offending, safeguarding and public policy.

This book review appeared in Therapy Today (December, 2011)

Thursday, 1 December 2011

Ivan Illich: Deschooling Society

Craig and Phil suggested reading Deschooling Society by Ivan Illich as part of the Edupunk course I'm on. It took just three baths to read as the book is only 116 pages long. It has a big idea - viz: schools institutionalise learning and stultify creativity, they are good for teaching but not for learning; much better to close them down and have open access to learning networks, where learners can borrow resources and arrange to meet fellow citizens in possession of the skills they want to learn. It's radical!

For me it would involve dismantling one of society's greatest achievements - universal education - so that people can more easily learn basket weaving and car maintenance rather than the broad curriculum needed to participate in a modern economy. There are a lot of problems with our education system but Deschooling Society and its rhetoric is no solution. Of course, we were invited to read the book because Illich's ideas about learning networks resemble the open educational resources we are exploring and creating on our Edupunk course. But these resources are additional - an extension - to the teaching and learning found in schools, colleges and universities. It seems to me that most OERs are the product of an already educated elite sharing resources amongst itself. Surely a society wide version of Summerhill would only perpetuate inequalities, favouring those who have parents with cultural capital, money and power. It is schools - properly organised and with resources targetted at the early years - that offer the possibility of a more egalitarian society.

Wednesday, 30 November 2011

Compassion Fatigue and Trauma Work


On Tuesday 29 November my students and I watched a DVD about secondary trauma, compassion fatigue and burn out; all conditions that can effect individuals working with clients who have suffered psychological trauma. Those of us who work with children are particularly at risk of developing a reaction - the vulnerability of children and an inbuilt need to protect them from harm can leave us feeling powerless and helpless when faced with a child's distress and suffering.

Secondary Trauma

Secondary trauma is a term used to describe a range of symptoms effecting individuals who attend traumatic incidents where people are killed or seriously injured. Fire fighters, police officers and paramedics are particularly at risk; but individuals working as nurses, doctors, therapists and support workers, caring for traumatised individuals, can also develop the symptoms of secondary trauma. Our ability to empathise with others leaves us vulnerable to traumatic reactions when we are helping individuals who have experienced overwhelming amounts of distress. Individuals exposed to secondary trauma may experience symptoms that are similar to Post Traumatic Stress Disorder (PTSD), a condition that effects individuals directly involved in the traumatic incident: flashbacks, intrusive thoughts, nightmares, depression, anxiety, avoidance, anger, hyper-vigilance, alcohol and drug misuse.

Compassion Fatigue

Individuals regularly working with the victims of trauma and abuse may develop or be at risk of developing compassion fatigue. Overwhelmed by the amount of traumatic information he or she is seeing, feeling and hearing, the individual's mind reacts to protect the individual. This involves closing down emotionally so the person is no longer emotionally available to their clients (and family); the individual may become tired, impatient, cynical and dissociated from their work. Stress builds and individuals react by becoming frustrated and angry. Losing our sense of humour is one of the first signs of compassion fatigue. An individual my also lose their common sense and become angry - passion replaces compassion. In these circumstances the individual needs to take a break. Once he or she has recharged his or her batteries the zest for work usually returns.

Burn Out

If the individual continues to work with trauma, despite experiencing compassion fatigue, then he or she may go on to experience burn out. In these circumstances the individual loses their desire and ability to do their job, a state of total exhaustion takes over, often accompanied by depression. The individual's mind and body is in revolt and will not allow them to continue being with distress and trauma. Recovery from burn out may take many months, or even years, and often results in a change of role for the individual or even a change in career.

Protecting Workers

Advice from senior professionals on the DVD centred on the need for a work-life balance: plenty of sleep, rest, exercise, sex, relationships, interests and hobbies, innoculate the trauma worker against compassion fatigue and burn out and increases resilience. At an agency level there is a need for supervision in order to help workers off load. Individuals new in post are particularly vulnerable to trauma reactions so effective training and support is essential.

Questions

How did you react to the DVD? What issues were important for you?

List some of the signs of stress in you and your colleagues?

Individuals working with children may be particularly at risk of developing compassion fatigue. What do you do to maintain a work life balance?

Further Reading

Educating Child Welfare Workers About Secondary Trauma and Stress: HERE

Saturday, 26 November 2011

Book Review: The Heroic Client by Duncan, Miller and Sparks

The Heroic Client is wonderfully polemical – a fearless examination of contemporary medical approaches to mental illness and its treatment. The book targets the pharmaceutical industry and the psychoactive drugs it produces. It attacks the medical model and its tendency to define mental illness reductively in terms of ‘biochemical imbalance”. The authors are sceptical of approaches that stigmatise individuals and reify the causes of mental illness by applying biological models and questionable diagnoses - an approach that turns clients into passive recipients of behavioural treatments and tablets. The authors ask for clients to be cast in a different light - competent, resourceful, and resilient – with the agency and self-efficacy to find solutions and make positive changes.

The book begins with a chapter entitled, “Therapy at the Crossroads”, in which the authors warn of a situation developing in which counsellors and psychotherapists exclusively work for medical practitioners. In these circumstances the medical model becomes the only way of explaining mental illness, with the therapist as an adjunct to medication, a fixer of broken people. In chapter two the authors challenge the supremacy of the medical model, calling into question the evidence base on which it rests and suggesting other constructions of mental health and mental illness that include the social context and the personal history of the client.

At the heart of the book are three chapters that provide an alternative to the established diagnostic approach. In examining the client’s story for signs of pathology the medical model misses an alternative interpretation of the client’s experience, one in which the client endures or overcomes trauma and loss through the discovery and use of social networks and inner resources. The ‘heroic client’ has a different tale to tell once he or she is freed from the template imposed on them by pathologising and medicating mental health professionals.

To support the heroic client practitioners ensure their therapy is client directed (chapter three) and outcome informed (chapter four). In my favourite chapter, rich with case material, the book highlights the importance of identifying and exploring the client’s theory of change (chapter four). The authors refer to research carried out on the innovative hypnotherapist Milton Erickson in the 1980s. Nobody could quite understand how he worked out which intervention his clients needed for recovery to take place. Eventually the researchers realised that Erickson didn’t know either, but that his clients did. Erickson listened to his clients and from them he discovered what they needed in order for therapeutic change to take place.

The book contains a critical examination of psychoactive medication. The fact that so many children are being prescribed stimulants and anti-depressants ought to concern us all. The authors explain just how flimsy the evidence is supporting anti-depressants, with many proving hardly more effective than placebos. So, this book is a cri de coeur – urging therapists to stand against the drug companies and the medical model and to listen instead to clients and their heroic stories. A very good read!

Thursday, 24 November 2011

A "Victim Letter" - the Start of a Process


The BBC News Website have a story here about a young burglar, under the supervision of the Youth Offending Team and required to write a remorseful letter to his victims. The young person does write a letter but instead of saying sorry, he blames the victim for leaving open the kitchen window, living in a high crime area and not closing the living room curtains. His last sentence is, "But anyways I don't feel sorry for you and I'm not going to show any sympathy or remorse".

The police released this letter to the public as a warning for householders to close their curtains. I would imagine they did this without consulting the Youth Offending Team or the Probation Service. The police often have their own agenda in these matters and don't see how their actions actually undermine public confidence in the Criminal Justice System. As a result we have a number of agencies rushing to defend the principles of restorative justice and someone from the Ministry of Justice providing a bland statement on the effectiveness of Intensive Supervision.

Of course restorative justice is only meaningful if the offender feels and expresses genuine remorse. If that happens then the results can be very positive for the victims and the offender. This type of response was never going to be sent to any victims, rather it is the beginning of a process in which the views expressed in the letter can be challenged and changed. If I was working with this young offender I would thank him for his honesty; I would then begin the process of confronting the beliefs and values that underpin the thoughts expressed in the letter. This young man (and I am assuming it is a young man) has no empathy for the victim, takes no responsibility for his actions and feels no remorse. It's the job of the Youth Offending Team to address those deficits. No need for outrage, just good probation work!

Wednesday, 23 November 2011

Book Review: An Anatomy of Addiction by Howard Markel

My favourite book this year turns out to be An Anatomy of Addiction: Sigmund Freud, William Halsted and the Miracle Drug Cocaine by Howard Markel. Such an enjoyable read: a good story, well written with humour and insight from a doctor and professor of the history of medicine.

Markel provides some entertaining chapters on the discovery and early use of cocaine. It was used as a pick-me-up added to soft drinks and wine, as a cure-all for the depressed and liverish and as a local anaesthetic that revolutionised surgery. By the time cocaine's addictive and destructive properties were recognised thousands were addicted to the drug.

Markel's account of Freud's cocaine use is fascinating, fair and balanced, an antidote to E.M. Thornton's tendentious Freud and Cocaine - also reviewed on my blog here. He describes Freud's early research into the drug's medicinal properties, including the disastrous treatment for morphine addiction of his friend, Ernst von Fleischl-Marxow. Despite his friend's double addiction to morphine and cocaine and resulting death, Freud became an advocate of cocaine and used the drug himself for around ten years. It is fascinating to consider how much cocaine influenced Freud's ideas in the 1890s, including his Analysis of Dreams.

William Halsted was a contemporary of Freuds. He has been called the father of modern surgery. He advocated the antiseptic approach of Lister, and at a time when surgeons operated in dress coats, insisted his staff wear surgical garb, scrubbed their hands and don rubber gloves. He developed new operations and new treatments and yet throughout his career he was addicted to morphine and cocaine. Halsted's cocaine addiction began when he started testing the drug's anaesthetic qualities, injecting himself under the skin and cutting himself to see how deep he could cut without pain. Soon he was addicted. His friends and colleagues attempted to rehabilitate Halsted whilst preserving his reputation. Thus they sent him on a sea voyage to wean him off the drug and when this failed he was sent to a mental hospital where he was prescribed morphine in order to manage the symptoms of cocaine withdrawal. Halsted was addicted to drugs for the remainder of his life but managed to control his drug use (but with frequent relapses) thanks to a huge effort of will. After some years working in the pathology lab at the new Johns Hopkins University Medical School he was appointed to a professorship and continued to advance the profession of surgery until his death in 1922.

Markel's book provides an entertaining account of the lives of these two great Victorians, advancing the cause of medicine whilst battling their own demons and the problems of drug misuse and dependency. An excellent read!

Monday, 21 November 2011

Book Review: What is Madness by Darian Leader

I’ve just finished reading Darian Leader’s latest book, What is Madness? It’s an absorbing read – sometimes difficult – but ultimately, fascinating and humane. Leader explains the roots of psychosis using the psychoanalytic theories of Jacques Lacan and at times the explanations seem rather more complex that the phenomena being explained. The discussion of Lacan’s client, “Aimee”, for example, is labyrinthine in its use of competing psychoanalytic explanations for her psychosis and behaviour. That's why I appreciated Leader's comment that, "A psychoanalytic theory of psychosis does not imply a psychoanalysis of psychotic subjects" (294). Indeed Leader points out that individuals experiencing psychosis are suffering from too much meaning and do not benefit from the interpretations of therapists.

The book opens with a chapter entitled, “Quiet Madness” in which Leader draws our attention to a mistake commonly made in conversations about psychosis. According to Leader it is wrongly assumed that madness and the visible symptoms of madness are the same thing. For Leader the symptoms of madness - hallucinations, paranoia, delusions - are the individual’s attempt to make sense of the horror that has befallen him or her: ‘responses to madness, attempts at self-cure’ (17). This is a fascinating insight and extends my own belief that emotional disorders such as depression or anxiety are perfectly functional when seen in the context of the individual's history and current experience. This realisation ought to guide the therapists approach. Attempts to remove the symptoms of psychosis without helping the patient to explore their condition may well interfere in the process of self-healing. As Leader says, medication is useful because it tempers the intensity of psychotic symptoms but should also serve as a 'platform for dialogue'.

Leader emphasises the importance of symbolism and language when explaining madness. He sees madness as a breakdown in these structures, resulting in a terrifying loss of meaning and a disconnection from reality. In response to this the individual cobbles together what he can to make sense of his experience. This may show itself as paranoia or other delusions. The individual may believe he or she has been abducted by aliens if this restores meaning and makes sense of a catastrophic event. Psychotic individuals (and psychoanalysts?) cling to the most unlikely ideas in their attempt to make sense of the world.

In what Leader calls, “Quiet Madness”, the individual may appear balanced, keeping his delusional world under wraps and thereby achieving the semblance of normality. In an interesting chapter, Leader suggests that the serial killer, Harold Shipman, is an example of “Quiet Madness”. To his patients and colleagues he appeared to be a professional, kind and diligent doctor; but it was this role that enabled Shipman to stabilise his madness, part of which involved the murder of hundreds of patients.

Leader argues that quiet madness can erupt into full blown psychosis through various trigger events, often associated with rites of passage. Marriage, divorce or having a book published, all have the potential to trigger psychosis: moving the individual from ‘being mad’ to ‘going mad’. Events have this potential because they require from the individual a new set of symbols, and if the individual cannot symbolise this transformation they are at risk of becoming psychotic. Leader spends several chapters exploring this process so my summary here is incredibly superficial.

The final chapter of this complex book suggests ways of working with psychosis. Following his hero, Jacques Lacan, the author uses the metaphor of the secretary - to quote Lacan, the therapist ought to be, “the secretary of the alienated subject” (305). Leader likes this description, likening the therapist to a secretary who faithfully records, asks for clarifications and doesn’t intrude too much (305). The therapist as secretary helps the client to build a personal history, helps the individual to explore their own frame of reference and thereby helps in the work of self-healing. Leader is honest about the amount of time, hard work and commitment required to work with clients experiencing psychosis. He is hostile to therapies that seek to return clients to “normal” and measure success by how far their clients have adapted to social and community norms. Instead Leader suggests that an “investment in dialogue and a curiosity about the logic of that person’s world can open up new therapeutic directions and offer the possibility of change. Therapy can do no more and no less here than to help the psychotic subject do what they have been trying to do all their lives: create a safe space in which to live” (330).

Leader, D. (2011) What is Madness? London, Hamish Hamilton

Monday, 14 November 2011

The Immortals Will Not Live Long in the Memory

Last night I went to the cinema to watch The Immortals 3D. I have to say up front that I am fussy in my movie viewing and have high expectations. I want films to be intelligent and to tell a good story with rounded characters I can believe in and empathise with. I am often disappointed and in The Immortals (I now realise) I was bound to be disappointed since it isn't that kind of film.

First of all I have a beef with 3D. There are a few moments when 3D is amazing, when objects float in mid air between the viewer and the screen. But these moments are so rare that they do not justify watching a film wearing sun glasses. What the viewer gains in depth of field he or she loses in brightness and colour. I have seen two films in 3D just recently and with both I wanted to say, 'Can someone please put the light on'.

On a positive side the Immortals has some spectacular computer generated imagery and the beefcake actors are lovely to look at. But the film is a disappointment because it presents charactures rather than characters: the evil Hyperion is covered in scars and crushes people's heads when they bring him bad news. He seeks to destroy mankind because the gods failed to save the lives of his wife and child. Thus he holds a special contempt for priests, setting fire to one after dowsing him in oil. This is all we know about Hyperion, a villain with no back story and no complexity, someone we can hate with a clean conscience.

The heroic Theseus is physically perfect but incredibly boring. We know nothing about him except he loves his mum, wants to protect poor people and has been blessed by the gods. He is naive and seems like a school boy in a man's body. When he makes a speech to raise the morale and stiffen the resolve of his army it isn't convincing. One soldier shouts, 'Who are you to lead us?' A good question! The response, 'I'm an ordinary Joe like you' didn't inspire much confidence.

At the same time as this human conflict is being acted out to it's predictable conclusion, complete with references to future conflict, in case this makes money and a sequel is needed, a conflict also rages in the heavens. The Olympians led by Zeus intervene once Hyperion unleashes the Titans. Keats' poem Hyperion has a wonderful image of a Titan led on the beach, the poet is able to communicate the vast size of the Titan in just a few sentences. In this film, and with all this technology to hand, the Titans are presented as imps, moving at Benny Hill speeds, they seem an unlikely scourge. Zeus joins the battle and at this point the stylised fight scenes, with heads and bodies hacked and smashed, tip over into silliness and a memory of the Ninja Turtles came into mind.

But more disappointing than all this was the plot. The 300 was a much better film, despite it's right wing agenda and xenophobia, because it told a simple story well. Not so The Immortals; which is a shame because the Greek Myths contain eternal truths, wonderful metaphors and great events. The Immortals captures none of this. Even Troy was better!

Wednesday, 9 November 2011

The Lobotomists on BBC Radio Four

I have just listened to an excellent BBC radio programme on the history of the Lobotomy. Hugh Levinson, the producer and presenter, has written a BBC News article about the programme here.

The programme was about the short lived idea that patients living with mental illness could be cured if only the connections between the frontal lobes and the rest of the brain could be severed. The operation (called a Leucotomy in Britain) involved drilling holes into the patient's skull just behind the eye sockets and below the temples, and then inserting a long spike, like an overly long ice-pick, into the brain to make cuts behind the frontal lobes. One commentator observed that the procedure contradicts the standard medical view that cutting healthy tissue tends to make things worse not better.

The programme featured three famous exponents of the procedure: Egas Moniz in Portugal, Walter Freeman in the States and Sir Wylie McKissock in the UK.

The Lobotomy was popular throughout the 1940s and into the '50s. The programme estimated, for example, that within that short period Sir Wylie McKissock carried out 3000 lobotomies. He would even tour provincial hospitals at the weekends operating on patients. Freeman also was an advocate of the procedure, even making a movie to advertise the benefits of the operation.

Shockingly there was no research done into the procedure and no follow up investigations to see how patients recovered after surgery. The Lobotomists convinced themselves that about a third of patients were helped by the surgery whilst the rest were no worse for it. There was no evidence for this and in fact many patients suffered catastrophic harm as a result of the treatment. With the discovery of anti-psychotic medication in the 1950s the practice faded. The history of medicine is full of such horrors.

Sunday, 6 November 2011

Book Review: Integration in Counselling and Psychotherapy by Lapworth and Sills

I teach on a counselling course that requires students to make sense of a number of different approaches to therapy; so I've been giving a lot of thought to integration and how it can be successfully achieved. After reviewing Cooper and McLeod on my blog here I have turned my attention to Lapworth and Sills and the second edition of their Integration in Counselling and Psychotherapy. The two books are similar because both are concerned with giving the reader an over-arching framework to help make integration possible; but whilst Cooper and McLeod provide one approach to integration - pluralistic counselling and psychotherapy - Lapworth and Sills provide an overview of what is needed if integration is to be achieved, their own model of integration - the Multi-dimensional Integrative Framework - and brief chapters on four other approaches, including a chapter on the therapeutic relationship and an outline of Multi-modal Therapy.

I am trying to work out why I disliked the first part of Lapworth and Sills. I found it too theoretical. I was left wondering how I had managed the task myself of integrating different counselling approaches. I was reminded of the cartoon strip in which Garfield the cat is stuck on the stairs after wondering how on earth he was able to co-ordinate the movement of his four legs. I could be at fault because I'm more of an activist when it comes to learning, which may also explain why my favourite chapter in the book is a case study of the Multi-dimensional Integrative Framework in action. But I don't think it's the theoretical nature of the material in these early chapters that's the problem, rather it's the lack of time taken to explain and illustrate what is being said. I was left with the sense of skating across the subject because of the authors' preference for summaries, outlines and bullet points. This tendency can also be seen at the end of the book when the authors give a brief outline of four competing theories of integration. It can also be seen in the first chapter where the authors give a potted history of integration in counselling whilst apologising because they don't have room to explore the topic further.

So for me the life saver, the thing that enabled me to go on reading, is the diagram on p89 and the case history that forms chapter six. Here the authors apply their Multi-dimensional Integrative Framework and the reader gets to see how useful it is as a model for explaining the problems experienced by the client, how these might be addressed (a formulation) and how therapy is progressing over time.

The authors argue in this book that in order for integration to happen successfully the therapist must have an over-arching framework that gives the therapist an understanding of human beings and of therapy and informs the choices the therapist makes about the strategies and techniques to borrow from different schools of therapy. It is the over-arching framework that gives those choices coherence and therapeutic power. I am reminded yet again of Yalom's point about creating a therapy for each client and I'm happy that ultimately Lapworth and Sills provide a way of doing that - and summaries of alternative frameworks that the reader can investigate further.

Friday, 4 November 2011

Marg Simpson Sees a Therapist for Her Flying Phobia


First click of play gives you a pop up, which you close, second click gets you the movie at which you can laugh!

Today @Shrink_at_Large Tweeted the link to a funny Simpsons video in which Marg sees a therapist to cure her flying phobia. In true Freudian style Marg lies on the couch and free associates. With the “help” of her therapist she’s able to trace her anxiety to a time when she caught her father working as a stewardess on a passenger jet. I say in true Freudian style because one of Freud’s most famous cases, The Wolf Man, was neurotic, according to Freud, chiefly because he’d intruded on his parents having sex. In fact Freud himself wrote about seeing his mother naked on a train, an image the young Freud found both disturbing and memorable. As with a great deal of Freud, what begins as theory turns out to be autobiography.

So the scene in which Marg intrudes on her father serving drinks has a pedigree. Interestingly Marg also remembers other train related trauma, such as the engines of her toy plane bursting into flames or being machine gunned by a crop duster whilst walking past a field of corn. These are discounted by her therapist in favour of the more significant trauma of seeing her father working his way along the aisle. Marg’s phobia only becomes apparent to us when the Simpsons are given free air tickets. These are to buy Homer’s silence after he crashes a plane whilst pretending to be a pilot (which he does to get a drink in a pilots only bar). Maybe it’s this parallel that leads to Marg’s crisis: all her life the phobia had served as a defence, enabling Marg to avoid planes and airports - and ultimately the memory of seeing her father serving cocktails on an economy airline.

Wednesday, 26 October 2011

The Cycle of Change



A particularly useful model for counsellors and clients is the cycle of change, developed by DiClemente, Prochaska and Norcross and described in their very readable book, Changing For Good. The video (above) is an interview with Carlo DiClemente co-developer of the model. The cycle of change is an excellent tool for understanding the process of change and for identifying where people are in the process. The model also provides a guide to the interventions that best support individuals at different stages in the cycle. The authors argue that the wrong intervention at the wrong time may actually hinder the process of change, raising defences and entrenching denial in clients.















Before individuals enter the cycle they are in a stage that DiClemente calls “pre-contemplation”. As the name suggests, individuals in this stage may be unaware of their problem or deny that the problems exists or affects them. Denial is an active process that involves pushing a problem out of awareness and a fascinating subject in itself. The appropriate intervention in this stage of the cycle is consciousness raising through the provision of information. A successful intervention helps the individual to the next stage of the cycle, which DiClemente terms “contemplation”.

When an individual begins to consider the possibility of change he or she has entered the “contemplation” stage of the cycle. This stage is marked by ambivalence, commonly expressed by clients in the form: “Part of me wants to make a change but another part wants to keep things as they are”. Resolving this ambivalence is the key task for individuals before they can move to the next stage of the cycle.

Two approaches to resolving ambivalence can be employed here. The first approach to resolving ambivalence is to create within the individual a psychological state known as cognitive dissonance. This state occurs when an individual’s actions are in conflict with his or her values. Cognitive dissonance is resolved when changes are made to bring a person’s behaviour in line with their values. The second approach is the decisional balance exercise in which clients are invited to consider the short-term and long-term positive and negative effects of their limiting behaviour. This also increases levels of cognitive dissonance in the individual as they recognise that the long-term consequences of their behaviour are negative.

Ambivalence is resolved when the individual moves to the next stage of the cycle, the “decision” or “commitment” stage. In this stage the individual decides to make a change or makes a commitment to the change process. It is commonplace for individuals at this moment to slip back into ambivalence or, more helpfully, to move round the cycle a little further to the “action” phase. The counsellor can reinforce the client’s commitment to change through genuine praise and by focusing on the gains that will be realised once changes are made.

The action stage of the cycle is the point at which the client prepares to make changes. Methodical preparation is a key factor in successful change. Counsellors can support their clients in this phase of the process by helping with goal setting and action planning. Effective goal setting and action planning can create a compelling future that pulls the client towards the next stage of the cycle: the maintenance of new and desired behaviours.

In the maintenance stage of the cycle the individual successfully creates change in their lives and sustains it over a period of time. If change is maintained then permanent change takes place and the individual leaves the cycle. Maintenance requires conscious effort. Permanent change has occurred when the new behaviour has become automatic, natural or effortless. Helpful interventions in the maintenance stage of the cycle include “old self” v “new self” comparisons, listing the gains and good feelings associated with the new behaviour and importantly relapse prevention.

Preparing clients for the possibility of relapse may seem like a risky thing to do, as though acknowledging the possibility of a relapse might bring it on. But exploring and planning for a relapse is preventative work and provides the client with the knowledge and skills the will need to manage a lapse and return to the maintenance phase of the process. If a lapse turns into a relapse the counsellor can reframe the relapse as essential learning - another piece of the jigsaw – on the way to permanent change. DiClemente discovered that individuals tended to go round the cycle a number of times before reaching permanent change, but each trip round the cycle is developmental and prepares the individual for their next more informed attempt at change.

Thursday, 20 October 2011

PowerPoint as an On-line Resource












It never occurred to me before to embed links into my presentations for learners to access on-line. That's because I have associated PowerPoint with "front of the class" presentations. Embedding links turns PowerPoint into a powerful on-line resource. This is one simple way to introduce learners to connectivism and the edgeless university. So, with a PowerPoint I can present my slides with narration, include links to websites and videos and then link students to a wiki where they can write their thoughts and reactions. Just like I've done here. And although I am providing the links, once my learners click on them who knows where they'll go! I am going to complete the learning cycle now and develop my own enhanced PowerPoint.

Thursday, 13 October 2011

Teaching in the 21st Century

I have just finished a thirty minute Webinar with students on my Working with Abuse course at the University Centre, Blackburn College and now I’m writing a blog about it. I have emailed a link to a recording of the Webinar to all my students so those who could not attend have an opportunity to see what they missed. In my Webinar I referred to a BBC radio programme, which I have now uploaded to Moodle, the University Centre’s virtual learning environment. I am creeping into the 21st Century.


As far as my willingness to use technology goes I’ve come a long way in just a few years: from a sceptic who refused to use PowerPoint to an enthusiast who advocates the use of technology enhanced learning (TEL).

My dislike of PowerPoint presentations grew out of the numerous probation service staff training days I attended. It was a struggle to keep awake during 150 slides on the Criminal Justice Act (2003) or some other bone dry topic. Each slide featured probation service corporate colours and fifteen bullet points - there was little relief from this monotony.

I now use PowerPoint as a backdrop to my lectures - pictures, videos and music punctuate the lesson and change the state of learners. My PowerPoint presentations are uploaded to Moodle for students to print if they wish. I’m currently experimenting with slideshare.net but my next real challenge is to begin adding a commentary so students can hear me expand on the bullet points I have listed and then the presentations will make much more sense.

The Webinar is another experiment and with mixed results. My students can see and hear me and they can write questions in response to what I am saying, but there is little interaction as yet. My job is to work my way through the PowerPoint students can see when I’m sharing my desktop. Unfortunately anymeeting.com has had a redesign since last week and I couldn’t get the desktop sharing function to work. This prevented me from sharing important diagrams and pictures. My experience of the Webinar is therefore pretty mixed. Interaction is limited and when the technology doesn’t work I am left with a strong sense of “just talking to myself”. Maybe a better way of transmitting knowledge is the tried and tested YouTube video – so popular that I’m about to go back into production!

The transmission of knowledge over the Web does allow more time for experiential learning in the classroom: discussion, exploration and interaction. I am using technology to enhance this too. I take pictures of students as they work in pairs and triads - capturing examples of rapport building that I upload to Moodle. I photograph work we have done on the whiteboard and on flipchart paper. Sometimes students let me take movies of their presentations and counselling sessions, which I also upload to Moodle. Finally the assessment of learning has incorporated technologies, including the audio and video recording of counselling sessions and presentations. The key question then – is this enhancing the learning experience of students? There is much more that I can do to make use of TEL and I shall keep you posted!

Sunday, 2 October 2011

Facebook, Twitter and Professional Boundaries

Counsellors are increasingly likely to use Twitter, Facebook and blogs to promote their practice and communicate with other professionals but can appropriate professional boundaries be maintained when using social media?

Over the summer I signed up for my first ever Facebook account and began collecting ‘friends’. Some were friends I had known for decades, some were ex-students I’d taught over the years and many were current students.

My intention was to create a social network that would allow me to interact with my friends and connect with my students. I began by posting links to interesting articles and research papers, complimenting people on their achievements and posting supportive comments whenever any of my new Facebook family met with adversity. Very quickly I became a witness to my students' unfolding personal dramas: nights out, hangovers, family celebrations and emotional crises. I have to say it felt inappropriate and after just one week, following discussions with colleagues, I deleted my first Facebook account.

I learnt two lessons from my first experience on Facebook. Firstly, I ought not to have mixed professional relationships with social relationships. Secondly, even though I might have been circumspect about the information I posted, I was nevertheless exposed to personal information about others that crossed professional boundaries. I am back on Facebook now with much stronger boundaries. I only accept friend invitations from people who really are personal friends. My response to students, supervisees and clients who wish to add me as a friend is heartfelt: let's not jeopardise or sacrifice a valuable professional relationship for something that is likely to be fairly superficial.

So how can I use social networking to promote my practice, share information and connect with other professionals and the public (including students and clients)? I have discussed this with colleagues and need more feedback as I tentatively embrace this new technology as a teacher, counsellor and supervisor. Here are three "platforms" I'm currently using:

Facebook Pages allow me to post on Facebook as "Marsden Therapy". Individuals can “like” my page and receive my updates but they have no access to my personal Facebook profile and I have no special access to their personal information either. This is still a work in progress as I haven’t developed my page yet or added any interesting content.

Twitter allows me to follow and communicate with other mental health professionals, post links to articles and feel part of an international community of counsellors and psychotherapists. I occassionally comment on things I’m doing but the vast majority of my posts are about my work and research interests. I have encouraged my students to follow me but I do not follow them and so far there have been no boundary issues.

Blogging is something else I like to do and again I’m working out what is and isn’t appropriate for a counsellor to share on a public forum. I want my personality to come through but I don’t want the blog to become too personal. At the moment I’m sticking to book reviews and mental health topics. But as my confidence as a blogger increases maybe I will relax and write more freely about my experiences.

Sunday, 25 September 2011

Keep Listening in HM Prisons

I was concerned to read in a Guardian article here that the prison listeners service may be under threat because of government cuts. Prison listeners are trusted prisoners who volunteer to be trained in listening skills by the Samaritans. Whenever other inmates are feeling suicidal or depressed they are padded up with a listener who can then help them to talk and share their feelings. The article states that prisoners volunteering as listeners help the prison staff to manage suicidal and depressed prisoners. I have visited prisons that have a listener's cell on each wing. It's a little roomier than your average cell, in recognition of the valued work that's being done in there and the need for more space. Prisoners rightly wear their volunteering as a badge of honour because when you are a listener you are in a position of trust.

So the listener service benefits those prisoners experiencing distress because they have someone to talk to who has an idea what it's like to be in prison, separated from family and friends. It benefits the prison service because they are having suicidal prisoners monitored in a cost effective way. It helps to rehabilitate offenders because they are learning and applying listening skills underpinned by empathy and compassion and one of the greatest challenges in the rehabilitation of offenders is making up for deficits in empathy and compassion. So rather than cutting the listeners service I would expand it: teaching as many prisoners as possible basic counselling skills, running prisons in more democratic ways, modelling constructive rather than aggressive ways of using power. This approach has been used in Therapeutic Communities and in institutions committed to the principles of restorative justice. It needs to operate across the whole prison - inmates and staff - and is an alternative to the power dynamics that currently rage in HM Prisons, where might is right and were it makes complete sense to remain emotionally detached and physically aggressive.

Friday, 23 September 2011

Personal Reflections: New Job, Good Feelings

Thursday was an important day for me. I attended a job interview at Blackburn College and was successful in my application for the post of part-time lecturer in counselling. An 18.5 hour contract in the place where I have enjoyed more than ten years as an hourly paid lecturer. I am very happy and excited to be given this contract, it's an exciting time for our expanding range of counselling courses at the University Centre.

Something unexpected happened during Thursday which has had a major impact. It was the amount of support, the good wishes and the affection I felt from so many people. There were Facebook comments, text messages and emails, as well as the support from friends and colleagues all around the building. I felt loved and valued to a degree I have not experienced since my counselling diploma ended ten years ago. I think I played a part in that too. I let people know that I was going for the job, I asked for help and gave people opportunities to offer kind words and encouragement. I think the old me (and it still happens) was too mistrusting of people and too frightened of feeling rejected to ask for help. Of course this does my friends a disservice and denies me the love I need and deserve.

As well as feeling loved I felt a strong sense of belonging. As I walked around the University Centre I knew so many people and have known many of them for such a long time. I attended the college as a 17 year old in 1986 to retake my 'O' Levels. A couple of my good friends were teachers back then, teaching government and politics and helping me get into university. That's not to say I am institutionalised. I've worked in private industry, the voluntary sector and for the probation service. When I worked in the private sector and with probation I never had a sense of belonging and neither job enabled me to live my mission quite like teaching at Blackburn College.

So, lots of learning from this week. If I continue being open about my feelings, ask for help and offer love and respect to others, then I create opportunities to feel love in return. I can travel all the way up Maslow's hierarchy of needs: to esteem and self-actualisation. I am not a religious person but I am sure Ecclesiastes had it right: 'Cast thy bread upon the waters and it shall be returned unto thee".

Sunday, 18 September 2011

Getting Back at Dad - Edward II at the Royal Exchange Theatre, Manchester

Last night I watched Edward II by Christopher Marlowe at the Royal Exchange Theatre, Manchester. I first saw the play in 1996 at the Bolton Octagon, when the production was given an optimistic ending, suggesting a spiritual reunion of the lovers after death: Gaveston as murderer, holding Edward in his arms beneath a cascade of rose petals. On reflection that ending seems out of sympathy with the play's pessimism. It romanticises Edward’s love for Gaveston, portraying it as some Platonic ideal, rather than an expression of hubris and defiance.

Toby Frow, director of last night’s production, provides a more faithful ending that also uses the same actor to play Gaveston and the murderer Lightborn (the excellent Sam Collings). It reminds us of Gaveston’s role in Edward's destruction and helps to provide the play with its sense of tragedy.

The production is excellent. It is set in the 1950s and begins in a rather louche club with a jazz band playing. The movement of furniture between scenes is sufficient to anchor a sense of changing time and place. Sometimes the place we are in is the disintegrating mind of the defeated King. In the final scenes the helpless Edward remains visible in his dungeon whilst we return to the Court to hear the plots of Queen Isabella and Mortimer.

The historical Edward II was emotionally deprived and bullied by his warrior father. When Edward’s affection for Gaveston, a childhood friend, became too intense, Edward’s father sent Gaveston into exile. Imagine how that must have burned in the young man’s heart? Chris New brilliantly plays the King as an emotionally undeveloped and slightly camp young man. In Act One Edward is prone to adolescent anger and flights of haughty rhetoric, but there is innocence there too, beautifully captured by New. The innocence turns to murderous wrath as the Lords opposition to Gaveston unleashes unresolved Oedipal rage that is never quenched.

Marlowe's play is a bleak portrait of human nature: each character is corrupted by the power they seek. Edmund's expresses his love for Gaveston but soon chooses another favourite once Gaveston is dead. It is a symbol of defiance that Edmund needs not a man to love. Edward’s love for Gaveston is narcissistic and reckless. It provokes others to take away his Kingdom so he can have his revenge. In the end he is undone and we are left feeling pity for a man brought down not by love but by hubris.

Thursday, 15 September 2011

Book Review: Resilience by Boris Cyrulnik

Boris Cyrulnik is a French psychiatrist and psychoanalyst who has worked with deeply traumatised children in Rwanda and Columbia, children who have survived genocide or served as soldiers. I mention this because Cyrulnik himself points out that an individual's traumatic history is often revealed in his or her choice of career, and Cyrulnik's history is certainly traumatic: a child during the Second World War, he evaded the Nazis by working on a farm, whilst his parents, like thousands of other French Jews, were arrested by the French police and deported to Auschwitz where they were murdered by the Nazis. Cyrulnik says that after the war nobody wanted to hear his story, it didn't fit with France's need for de Gaulle's narrative of resistance and liberation. So, like numerous victims, before and since, Cyrulnik adapted to his environment and developed a secret history, 'splitting' his personality into acceptable and unacceptable parts until the day when he would have enough strength to tell the whole story. There is a subtext here, and an insight into the French 'collective unconscious', still coming to terms with the events of the Second World War. Cyrulnik points out that cultures often need a narrative that negates the true horror of things. Thus the French war in Algeria, which resulted in the death of 28,000 French soldiers, was termed a 'policing operation' and the conflict in Northern Ireland, with over 3,500 deaths was known as the "Troubles".

Narratives are important for Cyrulnik, they have the ability to defend an individual, as well as a culture, from the horror of things. Cyrulnik's style is aphoristic and discursive so there is no bulleted list of protective factors contributing to a child's resilience, instead Cyrulnik argues that, 'Biological and developmental forces are articulated with a social context to create a self-representation that allows the subject to see his or her life in historical terms' (51). It is the historical perspective that offers redemption: 'The things I've been through. I've come one hell of a long way. It wasn't always an easy journey' (51). The trauma of the victim is reframed as the triumph of the survivor, victor in the face of death! So, Cyrulnik's message is an optimistic one because he believes our histories do not determine our fate, that many individuals experience traumatic events in childhood and go on to live happy and meaningful lives. Like another psychotherapy optimist, Bill O'Hanlon, Cyrulnik argues that the wounds we suffer have the potential to give our lives substance and meaning, they are, or can be, to use Cyrulnik's metaphor, the grit in the oyster that transforms into a pearl.


Wednesday, 14 September 2011

New Term Excitement!


Next week I begin another term of teaching at my local HE college - the University Centre, Blackburn College. I'll be teaching a course called Contemporary Psychotherapies to two groups of BA(Hons) degree students. The course looks at Motivational Interviewing, Neuro Linguistic Programming (NLP) and Cognitive Behavioural Therapy (CBT) and evaluates what they offer to those working with difficult to engage young people and unmotivated adult clients. I'll also be teaching counselling skills to 'eager for knowledge' first year students on the Foundation Degree in Positive Practice with Children and Young People. All the sessions are written, with the resources ready and printed, so they'll be an absolute joy to teach!

Just as exciting are the two new foundation degree courses we are running in Counselling with Coaching and Mentoring and Counselling with Brief Therapies. I am mainly involved in facilitating the personal and professional development modules and I'll be a personal tutor too. In the second year I'll be teaching modules on Motivational Interviewing, Solution Focused Therapy and Group Work Skills. I can't wait for the teaching to start!

Tuesday, 13 September 2011

Book Review: Pluralistic Counselling and Psychotherapy by Cooper and McLeod


If the counselling and psychotherapy profession had a cricket team then Cooper and McLeod might make a fine opening pair. Historically Freud and Jung are the greatest openers we've ever had, though they ended their careers on opposing teams. Sorry, I'm being silly! Cooper and McLeod have written an excellent book on the need for a pluralistic approach to counselling and psychotherapy. They argue, convincingly I think, that no one school of therapy has all the answers when it comes to helping clients make changes; instead the authors recommend an approach based on goal setting and collaboration: an exploration with the client of the changes they would like to make, the tasks that need to be completed to get there and the methods most appropriate to achieving those tasks. Interestingly Cooper and McLeod extend their pluralism to counselling research, training and supervision. So the book advocates a sea change in how we approach therapy, one that is inclusive, drawing on many traditions to makes sure 'each client gets the therapy that is most suited to them' (vi). This seems to be the trend in therapy. I'm reminded, for instance, that Yalom talks of the psychotherapist creating a therapy for each individual client, though I would call it co-creating. It's an approach I follow and I'm grateful to the authors for producing what amounts to a manifesto for the pluralist approach. It's going to be essential reading for students attending my courses on brief therapies, giving coherence to the plethora of different but equally valid approaches they'll study.

Saturday, 10 September 2011

Book Review: Tales from the Therapy Room by Phil Lapworth


There are numerous great story tellers amongst the psychotherapy fraternity, even if I can think immediately only of Sigmund Freud and Irvin Yalom - a lack of knowledge on my part rather than a lack of style on the part of my colleagues. I can reveal another name to join my brief list of fine story tellers, because Phil Lapworth has written a lovely collection of ten short stories about therapy and what goes on in the therapeutic relationship. I read his Tales from the Therapy Room in a couple of ways: firstly, I read them for enjoyment, because each tale is full of humour and pathos; and secondly, I read them with a critical eye on the role of the therapist and the observations and interventions he makes. So each of the stories is both an entertainment and an education. On reflection there is a third way of reading this book, an invitation I have yet to take, and that is to use each story as a starting point for an exploration of practice issues, ethical dilemmas and counselling theory. The book contains what Irvin Yalom calls, "teaching tales". Lapworth helps with this process by providing an interesting final chapter, in which he recommends further reading and asks questions about each of the stories he has so beautifully written. So I will revisit each of these tales and reflect on what they have to say about me, my practice, psychotherapy and the human condition. Thanks Phil!

Lapworth, P. (2011) Tales from the Therapy Room: Shrink Wrapped, London, Sage

Thursday, 8 September 2011

Trainees and Personal Therapy

I think it's true to say that out of all the clients I have worked with, those in training as psychotherapists have initially proved the most trying. Not all of them. There have been notable exceptions where the trainee’s excited absorption in the theory and practice of psychotherapy has been duly match my devotion to an intrepid exploration of themselves from the start. One might expect that this would always be the case, but others have arrived reluctantly, even resentfully, seeing their attendance immediately as a course requirement rather than an opportunity for self-discovery and transformation. They see little, if anything, in need of discovering or transforming. This in itself is, of course, a self delusional problem, much in need of discovery and transformation. While I don't quite put it like that, I do suggest they go away and think about how they might want to use our time together therapeutically.

From ‘Not Playing it by the Book’ by Phil Lapworth in Lapworth, P. (2011) Tales from the Therapy Room: Shrink Wrapped, London, Sage

When I began my diploma in counselling thirteen years ago there was a requirement for twenty hours of personal therapy. In the end I had 50 hours and I've been back since, with different therapists, from different traditions, using different models of therapy. I see this as part of my personal and professional development, an investment in me as a therapist, committed to connecting with others and addressing those parts of me that unconsciously sabotage working at relational depth.

There is, of course, an argument which suggests trainee counsellors ought not to be forced to have personal therapy, that to make someone attend counselling contradicts the counselling ethos of promoting individual choice and autonomy. I see the point, but those same courses see nothing wrong with setting and assessing assignments, and the student who asserts their autonomy by not handing in their assignments doesn’t pass the course. Maybe that isn’t an appropriate comparison; I am not much good at rhetoric, despite a degree in Scholastic Philosophy, so let me instead promote the merits of personal counselling for trainees with a little list:

Personal therapy can promote self-awareness and reflexivity

It enables trainees to experience what it feels like for clients when they come for help

It's an opportunity to work on personal issues in a safe space. It provides a confidential place to take personal issues that may result from reflective practice and supervision

It’s much better to work on distressing experiences in personal counselling than to have them activated by a distressed client during a counselling session

Working with an experienced therapist provides an opportunity to model how they work and to experience a therapeutic relationship. It is also an opportunity to experience different approaches to therapy

I’d be interested to hear arguments against personal therapy for trainees, especially from those providing personal therapy. I think I will need some convincing before I stop advocating personal counselling for trainees. And if Liz Johnson my first therapist ever reads this – thanks for what you did Liz and how you did it!

Friday, 2 September 2011

Joan Halifax on Compassion




Twitter promotes serendipity - one of my favourite words - to make fortunate discoveries by accident. I was sat at my desk, doing some lesson planning for the upcoming academic year, when I just happened to check my Twitter feed. I found a post from @psychoBOBlogy which contained a link to a video of Joan Halifax giving a short talk at a TED conference.

She talks about compassion and she says that compassion means, "To see clearly into the nature of suffering". She says that compassion is to desire the transformation of suffering but that compassion is not being attached to an outcome, but instead to be "fully present to the whole catastrophe". I think this credo could be a guiding light for counsellors and psychotherapists, sometimes we need a guiding light to guide us home, and then we can stop fixing things and be fully present to the whole catasrophe.

Well I watched Joan's passionate and moving presentation and I wanted to share it with you on this Blog. Maybe someone here will stumble across it by accident and be moved to share as I was moved.

Wednesday, 31 August 2011

Punk Education - Learning with Twitter!

I have been using computers since the 1980s, when I bought my first (and last) Amstrad. It was a portable, which meant it had it's own room in the house. How I marvelled at the green screen and dot matrix printer! Now I'm marvelling again, at the way I'm able to access and manage so much useful information flooding over the Internet. Google Chrome has taken my browsing into another realm: all my favourite sites are on the tool bar, snazzy extensions give me instant access to news feeds and the Evernote clipper. I can write a blog from there and shorten a long url before posting to Twitter.

I have been using Twitter as a research tool, checking out the articles posted by the Tweeters I follow, those interested in counselling and mental health. When I find a good article I return the favour and in this way a community of learning - a professional network - is built across the Web. My colleagues, Craig and Phil, at University Centre, Blackburn College, refer to this as "punk" education - learning that is informal and democratic, technology that takes knowledge out of elite universities and into the homes of citizens.

Just today I (finally) learnt how to use Google Reader and I have now subscribed to dozens of blogs, websites and podcasts. I can now dip into a stream of information about mental health as it travels down my computer screen. Anything interesting and I send it to Evernote, where I'm building a collection of interesting articles and opinion pieces. OK this is not a methodical approach to research, and I'm happy spending time in the library conducting detailed and systematic literature searches, but Google Reader is giving me an overview of what professionals in my field are writing, talking about and reading and it's great to be part of the conversation!