Friday, August 27, 2010
Here is the title and list of contents.
What they are doing to my book
Working with suicidal individuals: A guide to providing understanding, assessment and support
PART 1. UNDERSTANDING SUICIDE
Goal of the book
The author's background
The personal level for practitioners
2. WHAT IS SUICIDE
What constitutes a suicide?
Accidents and suicide
Suicide by being killed
3. TRANSACTIONAL ANALYSIS
Theory of personality
Ego states and the newborn child
The functional ego states
4. THE SUICIDE DECISION
The suicide decision
The process of early decision making
Aspects of the decision making process
5. MODELING SUICIDAL BEHAVIOR
Modeling and imitation
Modifying Parent ego state tapes
The suicide pact and supported suicide
6. REACTIONS TO HIGH STRESS
Three reactions to stress
Suicide is usually a flight response
The counseling response to stress
7. SUICIDE AND SELF HARM
Self harm and suicide are separate
Bodily mutilation in context
The eight motives for self harming
Self harming with multiple motives
Harm minimization for the self harmer
PART 2. ASSESSING SUICIDE RISK
8. QUANTITATIVE MEASURES OF ASSESSING SUICIDE RISK
Alternate methods of assessing suicide risk
The quantitative approach
Accuracy of client information in reporting suicidal thoughts and behaviors
The tendency and degree of regression
History of high risk behavior
History of substance use
History of mental illness
Lack of any secondary gain
The prison population as a high risk group
Depression as an indicator of suicidal thoughts and actions
Single people are more likely to suicide than the married
Previous history of suicide attempts as an indicator of suicide risk
The suicide note as a measure of assessing suicide risk
Way of talking about suicide
Planning suicide as a method of risk assessment
Those with a flight response to stress
9. QUALITATIVE MEASURES OF ASSESSING SUICIDE RISK
Assessing long term suicide risk
Identifying the suicide decision
The Stopper Questionnaire
The Don’t exist interview
The bad day at black rock exercise
Reaction to the no suicide statement as a means of assessing suicide risk
PART 3. SUPPORTING THE SUICIDAL INDIVIDUAL
10. THE SUICIDE SECRET AND THE DELIBERATE SUICIDE RISK
Disclosing the suicide secret
The deliberate suicide risk
11. PSEUDO SUICIDE, SUICIDE AND TEENAGE SUICIDE
The non suicidal
The suicidal - the suicide decision
The suicidal - command hallucinations
The suicidal - impulsive acts
Magical thinking about death
One teenager's statement about suicide
Another teenager's view of suicide
12. SUICIDAL AMBIVALENCE
Understanding the ambivalence
Working with the suicidal ambivalence
Assessing the suicidal ambivalence
13. SUICIDAL TIMELINES
Suicidal behavior in context
The acute suicidal crisis
Slow developing suicidal crisis
Chronic suicidal crisis
14. THE NO SUICIDE CONTRACT
Origin of the no suicide contract
Theory behind the no suicide contract
Under the NSC iceberg waterline
The no suicide promise, no suicide assurance or no suicide commitment
The no suicide contracting procedure
To summarize the steps in the no suicide contract procedure
Refusal to make a no suicide contract
15. REDECISION THERAPY
The process of Redecision therapy
Contract for change
Diagnosis of early decision
Recreating the early scene
Bring the client back to the here and now
Making behavioral contracts to carry out the new decision
Ongoing relational contact with the self destructive aspect of the client
Thursday, August 26, 2010
Are women becoming more sexually aggressive?
Do women now make the first steps in approaching a man rather than the man always being the first one?
I answer with:
I have counselled men and women over 25 years and have listened to them talk candidly about love, relationships and sex within the safe confines of the counselling room and confidentiality. From what I have seen in the last two decades, women are indeed becoming more likely to approach a man rather than always waiting for the man to ‘make the first move’.
However these approaches by women usually remain sexually limited to first base only. Most women will not sexually approach a man with the idea having full sexual contact. That motive for the sexual approach remains in the realm of the male psyche, so not much has changed really. This is because relationships and sex have different psychological meanings for men and women.
For most women sex and relationship are intimately interwoven. They go together. For men this can also be the case but does not have to be. For men relationships and sex can be intertwined but men can also have sex without a relationship attached. The most obvious example of this is prostitution. Every society on earth has female prostitutes for male customers. One does not find male prostitutes for female customers because one can assume there is no demand.
However it must be noted that men have just the same needs for emotional closeness and intimacy as women. They have the same wants for non sexual physical and psychological closeness. In this way men are in a more difficult position because sex can get in the way and complicates matters. They can loose their understanding of the need for emotional intimacy and get lost in the pursuit of sex.
There is however one exception to this hypothesis. There are a group of women who can be quite sexually aggressive in their approaches to men with the motive of full sexual contact. These women can have a number of different male partners in a relatively short space of time. Most women who enter such a phase of promiscuity are in a poor psychological condition. They are emotionally messed up and by the end of the phase they are even more disturbed. It’s just not a natural thing for women to do.
They may be promiscuous because they have mixed up sex with love and affection in their own mind. They usually have a low self esteem and the repeated sexual contacts can be a kind of self harm which is an expression of their self loathing. In other instances there may be a rebellious aspect where the woman is being promiscuous as a rebellion against strict parental or religious sexual prohibitions.
Then there is the man who has a series of female sexual partners in a short space of time. At one level society can view this man as successful and a ‘big’ man, however that is not really so. At a more base level I don’t think people view such a person in a favourable light.
He may have quite a number of associates around him. For him to have a number of female partners he must have some kind of charisma, or wealth or fame that causes the attraction. But those around him (men and women) don’t really like him but are there for some personal gain of their own. Such a man is not ‘liked’ because at the bottom line this man is using women for his own personal gain and nobody likes or admires a ‘user’. He is certainly not treating other human beings with respect, In my view people see this and make their assessments of him accordingly.
Sunday, August 22, 2010
“Yes - listening to the child ego state... that would have to be a learned thing? With practice it will get easier? “
How difficult it is depends on what is the cause my friend and in the previous post I have only mentioned one way in which this can occur. There I mentioned some people have considerable difficulty listening to their Child ego state or that part of the personality.
When this happens the person can end up stroke deprived or has a general sense of deprivation where what the individual’s wants are rarely satisfied. It never gets to be ‘their turn’ when their needs are met and they get satisfied. This is common in people who are depressed or those who used drugs excessively like I said in the pervious post.
This can be a function of an overly active Critical Parent. That part of the personality which criticises self and makes them work all the time or never ask for what they want and so forth. The diagram I used was this one. The person is said to have a large internal critic.
This can be treated as I said by reducing the expression of the CP at ones own Child. Or more correctly, in counselling it is always better to increase behaviour rather than trying to decrease behaviour. One would make contracts to increase the expression of their Nurturing Parent ego state to the Child. If this happens then the CP will naturally decline.
On other occasions the self deprivation is not caused by an overly active CP but is a function of a maladapted Child ego state. This is usually a sign of more serious psychopathology and the person is more psychologically damaged. In this case the Child ego state does not believe its need should be met. It feels it is of little worth so its needs and wants are not valuable enough to be satisfied. This is not from the CP but is what the Child ego state feels about itself.
After this has been the case for some time the person looses touch with their own Child needs and wants such that the are not even aware they are being deprived. The Free Child is so deprived that the person is not even ware of what their needs are anymore. If one is not aware of them, then obviously the needs are not going to be expressed, let alone satisfied.
As I said this is indicative of ‘deeper’ emotional problems and thus more difficult to treat. The person needs to start to feel more worthy, then the needs can start to be expressed and ways of meeting them can be established. However feeling more worthy is not an easy thing to do and this is where the therapeutic relationship assumes importance. It is through the relationship with the therapist where the client can begin to feel a bit more self worth.
The term drug addict is an nebulous term that is used in a wide variety of ways. Functional drug addict, usually refers to a person who can use recreational drugs regularly, in significant quantities and still maintain their life style, in particular their work life, in a functional way. The drugs do not debilitate the person in the place of work in any significant way.
This is a bit of a contradiction in terms because the term addict often means a person whom is consumed by their drug use. The person who wakes up in the morning and the first thing they think of is how are going to get their next hit. And if they manage to find some drugs then they take it. That means they will take it before going to work or even in the work place. This will effect their performance in the work place and thus they cannot remain functional in this way as sooner or later this will be noticed and they will be ‘sacked’ from the job or at least their performance on the job will be significantly reduced.
Ben Cousins functioned at a very high level in the workplace (the football field) over a long period of time. He was amongst the best of the best in that occupation. He states in his biopic that he never took drugs on game day or the day before game day. This must have been true most of the time because any drug use would quickly reduce his level of performance at such an elite sporting level.
So he is not a drug addict in the usual sense of the word. Just go and meet a few such addicts and one quickly sees they are physically wrecked. The drugs quickly take their toll on the physique. There is no way a drug addict can function at an elite physical level. They can’t even function at a moderate physical level. They would struggle to run around a football field a couple of times let alone run a marathon every game of football they play.
The other thing about him which he states in his biopic and has been reported by others on many occasions is his work ethic. It was unparalleled. He would train longer and harder than all other footballers and thus his fitness was at the highest level amongst a group of very fit men. This is where the psychology behind his drug use starts to become apparent.
To train in such a way means he has a driven quality that others do not have. He can deprive his Child ego state more than most others. When others are exhausted and stop he keeps going. To do that he must have a very large internal critic inside his head. It pushes his Child ego state relentlessly and thus he has that driven quality about him such that he can keep training when others can’t.
The problem with such a psychological structure is it can’t continue on for too long without some symptom developing. The Child ego state is being deprived of pleasant feelings and comfort such that sooner or later some symptom will develop and thus we have the psychological basis of such drug use. He even says this, that the drugs were his reward after training so hard. The good feelings provided by the drugs were the relief for his Child ego state. After training so hard he allowed himself to party and thus he could continue on psychologically. The Child aspect of the personality felt looked after and thus the sense of deprivation subsided. In this way he would be described as a symptomatic drug user rather than a drug dependent user. The drugs solved the problem of physical and psychological deprivation.
If he had not found the drugs worked then some other symptom would have developed. This applies for any person who is highly driven in any kind of workplace. It cannot continue on for any length of time with out something happening. If the drugs or alcohol did not work for him he could have developed depression or had panic attacks which is the Child ego state stating that it can no longer handle the deprivation. It is the Child ego state putting up its hand and saying, “Hello!! I am still here, take notice of me” as indeed any child will do when it is being ignored. If it cannot get noticed for being good it will start doing bad behaviour to get noticed.
This type of drug user does not have the ability to self regulate. As shown in the diagram the Critical Parent ego state is so dominant in the personality the Child ego state is overwhelmed and its needs are lost under a tsunami of parental directives from the CP.
Thus the treatment strategy for this type of drug user is clear. Reduce the CP allowing the Child ego state to gets its needs met, then the desire for the drugs looses its importance, or the depression lifts or panic attacks subside. The person learns how to listen to their Child ego state thus allowing them to self regulate.
Saturday, August 21, 2010
As I have said before I have always used photographs in therapy with clients. They can be most helpful therapeutically. With the proliferation of the internet I now use FaceBook and Google Earth (along with blogs, websites, linkedin, YouTube, TrueLocal and all the other networking sites) almost on a daily basis.
For homework I may suggest a client does a search on FaceBook for a person they have been discussing or suggest they search on Google Earth for a particular place or location. This can form the same therapeutic function as suggesting the client to get some photographs they may have of a person or a place that is psychologically important for them.
These can serve a number of therapeutic functions. Whenever a client says, “I am never going to see him again”, the first thing they need to do is see the person again. One way to do that is through a FaceBook search. Even if the search comes up with nothing, therapeutic gain has been achieved. The person has actively set out to find the feared or disliked other by the very act of doing the search and thus there is psychological impact on their Child ego state.
Why is there a psychological gain? In Gestalt terms it brings the issue to the foreground of the psyche. It makes the person or place front and centre in the persons psychology. Over time people will unconsciously neatly pack away the painful person, event or relationship into a safe place in the psyche. By searching for them and maybe finding them on FaceBook or seeing the place on Google Earth that painful person, event or relationship is unpacked from the psyche and comes to the fore front of the mind.
When this is done the personality is destabilised and the person is primed for psychological change. They are placed into a frame of mind where psychological change is more likely to occur. I have discussed this on YouTube before.
By searching for the person, maybe seeing their picture and even talking to them the Child ego state is destabilised and thus ready for change. By seeing the place (house) where the abuse occurred the Child ego state is destabilised and ready for change.
Secondly, when an event occurs, over time the Adult ego state memory of it fades. When that happens the Child ego state will start to fill in the gaps, but the person will perceive these as Adult facts not Child ego states ‘fill ins’. As the Child ego state fills in the gaps it will structure the memory of the person or event such that it fits the life script and thus problems are solidified by a past memory that isn't even true at least to some degree. FaceBook and Google Earth can allow for an Adult ego state update.
Say the person was bullied by someone at high school. That bully may be remembered 20 years later as a big and overpowering person. To be seen years later on FaceBook the new Adult facts obtained can significantly reduce the Child ego state memory of the over powering person they were.
A person involved in a car accident at a particular intersection. Since then they avoid that intersection by driving other ways to get home. Google Earth is a good way to go and see that intersection again. Thus FaceBook and Google Earth have direct therapeutic uses in the trauma debriefing process.
Related to this it can help in doing goodbye work. In working with a recent client it became apparent that she still had a significant attachment (and love) to the first real love of her life. A teenage 3 year relationship that was semi abusive, where she fell deeply in love with him. In the past I would normally suggest she does a ‘drive by’. That is go and drive by the house where he now lives. However in this instance she did a FaceBook search, found him and became his FaceBook friend.
She saw some old photos that he had on his FaceBook and saw him as he is now. The Child ego state fill ins of her memory were dissolved. After a number of discussions with him she came back to therapy and said, “How did I ever fall in love with him!”. Combining this with 2 chair regressive goodbye work in therapy and that chapter in her life was quickly closed. The attachment was dissolved and she was this more able to attach with her current partner.
Wednesday, August 18, 2010
However the AFL holds the sword of damocles above all players. If they take recreational drugs and test positive they risk loosing their income and right to play football in that league. Ben Cousins retires in two weeks and thus the sword of damocles disappears and he can take as many drugs as he likes. And you know what, he now has the chance to really deal with the drug issues he has. This raises the issue of the difference between externally driven prohibitions and internal choices in the want to use drugs.
The problem if you have an external force whether that be a spouse, a parent or the AFL, pressuring you to stop using then it does not allow you to make your own decisions. Or at least it makes it harder to make your own decisions as this diagram shows.
If an outside person or organisation gives the directive “Don’t use” (particularly if they are using some kind of punishment like loss of income) then the user is pressured to respond from an AC (Adapted Child ego state) position. They can adapt to the directive in two different ways. They can either conform and don’t use or rebel and the use simply goes under ground and they try and outsmart the detection system.
The problem with both of these responses is neither is about what the user wants. The external prohibitor makes it much harder for the user to find out what they actually want. That comes from the Free Child aspect of the personality and it is here that one gets the possibility of the user deciding that drugs are not for him or he uses recreationally or he is OK with his current drug use. The decision comes from inside the psyche of the drug user and not as a reaction to some outside pressure.
Now the AFL can no longer pressure Ben Cousins about his drug use, he is much more likely to be able to find out what he actually wants in relation to using drugs. And that is his decision.
As I mentioned before, with pressure from out side the person can continue using by rebelling against the pressure and the use simply goes under ground. This is why drug counsellors need to be careful not to present themselves as an outside pressure because the client will simply stop telling the truth about their drug use. Then the counselling starts to flounder.
Others respond to the outside pressure by conforming and do stop using. But this is fragile because the use depends on the other remaining present. In this sense the person becomes addicted to the outside force which at times can be something like a religion. If the person drifts away from the ‘force’ then the risk of using significantly increases and thus we have the new “addiction”.
Having said this sometimes this approach can work in the longer term with AA being an example. In the initial stages the person becomes addicted to AA, the sponsors and uses them to stop drinking by responding from a conforming position to the ‘pressure’. If the conforming non use can persist for a long time then the person can construct quite a solid non drinking type of life style. Such a person is less likely to fall off the wagon because their whole life style and family are structured to ‘pressure’ them not to drink. And some remain sober for the rest of their lives. A good result indeed.
However in my view, by and large it is better for the user to be given the opportunity to take a look at self with no outside pressure. Then they can begin to decide what they want out of life and one is more likely to get longer term change in their drug using patterns. Again it is their decision.
Monday, August 9, 2010
Instead repetitive gambling could be seen as more as what is known as the defence mechanism of regression. The person responds to stress by engaging in behaviour where they end up in a child like position such that someone else has to take over for them to cope. Whilst this happens with some drug takers there are those where it does not happen for instance with many recreational users and what are known as functional alcoholics.
The point at hand here questions the definition of addiction. Those people who feel a compulsion to engage in a piece of behaviour that they find very hard to resist. With some discussion it becomes apparent that there are many differing reasons why that compulsion may exist. This would seem to be important to articulate because the way of treating such an addiction could vary considerably than if they are all assumed to be of a similar nature. As mentioned above if this thing that have been called a “gambling addiction” is actually more of a defence mechanism than an addiction how one deals with it will vary. Another example of this is described below.
There are a group of people who use drugs, some of them in a habitual and addictive way that are different and separate from the mainstream type of drug addict. Drug use in this group is more of a suicide attempt than drug use in the usual sense of the word.
The suicidal person has made one of seven suicide decisions:
If you don’t change I will kill myself
If things get too bad I will kill myself
I will show you even if it kills me
I will get you to kill me
I will kill myself by accident
I will almost die (over and over) to get you to love me
I will kill myself to hurt you
To summarise, some people have the ability to be able to take their own life if things get too bad or to hit back at someone and so forth. These people can imagine killing self, they have it in their behavioural repertoire to do such a thing.
If you don’t change I will kill myself
If things get too bad I will kill myself
I will kill myself to hurt you
Some people do not have that. They cannot conceptualise of planning a suicide attempt, obtaining the items necessary and going through by acting out the plan. It is simply something beyond their imagination. However these people may still have made the suicide decision and thus they need to achieve it some other way.
I will get you to kill me
These suicidal people can get others to kill them such as ‘Death by cop’ where the person behaves in such a threatening way to the police that they shoot him dead. They can voluntarily enter into a war zone and behave in such a way that the enemy kills them, or they can behave in such a way in a country that has the death penalty where the state kills them. The suicidal act is carried out by someone else.
Or there is another decision:
I will kill myself by accident
This person engages repetitively and voluntarily in high risk behaviour. This is where the line between accident and suicide gets blurry.
Some behaviour is a bit of both, an accident and a suicide and you can’t clearly distinguish between the two. This can include dangerous sports, driving cars at high speed (Peter Brock), working with dangerous animals (Steve Irwin), working in high risk occupations and also dangerous drug taking.
The type of drug taken and the method of ingestion can vary enormously. Smoking marijuana is quite safe compared to injecting heroin which is much more dangerous. If the person has had a few over doses where they were getting closer to the point of death then one could begin to diagnose that the drug taking has a suicidal motive underlying it. Alternatively one can do a life script analysis and ascertain if such a suicide decision exists in the person’s psyche.
If this is the case then there are significant treatment implications. Why would one work with a drug user to identifying the triggers for use, do motivational interviewing or work on relapse prevention with some one who could easily die a month or two latter by and ‘accidental suicide’ in a car accident.
In these circumstances they are suicidal first and a drug taker second and ones treatment plan would need to reflect this.
Sunday, August 8, 2010
Any person prone to regression in the sense of using the defence mechanism of regression could be seen to be a potential problem drug user for the reasons just described. However even when not intoxicated often such people will still have a child like quality in the sense of being irresponsible, some times unemployed, perhaps endlessly sick or perhaps incapacitated by some form of physical or psychological illness and establishing relationships with others who tend to take the parental role.
A good example of this regressed quality in relationships comes with the addicted gambler. These people could be seen as being financially irresponsible. They do not know how to manage their finances. From a psychological point of view I would see gambling addicts as no different from the person who mismanages money by accruing large credit card debt or investing in dodgy business deals where they end up broke and in debt. A person who ends up broke from share trading is no different from a gambling addict at least in the psychological sense.
They both end up in a child like position or in a state of regression in this way. A young child does not know how to manage its money and if left to its own devices will end up in financial trouble. Thus it has a person, usually the parents who will manage it for them. Many a gambling addict will end up in the same kind of relationship where someone else basically gives them pocket money once a week. The person who spends all their money and ends up with large credit card debt may be compelled to see a ‘financial’ counsellor who ‘guides’ them on how to mange their money. All these individuals end up in the same kind of position in relationships.
The psychologically interesting part of this person compared to the drug user is the thing they are addicted to does not regress them. Drugs remove the Parent and Adult ego states whereas gambling does not. Thus even while they are engaged in their addiction (at the casino, share trading or on a shopping spree) their Parent and Adult ego states are still quite cathectable whereas the drug user’s is not.
Treatment will tend to have some different features. While engaged in their addiction (at the casino, share trading or on a shopping spree) how do they disconnect their Adult and Parent ego states. They know they are going to end up broke by doing their addictive behaviour so whilst in the actual act of unwise spending they much be able to disconnect at least their Adult ego state to some degree. How they do that is critical to dealing with the addiction.
As with the drug user the regression they are prone to is also necessary to address.
For instance if the person is involved in some kind of conflict, the person is being approached sexually, or the person is required to look after a child or become responsible for some reason. If these situations result in the person feeling anxious they can deal with their anxiety by ‘running away’ and becoming child like. Once done they don’t have to deal with the here and now situation and the anxiety is avoided.
Usually the stage to which the person regresses is determined by a fixation point. As we grow through our developmental stages we usually have trouble at some of them and thus don’t completely resolve them. These are then seen as fixation points so when the person regresses they will regress to the stage at which they are fixated. That maybe 3 years old for some or 8 years old for another.
Every person is capable of regression, but some are more liable than others. There are many ways to regress. Those with significant fixations can regress spontaneously as in the situations described above. The more pressure and stress applied to a person the more likely they are to regress.
As I have written before
The mechanism of regression is supported by research in neuro-psychology as cited by Johnston (2009). When people are placed under stress they are less able to access the pre-frontal cortex of the brain which is associated with the more developed functions like problem solving, decision making and stress management (Adult ego state). Instead people tend to access the more primitive part of the brain in the amygdala (Child ego state).
In psychotherapy sometimes regressive techniques such as two chair are used. Indeed the therapeutic relationship in itself will pressure the client to regress and become more child like in the relationship with the therapist.
However one of the more efficient ways to regress is to consume alcohol and drugs. When done this situation evolves.
Firstly the alcohol will diminish the Parent ego state and the person becomes disinhibited. The Parent ego state makes us behave in socially appropriate ways and thus people can become aggressive when drinking because their prohibitions against physically hitting out are diminished.
This is also the reason why some men like their female ‘dates’ to drink alcohol because they know it will lower the woman’s own internal prohibitions about sexual behaviour.
With more consumption of the drug the Adult ego state is then decathected such that one is only left with the Child ego state and the regression is complete. Thus we have the link between drug use and the mechanism of regression. It seems reasonable to conclude that some drug users may have this motivation in their substance use. They are unconsciously motivated to regress.
If this is the case then there are treatment implications. As mentioned before the person will regress to that stage of development where they are fixated. Their normal psychological development for some reason got stuck at a particular stage and thus the Free Child seeks to return to that stage in the hope that somehow it will be resolved this time around.
The chronic alcohol user is often fixated at the oral stage of development which would require some kind of therapeutic resolution of the fixation there. That is to work through the developmental issues relevant to that stage with the therapist. If the person is using drugs for the need to regress then one would not expect the usual behavioural techniques to be all that effective.
The thing about regression is that it is a running away or an escape from the here and now. Like the scared young child who simply closes her eyes and puts her hands over their ears as a way to deal with stress. In this sense regression as a defence mechanism is a very child like solution. Compared with intellectualisation which is sort of a more grown up reaction or other defence mechanisms where the Adult and Parent ego states do not disappear.
Of course a person who is regressed will attract others who will take on the parental role in a relationship with them. Thus we end up with people who are called enablers, co dependants and so forth. Of course they will say they want to husband to stop drinking, being child like and irresponsible but the other side of the wife does not.
With regression and drug counselling
Adult and Parent ego state development
Working through the fixation in the therapeutic relationship with the therapist
Altering relationships which encourage the regressive behaviour