Fetal Alcohol Spectrum Disorder - The new sexism.

Once upon a time there was a condition called Fetal Alcohol Syndrome (FAS). This was a condition with identifiable physical and psychological symptoms. It would sometimes occur in children from mothers who engaged in frequent and protracted binge drinking during pregnancy.

This diagnosis has now been changed to Fetal Alcohol Spectrum Disorder (FASD).

FAS has now become FASD

“dum dum, dum dum, dum dum...”

This is meant to be music from the movie, Jaws. I am building atmosphere here. Impending evil is about to descend on women.

FASD as it says, is a spectrum disorder which means it includes far greater numbers than FAS did. Now children only have to have a few of the diagnostic symptoms to be diagnosed with FASD. The ‘edges’ of the diagnosis are now more blurry, so a lot more children can be included in the spectrum.

Public health officials are now highlighting the dangers of alcohol by quoting this new condition called FASD and the ever increasing numbers of children effected. 

And the impending evil? 

The potential for over diagnosis is large, and the consequences of that over diagnosis on the self esteem if women is potentially severe.

In Australia we are quite prepared to label people with mental health conditions. Nowadays in Australia, any badly behaved child is seen to have ADD. The prescription rates of medication to children with ADD in Australia is amongst the highest in the world. There is significant over diagnosis. The same has happened with the diagnosis of a drug induced psychosis. I discuss this in my new book - Working with drug and alcohol users - and how there is over diagnosis on a large scale for a number of reasons.

It will be easy for men to pontificate about FASD

In Australia we are now told by public health officials that there is no safe drinking level for women during pregnancy. Even a little alcohol consumption by a pregnant woman is considered dangerous to the child and it can cause all sorts of brain damage leading to low IQ, speech disorders, coordination problems and so forth.

A study by Jones and Streissguth (2010) looked at the children of alcoholic mothers and it found that 32% were born with FAS. A shocking statistic indeed for these children born to mothers who drank very heavily all through the pregnancy. However this means that 68% of children born to heavily drinking mothers did not get FAS. A significant majority of children born to women who consumed large quantities of alcohol did not get FAS.

But public health officials tell us there is no safe level of alcohol consumption for pregnant women, not even the odd glass of wine. The potential for over diagnosis is large especially now we have a spectrum disorder diagnosis.

I am a psychologist who has spent 25 years doing neuropsychological investigations of children who are brought to me for a variety of reasons. Often the child is not doing well academically at school and the parents want a neuropsycholigcal assessment done to find out what is going on. Lots of psychologists do the same sort of thing.

Typically the parents are asked many questions about the child’s development, any problems during pregnancy, was it a forceps delivery and so forth and now with FASD mothers will be asked if they drank alcohol during pregnancy. The child is then given an IQ test and one can begin to ascertain if there is any potential brain damage.

25% of children are above average IQ, 50% are average and 25% are below average IQ. That is how IQ tests are constructed. Some children are just born with a low IQ . There does not have to be a cause of brain damage. Some people are born with wonderful sporting ability and some are born such that if they run they trip over themselves. Some people are born with musical ability and some people when they sing the cat runs away. Some people are born with low IQ and some with high IQ. People are just naturally different in these ways.

If FASD goes the same way as the over diagnosis of ADD, then many women are going to suffer and suffer badly. A child who is performing poorly at school and mother wants to find out why will come into contact with mental health experts of all kinds -psychologists, psychiatrists, GPs, social workers, neurologists, pediatricians and so forth. She will be asked if she drank alcohol during pregnancy and if she says yes then there will be some who say directly to her that it was her drinking that caused the brain damage in the child. Even if she is not told directly she will see the look on some of the experts faces which says, “You should be ashamed of yourself”.

This will create guilt of the worst kind for the woman, “My selfish behaviour during pregnancy caused my child to be brain damaged” she may think. A woman living with that kind of guilt for years is going to have her self esteem eroded significantly. She listens to public health officials tell her that any alcohol consumption is dangerous for the child. They don’t tell her about studies which showed 68% of children did not get FAS from alcoholic mothers. They don’t tell her that sometimes children are just born with a low IQ and it was not her alcohol consumption that caused it. There are going to be many times when a woman is completely not at fault but will suffer years of this terrible guilt.

Society likes the temperate woman.

Even if she didn’t drink she may still suffer prejudice. If the child is performing poorly and she is asked if she drank and she says no there are going to be those who will still think, “Not only is she to blame because she probably did drink but now she is also lying about it.” If the FASD diagnosis becomes over used like ADD has, she is going to come up against prejudice like this from all sorts of people including family and friends. Even the husband may think such things because when she was pregnant and they socialized he always got too inebriated to remember if he saw her drinking.

Again from the Jones and Streissguth (2010) studies, they state:

“The developmental profile of the child with foetal alcohol spectrum disorders is variable, and the severity of presentation is not necessarily indicative of the severity of impairment (Stratton et al., 1996). Some children will not present any observable characteristics of FASD; their symptoms will be purely behavioural.”

“Children with foetal alcohol spectrum disorders may score within normal limits on measures of IQ, appear physically mature and give the appearance of functioning at a level consistent with their chronological age.”

In other words they don’t know clearly, it is inconsistent and it at times is going to involve guess work for the diagnosis of FASD. What it does mean is that with a diagnosis like this the potential for over diagnosis is very real and potentially large as could be the sexism and prejudice against women that may go along with it. Then there is also the possibility of years of guilt women could suffer when the child’s lower IQ has nothing to do with her alcohol consumption.

Women need to nip this in the bud before the diagnosis of FASD gets out of control like ADD has. With public health officials starting to say that any alcohol consumption during pregnancy is dangerous. These people need to be questioned on making such public health statements as this potentially new form of sexism evolves.

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New book

This book has now been released and is available to purchase.

You can get an autographed copy from me by ordering from here.

If you have a read let me know what you think.

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Third adulthood stage of development

The marital stage of developmental . The first task is to find another person who is willing to enter into marriage, second, for both parties make the decision to get married. The third task is to successfully negotiate a marriage relationship without significant psychological disengagement (or a psychological divorce to differentiate from a divorce in the legal sense).

This disengagement would usually be seen to occur after 5 to 10 years of marriage

The three main reasons in that time frame are:

1. Any significant scarring of the Free Child ego state has occurred

The Free Child is the most sensitive aspect of the personality. It is where we experience intimacy, vulnerability, closeness and the other sensitive emotions. It provides us with the ability to be truly human and allows us to obtain the most health promoting and rich positive strokes that we can receive. 

Family

However, as it is so sensitive it is also the most susceptible to ‘assault’ and it can be damaged easily. The assault can be physical when we are hit but more often it is harmed by some kind of verbal attack on the Free Child. If we are made fun of, discounted, involved in conflict, ignored or verbally abused in some kind of way it is the Free Child aspect of our personality that is most effected. One of the most basic responses the Free Child has to such offensive communication is to run away. We will automatically hide or defend that part of ourself if we perceive such assault is occurring or think that such things may happen. The Free Child is a quick learner in this way.

This is a good response in that we protect the most sensitive aspect of ourself from being hurt and future damage. On the down side, if hidden away, then we loose the ability to be sensitive in our communication with that person.

In a marriage two people are living in close quarters, day after day for years at a time. It is inevitable there will be times of conflict, feeling hurt, doing unthinking things which adversely effect the FC of the other party, abandoning the other and so on. As a result this will happen as shown in the diagram.

It is inevitable the Free Child of both parties will retreat into hiding in a marriage over time. It is not a matter of if it will happen but how much it will happen. In most instances it is not to severe so as to destroy the quality of the marriage in any significant way. To successfully negotiate this stage of human development the Free Child will not retreat significantly.

It is quite easy to ascertain if this has happened. Imagine that your husband (or wife) was not your husband, you were not married to him, you had never had any romantic love for him, you did not have children, there was no financial connection but he was just a person you knew as a friend. If this was the case would you seek him out to spend time with, would you enjoy his company and want to be with him when socializing?

The more you answer yes to this question the more the relationship still has significant Free Child to Free Child contact. Clearly there is more to a marriage then just FC to FC contact. However if the marriage has it then both parties are motivated to be together, enjoy each other and have that ‘spark’ together in the relationship. This is a very good thing to maintain in a marriage. To successfully complete this stage of development in adulthood the FC to FC contact is maintained to a significant degree. If there is going to be a significant reduction in FC to FC transactions then it will usually have happened in the first 5 to 10 years of marriage.

When the Free Child part of us has been hurt it will automatically withdraw to safety even if we consciously try to avoid doing so.

2. Any psychological agendas have now been fully developed

3. Any difficulties are now fully habituated

Successful completion of this stage of adulthood is to have not obtained a psychological divorce from the marital partner. In the psychology of the individual he and/or she remains psychologically engaged with the partner. The level of psychological disengagement has not reached a point of significance.

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Developmental stages of adulthood

I am currently reading a book by Jay Haley about the work of Milton Erikson. It’s a summation of the work of Erikson. Haley was probably trained in psychoanalysis because in his writing there are a number of references to how it is not necessary look at the past, what a therapist deals with is what the client presents now. There is a flavor of rebellion against the psychoanalytic approach in this way.

This leaves one with a telling question: if you don’t go back to the past of the person what do you do? He suggests a short term, here and now approach that is family therapy oriented. 

However one thing I have discovered that was somewhat insightful for me, is one of the greats of family therapy - Milton H. Erikson - rarely saw the whole family together. What he did see was various family members alone or in various combinations separately.

This is what I have done over the years even though I never considered myself a true family therapist because I rarely saw the whole family together. Now I discover to do family therapy you do not actually have to see all the family together. In my book working with drug and alcohol users I spend significant time discussing therapy with the teenage drug user and this is exactly the approach I describe when I work with them. You see any person in the family who becomes relevant to the issue at hand and in any combination that is relevant.

Family therapy

In essence I am doing family therapy but I certainly diverge from Erikson and Haley in that I will and regularly do delve into the past and individual psychology of the various parties. However this ‘discovery’ has solved another problem for me as well.

Some counsellors have a rule that if you see a couple then you cannot see either party  in individual counselling. Or if you see an individual then you cannot also start seeing them and their partner for couples counselling. I (along with other therapists I may add)  have never adhered to this view but some can get quite hot under the collar about it all and start saying things like it is unethical and so forth.

Well know I have theoretical back up for it all. I am doing family therapy Milton H. Erikson style, which is true, I am.

Body dysmorphia

However I have digressed from the point at hand

When working with an adult client at some point I always ask myself the question -why now? Why has the client sought psychological help now and why not 5 years before or in 5 years time? If there has not been a specific event that has resulted in the client attending counselling why has the client appeared now? The answer to it can of course be related to developmental psychology. The person has reached a particular developmental stage in the human life cycle and it is causing difficulties for them.

Developmental psychology

There has been a huge amount written on this area with a prime example being Freud. This chart summaries Freud’s theory of the psychosexual genesis

It shows the different developmental stages a child goes through and isolates the the developmental tasks it has to master. Most notably the oral, anal and phallic stages. Although the latency, eurethral and genital stages are added here most of the emphasis is on the pre latency stages. As a child goes through each of the stages they effect its personality development and the person becomes who they are. We all get fixed to some degree in the oral, anal and phallic stages.

The two charts below show what can happen if a person is fixated at the oral stage of development. It is divided into the oral sucking and oral biting stages. If unsuccessfully mastered the person can develop things like eating disorders or addictions especially an addiction to cigarettes.

***

In the second chart the top two rows relate to oral sucking and the bottom two rows relate to oral biting.

Whilst this is all good and well it only relates to childhood. In one way this is logical as it is during that stage that we develop the basis of our personalty. By adulthood most theories of child development agree that the personality is formed and in most instances after that time little extra change occurs.

However that does not mean there are not subsequent stages of development to master. Just like the child has to master the oral and anal stages of development the adult also has to successfully move through various stages. Thus we have the following equations

Childhood stages = master the stage and major impact on personality formation

Adulthood stages = master the stage and minor impact on personality formation

Throughout history these adult stages of development have been the poor cousin in developmental psychology. Not much has been said about them and they are by and large ignored or at least viewed as much less important than the childhood stages of development.

When adult stages have been discussed people often gravitate to the theories of Erik Erikson (No he wasn’t Milton’s brother!). A summary of Erik Erikson’s theory of development called the eight ages of man, is illustrated below

As one can see it covers the whole life span from birth until the end of life in old age.   The last three are the adulthood stages of development. He saw each stage as being a ‘battle’ between two possible outcomes. For instance in the stage he calls Adulthood he sees the goal for the individual to develop generativity versus a state of stagnation. 

In generativity the adult person seeks to establish and guide the next generation including things like productivity and creativity. He says in this way the mature person is dependent on the younger generation. The adult person needs to be needed and this need can be satisfied by guiding the young. If this is not achieved then the adult person will suffer a pervading sense of stagnation and personal impoverishment.

I find this a reasonably good statement but to me it lacks substance. It would be good for the adult person to become a guide and teacher for the young but is that it! Is that the one and only developmental task the adult person is meant to master? And from a therapeutic point of view, if one has a client who is 40 years old how is this idea of generativity vs stagnation meant to help. To me it is too esoteric in this way.

There needs to be more and by and large developmental psychology has failed in this way. Hence I arrive at Milton Erikson and Haley and what they developed. As mentioned before they refused to delve into the past unlike the majority of developmental psychology and therapeutic approaches. In my view this was a counter reaction away form the psychoanalytic philosophy of Freud.

I stated before, “if you don’t go back to the past of the person what do you do?”

As a result of this philosophy they were forced to construct a developmental theory of adulthood that was based on a behavioral understanding or focus. They developed a therapy that was short term solution focused, oriented primarily to behavioral change in how the family members related to each other.

This theory came from a clinical therapeutic basis, meaning it will tend to be readily applicable in the therapeutic setting unlike Erik Erikson’s theory. As this evolved out of their own experience with clients it meant it was their observations of a large number of clients. They were starting to identify where people tended to have problems as they moved through their adulthood. They were identifying the times (or stages) when adults had to master new tasks as a result of their increasing age.

But they kind of did it back to front. Instead of saying OK a child has to learn how to breast feed successfully whilst relating to mother, therefore the first developmental stage is the oral stage. If it does not successfully master this then the problems it will have are....

In this case they were identifying the developmental stage first which then subsequently led to the formulation of the problems relevant to that stage.

Instead Milton Erikson and Haley said, “I observe that children who present with problems seem to have difficulty leaving the parents and the home.”

In this instance first they identified the problem which subsequently led to the formulation of the developmental stage

In essence they came up with a developmental theory of adulthood by accident.

Adulthood developmental stages

The courtship period developmental task - establish a long term relationship with a mate.

Being a social person as an adult developmental task - establishing a social world external to the family of origin and some what external to the mate.

Getting married developmental task - make the decision to enter into a marriage type relationship.

Dealing with childbirth and young children developmental task - coping with and mastering the difficulties of raising young children

The middle years of marriage developmental task - between 5 to 15 years of marriage when divorce tends to happen due to the change in perception of marriage by one or both parties.

Parents letting children leave home developmental task - parents being able to wean self off children and let them move away.

Resolving the movement into old age developmental task - mastering coping with changes in the body and accepting death as a matter of course.

An interesting collection of stages that are directly applicable in counselling. If a 25 year old female presents with agoraphobia the question must be asked, “Is she successfully mastering the courtship stage developmental stage”? As I have said before sometimes it’s clear that family dynamics are involved and at other times they are just not relevant and then one moves to an individual past oriented approach to the counselling.

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Theory of contracts - Part 3.

In the previous post on contracts KYLady makes some good comments about lying to self, others and breaking them.

Thanx for that as it allows me to clarify what I mean by lying to self. In one sense people lie to themselves regularly and indeed one could say it is the role of the counsellor to ‘expose’ these lies in some way. Any time one packages off part of their thinking, feeling or behaving to the unconscious you could say they are lying to self. They are pretending to self that they are one way when they are in fact another. Every projection is a lie to self as is every denial that we all have.

For example, I was working with a woman recently and she expressed much sadness about being sent to boarding school as a child. Within just a few minutes it became obvious to me (as an outside observer) she also had considerable anger at her mother for doing such a thing. She was completely unaware of this and she had used the defence mechanism of denial. To be angry at her mother was unacceptable to her so she moved it into her unconscious and then could pretend to herself that she was not angry. 

For some of us our own inner angry child is unacceptable. To deal with this we place it in the unconscious and then can pretend it does not exist.

I suppose one could call this a lie, and one of my jobs as the counsellor is to expose the lie and bring it into her conscious which I did. I had to say it on 4 different occasion before she acknowledged what I was saying. Finally she did let in what I saying and then expressed some surprise that she felt such anger.

However this is not really what I am talking about when it comes to contracts. I often suggest homework contracts to the client at the end of the session. When they make them I will often ask, “Do you think there is any chance you will do it” and people generally can answer that question quite readily and easily. Sometimes they say yes with certainty and other times they will say no. If they say no then I suggest they forget the contract. This is what I am really talking about when it comes to lying to self.

If you know you are not going to do it or there is quite a probability you wont then don’t make the contract in the first place. What I am communicating to the client is - Contracts are not promises or statements from you to me. If you know you wont do it then don’t make it and most people quickly see that is a senseless task, as indeed it is. I not only do this with homework contracts but will do it with every contract including a no suicide contract. If a person will not make a no suicide contract that does not mean they are necessarily a current suicide risk.

In this sense the process of contracting is changed. Consider the contract, 

“I will tell my husband I am angry he wont keep to the budget each week”.  

Bill Holloway makes this point about contracts:

My preference is that the client elaborates the objective to include behavioral confirmation that the objective had been reached. A simple question by the therapist is often useful, “How will you know and how will I know that you have achieved the change you desire and intend?” (end quote)

Others would agree with him as this is not an uncommon thing to do with contracts. The client and counsellor define what behaviors will show the contract has been completed. This works on the basis that the client may or may not carry out the contract and effort is expended in the contracting to establish if they have or have not. For example the wife may say, “I will sit down with him after dinner on Wednesday and tell him about my angry feelings”. After Wednesday the client and the counsellor will know if she carried out the contract or not.

The contracting I am suggesting here is that even before the contract is made the client has established they are going to complete it so there is no need to ask the question suggested by Holloway. The ambivalence or reluctance to complete the contract is dealt with before the contract is made rather than setting the contract and then seeing if it is completed or not. 

If a contact is a statement the individual makes to self then this alternative approach has to be the case. They will not make a contract in the first place if they do not intend to complete it.

Finally KYLady:

If you break promises to self all the time I would suggest  you don’t make them. If you break most of them what is the point. If you stop making them, after some time you may find a new attitude developing in yourself about this.

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The theory of contracts - Part 2

It is proposed that the best contract is where the client makes a statement to self about a change they want in their behaviour, thinking and/or feeling. This is how the counsellor wants the client to view it in her mind.

The reason why this is seen as the best is that it involves no other people which is why I have a problem with Eric Berne’s definition of a contract.

Berne - A contract is an explicit bilateral commitment to a well defined course of action.

The logic behind my proposal rests on the assumption that very few people will lie to themselves. There is no point. It’s like cheating in a game of solitaire. There is no point. Why would someone say to self, “I will finish my assignment by Tuesday” when they know they have no intention of doing so. There is no use making the contract in the first place.

If however there is another person involved in making the contract then there may be a reason to lie, even unconsciously. If there is no other person involved then this cannot happen. Hence the statement that the best contract is one where the client perceives them self making a contract with self and no one else.

The worst contract one can make, is where the client perceives the contract as a promise. This is for a number of reasons. A promise is where a person is manipulated into behaving in a particular way by the use of guilt. For example on the way to christmas lunch mother may ask the children to promise they wont make rude noises in front of grandma. The children want to make rude noises in front of grandma because its fun. If they agree to the promise they have moved into the Conforming Child ego state (CC). A promise is made by the Conforming Child ego state. If the child subsequently breaks the promise then he will feel guilty because he has made a promise to mummy and knows she will feel disappointed or hurt because he broke the promise.

 

He promised not to do it. It is inevitable there will be a switch into RC at some point.

On thing you do not want to do is create a situation where the client is manipulated in behaving a certain way so as not to disappoint or hurt the feelings of the counsellor. If this does happen then the therapeutic relationship could be seen to be quite dysfunctional and the long term therapeutic outcomes are going to be poor. In addition, if a person is in CC then it is highly likely they will at some point in the future switch to Rebellious Child (RC) and break the promise. If the client perceives the contract to be a promise to the counsellor then they will eventually break the contract simply because they will have an urge to switch into RC in relation to the counsellor. 

As I discuss in my book, Working with suicidal individuals this is especially important when a client is making a no suicide contract. One thing you do not want is for the client to perceive the no suicide contract as a promise to the counsellor. If someone is in CC for a period of time then it is very likely they will sooner or later move to RC. You do not want this to happen with a no suicide contract where the person moves into RC and breaks the contract simply as a means to rebel against the contract/promise.

This is one problem I have with the Berne definition of a contract. It relates to his use of the word commitment. What is a commitment? My computer definition states:

the state or quality of being dedicated to a cause, activity

a pledge or undertaking

an engagement or obligation that restricts freedom of action

If you are presenting to a client that a contract is a commitment it would not be too hard for them to start perceiving it to be ‘promise’ like. Of course it does not matter what the actual definition of the word commitment is, all that matters is how the client perceives the contract in his own mind. If he is told it is a commitment then he could more easily begin to see it as having promise like qualities.

Thus we have a reason why it is more productive to view the contract as a statement by the client to self, as it does not involve another party and all the dynamics just described can be avoided. This of course is easier said than done but if the counsellor consistently presents to the client that a contract is a statement they make to self it is harder for them to see it as having promise like qualities.

The bilateral aspect of contracting

Whilst it is suggested that contracting is best to stated by the client to the client Berne’s point about it being bilateral is also true. In Part 1 of this I presented the contract transaction and that did involve the counsellor so it is bilateral in that way. Also as has been pointed out by Bill Holloway the counsellor is also going to make his assessment as to the validity of the contract. That is, the counsellor will not work with a client to achieve the contract unless he thinks the contract is OK. 

Recently I worked with a man who complained of procrastination. He reported that when he got home from work instead of putting in an an hour or two of work he would tend to procrastinate and do non work activities. He presented a contract to stop procrastinating in this way. Upon further discussion I discovered he was already working a 50 hour week and he wanted to work an extra 5 to 10 hours per week when he got home from work. I thought this was a not OK contract that simply allowed him to live out his work hard driver in his life script so I refused to work with him on it. 

In this way it could be argued that contracting is not simply a client making a statement to self.

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The theory of contracts - Part 1

Central to the theory of Transactional Analysis is the idea of contracts. It’s what is called a contractual therapy.

Two definitions of a contact:

Berne - A contract is an explicit bilateral commitment to a well defined course of action

James & Jongeward - A contract is an Adult commitment to one’s self and/or someone else to make a change.

I have a problem with these in some ways. My definition of a contract would be:

 A contract is a statement the client makes to self about how they will behave, think and/or feel in the future. 

This statement is often made in the presence of a counsellor but it is a statement that the client is making to self. It only involves the counsellor as an outside person who can report back to the client about incongruencies in making the contract, self sabotages that may exist in the contract or other issues such as the lawfulness or morality of making such a change. 

A contract is made from the Adult ego state of the client along with consultation with the Parent and Child ego states in the client (and in the therapist). The contracting transaction could be drawn as such. As one can see it is quite complex process

1. Client thinks of a contract

“I will finish my assignment by Tuesday.”

2. Parent ego state of the client gives its view on the contract

3. Child ego state of the client gives its view on the contract

4. Client makes the contract from Adult with the views of the Parent and Child ego states taken into consideration. The transaction is drawn as coming from the client’s Adult ego state and returning to it. That is, the client is making a statement to self rather than to the counsellor. However the client is stating it in the presence of the counsellor because she wants the counsellor’s thoughts on the contract. She is letting the counsellor listen to it but it is not being made to the counsellor.

5. The counsellor’s Adult ego state hears and understands the contract.

6. The counsellor’s Parent expresses its thoughts on the contract to the Adult of the counsellor.

7. The counsellor’s Child expresses its thoughts on the contract to the Adult of the counsellor.

8. The Adult of the counsellor assesses the contract in their Adult with the views of the Parent and Child ego states taken into consideration and reports to the client what his thoughts of the contract are.

With a contract like, “I will finish my assignment by Tuesday.” there is unlikely to be many problems reflected by the Adult, Parent and Child ego states of both the client and the counsellor. However there maybe if it is what is called a magical contract. If it happens to be Sunday and the client still has to read 5 research papers and write 20,000 words then it cannot be completed in two days time. It is simply not possible to do and thus it can be seen as a magical contract by the client.

If the Adult of the client does not realize this anomaly then the Adult, Parent and Child ego states of the counsellor is more likely to. Thus one can see the usefulness of having an outside person looking in on the contracting by the client. However it still remains that the client is making a statement of the contract to self but can refine the contract with the help of the counsellor. The contract is not made to the counsellor nor is it a bilateral commitment between the two of them as Berne’s definition of contracting states.

Contract ambivalence

Every contract a client makes reflects a state of ambivalence in them. The Free Child wants to make the change and the Adapted Child does not want to make the change and will set about sabotaging the contracting process. This diagram is seen to show how the ambivalence exists in the personality.

In any contracting these two forces in the personality will be involved and thus you can again see the necessity to have an outside observer who can identify when the AC is sabotaging the contracting process. If the person 100% wanted to change then they would already have and wouldn’t need a counsellor. If they 100% did not want to change then they would not come to counselling in the first place.

For example the AC can interfere and influence the Adult to construct what is called a change others contract. The client may make the contract:

“I want my husband to show his love”

“I want my kids to behave at grandmas house”

A change others contract is not uncommon for a client to present. It can never work because the husband and kids are not in the counselling session and thus they cannot change. In this sense it can also be seen as a magical contract but the client’s Adult does not identify it as so because the AC is working unconsciously in the background sabotaging the contracting process. The counsellor’s Adult will hopefully see this and suggest the client alter the contract so it is not a change others contract.

Parent ego state difficulties with contracts

In my new book Working with drug and alcohol users, I describe a therapeutic procedure called the harm reduction contract. This is where the drug user makes a contract to behave in a more safe way when they take drugs. For example if a heroin user recently almost died from an OD he may make the contract to only use heroin when he is in the company of others. Thus reducing the chance of fatal OD.

However using heroin is illegal and some have a moral problem with assisting clients to take drugs more safely. They believe the client should abstain and then there is no reason to have a harm reduction contract. Or they believe there is a moral issue in working with a client who is contracting to do something illegal. Hence we can see how the Parent ego state of the counsellor could influence the Adult response to the client not based on a Child magical thinking contract but because of a disagreement from the Parent ego state.

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New book review - Working with suicidal individuals

The first sentence is nice and it gets better as it goes on. Feels good to have peers (I have no idea who he is) who obviously know what they are talking about, give praise like this.

Article citation: William Harper, (2012) "Working with Suicidal Individuals: A Guide to Providing, Understanding, Assessment and Support", Social Care and Neurod

isability, Vol. 3 Iss: 2, pp. -

Article Type: Resource reviews From: Social Care and Neurodisability, Volume 3, Issue 2
Tony White,Jessica Kingsley Publishers,London,2010,£19.99,272 pp.,ISBN: 978 1 84905 115 6

Psychologist Tony White delivers a commanding exposition in his guide to providing understanding, assessment and support in working with suicidal individuals. At the outset, Tony describes his first hand experience of the associated “affective” state by sharing that he twice attempted suicide as an adolescent. This was clearly a profound personal experience and one that has enabled a unique “inside” view of the area of suicide and comes across particularly strong in the area of teenage suicide in this book.

The book is divided into three parts. Understanding suicide; assessing suicide risk and supporting the suicidal individual. Building his model around Eric Berne’s transactional analysis and supplementing this with attachment theory, he provides a robust framework with which to explore the varied and complex existential reasons why someone may seek suicide as a solution and to understand their motivations. This is an accessible model that will indeed be useful for frontline clinicians and practitioners who will be able to conceptualise in more depth, the potential presenting influences that may be in the consulting room such as the nature of human communication, transactions, the driving force of historical figures and their relationship to the unconscious.

The “mind” here is conceptualised as a series of “tapes” that are laid down at key areas of development throughout the life course. This is particularly helpful when considering the assessment of the suicidal individual and offers clear paths to tailor intervention strategies accordingly. Moreover, the integration of both quantitative and qualitative measures of risk, points the reader to a more comprehensive and individualistic assessment. Chapter 14 on the no-suicide contract should prove particularly powerful for frontline clinicians engaged in this emotionally charged task. There is clear guidance about theoretical framework behind this intervention and when and who it works well for. The no-suicide contract “iceberg” is a useful short-hand conceptualisation for understanding the complexities of contracting with vulnerable individuals. Case studies are woven throughout the text and capably demonstrate the theory and the practice of this approach.

In the therapy section a ”gestalt” like or whole form approach is sought to define principles of perception through the use of a two-chair technique to permit regression, in order to achieve the same emotional and physiological states of arousal as occurred when the first set of state-dependent learning was achieved. The extra chair here, representing the critical parent ego state and the potential to rework this and integrate into the adult self.

Transactional analysis can have its limitations. Purist object relation theorists may argue that from the standpoint of the ego, suicide is, first of all, an expression of the fact that the terrible tension the pressure of the superego induces has become unbearable. To have a desire to live evidently means to feel a certain self-esteem, to feel supported by the protective forces of the super ego. When this feeling vanishes, the original annihilation of the deserted hungry baby reappears.

Tony White’s dynamic psychology has the task of reconstructing, from certain given manifestations, the constellation of forces that produced the manifestations. The client work demonstrates significant effort to enable a more direct expression of its dynamic foundations and will be essential reading for frontline practitioners and clinicians working with people at risk of suicide and harm in the neurodisability field.

William Harper Team Manager, Islington Assertive Outreach Team

Suicide as a threat

In my book, Working with Suicidal Individuals, I note in the psychological sense that the suicidal person makes the early suicide decision usually before the age of 6 years. This can be seen as the truly suicidal person. The traditional literature on suicide tends to try and explain suicide as the consequence of things like depression, harsh economic times, as a consequence of mental illness and so forth. The big problem for this approach is it cannot explain why some depressed people are suicidal and others are not. There are some depressed people who are not suicidal at all. In my book I note research which shows that 50% of significantly depressed people are not suicidal at all. They don’t even consider the option of killing self because they are depressed. The concept of the suicide decision provides a clear explanation of how this could be so.

Having said that, people end their lives by their own hand for a number of different reasons and some have not made this early decision. However if they have made an early suicide decision then this person is a suicide risk. 

I also make a distinction between short term suicide risk and long term suicide risk. The person who has made a suicide decision can be seen as a long term suicide risk. This means that at the moment there may not be at any imminent risk but in their psychology they have decided that suicide is a option for them under certain conditions. If such a person is identified, one needs to isolate what those conditions may be so one can be prepared should they develop. Also of course one engages in counselling like redecision therapy such that the early suicide decision can be rescinded or reduced in its potency.

Seven suicide decisions have been identified, these being:

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

In recent times I was working with a man who six months ago had separated from his wife. Prior to the separation she had threatened to kill herself if he left. He eventually did leave and two days latter she killed herself. She could have made one of a few decisions, such as:

If you don’t change I will kill myself

I will show you even if it kills me

I will kill myself to hurt you

He now was endeavoring to come to terms with this, make some sense of it such that he can go on and live his life. It is probably safe to say that to use the threat of suicide as a means of getting a person to behave a certain way is a very unprincipled thing to do. In one way it is the ultimate threat. To make another person feel responsible for their life.

The bottom line in these situations is you cannot let yourself be blackmailed by such threats. If one does then such threats are likely to continue in the future. Also the bottom line is no one is responsible for the life or suicide of another person. This man knew this in his Adult ego state however he still had to live the rest of his life knowing that a woman he once loved and the mother of his children had killed herself because he left the marriage. I think it is safe to say that it is a difficult thing to come to terms with and not be effected by in a profound way.

Besides being a highly unprincipled thing to do it is probably a very regressed and child like way of acting. It is certainly angry, punishing behaviour and it works most of the time. Few people would not be effected by it even knowing in a logical way that they are not responsible for her choice to kill herself.

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The dilemma of scare tactics for the drug counsellor

In my book on drug counselling, a number of times I raise the issue of scare tactics. In my view this is a widely misunderstood area and its importance is significantly underated.

Scare tactics is basically the exaggeration of the dangers of drugs. The motive behind this is a noble one. The person providing the ‘facts’ about drugs exaggerates the dangers in the hope that the potential drug user gets scared off using them. This is commonly done by parents, counsellors, teachers, police and so forth. Often the exaggerator is not even aware they are doing so, as it is done so often. I have certainly seen it done by drug counsellors.

It is imperative the drug counsellor takes a completely dispassionate look at the effects and dangers of drugs such that he or she can be fully informed in this way. To do this one needs to go to the research directly and not rely on official government sources of information. Unfortunately in most circumstances they do not give a full and accurate statement about the dangers of drugs and indeed practice scare tactics themselves.

The problem for the counsellor who uses scare tactics is they loose credibility in the eyes of the client. If the counsellor highlights to the client that marijuana can result in the development of psychotic symptoms without adding that this is quite rare and that some of the research suggests the connection between marijuana and psychosis is a dubious one  at that. Also that marijuana use can result in depression, anxiety, brain damage, subsequent hard drug use and so forth without stating that the majority of marijuana users suffer few if any mental health issues, then in the eyes of the client the counsellor is starting to look unreliable and the same as all the others who have used scare tactics before with him.

People will make their own observations of the world. Don't expect them to automatically believe what you tell them.

If a counsellor makes these kinds of statements which are not uncommon for them to do they will loose credibility in the eyes of most clients. The clients will simply go out and make their own observations and quickly see that the vast majority of marijuana users remain problem free in the ways described. There will be the odd one who does suffer some kind of problem but the vast majority wont.

They will quickly come to the conclusion that the counsellor is simply using scare tactics and they are again being given the false public health line. How will this effect the therapeutic relationship? I would suggest in an negative way that is not going to be conducive to a good therapeutic outcome. In my view the damage this causes to the counselling is significantly under rated.

However this leaves the drug counsellor in a very difficult position. If he says to the client  that ecstasy is a relative safe drug (and there is significant research to suggest it is one of the safest going around) then this can be taken by the client as permission to take ecstasy. This could certainly happen.

On the other hand if the counsellor tells the client that ecstasy is dangerous and can cause death by over heating the body (without putting these dangers in context) then he will loose credibility because very few people die from ecstasy use and the client will quickly see this when he talks with his friends.

A most difficult dilemma indeed for the drug counsellor to deal with.

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