Drug using careers

In my book working with drug and alcohol users I highlight the point that people use drugs for a variety of different reasons with the 6 most common being:

Experimental use 

Rebellious use 

Recreational use 

Situational use 

Symptomatic use 

Dependent use

Each of these represent quite different clinical situations. As a consequence they require quite different approaches and often have quite different goals of treatment. Clearly one of the first things the drug counsellor must do is determine which type of use is apparent.

One of the most problematic types of drug use is dependent use or the drug addict type of drug user. These people can be said to have drug using careers. That is these people will use in a very habitual addicted manner but eventually grow out of it and their career is said to come to an end. Considerable research has been done on this and it has been determined that the average length of such drug using careers is 10 years (or 9.9 years to be exact).

However it should be noted there is considerable variation on this 10 year average. This can best be explained by two graphs as shown

With this type of drug use there are three main avenues for treatment. One is to facilitate a more rapid ending of the career with certain therapeutic interventions.

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Drug counselling - authoritarian or permissive - part 2?

Thanks for your comment in the pervious post Dena. The two points you raise were exactly the ones I had considered including in the original post but decided not to as it would have made it too long. Now you have asked them I will address them in part two here.

Dena: “With the drug user that does not respond well to your permissive approach, that may in some cases 'stay sober for long periods of time', would you say then that they are unlikely to be drug free for the rest of their life?” (end quote)

There are three (well 4 really) possible outcomes with this Dena which I cover when I talk about the dependent drug user. These people are not uncommonly found in the health system and legal system even though they actually constitute a small number of the overall drug using population.

These are the truly problematic drug users who often have tragic lives. This is the kind of person you see in Hollywood movies who is the ‘drug addict’. Again this is only a small group of drug users but they are often quite noticeable. In my book I use this chart to indicate who I am talking about when I discuss the treatment of the dependent drug user.

Length of heroin career - 10 years

Male gender - 66.5%

Employed - 17%

Ever been in treatment - 90.5%

First age of intoxication - 13.7 years

Age of first heroin use - 19.7 years

Daily heroin use - 80%

Ever overdosed - 59%

Ever imprisoned - 46%

As you can see this is a person who lives a tragic life script. Some don’t make it during their drug using career. With that level of overdose they are walking close to the line of death. Most however do not die and come out the end of their drug using careers with criminal records and/or some unpleasant viruses or other significant health problems.

Some get relatively drug free by combining the authoritarian and permissive approaches. They initially go into a strict residential program (Authoritarian) and get their lives less chaotic and more conventional. When this has been achieved they can then ‘leave’ the strict program to some degree and then enter a more permissive treatment approach where the FC can make its decisions about being drug free. If that happens then they can be drug free for very long periods of time.

Your second point Dena: “There is also the question of value and worth as the counsellor is having to seek them out, that if they do not motivate themselves to get help that they will not invest their time and energy into resolving their problems, with this in mind is outreach work something that you think works, or even something that you would recommend?” (end quote)

My view is that with some drug users I would recommend it. Well it’s not so much a matter of it working as you don’t really have any choice in the matter. I worked in a drug rehabilitation center for 5 years and this point you raised often came up in supervision and at times lead to heated discussion. The key phrase you use is:

If they do not motivate themselves to get help that they will not invest their time and energy into resolving their problems

The two schools of thought on this are

1. They agree with your point. It is a matter of the client not being interested in seeking treatment consistently and does not turn up to appointments regularly. If this is true then outreach work could be seen as perpetuating the problem where the therapist becomes a rescuer and makes the client more of a victim who can’t help  himself.

2. They do not have the psychological capability to get regular help. To make an hour long appointment in one weeks time for many weeks in a row requires the ability to be able to plan ones life such that those appointments can be kept. To you and I and the average Joe this seems like a pretty basic thing that anyone could do.

However if you get someone whose Adult ego state is just functioning and the Parent ego state is basically nonexistent then it becomes a much more onerous task. In my view there are some dependent drug users who are like this. They are simply not going to get to a lot of appointments and it is not because they couldn’t care less or because want to be rescued by the therapist.

This is where the therapist’s clinical judgement is tested. Is the client not attending because he wants to play a game and be rescued or is it because he does not currently have the psychological capabilities to keep such regular appointments? At times a difficult question to answer.

Thanks for your question Dena.

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Drug counselling - authoritarian or permissive?

I use this diagram in my book - Working with drug and alcohol users - to illustrate the position I take on the continuum when counselling drug and alcohol users. It would also be typical for me when I counsel clients for non drug related issues although there may be more instances when I am less permissive in my overall approach.

As I mention in the book there are positives and negatives being authoritarian just as there are positives and negatives with the more permissive approach. Obviously in my view there are more positives up the permissive end than the authoritarian end and hence my decision to be where I am indicated on the diagram. The negatives of the permissive approach are a problem but in my view less of a problem than the negatives of the authoritarian approach.

I wish to add some further considerations to this diagram. At the authoritarian end the counsellor will of course be using more CP (Positive and negative CP). When this occurs the following will tend to happen as shown in the diagram

As the counsellor uses more CP as shown in line 1 there will tend to be a similar increase in line 2 in the client. They will tend to respond to the therapist from either the CC or RC ego states as shown in line 2. If a ‘parent’ like figure (as a counsellor often is) gets critical or controlling, those around will tend to become more conforming or rebellious or switch between the two at varying times.

At the same time the likelihood of FC involvement decreases. The FC in the client will become less prominent and play less of a role in the clients decisions and transactions as line 3 shows. The more CP then the less FC. The problem here is the more FC there is in decision making around drug use the better the long term prognosis. Being CP makes it harder for the client to stop problem drug use in the long term.

However the CP approach can be seductive. If the counsellor says, “Drugs are bad. don’t do drugs, only abstinence is acceptable...” then the client may move into CC and stop using. When people see this reaction they think this is all very good and obviously is the approach to use in the future. The problem is the likelihood of a relapse is very real because the shift from CC to RC is possible even highly possible at some time in the future. When there is a switch to RC obviously then comes the drug use. The long term prognosis is not good in these circumstances.

Also if it is a CC decision to stop the drug use then there has to be a CP some where nearby for that to last. The CP approach can be found sometimes in religion based drug treatment approaches that are residential. The drug user lives in some kind of drug rehabilitation facility. This can allow for a more consistent CC response because the CP is there consistently in their life. If they leave or significantly reduce the contact with the CP then the CC response will tend to wane and relapse is more likely to occur. If there is more FC in the decision to reduce drug use then this is less likely to happen.

In addition to this I would like to highlight an exception to the idea of the more permissive type of approach that I did not mention in the book. There is a type of drug user where this is not helpful and indeed has serious limitations. This type of drug user is not uncommonly found in counselling or in the health system in some way. It is the drug dependent user who is living out quite a tragic life script. They may be homeless in varying degrees, their lives are chaotic and maybe quite non conventional in that they may be unemployed and exist within the criminal world in varying degrees. Often they have quite poor Parent and Adult ego state development

When I worked in drug rehabilitation people would make appointments to see me, usually once a week. This type of drug user would keep the appointments about 30% of the time. They simply did not have a life style that allowed them to plan and structure their lives the way the average person can such that they can keep an appointment they organized a week before. They simply do not have the Adult ego state development to achieve that. 

With these people the counselor needs to seek them out in their homes and places where they hang out like with outreach work. The permissive approach that I describe is not very useful for them. Some of these people do respond to an authoritarian approach. They can take it on as their Parent ego state for a period of time and in some cases stay sober for long periods of time. They need to be told in a clear and direct way what to do and what not to do. The permissive approach does not do this and as a result is not that useful with such clients.

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I, the psychotherapist

Prominent influences in my professional development as a psychotherapist

Early to mid 20s - Psychology at university

Cognitive behavioral therapy

Psychology as an empirical science

Early to mid 20s  

Transactional analysis and Gestalt therapy - Bob and Mary Goulding

Psychoanalytic approach to child psychotherapy - Julia Solomon

Late 20s - early 30s

Gestalt therapy - Jim Simkin

Bioenergetics - Michael Conant 

30s until present

Study in a variety of modalities

Particularly transference based therapies

Psychoanalysis

Rebirthing (Traditional)

Family therapy of Milton H. Erikson

Other training over the years which has influenced me in particular

Ellyn Bader - Couples therapy

Stan and Ruth Kaplan - Sex therapy

Sue Helfgott - Drug and alcohol therapy

Lanktons - NLP


On the job learning that has impacted me significantly
Singapore Airlines - Organizational psychology
St John Ambulance Service - Trauma and trauma counselling
Association of the Relatives and Friends of the Mentally Ill - Chronic schizophrenia, bipolar and borderline personality 
Acacia Prison - Antisocial personality, schizophrenia, narcissistic personality, drug and alcohol problems, methadone as a treatment, suicidality and self harm.

Doing cotherapy with Mary Goulding in the early 1990s

I was recently asked by a supervisee what approach I use and I could not answer the question. I used to be able to answer that question and was surprised that I felt I no longer could. I felt I could no longer satisfactorily identify an approach that would define me as a counselor or psychotherapist. Initially this concerned me as it seemed a retrograde step. I had gone from knowing who I was to not knowing who I was. Needless to say I subsequently pondered this question for some time.

I can state the practicalities of what I do with a client and I can cite the influences on myself as a counselor, as I have done above. Perhaps that means I am now eclectic in my approach. I have never liked the idea of being an eclectic counselor as it seems to be a collection of a lot of things but not really any of them. It seems to lack a substance.

As I thought about the question in subsequent days, I wondered what had changed such that a question I once could answer, I no longer could. In my musing I calculated that I would have done between forty to fifty thousand hours of counseling in my thirty two years of working. It seems logical that if one does a task for that long then it stops being something that you do and becomes part of who you are. You have done the task so many times it becomes second nature, ‘in your bones’ and part of your character.

This idea then allowed me to answer the question. I am a person, Tony White and there are many parts or aspects of me, one being a counselor. When I go to work I am simply being me. This is what the client gets, me the person, with the counselor being part of me. I think I have shifted from being a counselor who happens to be named Tony, to being Tony who also happens to be a counselor. I now have some kind of answer should I be asked that question again. A two tiered answer, the theoretical approach I use with the practicalities of counseling and a more deeper understanding of myself as a counsellor as being part of my perception of who I am.

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The finite nature of grief

Grief can be a finite process that has a beginning, a middle and an end.

“In a previous study, we found that the majority of bereaved parents interviewed after the loss of a child were able to adjust to the child’s death and to integrate the experience into daily life, navigating the fine line between remembering their deceased child and reliving their intense grief, while also engaging in their family life and jobs.” In Death Studies, 33: 497–520, 2009

It is not uncommon to hear people say they would never get over the death of a child. It is important for therapists to confront this faulty belief in some way. Humans can get over tremendous loss if the bereavement process is dealt with properly. It is also important for therapists to let the client know that grief can be finite.



The pain from the loss of a loved one can be severe but it can also be temporary.

One hears statements made by therapists such as: “You will grieve at your pace, in your time and in your way”. Whilst this is somewhat true it is potentially harmful as it gives the person permission to extend their grief process for many years in some cases. 

When I work with clients who have had the loss of a child at some point I will usually say that 80 years ago parents would have 7 or 8 children because half of them were likely to die before they reached adulthood. We have become a death phobic society and become hyper sensitized to death as we progressively remove ‘offensive’ images and material from our lives and vision. The less we see such images like of dead people, the more hyper sensitized we become to them and the more images we need to remove. This is particularly happening in the news media.

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Early decisions and a child's thinking

In Transactional Analysis the A1 or Little Professor ego state is of considerable importance as it is a core component to the formation of our personality and script beliefs. In CBT terms this is how we get our thinking errors. It is the A1 that makes the early life script decisions that determine how we live the rest of our lives. 

Unfortunately these decisions are usually made in the first 6 years of life and as will become apparent that means they are made with little or no A2 or fully formed thinking ability. They are made by the A1 in what are known as the stages of sensori motor egocentrism and pre-operational egocentrism.

This is some what disconcerting if not frightening because as will be demonstrated that thinking is quite illogical and distorted meaning the young child can make quite illogical and distorted decisions that are not reality based at all.

However this does explain how a child can make the suicide decision early in life which some people consider a bizarre thing to do. 

There are in fact seven suicide decisions a child can make:

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 my book - Working with suicidal individuals - I state the following:

In the histories of suicidal individuals one finds parents can say many things which imply the suicidal message. For instance parents can say to the child:

“He’s our little accident”

“If it wasn’t for you I wouldn’t have had to marry your mother”

“We only stayed together for the kids”

“When you were born you tore your mother apart”

“You’re always hanging around me Jenny, why don’t you go and play on the freeway, Ha, ha, ha.”

Of course these only imply a possible suicide decision and as always it is up to the illogical thinking of the young child to conclude what it thinks about its own life. However if these kinds of things are said repetitively then it makes it more likely a child will made the suicide decision but is by no means a certainty.

What follows is an explanation of A1 thinking in order to demonstrate how a child can make what is a seemingly bizarre decision about how it should live or not. (Some of this is adapted from:  Helman & Austin TAJ 1977.)

Egocentrism

Piaget noted this as a major cognitive limitation in a child’s thinking as it develops.

Egocentrism is the inability to differentiate one’s cognitive perspective from that of others. The child mistakenly believes that its thoughts and beliefs are also held by others around it.

Cognitive development proceeds from an egocentric perspective to a more objective perspective.  Objective thinking remains in the domain of the Adult (A2) ego state. In this type of thinking the person understands and acknowledges perspectives other than her own and they can be taken into account in any decision making process.

A mother who is arguing with her husband and then finds her daughter not in bed yet may hit the child angrily. A child who is only capable of A1 (Little Professor ego state) thinking cannot take into account other objective causal facts for the anger. The child may think. “There must be something wrong with me to make her so angry that she hits me.”

An older person with A2 thinking is able to understand there may be other causes of mother’s anger, such as just having had an argument with her husband. Thus it is less likely to make false conclusions about itself and mother.

Sensori motor egocentrism  (Birth to 2 years)

A1 thinking is beginning and the child cannot differentiate between her own physical and cognitive being, and that of others. The child does not comprehend there is a separate physical boundary between mother and itself and of course all its rudimentary thoughts are perceived as belonging to mother and self as they are perceived as one entity.

Pre-operational egocentrism  (2 to 7 years)

A1 thinking continues to predominate but the child is now aware there is a physical boundary between itself and mother. However cognitively she 

1. Does not understand that others have cognitive perspectives besides her, or

2. Does understand this but is incapable of taking them into consideration at the time of her decision making.

Two girls (Jenny and Jody) are running along, Jody trips and cuts her face badly. Jenny who a few hours earlier had been angry at Jody thinks either:

1. Her anger caused the accident. “People will get hurt if I am angry at them.” Jenny is incapable of seeing Jody as being separate from her.

2. Jenny is capable of seeing herself as separate from Jody thus knowing she did not physically cause the accident. However she did feel angry at Jody and still has the belief that the anger caused the accident.

Also in this stage the child has the view that everyone thinks like she does and the whole world shares her feelings and desires. This sense of oneness with the world leads her to assume that she is magically omnipotent - “The world is created for me and I can control it magically”.

Finally in the stage of pre-operational egocentrism we have pre-causal reasoning which to many mature adults appears disconcertingly illogical

Phenomenism

The child makes causal connections between events that just happen to occur together when there is no causal relationship.

The child sees a red object floating and says that it floats because it is red.

“When I was angry, mummy looked sad, I can control (am responsible for) mummy’s feelings”.

Finalism

Things happen because they are supposed to. There is always a reason for things occurring as they do

“Bad dreams happen to punish me because I am bad.”

Artificialism

There are two parts to this. First the child believes grownups are omnipotent, so the child feels defined by what they say. A child spills milk and mother says, “You always do these bad things to me”. Child then believes, “I am bad so things would be better if I was not here”.

Second, the child identifies with these omnipotent beings and believes she is omnipotent as well. This can result in grandiose thinking. Watching and angry father the child may think, “You could kill (obliterate) me. I can kill (obliterate) you.”

Animism

Child believes world and nature are alive and have consciousness like it does.

“A stone is alive because it moves”.

“It gets dark at night so I can go to sleep.”

Concrete operational egocentrism  (7 to 11 years)

Child becomes able to coordinate other people’s perspectives using both A1 & A2 processing. As she interacts with more people she learns there are others who have different perspectives and she becomes more able to coordinate these differing perspectives. This also results in a giving up on beliefs like father christmas and the tooth fairy due to peer input and increasing A2 abilities.

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The machinations of developmental psychological theory

This comes from a book on developmental psychology. 

“Although many people cope with old age gracefully and meet death with dignity, this is not always so.”

Developmental psychologists often present human development as a series of tasks that have to be dealt with or mastered at the various stages in life. This is no better illustrated than with the developmental theory of Erik Erikson and the 8 ages of man as it has become to be known.

The diagram shows the various conflicts and tasks each person tries to resolve at each stage. For example as a child reaches adolescence he has to master the stage of leaving home. That means psychologically breaking away from the parents and developing his own social world. At the same time the parents have to master the task of letting the child go and restructuring their life as necessary as their parenting of children comes to an end.

People who complete the different developmental tasks are said to be developing normally. Those who don’t would be seen to develop a neurosis of some kind and this is where therapy is meant to intervene to assist the person to get through the developmental tasks and to move onto the next stage of human development.

According to the original quote I cited above if one enters old age gracefully and meets death with dignity then they are said to be finally completing their last stage of development. This means of course that the elderly person who is not being graceful or dignified would be neurotic and in need of some counsel to assist them to be so.

I am reminded of a time a few years ago when two sisters came to seek my counsel on a matter just like this. Their mother was in her mid eighties and in reasonably good health physically and mentally. She lived in her house where she had lived the last 50 years of her life and indeed one of the daughters lived with her at that time.

The problem presented was that the mother was being recalcitrant and obstreperous. She was hard at hearing and refused to get a hearing aid, she had no intention of leaving her house for a old people’s home and basically did very little of what the daughter’s suggested she do with her life and circumstances. This had the two daughters fatigued, at a total loss for what to do, exasperated with their mother and hence they came to see me.

According to developmental psychology the mother was neurotic and not successfully adjusting to her final stage of development. She certainly was not being graceful and had no desire at all to meet death with dignity.

After much discussion I presented to the sisters that perhaps it was mother’s rebellious, defiant and hard headed attitude that was keeping her alive at this juncture. Perhaps the mother knew (probably unconsciously) that if she ‘gave in’ to their wishes and became more graceful and dignified she could quickly deteriorate and die. If this was the case then one could understand the mothers gritty determination in that she was scared of dying.

The sisters did not know what to make of my suggestion and did not expect me to make such a determination about their domestic situation. They left some what perplexed and decided to think some more on my proposal before they decided about what path to take with their mother in the future.

Human psychological theory can sometimes be a precarious and malevolent thing. One needs to be clear that such theories of human development are not really a mechanism of social control. The study of human psychology is meant to be about how the human functions psychologically not about how society says they should function psychologically.

If an elderly person is meeting their final time of life with grace and dignity who benefits from that? The children and loved ones of the elderly person are feeling stressed and scared as they know their mother is going to die and that will be a painful event for them all. If mother is graceful and dignified about the ending period of her life that will certainly make it much easier for the children and loved ones than if she is being recalcitrant and obstreperous.

Assuming my proposal to the sisters was accurate then the mother’s own Child ego state was scared of dying and she was coping with that fear in the best way she knew.

A psychological theory which says the last stage of life is meant to be graceful and dignified, is that because it is better for those others around the elderly person than for the elderly person. If it is, then it is no longer a theory of human psychology instead it has become a system of social control of a particular group in the society.

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The teenage alcohol and drug user

In my book - Working with drug and alcohol users - I make quite a long statement on the teenage drug and alcohol user. I spend some time discussing the psychology of teenagers and how they differ from the adult population. This means of course that one needs to treat them differently when doing drug and alcohol counselling.

This is a short excerpt from the book:

 Adolescents are also somewhat tribal in nature, they congregate in groups to hang out together. Hence the peer group (tribe) for the adolescent can assume significant importance in many ways including drug and alcohol use. Although parents sometimes like to think that their teenage boy is taking drugs because he has fallen in with a bad crowd, in the majority of cases peer groups and peer relationships are bi-directional in nature. Their ‘good’ teenage boy is probably contributing to the 'bad' behaviour of other teenagers in his peer group. He is effecting their behaviour as much as the others are effecting his.

There are some adolescents (and adults for that matter) who are highly dependent and passive individuals, who are significantly influenced by the ideas and wishes of others. However this is a small group and most are quite capable of making their own decisions even if there is peer pressure to take drugs which they may not wish to take. Despite this, any member of a peer group (passive/dependent or otherwise) who smokes marijuana gives permission to the other members to also smoke marijuana. It says to the others watching, "In our group this is the thing to do." So all peer group members influence the drug taking behavior of the others involved in the tribe. Hence the bi-directional nature of influence in peer group behavior. (end excerpt)

It is a very convenient excuse, like the alcohol excuse. Invariably a defence lawyer will say their client was intoxicated at the time of the crime. The hidden transaction being, “It’s not really his fault but it was the alcohol that made him do it.” 

To say the teenager did it because of peer pressure says the same, “It’s not really his fault but he only did it because he was pressured to do it.” Parents and the teenager often both want this to be the case and at times they will collude with each other in this way without even realizing they are doing so. It is a very convenient psychological position to take and any counselor should consider it with suspicion when presented by the parents and/or teenager.

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Workshop on talking someone down

First review

First review of my book - Working with drug and alcohol users by Dr Linda Gregory.

Thanks for your book, it arrived OK.

I have read the first chapter so far and want to say I am enjoying reading what you are saying. As always, which I admire, your writing is clear and easy to read and understand, as well as being excellent and in depth theory.
I am excited about reading more. Working with alcohol and drug addictions has been an area I feel in need to learn more about. I am sure you book will fill that need.

Stage fright and performance anxiety

What is stage fright?

This it seems safe to say this is an anxiety based condition

I will mainly talk about people giving a workshop or some kind of public speaking as I have dealt with this mainly, including my own public speaking. However I have dealt with many others over the years who present the problem of stage fright in a wide variety of areas. For instance I knew a woman who plays the guitar and she used to get very anxious before any performance and used to take Beta blockers before auditions.

That is one solution to stage fright, some kind of anti anxiety medication. I recall another client who was very religious and had strong views against drugs or alcohol of any kind. She had to give a presentation in a tutorial to fellow university students. I recall being surprised when she said that before the tutorial she dank a glass of beer. She was that anxious that she dropped her views on alcohol to deal with the fright. This demonstrates just how significant stage fright or performance anxiety can be for some people.

I think it is fair to say that every person who does some kind of public presentation suffers stage fright to some degree. The Free Child ego state will naturally be nervous as you are performing to some degree. You are up there in front of an audience who are all looking at you and who will make a judgement of you of some kind. 

For some however the anxiety is neurotic in that it is beyond the normal degree of stage fright or has some other psychological meaning. People who present for stage fright or public speaking anxiety in counselling usually have all sorts of thoughts and produced many scenarios about how the audience will negatively asses them. Interestingly however, stage fright has little to do with them (the audience) and much more to do with you. In most cases the audience is somewhat irrelevant to what is going on psychologically.

There is a small group who suffer stage fright because of a problem in the Child ego state of the presenter. In this case the person has significant doubts about their own worth or OKness. They feel bad as a person in themselves. In their mind they start to link performance with OKness such that if they perform badly then that proves they are a bad person or their sense of personal worth is diminished. 

This person can suffer very badly from performance anxiety because each time they go out and perform their very sense of self worth is on the line. Whilst this does occur I would say that this is a small group of sufferers of stage fright. Most sufferers usually have an active internal Critical Parent ego state which they project onto the audience. This is why I say stage fright has much less to do with the audience than the performer them self.

When a client says the audience will think they are bad, performed poorly or give them a highly critical assessment I usually respond with - “Some will and some wont”. Those in the audience with a high CP will give a critical assessment no matter how good you are and those with a low CP will give a non critical assessment no matter how bad you are. (This is to be distinguished from an Adult ego state assessment which audience members can also make, however this is not usually what the stage fright person is anxious about.)

Stage fright is about how much CP the performer has in their own mind. Usually those who come from a background with highly critical parents often have their own high CP and those with less critical parents will have a lower CP and suffer less performance anxiety.

Dealing with stage fright is about 

Increasing internal NP

Reducing internal CP

Developing a strong A

Making sure the Child feels OK about self such that its OKness is not linked with performance.

After a presentation of a workshop or performance of some kind one needs to use their Adult to make an assessment and hence a robust Adult is most useful. Sometimes you do well and sometimes you don’t do so well. An Adult ego state assessment allows the presenter to get better and learn from each presentation they do. It is important to assess self but it must be an Adult assessment and not a CP assessment.

Finally there is a related type of stage fright that is solely a male condition. Indeed, it is often referred to as stage fright. Some men cannot stand at a urinal and urinate especially when there is another man standing next to him. However even if no one is there, for some men the thought that another man may enter the toilet and stand at the urinal is enough to produce significant anxiety. 

When that happens either the internal and/or external sphincter will not release and the urine cannot flow. He will have to wait for a cubicle to become available or urinate elsewhere. In many ways this is similar to the stage fright I discussed initially. It is an anxiety based condition that can revolve around a Be Perfect type of mindset and is a kind of performance anxiety. He thinks the other men will see he is not urinating and imagines they are making a CP assessment of his ‘performance’ at the urinal.

Whilst this may seem odd or even mildly humorous. Urinating can hold a special place in the male psyche that many women do not understand. Most men can recount urinating competitions when they were young boys. Competitions to see who can urinate the highest up the wall or over the longest distance are important psychological rituals for any young boy. With the winner achieving a special status amongst his peers (no pun intended). Who knows, maybe the grown man who cannot urinate in the public toilet suffered damage to his psyche by poor performances in these early urinating competitions.

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Library book update

Current list of university, college and training insititute libraries that have the book - Working with drug and alcohol users - released last month

The British library - British National Bibliography (UK)
Norfolk County Council (UK)
University of Sussex (UK)
Kingston University (UK)
Sandwell Hospital library (UK)

Prince of Wales Hospital library (Wales)

Library of Congress  (USA)
Tennessee State University (USA)
Boise State University (USA)
Purdue University Library (USA)
University of Notre Dame (USA)

Chisholm Institute of TAFE  (Aust)
Cairns Base Hospital (Aust)
National Library of Australia (Aust)
Mater Hospital Library (Aust)
University of Ballarat (Aust)
University of Canberra (Aust)
Deakin University (Aust)
Bond University (Aust)
University of Newcastle (Aust)
State library of Western Australia (Aust)

Unitec Institute of Technology (New Zealand)
Rotorua Public Library (New Zealand)

Hong Kong PolyU Library (China)

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Working with suicidal individuals

Current list of university, college and training insititute libraries that have the book - Working with suicidal individuals. Released in 2011.

Curtin University (Aust)

University of Western Australia (Aust)

Murdoch University (Aust)

Edith Cowan University (Aust)

Bond University (Aust)

Monash University (Aust)

Victoria University (Aust)

Bankstown Campus library (Aust)

University of Sydney (Aust)

University of Adelaide (Aust)

University of Newcastle (Aust)

University of Melbourne (Aust)

University of Queensland (Aust)

University of Ballarat (Aust)

University of New England (Aust)

University of Western Sydney (Aust)

TAFE Gosford campus library (Aust)

TAFE Bathurst campus library (Aust)

TAFE Tamworth campus library (Aust)

Deakin University (Aust)

LaTrobe University (Aust)

State library of Queensland (Aust)

Queensland University of Technology (Aust)

RMIT University (Aust)

Charles Sturt University (Aust)

Australian Catholic University (Aust)

James Cook University (Aust)

National Library of Australia (Aust)

Trinity College Dublin (Ireland)

Dublin Institute of Technology (Ireland)

National University of Ireland, Maynooth (Ireland)

National library of Scotland (Scotland)

University of Strathclyde (Scotland)

National Library of Wales (Wales)

Swansea University (Wales)

University of Glamorgan (Wales)

Bangor University (Wales)

PJ Library (Norway)

University of Bergen (Norway)

Norges teknisk-naturvitenskapelige universitet (Norway)

University of Oslo (Norway)

University of Tromso (Norway)

Universitetet I Agder (Norway)

Maribor General Hospital Library (Slovenia)

National library of the Netherlands (Netherlands)

TA Centre Library (Serbia)

Mitt hogskolan library (Sweden)

Stockholm University (Sweden)

Högskolan Dalarna (Sweden)

Mid Sweden University (Sweden)

Central Library of Zurich (Switzerland)

Swiss Federal Insitute of Technology Zurich (Switzerland)

Freie Universitat Berlin (Germany)

Humboldt University of Berlin (Germany)

State and University Library of Dresden (Germany)

Bibliotheksservice - zentrum baden-württemberg (Germany)

Universitat Des Saarlandes (Germany)

University of Erlangen-Nuremberg (Germany)

Universitat Leipzig (Germany)

Bavarian State Library (Germany)

Stellenbosch University Library (South Africa)

University of California  San Diego (USA)

San Diego Christian College (USA)

Open Library. California State Library (USA)

University of Southern California (USA)

University of California San Francisco (USA)

University of California Merced (USA)

Loyola Marymount University California (USA)

Golden Gate University (USA)

University of Alaska - Fairbanks (USA)

Boise State University (USA)

Huntingdon College (USA)

University of Nebraska at Omaha (USA)

Catholic University of America (USA)

Gallaudet University (USA)

Virginia Tech (USA)

Old Dominion University (USA)

City University of Seattle (USA)

University of Washington (USA)

George Washington University (USA)

University of Miami (USA)

Miami Dade College (USA)

Georgia Southern University (USA)

University of Nevada - Reno (USA)

Iowa State University (USA)

Dordt College Iowa (USA)

University of Iowa (USA)

Cameron University Oklahoma (USA)

Butler Community College (USA)

Frostburg State University (USA)

Arizona State University (USA)

Arizona Western College (USA)

Brigham Young University Utah (USA)

Bloomsburg University (USA)

Massachusetts Institute of Technology (USA)

University of Massachusetts Amherst (USA)

Williams College  Massachusetts  (USA)

Hampshire College (USA)

Wellesley College (USA)

Boston College (USA)

Kean University (USA)

Cedar Crest College (USA)

Cedar Park Public Library (USA)

Colorado State University (USA)

University of Minnesota (USA)

Norwich University (USA)

Santa Clara University (USA)

Ithaca College (USA)

State University of New York - Plattsburg (USA)

University of Buffalo (USA)

Marquette University Raynor Memorial Library (USA)

City University of Seattle (USA)

National Library of Medicine Maryland (USA)

Illinois State University (USA)

College of DuPage  Illinois (USA)

University of Chicago  Illinois (USA)

Indiana University Bloomington (USA)

Central Michigan University (USA)

St Clair County Library (USA)

University of Michigan (USA)

Grand Valley State University (USA)

Central Michigan University (USA)

University of North Carolina  Chapel Hill (USA)

University of North Carolina  Greensboro (USA)

University of North Carolina (USA)

University of Missouri-Columbia (USA)

University of Missouri-Kansas (USA)

Forrest Institute of Professional Psychology (USA)

Akron-Summit County Public Library, Ohio (USA)

Library of congress (USA)

Portland Community College Oregon (USA)

Mt. Hood Community College Library Oregon (USA)

National College of Natural Medicine Oregon (USA)

Oregon Health and Science University (USA)

Northeast WI Public Libraries (USA)

University of North Texas  (USA)

Laredo Public Library Texas (USA)

University of Texas-Pan American (USA)

University of Texas at Dallas (USA)

University of Texas at Austin (USA)

University of Texas at San Antonio (USA)

Texas State University (USA)

St. Edwards University Texas (USA)

Texas Tech University (USA)

Lone Star College  Texas (USA)

British Medical Association Library (UK)

Sheffield Hallam University (UK)

Brunel University (UK)

Kingston University (UK)

Liverpool John Moores University (UK)

Loughborough University (UK)

Stowmarket library Suffolk (UK)

Northumbria University (UK)

King’s College London (UK)

Derbyshire library (UK)

Dorset County Libraries (UK)

Berrywood Library Northampton (UK)

Oxford University library (UK)

Manchester Metropolitan University (UK)

University of Northumbria (UK)

Lancaster University (UK)

University of East London (UK)

University of Hull (UK)

University of Hertfordshire (UK)

University of Plymouth (UK)

University of the West of England (UK)

University of East Anglia (UK)

University of Cambridge (UK)

University of Exeter (UK)

University of London, Goldsmiths (UK)

Coventry City Council library (UK)

The Berne Institute (UK)

The Link Centre (UK)

Bromley Library service (UK)

Cadbury Heath Library (UK)

Kingswood Library (UK)

Nottingham Central Library (UK)

Yate Library (UK)

British Library, St. Pancras (UK)

British Library, Document supply (UK)

British Library, British National Bibliography (UK)

Ebook Library London (UK)

Hounslow Library (UK)

Barnet London Borough Library (UK)

University of Waterloo (Canada)

University of Manitoba (Canada)

Nova Scotia Community College (Canada)

Memorial University of Newfoundland (Canada)

Grant MacEwan University (Canada)

University of Western Ontario (Canada)

Saint Francis Xavier University (Canada)

University of Victoria (Canada)

Vancouver Island University (Canada)

Ryerson University (Canada)

Royal Roads University (Canada)

Simon Frasier University (Canada)

St. Clair College (Canada)

Universite de Montreal (Canada)

Universite du Quebec (Canada)

Universite du Quebec en Outaouais (Canada)

Memorial University (Canada)

Mount Saint Vincent University (Canada)

Mount Royal University (Canada)

Wilfrid Laurier University (Canada)

Cambrian College (Canada)

Kwantlen Polytechnic University (Canada)

University of Lethbridge (Canada)

Concordia University (Canada)

University of Guelph (Canada)

Library and Archives Canada (Canada)

Executive Counseling and Training Academy (Singapore)

Ngee Ann Polytechnic Library(Singapore)

Singapore Polytechnic Library (Singapore)

National University of Singapore (Singapore)

Nanyang Technological University (Singapore)

City University of Hong Kong (China)

Hong Kong Academic Library (China)

National Cheng Kung University (Taiwan)

National Chengchi University (Taiwan)

Taipei City Hospital library (Taiwan)

National Kaohsiung Normal University Library (Taiwan)

National Bibliographic Information Network (Taiwan)

University of Auckland General Library (New Zealand)

University of Auckland Philson Library (New Zealand)

Mental Health Foundation of New Zealand  (New Zealand)

University of Canterbury (New Zealand)

Lincoln University (New Zealand)

Northtec library (New Zealand)

Auckland University of Technology (New Zealand)

Unitec Institute of Technology (New Zealand)

Eastern Institute of Technology (New Zealand)

University of Otago (New Zealand)

Rotorua District Library (New Zealand)