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CQ

The CAPA Quarterly

Issue Four 2011

s o n i t c i A dd Journal of the Counsellors and Psychotherapists Association of NSW, Inc.


Preliminary conference announcement The Australian Centre for Integrative Studies

G de ain ve pr lop ofe me ss nt ion po al int s

Allies and Enemies

The role of real and metaphoric siblings in our psychological worlds 23rd to 24th March 2012

Keynote Speaker - William Cornell Historically our theory has been influenced by the interpretations of unconscious processes. As a result our work, theories and methodologies have predominantly explored the vertical transference (parent to child). Whilst this emphasis remains central and significant we also recognise that much of our work still focuses on the individual even when we are working with external systems. This conference therefore wishes to extend our focus and address the impact of siblings and how these relationships translate into horizontal transferences (sibling to sibling). A focus on siblings, and attention to the horizontal transference, encourages us to broaden our lens from the individual to the collective. This conference will address and explore some of the following topics: • The nature of the horizontal transference within our psychological work • The psychological dynamics of sibling and how we can include this more consciously in our therapeutic work • The impact of siblings on both the personal and collective level • The metaphor of “the sibling” within a political context and how this affects our work This is an integrative conference, bringing together different modalities but while being held through the lens of relational theories, philosophies and methodologies.

Bill is a prolific author. He was the editor of the international Transactional Analysis newsletter The Script for 10 years and is the co editor of the Transactional journal. He has written more than 40 journal articles and 10 book chapters. He is the editor of the Healers Bent: Solitude and Dialogue in the Clinical Encounter, a collection of the psychoanalytic writings of James McLaughlin for which Bill wrote the introduction. With Helena Hargaden he is co-editor and author of Transactions to Relations: The emergence of Relational Paradigms in Transactional Analysis published by Haddon Press. He is also the author of Explorations in Transactional Analysis. Bill brings a high level of integration to his thinking, writing and clinical practice. He is passionate in the areas of diversity and inclusivity and is a man who walks the talk. He maintains an independent private practice in psychotherapy, consulting and training in Pittsburgh, PA. He also spends considerable time in Europe leading training groups in psychotherapy. Visit our website to register your interest and receive updates as this profound conference takes shape. Website - www.acissydney.com.au Email - info@acissydney.com.au Conference Convener: Jo Frasca

The international keynote speaker William (Bill) Cornell MA, TSTA studied behavioural psychology at Reed College in Portland, Oregon and phenomenological psychology at Duquesne University in Pittsburgh. He is a teaching and supervising Transactional Analyst, Body-centred and Relational analyst.

3 Church St, Waverley, NSW 2024 P: (02) 9386 1600 E: info@acissydney.com.au W: www.acissydney.com.au


Welcome

Editorial

What is addiction? We use the word loosely to mean enthusiastic devotion to a particular thing or activity—even apparently innocuous things like the daily crossword—but it takes on a more serious and sinister tone when applied clinically, to describe a disease or condition that is harmful—one which, if left to run its course, can destroy lives, metaphorically and literally. Dictionary.reference.com defines addiction as “the state of being enslaved to a [behaviour] or practice, or to something that is psychologically or physically habit-forming, [such] as narcotics, to such as extent that its cessation causes severe trauma.” That definition can encompass a great many things. Traditionally, addiction referred only to substance abuse. Medterms.net calls it “a chronic relapsing condition characterised by compulsive drugseeking and abuse and by long-lasting chemical changes in the brain. …” Nowadays the term is increasingly all encompassing as similarities between substance abuse and what the DSM calls ‘impulse control disorders’ are identified. Some of those are addressed in these pages. Who are the addicts? The homeless junkie shooting up in a derelict building and feeling a temporary release from his troubles? The compulsive gambler feeding the rent money into the pokies, hyped with the hope that this time she’ll hit the big one? The extreme sports enthusiast seeking the thrill of close encounters with danger, even death? The performer who lives for the thrill of applause and, when it is absent, substitutes the high of drugs to compensate? The professional or executive escaping the pressures of life in the real world by escaping into online gaming? The shopaholic spending money she can’t afford on unneeded items? Or maybe the large swathe of the population that can’t start the day without a cuppa? The topic is vast. In this issue of CQ: The CAPA Quarterly we look at a few of the many forms addiction can take, viewed from different perspectives, and at how therapists and counsellors can approach the daunting challenges involved in helping addicts of all sorts to release themselves from the dependency that rules their lives when addiction takes hold. These insights also tend to illuminate behaviours that our society deplores which are perhaps brought on or at least encouraged by behaviours our society accepts and even applauds. In our first feature article, leading addiction psychiatry specialist and researcher Dr Peter Martin, explains that addiction is learned behaviour that results in disorders of the brain’s circuitry, and may be the primary problem presenting for treatment or may be secondary to an underlying problem of a different nature—illustrating a fundamental need for professionals treating addiction to look at the bigger picture. Dr Archibald Hart describes the pitfalls of addiction to the adrenaline rush of stress-inducing behaviours—behaviours that, for the most part, our society embraces as positive—and in a companion article, your Editor (moi) explores other aspects of this addiction to our natural ‘fight or flight’ hormones. Therapist Jodie Gale, who specialises in eating disorders, relates the history of eating disorders, looks at the changes in socially desirable body image over time, and explores November 2011

recent science on eating disorders and food addiction in the therapeutic context, noting that “each symptom has a healthy impulse towards wholeness”. Academic and researcher Katherine Mills highlights research findings indicating that sufferers of substance abuse disorders often have a history of trauma. Lifeline counsellor Jeanette Svehla examines the phenomenon of out-of control gambling—an addiction?—touching also on the controversy surrounding proposed legislation aimed at mitigating the effects of this behaviour in Australia. The modern malady of internet addiction is explored by Dr Kimberly Young, founder of the US-based Center for Internet Addiction, which provides assessment and treatment for internet-addicted patients and their families. Finally, counsellor and psychotherapist Beate Zanner shares a personal perspective: her experience working in a residential substance abuse treatment facility—a world of which few of us not working in that specialty are truly aware. I rue the limitation of page space for this topic, for there is so much more I would have liked to cover, so many more aspects of this broad phenomenon left untouched here, so many varieties of emerging recognition of ways in which ‘addictions’ impact our lives. I hope these brief glimpses into the realm of addictions whet your appetites to explore further this fascinating topic and to examine how greater understanding of it can help both your clients and yourselves in your practice. A reminder: The CAPA Quarterly blog has been taken down, and the information previously found there is being moved to the main CAPA website, www.capa.asn.au. In the interim, that information can be obtained from office@capa.asn.au, editor@ capa.asn.au or advertising@capa.asn.au, depending on the nature of your enquiry. We apologise for any inconvenience this time off line may cause. As always, this journal is for you, our valued members, and I enthusiastically encourage your active participation in the professional dialogue and sharing that this journal and the accompanying blog pages provide. Please have a look at the upcoming themes announced on Page 36 of this issue and have your say on the topics that interest you. Journal articles are, by the nature of page space, limited, and early contact with me improves the chances of your contribution being included. Dialogue is welcome and encouraged. If you’d like to contribute to future issues, please contact me at editor@capa.asn.au. Laura Daniel Editor

Laura Daniel, BA, JD, is a Sydney-based publishing professional with more than forty years’ experience in the industry, both in Australia and overseas (http://www.editorsnsw.com/esd/ae1445523.htm). In addition to editing, she also designs, writes, mentors, composes, paints, sculpts, photographs, sings, dances, walks, rides horses, does yoga and appears in minor film roles and commercials.

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CAPA NSW Executive and Staff President Jeni Marin president@capa.asn.au Vice-President Tara Gulliver vicepresident@capa.asn.au Secretary Jennifer Heward secretary@capa.asn.au Treasurer Mary Jane Beach treasurer@capa.asn.au Ethics Chair Tara Gulliver ethics@capa.asn.au Membership Chair Beate Zanner membership@capa.asn.au Regional and Rural Liaison Chair Sharon Ellam regional@capa.asn.au Professional Recognition Chair Barry Borham recognition@capa.asn.au PD Coordinator Juliana Triml capa.pde@hotmail.com Administrative Assistant Christine Rivers office@capa.asn.au CQ: The CAPA Quarterly Editor Laura Daniel editor@capa.asn.au Advertising Coordinator Christine Rivers advertising@capa.asn.au

Contents Welcome

1 Editiorial CAPA News 3 From the President’s Desk 4 The New Officers 6 Rural and Regional Report ~ Sharon Ellam Features 8 10 12 14 18 20 24

Addiction: the Big Picture ~ Peter R. Martin & Laura Daniel Addiction to Adrenaline: Thrilled to Death? ~ Archibald D. Hart The World’s Most Popular Drug? A Different Look at Adrenaline ~ Laura Daniel Eating Disorders: A Search for Wholeness ~ Jodie Gale Trauma and Substance Use Disorders: Common Co-Occurrence ~ Katherine Mills Gambling: Recreation or Behavioural Addiction? ~ Jeanette Svehla Hooked On Line: The Lure of the ’Net ~ Kimberley Young

First Person 28 Working in Drug and Alcohol Rehab ~ Beate Zanner Professional Development 30 The Needs of Gender Variant Children and Their Parents ~ Review by Juliana Triml 31 Professional Development Events Noticeboard 36 Calls for Contributions 36 Ad Rates 37 Classifieds Back Cover Conference Calendar

Cover art by Jim Frazier/Stock Illustration Source Design by Sarah Marsden for Unik Printing The CAPA Quarterly respectfully acknowledges the Cadigal people of the Eora Nation, the traditional owners and custodians of the land on which the CAPA NSW office is located; and the traditional owners of all the lands through which this journal may pass.

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© CAPA NSW 2011. Copyright is held with CAPA NSW and individual authors. Please direct permission requests to the editor. Opinions expressed in The CAPA Quarterly do not necessarily represent those of the Editor or of CAPA NSW. While all reasonable care has been taken in the preparation of this publication, no liability is assumed for any errors or omissions. Liability howsoever as a result of use or reliance upon advice, representation, statement or opinion expressed in The CAPA Quarterly is expressly disclaimed by CAPA NSW and all persons involved in the preparation of this publication. The appearance of an advertisement in The CAPA Quarterly does not imply endorsement of the service or approval of professional development hours from the service. Advertisers are advised that all advertising is their responsibility under the Trade Practices Act.

The Capa Quarterly


CAPA News

From the President’s Desk Well, here we are, well into the second half of 2011, and a new CAPA Executive team, with some familiar faces from the previous year and some brand new faces, came on board at the Annual General Meeting on 13 August 2011. In addition to the business aspects of the Annual General Meeting the assemblage was fortunate to learn more about the role of PACFA and the relationship between PACFA and CAPA from Ione Lewis, and enthralled by the Professional Development presentation of doctoral candidate Elizabeth Riley on transgender issues in children and youth and their families (see Professional Development review on Page 30). Juliana Triml who has so ably coordinated our professional development for the past year has agreed to continue with that responsibility and is already lining up interesting and, dare I say, exciting events for us. The AGM returned the following members to the Executive: I have moved from Ethics Chair to President, Jennifer Heward has kindly agreed to stay on as Secretary until our new Secretary can come on board, and Beate Zanner will continue her excellent service in the vital role of Membership Chair. New

Executive members are Tara Gulliver, who will take up the role of Vice-President and will also act as Chair of the Ethics committee until a new person is found for that role; Mary Jane Beach, who will be tackling the important role of Treasurer, a role so efficiently handled for the past few years by Campbell Forsyth; Sharon Ellam, who replaces Phil Hough as Rural and Regional Chair; and Barry Borham, who will be heading up a new Professional Recognition Committee designed to further our initiatives in that regard. Past President Maxine Rosenfeld and past Vice President Linda Magson have both generously offered to act in a consulting role whilst the new Executive finds its way, and Campbell Forsyth will be in the wings to support the new Treasurer as she takes over. A huge thank you to all the retiring executive members who have done so much to move our association forward. By the time you read this issue of CQ: The CAPA Quarterly, the PACFA Conference will have been held here in Sydney, and although I will not have been able to attend, CAPA will have had good representation, which undoubtedly we will hear about very shortly. For myself, I am looking forward to a oneon-one meeting with the new PACFA President Maria Brett shortly after the conference. Serving on the Executive these past two years has been a privilege and a pleasure, and I urge all CAPA Members from brand new Interns to Clinical members who have been part of CAPA since its inception, to give some time to a committee and, from there, hopefully to take a place on the Executive in future years. Previous Executives, of which it has been such a pleasure to be a part, have worked as a cohesive team, sharing what at times could be quite a sizeable workload down into manageable ‘bite-size’ pieces. CAPA is, as you are no doubt aware, the largest state-based counselling and psychotherapy association in Australia, but it can only continue to move forward with the support and participation of its membership. Please contact me or any member of the Executive if you would like to know more about any committee.

Jeni In recognition of her outstanding service, outgoing President Maxine Rosenfield was presented with a Lifetime Membership. November 2011

Jeni Marin President president@capa..asn.au 3


CAPA News

The New Officers President – Jeni Marin president@capa.asn.au Jeni started her counselling practice, The Complete Individual, in 1993, initially working mostly with individuals but gradually becoming more involved in working with families in crisis using primarily Narrative and SolutionFocussed Therapies. Over the years, she has also undertaken a range of contracts in the design and delivery of adult education and finds that now her days are filled with both counselling and delivery of training in Child, Youth and Family Intervention, Counselling and Community Services Management. Jeni’s formal qualifications include Undergraduate and Masters Degrees in Social Science and Counselling, and accreditation in Adult Education. A strong believer in ongoing education, she has also completed a number of Diplomas in Community Service, Mental Health and Counselling disciplines. She has been a member of CAPA NSW since its inception and, since ethics and social justice are two areas in which Jeni is passionately interested, she served two years as Chair of the CAPA Ethics Committee prior to accepting the role of President. Vice-President & Acting Ethics Chair – Tara Gulliver vicepresident@capa.asn.au ethics@capa.asn.au Tara has been a volunteer with Life Line for twenty-four years. She started as a telephone counsellor and then continued her training at the Institute of Counselling with a  Graduate Diploma of Counselling, furthering her studies at Unifam with a 4

Diploma of Individual, Couple and Family Therapy. Still with Life Line, Tara moved into personal, family and relationship counselling. She has also completed extensive Personal Development inservices with Life Line. Trained as a Suicide Awareness and Prevention educator with Living Works, for two years Tara was coordinator of the suicide support scheme for the northern beaches in Sydney. For the last five years, in conjunction with the Department of Probation and Parole and local community services, Tara has facilitated men’s anger management groups. She has recently joined the CAPA Ethics Commitee and is a clinical member of CAPA and a member of PACFA. Secretary – Jennifer Heward secretary@capa.asn.au Jennifer brings to the Executive her wide experience and skills gained from a variety of roles over 40 years, her own personal growth and, most of all, from Life! Her career has taken her in interesting and diverse directions over her working life. From her initial training as a bilingual secretary, she moved into radio and television in London, eventually producing programs with ABC Radio in Sydney. Jennifer’s interest in natural therapies then led her to achieve qualifications in remedial massage therapy, aromatherapy and other holistic treatments, which in turn took her into counselling and psychotherapy. She graduated from the Jansen Newman Institute with a Bachelor of Counselling & Human Change in 2004. Her main focus in her counselling practice is in the area of grief and loss/ palliative care. She’s a member of Cancer Counselling Professionals NSW, Inc.

and works with cancer patients and their carers, both face to face and by phone for those NSW country residents who don’t have access to counselling in their local area. Jennifer has also been a volunteer Personal Counsellor with Lifeline Harbour to Hawkesbury since 2003. Treasurer – Mary Jane Beach treasurer@capa.asn.au Mary Jane has had a very varied career, beginning with nursing 100 years ago (or it seems that way), and she studied midwifery in the UK. She returned to Australia and worked as a midwife for ten years, then studied child and maternal health at Hawkesbury University, now the University of Western Sydney. She worked at Red Bank House for another ten years, while studying  Counselling, again at Western Sydney Uni, followed by two years training in Solution-Focussed Family Therapy.  She currently works in private practice in Winston Hills seeing families, couples, and individuals. Mary Jane also works a couple of days a week at the St John of God drug and alcohol program—running groups and,  again, seeing individuals,  couples, and families. She has also been involved with foster care for the last 20 years. Membership Chair – Beate Zanner membership@capa.asn.au Prior to becoming a therapist, Beate had numerous occupations in theatrical management and production and in corporate administration. She then went for a dream, studying at Macquarie University and receiving a BA in Psychology. She subsequently The Capa Quarterly


completed a Graduate Diploma in Individual Psychotherapy and Relationship Therapy, at the Jansen Newman Institute. Since 2002, she has been a psychotherapist and counsellor, with a background working with drug and alcohol related issues and the issues associated with substance misuse. Currently, she works part-time as an Acting Team Leader for clients with a mental illness, in Aftercare’s Personal Helpers and Mentors Program (PHaMs). She also has her own private practice in Wollongong, working with individuals, couples and groups. She really enjoys running yoga laughter groups, as she believes we can never laugh enough, and is continually blown away by the strength of people when they are given the opportunity to find their own answers in the right environment. Beate has been a member of CAPA NSW since 2002, and has served as Membership Chair since 2010. She sees this as another adventure, to support our membership so CAPA gains appropriate recognition as an alternative, professional group of registered psychotherapists and counsellors. Rural & Regional Liaison Chair – Sharon Ellam

regional@capa.asn.au Sharon is based on the western shores of Lake Macquarie. Working in private practice with individuals, couples and families, she is known in the Ne wc a st le/C entra l Coast area as having a particular interest in Childhood Anxiety. With an eclectic approach, but a strong emphasis on building resilient family November 2011

systems, she works with children and their parents as a single entity. With very young children, she aims to effect change through re-focussing parental behaviours, and teaching them a childspecific ‘language’ to begin the process of teaching their child to self-calm and seek help. With a background in Guiding and being a Brownie Guide Leader for many years, Sharon uses some of her old skills in communicating with the very young, facilitating playful learning experiences and ‘thinking outside the square’ to ‘translate’ many of the concepts of CBT for this age group. In her previous life, she was a Registered Nurse, with specialities in Midwifery and Neonatal Nursing. Having strong foundations with children and families in the health sense compliments Sharon’s practise as a Counsellor. Working in a Neonatal Intensive Care Nursery for eight years also gave her a particular perspective in supporting and educating families affected by an abnormal pregnancy or birth. Female/Post-Natal Depression and assisting women who are struggling with an identity crisis after the birth of their baby is a particular interest. She compliments her practice by teaching piano. As well as paying the bills, combining Counselling with Piano Teaching is a strategic decision in managing her self-care, which is another priority in her life. Sharon was a founding member of CAPA’s Regional and Rural Committee. She is passionate about facilitating members to connect and communicate to enhance their practice, and also gain support through sharing. She is equally passionate about assisting CAPA to be more inclusive in a practical sense for regional members in all membership

categories. She lives life with a great sense of fun and flexibility. Studying music, laughing, gardening, painting, reading and ‘smelling the roses’ are some of her interests. Professional Recognition Chair – Barry Borham

recognition@capa.asn.au Following twenty-five years in the public sector in a number of management and policy roles Barry shifted to the corporate world in 1998. He now shares his time between his corporate role and his private practice, Shire Psychology and Counselling, at Sutherland. He enjoys working with couples and individuals and especially likes working with emotions in men. In his interactions with practitioners and educators within the profession, he is often deeply impressed by the professionalism, knowledge, skill and wisdom that he has encountered. He perceives that this wealth of talent and skill is not adequately recognised by politicians, the public sector and funding bodies. It is for this reason that he decided to use some of his experience and take on the role of Chair of the Professional Recognition Committee to work toward gaining appropriate levels of recognition for our profession. On a personal level, he is married with three adult children and, in his spare time is a keen bush walker, enjoying nothing better than holidays walking in wild places. He has a degree in Geography and English Literature, a Masters Degree in Public Policy plus both undergraduate qualifications and a Masters degree in Counselling. 5


CAPA News

Rural and Regional Report The RnR Committee has undergone change since the August AGM. With thanks and appreciation, we said farewell to our outgoing Chair, Phil Hough, and fellow original member Trish Herbert. CAPA members who attended a regional PDE in the last twelve months could not have done so without the tireless work in both planning and organising those events by what has been a three-person committee that communicated by teleconference or email. As of the AGM, the new RnR Committee comprises: Chair, Sharon Ellam, based at Lake Macquarie near Newcastle. Please see the New Officers page in this journal for more information. Claudia Pit-Mairbock, a Counsellor and Psychotherapist working in private practice on the Central Coast, she helps individuals and couples manage change and life transitions. She grew up in Austria, has lived in the Netherlands, and is settled now in Australia. Before she became a counsellor, she worked in internal and external communications. Her experience of having lived in different countries and worked with people from various cultural backgrounds sparked her passion to help people use their authentic voices so that they can fully engage in life. Christine Judd works at the Sydney Women’s Counselling Centre in Campsie as a generalist Counsellor with long-term clients and as a short-term Domestic Violence Counsellor. She entered the psychotherapy field more than ten years ago through studies in Somatic Psychotherapy. Having lived in India for ten years, mindfulness and awareness are her core therapeutic principles for creating greater wellbeing and self-determination. Chris is about to start a Masters of Social Work through Griffith University with visions of working in regional areas in a Counselling/Mental Health role. Having grown up in

the Bourke/Cobar area of western NSW, and with family members situated in Dubbo, she is familiar with life on the land, for farmers and for dwellers of small outback townships. Jane Ewins is a Counsellor, Supervisor and Facilitator working in private practice in the Shoalhaven district (Berry) of the NSW South Coast, consulting to the business and community sectors. She worked as a Counsellor and Advocate for Carers with Anglicare, and as a Family Relationship Counsellor and Educator with Catholic Care. For more than a decade she has developed or run programs, workshops and ‘Strategic Visioning Days’ for organisations including Cancer Council (NSW), Quest for Life, Anglicare, Catholic Care, Good Beginnings, The Coalition for Australia’s Children, Create, and Dads, Inc. Previously, Jane had marketing and communications senior management roles for large multinational companies and community organisations including NAPCAN (National Association for the Prevention of Child Abuse and Neglect) and Good Beginnings. Brian Edwards is a Counsellor, Clinical Hypnotherapist, Supervisor and Educator on the NSW Central Coast. He has experience in Counselling and Hypnotherapy using a wide range of therapeutic approaches for crisis work with families, particularly young people, and marital issues, bereavement, grief, phobias, learning difficulties, cessation of smoking, relaxation and gambling problems. Brian is also Workcover-approved. Looking forward to the next year, the RnR Committee has a few things on the agenda: • Re-building the committee. It’s exciting to see new members with a range of worldviews! Current committee members represent a range of membership categories, reside in both metropolitan and regional areas, and work in a variety of settings. This represents CAPA’s increasing focus on supporting, building connections, and linking all members regardless of membership status or demographics.

Motivational Interviewing

for Addictions & Challenging Behaviours Wed 23rd and Thurs 24th November 2011   

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Sharon Ellam

Gain an understanding of the principles and evidence underpinning Motivational Interviewing theories Learn core skills of Motivational Interviewing Identify and work with stages of change

See website for more details

Cost:

$352 (inc GST)

Venue:

11 Lowe Street, Merrylands 9760 1110

www.merrylandscounselling.com.au

The Capa Quarterly


• We excitedly await the new CAPA website and database! This means that we will be able to specifically identify regional and rural members, and then communicate with them in order to further the work of supporting regional areas. The previous committee were convinced that we were yet to fully identify the strengths of regional and rural members. • Plan more regional PDEs with greater notice in CQ: The CAPA Quarterly to allow members to forward-plan their PDE schedule. • Describe, in demographical terms, the regional and rural members of CAPA. To date, this goal has been unattainable. With the database update, and possibly a survey of regional and rural members, we will have more information about where best to hold PDEs and who can help or be helped in specific areas. This could possibly then allow us to create a Regional Resource for CAPA members that enables regional members to create or join local links for support, supervision, education, referral and communication. • Continue to work on improving communication for and with regional members. There is a wide spectrum of ‘communication realities’ for regional and rural members. Some of this work will include education for members on newer technologies such as teleconferencing, Skype, or other options within the social media world such as chats, blogs, and Facebook. The new website will also advance CAPA a long way towards becoming an association where all members can easily communicate and contribute. Our regular presence in CQ: The CAPA Quarterly is also aimed at stimulating contributions and discussion about regional issues. • Reporting to the CAPA Executive and advising them of current needs or issues in regional or rural areas for members. So far, advice has been given regarding regional members’ need for information, support, supervision, clarification of member issues, and logistical problems chiefly regarding communication, connections or staging PDEs.

Membership Total as at 4 October 2011

Clinical Members Associate Members Intern Members Provisional Members Student Member Affiliate Members Special Leave Honorary Life Members Total Financial Members November 2011

399 0 170 0 72 22 3 2 668

Code of Conduct for Unregistered Health Practitioners

As counsellors and psychotherapists, we are legally required to display two documents in our practice(s): • the NSW Code of Conduct for Unregistered Health Practitioners • information on how clients can make formal complaints to the Health Care Complaints Commission. Both are available online in the members area of the CAPA NSW website: www.capa.asn.au The Code of Conduct is also available in several community languages on the Health Care Complaints Commission website: www.hccc.nsw.gov.au These legal requirements are set out in ‘Public Health (General) Amendment Regulation 2008’ under the NSW Public Health Act (1991), and came into effect on 01/08/2008.

Ethics Checkout the CAPA NSW website for information on: • Ethics and Counselling • Problem Solving Steps • Client Confidentiality and Privacy and Relevant NSW and Commonwealth Legislation • Duty of Care • Workplace Bullying and Violence • Mandatory Reporting • Keeping Track of Paperwork • Information for Counsellors who have been served with Subpoenas • Complaints Form for Submission of Complaints and Grievances by a CAPA Member

Just login to the members area of www.capa.asn.au and click on the “Ethics” button on the left.

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Features

Addiction :

The Big Picture

Addiction has become the number one health problem in much of the Western world—the most widespread and costly of all diseases, effectively outstripping even cancer and cardiovascular conditions—in part because it underpins so many of our society’s common ‘lifestyle-related’ diseases (Martin, et al. 2007). While some psychiatrists hold that addiction necessarily “involves self-administration of an agent to alter the experience of self or the environment ... [which behavior] … then becomes maladaptive with harmful consequences when impaired control, behavorial salience, and neuroadaptation ensue … in considering addiction, we must also include the repetitive and harmful nature of many other behaviors in the human repertoire.” There is considerable and increasing support for the view that “various irresistible, repetitive, and harmful behaviors … not only resemble each other clinically but also share neurobiological underpinnings with drug and alcohol dependence. …” These drive disorders share similar causal factors and complications, and clusters of more than one such behaviour often occur in the same person (Martin 2005). ‘Addiction’ is here defined as a persistent, repetitive and often irresistible self-destructive activity that is perceived by the actor as rewarding—at least in its initial stages—but that robs the individual of time, resources, or the motivation to live a balanced life and that may well have been part of the person’s life before it rose to the level of addiction. Substance abuse disorders including alcoholism, tobacco and marijuana smoking, and recreational use and abuse of cocaine, heroin, amphetamines and other chemicals, are commonly recognised; however, recent research findings indicate that the mechanisms of addiction are shared with other problematic and repetitive behaviours that interfere with a balanced lifestyle, such as excessive exercise and extreme sports, out-of-control gambling, compulsive eating, computer gaming, viewing pornography, and problematic hypersexuality. When the definition includes all these behavioural disorders, the scope of the problem expands greatly. Because these afflictions often have catastrophic consequences—not only for the addicts themselves but also for their family, friends, co-workers and other associates—it is fair to say that the overwhelming majority of us—indeed, much of the population of the entire world—will, at some point in their lives, suffer some level of adverse consequence from some variety of addiction. “Most child abuse and domestic violence involves addiction. Most crime is committed under the influence” (Carnes 2007). 8

Primary and Secondary Addiction Addiction may be a person’s primary problem, or it may be a problem secondary to a person’s efforts to cope with a deepseated mental or emotional disorder. Primary addiction, like all psychiatric illnesses, arises directly from a combination of biological, psychological, and social factors. Secondary addiction results from an attempt by a person with another disorder, such as a thought or mood disorder or a physical incapacity, to relieve suffering through self-medication. A few examples of secondary addiction are: • the physically abusive and rigid father who produces an antisocial son who becomes an addict • the solider returned from combat who suffers PTSD and attempts to self-medicate with marijuana and alcohol • the young man who was given opioids for pain suffered in an auto accident and found they gave him energy • the prostitute who can only work while high • the head injury patient whose irritability and impulsiveness led to sexual and other acting-out that he cannot discontinue … The list could go on and on. Neurological Changes Recent studies by neuroscientists using brain imaging tools such as functional magnetic resource imaging (fMRI) have shown that addiction alters the neurophysiological operations of the brain. All addictions are disorders of brain circuitry that result in uncontrolled and repetitive behaviour, which addicts may often not recognise as harmful until they have progressed to the point of completely disrupting the lives of the addicts, and those close to them as well, and which, if left to run their course, will eventually displace all other pursuits. About half of all addicts are born with genetic markers that predispose them to becoming addicted, but this genetic component does not pre-ordain addiction. Addiction is learned behaviour. Our learning is modulated by our emotions and our experiences in the world. Over time, addicts learn to become numb to the pleasures they had previously gained from life’s ordinary activities, which are progressively supplanted by repetitive and out-of-control behaviours. Such behaviours are initially perceived as pleasurable, but as they become all consuming and overwhelming, brain chemistry is eventually modified in such a way that the brain becomes ‘hard-wired’ to enact them. Treatment There is a plethora of research and writing on particular addictions. Each specific addiction may have unique features The Capa Quarterly


Peter R. Martin and Laura Daniel

that set it apart from others, but the emphasis should perhaps be on the similarities shared by sufferers of all addictive disorders. The most important of these similarities are those related to treatment. Therefore, the focus has in recent years shifted to understanding and treating addiction as a whole, with newer integrative perspectives on treatment stemming from neuroscience. This unitary notion of addiction is also supported by genetic studies of psychiatric illnesses that tend to co-occur with addictive disorders; these studies have demonstrated how various addictive behaviours tend to cluster and interact with each other within the same families. Neuroimaging studies have identified shared regions of the brain that are pathologically activated in many of these related disorders. The medical profession was perhaps the last to consider and embrace this unitary perspective in which out-of-control behaviour disorders and substance abuse disorders were viewed as mechanistically similar. Dr Peter Martin has stated that he started to appreciate that some of the counsellors and psychologists he had worked with over the years were onto something when they first began studying brain functional resonance images of sexual arousal and humour in healthy men and found that the reward pathways activated when healthy men viewed sexually explicit videotape segments overlap those activated in addicts by exposure to drug-related stimuli. More recently he has developed methods and written, with colleagues, a comprehensive guide referenced below (2007) to show patients, physicians, and counsellors how to communicate more effectively and thus increase chances of successful treatment using the newer integrative perspective on treatments stemming from the latest findings of neuroscience. People with primary psychopathologies other than addiction—for example, depression, anxiety, or psychosis— frequently develop a secondary addiction to drugs or alcohol. When addiction is the secondary problem, treatment for the underlying primary condition must come first. In order to provide enlightened treatment, doctors and therapists must be able to grapple with the complex relationship of addiction with other mental and physical illnesses. Unfortunately, many addiction treatment programs are poorly equipped to address those other disorders, and psychiatric treatment facilities often fail to address the needs of addicted patients, even though they suffer from bona fide psychiatric illnesses. (See related article, Page 18). Recovery The bad news is that although some addicts can recover on their own or through such approaches as the twelve-step programs, November 2011

those who don’t seek and receive professional help are more likely than not destined to see their condition worsen until it eventually destroys their health and their life. The good news is that medical science now recognises that addiction is treatable and that success rates are similar to those for other long-term chronic illnesses. So what can those suffering from addiction do? First, they must decide that their behaviour creates significant problems for themselves and those they hold dear, and they must conclude that they are ready to participate in treatment. They must be open to and ready to accept and embrace the changes that will come with treatment, and must commit themselves to persevere until their addiction is under control and they can lead productive lives, including relationships with others with whom they engage in their journey of recovery. Addiction is a lonely state focussed on illness. Recovery involves broadening clients’ horizons and developing relationships that allow them to grow beyond the myopic concerns of repetitive harmful behaviours. Once addicts have made this commitment, they must learn what the biopsychosocial perspective and neuroscience can teach us about their disease. Equally important, they must come to appreciate which components of recovery require personal growth beyond the scope of medical understanding. This aspect of recovery is often referred to as spirituality. In essence it represents a level of comfort with the uncertainties of life over which none of us has much control. To live life successfully, addicts must come to grips with a delicate balance of relative certainties and uncertainties. Mastery of this skill can save their lives. References Martin, P, Weinberg, B and Bealer, B 2007, Healing Addiction, Hoboken: John Wiley & Sons Martin, PR 2005, in Martin, PR and Petry, NM 2005, ‘Are Non-substance-related Addictions Really Addictions?’ Clinical Controversy Series, The American Journal on Addictions, 14:1-7 Carnes, P 2007, ‘Foreword’, in Martin, P, Weinberg, B and Bealer, B, Healing Addiction, Hoboken: John Wiley & Sons

Peter Martin MD is Professor of Psychiatry and Pharmacology at Vanderbilt University USA and Director of the Division of Addiction Psychiatry, Addiction Psychiatry Interdisciplinary Research Training Program and the Vanderbilt Addiction Center. His research and scholarly interests include the molecular basis, diagnosis, and treatment of drug use disorders with an emphasis on substance-induced mental disorders and medical illnesses such as obesity using the perspective offered by addiction psychiatry.peter.martin@vanderbilt.edu

Laura Daniel BA, JD is a Sydney-based freelance writer and is Editor of CQ: The CAPA Quarterly.

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Features

Addiction to Adrenaline I might as well confess it right up front. I am a classic ‘adrenaline junkie’. I thrive on emergencies and am driven by challenges of new conquests. I also feel miserable whenever things are humdrum and in a rut. When I relax, I don’t just feel guilty, I feel gloomy and murky. My wife doesn’t like it, nor do I. Am I alone in this malady? I doubt it! But over the last twenty or so years I have made a determined effort to overcome this addiction. I have been reasonably successful and the result is a more peaceful and satisfying life. The Power of Adrenaline Behind every addiction is a compelling urge to feel wonderful and avoid pain—physical or emotional. One of the commonest ways we pursue this goal of exalted delight is through the use of the body’s own natural and powerful stimulant: adrenaline. I recently came across an advertisement for a new sports car. The photograph depicted a sleek, red, obviously powerful dream car. Across the top of the ad were the words: Pure Adrenaline. They said it all and just about sum up the attitude of most of us today, even if we don’t realise it! Like it or not, we worship adrenaline and all it offers—increased vitality, delayed pain, and deep euphoria—and thrive on its added thrill. Many have become so dependent on it that I believe it is now our greatest addiction problem. It seems that half the working population out there cannot start the day without a coffee jumpstart, judging by the number of people I know who make a regular ‘pit stop’ at a caffeine den on their way to work. And if you don’t know what the primary effect of caffeine is on our bodies, you really need to read this article to the end! What Is Adrenaline Addiction? The term ‘adrenaline addiction’, while not yet scientifically validated (I don’t see too many experts warning us of it besides myself), is as accurate a term as I can come up with to describe what I know so well. It implies that we can become ‘hooked’ on the pleasurable feelings produced by the main hormones manufactured by the adrenal glands. Intended to produce a ‘fight or flight’ in an emergency situation, these hormones, collectively called catecholamines, are the body’s stress hormones. Chief among them is adrenaline itself, but it doesn’t act in isolation. It is in cahoots with several others, notably cortisol which is responsible for much of the anxiety distress that follows too much stress. At high risk for adrenaline addiction are those of us who can be described as ‘hurried personalities’. At home, in the office, in church, or even when engaging in our favourite recreational activity, we are always rushing. We constantly carry around a sense of urgency. Like the white rabbit in Alice in Wonderland, we are always muttering: “I’m late! I’m late, for a very important date!” As we get older we lose our ability to slow down, and rushing becomes a part of our personalities. And we like it that way. Being in a hurry makes us feel alive, 10

Thrilled to D

important and efficient. All delusions, I know, but it is the feeling that counts! What is perhaps the most fascinating aspect of adrenaline addiction is how we react when we are forced into idleness. When we try to slow down or take a vacation, we nearly go berserk. In fact, the most telling sign that one is an adrenaline devotee is what happens when you are forced to slow down. This reaction to slowing down is, in my opinion, the clearest evidence that excessive use of adrenaline is addictive. There is a very clear pattern of withdrawal symptoms. I know all about this type of withdrawal from personal experience!

Adrenaline Withdrawal What are the signs of adrenaline withdrawal? • a strong compulsion to get back into doing something • obsessing about what ‘what has been left undone’ • vague guilt feelings when idle • a mild to moderate feeling of depression (called ‘post-adrenaline depression’) • fidgetiness, restlessness, pacing, leg kicking, finger drumming, or fast gum-chewing • feelings of irritability and aggressiveness. The phenomenon of ‘post-adrenaline depression’ is very common among clergy who experience it on Mondays after an intense weekend adrenaline demand. Sports enthusiasts (players and specta­tors) experience it the day after a big event (see accompanying article on Page 12). The depres­sion is caused by the steep drop in the level of adrenaline and is part of the restorative process of the body. Because the symptoms of adrenaline withdrawal are unpleasant, most people try to create an adrenaline boost. They might try ‘psyching themselves up’. A shot of caffeine becomes a regular feature every morning. Caffeine is an adrenaline stimulant. Boosting the adrenal system accelerates the normal wear and tear on our bodies, thus hastening the onset of stress and heart disease. It also signals its protest by creating distress signals in the body: ulcers, headaches, and gastric distress, to name but a few. These need to be heeded if one is to overcome one’s addiction here. Beyond Adrenaline Addiction – Adrenaline Exhaustion Adrenaline addiction can be damaging enough in itself. Beyond adrenaline addiction, however, lies even more trouble: adrenaline exhaustion. The adrenal glands do not have an unlimited supply for the body. Sooner or later, if pushed to the limit by pro­ longed stimulation, they will ‘switch off’. The result is a state of ‘hypoadrenia’, or adrenal fatigue. For some, this can be quite a serious disorder requiring many months of rest for recovery. While severe depletion can occur, most of us who are pushing the envelope here are more likely to create another problem: enlargement of the adrenal glands. Over the past few years, several reports have come out showing a connection The Capa Quarterly


Death?

Archibald D. Hart

between the excessive use of adrenaline and major health problems. For instance, in early heart disease, enlarged adrenal glands are quite common, signalling the possible link with prolonged stress. Also, about 50% of people who suffer from major depression are found to have enlarged adrenal glands. Is it possible that it is chronic stress that is causing the depression, or is it that depression itself is a significant stressor that forces the adrenals to work overtime? We don’t know yet. What is clear is that we were designed with a system that will adapt to increased emergency demands. We need to be responsible in how we treat our bodies so as to stay within the bounds of this wonderful creation. Coping with Adrenaline Addiction While we cannot survive without adrenaline, we also cannot survive if we abuse it! Stress symptoms like headaches, panic anxiety, muscle pain, rapid heartbeats, bruxism (teeth grinding), gastric distress, fatigue and sleep disturbances are all a safe bet that you are over-adrenalised, if not addicted. Recovery can be as resistant to change as that from any drug addiction. In some ways, it may be more resistant. It is socially acceptable, even admired in our success-driven culture. This makes it an even harder habit to ‘kick’. The healing of adrenaline addiction, as with all addictions, involves making changes in lifestyle and personality and in developing those spiritual qualities and disciplines that can enhance inner peace and quietness. Lifestyle changes are the starting point. Humans need time for restoration and recovery. This human need for rest is a clear biblical concept. Rest is not only a necessary part of the human life cycle; it is also linked with worship in the Judaeo-Christian tradition: “Six days thou shalt work, but on the seventh day thou shalt rest” (Ex 34:21). The seventh day was to be a holy day, set apart for worship, no matter what was waiting to be done. This principle tends to be misunderstood and misused in Chris­tian evangelical circles. We abuse our bodies for six days—then spend the seventh in religious activities that are as adrenally demanding as what we do during the other six days! Personality changes are the most difficult. Those of us who are high-octane Type A need to learn how to behave like Type B when the occasion demands it—slow down, don’t be so easily angered, and be quick to forgive. Other articles in this issue also speak to some of these changes. Enhancing peacefulness through spiritual disciplines is the most important because it is foundational to all other changes. Here are some practical steps that your clients might find helpful as you assist and guide them in their recovery: • Don’t try to rush your healing from adrenaline addiction. If you already suffer from hurry sickness, you will probably want to hurry your recovery as well. Remember, this attitude is part November 2011

of the problem. Allow yourself space and time to make the necessary changes in your life. Incorporate healthy physical changes. Since adrenaline addiction is a physical as well as a psychological and spiritual phenomenon, certain skills and abilities that help the body manage adrenaline can help tremendously. Regu­lar exercise, for instance, burns off excess adrenaline (though exercising to excess has the opposite effect). Relaxation techniques can promote natural lowering of adrenaline. Getting enough sleep allows rejuvenation of the adrenal glands. Learn to tolerate frustration. Accept that in the natural world projects will grind to a halt, people will let you down, and lines will get long just before you go to the checkout counter. If you are an adrenaline addict your body has learned that ‘fighting’ is the appropriate response to every obstruction and challenge. So teach your body to calm down and accept the uneven flow of life without becoming angered. Practice ‘disengagement’ techniques. Of all the strategies I have used over the years to control my adrenaline infatuation, this is the one that has helped the most. It is a strategy that puts you into neutral gear, so that you are not being driven but are coasting smoothly. For instance, if someone is really bugging you, just disengage and ‘let it go’. If you catch yourself hurrying or racing from too much adrenaline, apply the brakes, so to speak, and consciously slow down your action. Schedule appointments, activities, meetings, and obli­gations to allow yourself a breather several times each day. Reorder your values and make sure that your priorities, goals, commitments, and friendships are what you really want. Stop trying to please others or keep up with them. Get off at the next station of your life’s journey and take time to rearrange your priorities. There’ll be another train along soon enough. Overhaul your personality. Your personality may have changed over the years as well. Maybe you don’t have time for the good things of life anymore. You’ve forgotten how to relax or enjoy leisure. Your feelings may be out of control—too much anger and impatience. Perhaps your laughter has turned cynical, your good nature acerbic. This is what adrenaline addiction can do to you. Right now you could probably do with a personality transplant!

Archibald Hart, PhD, FPPR, FCIP—a licensed psychologist, certified biofeedback practitioner, and board certified diplomate fellow in psychopharmacology—is Senior Professor of Psychology and Dean Emeritus at the Graduate School of Psychology, Fuller Theological Seminary, Pasadena, California, and is best known for his research on the vocational hazards of ministry. Author of 25 books, he explores the topic of the above article in depth in Thrilled to Death: How the Endless Pursuit of Pleasure is Leaving us Numb (2007). He has authored numerous books with his two daughters, both physicians. See www.hartinstitute.com.

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The World’s M Google ‘adrenaline’ and your top hit will be adrenalin.com, a company promoting extreme sport and other adventure experiences, amongst other things. Also on the first page are adrenalindive.com, the online game Adrenaline Challenge, and the website of the Adelaide Adrenaline, the actual name of a hockey team. Adrenaline, once crucial to survival as the signal for ‘fight or flight’ has come to be commonly invoked by commercial enterprises and their advertisers to signal excitement and adventure. Adrenaline is a catecholamine hormone produced in the medulla of the adrenal glands and is the most potent stimulant of the sympathetic nervous system, resulting in increased heart rate and force of contraction, vasoconstriction (diminishing blood flow) or vasodilation (increasing blood flow), relaxation of bronchiolar and intestinal smooth muscle, glycogenolysis (sugar metabolism), lipolysis (fat metabolism), and other metabolic effects (Stedman 2007). Both the Latin-derived word adrenaline, from the roots ad- and renes and the Greekderived term from the roots epi- and nephros literally mean ‘on the kidney’, in reference to the location of the adrenal glands on top of the kidneys (Askew & Smith-Stoner 2001: 4-6). According to American psychologist Dr Michael Todd, the release of adrenaline—which also stimulates the release of endorphins, known as internal morphines, according to Dr Todd—equips the body to deal with immediate emergencies of pain, exhaustion and strength. This wonder chemical enables a person to lift a car off a child, drop from a helicopter to ski down a glacier, run a gamut of burly defenders to score a try, or jump over a canyon on a motorcycle. It can also, however, wreak havoc on the mind and body of someone addicted to the feelings caused by an adrenaline rush. Adrenaline addiction is as real as drug or alcohol addiction, rewarding the body with exquisite pleasure and pain relief. As with any other addiction, the body builds tolerance to the chemical and needs larger, more 12

frequent doses to achieve the desired effect. Although it allows enhanced achievement and temporarily increases stamina, it has serious, sometimes life-threatening consequences— not just to the addicts but to their family and friends as well (Harkleroad 2006). Professional athletes, extreme sports enthusiasts and daredevils spring to mind at the mention of ‘adrenaline junkies’. Many such individuals experience an ‘adrenaline high’ so regularly that they become literally addicted to adrenaline. Dr Todd, developer of the Adrenaline Addiction Treatment Program for Sport Athletes (AATPSA), has stated that based on a survey of 167 professional and amateur athletes, he sees the greatest danger in an addiction as arising when a person is no longer able to experience the adrenaline high. “Sometimes athletes are hooked on the attention. They crave the applause, cheering, interest from the opposite sex, or the fame. Take those rewards away due to injury or retirement and withdrawal begins.” He related that one athlete surveyed described the effect of exposure to the crowd as “walking into a bright room where all your senses are heightened. When it’s over, you walk into a dark room where your senses all shut down.” The latter description flashes a red warning light. Todd says that “withdrawal causes symptoms such as confusion, irritability, anxiety, depression, lack of energy and decreased self-confidence. The athlete then becomes chemically less equipped to cope with daily pains and stress. Thus, we see athletes sent to jail for rape, drug sales and use, gambling, spousal abuse and attempted murder or murder” (Harkleroad 2006). Other high-voltage entertainers suffer similarly. Spouses and children usually bear the brunt of either the athlete’s addiction or the withdrawal from it. Often neglected or ignored, families learn to work around the adrenaline junkies’ needs and demands. They spend days and weeks alone while their spouse is on the road for the next competition, concert or The Capa Quarterly


Most Popular Drug? A Different Look at Adrenaline Laura Daniel

promotion. Children are trained never to interrupt when their parent is home. Families fall apart, and children grow up to repeat the pattern (Harkleroad 2006). The hormone adrenaline is a top-notch drug—a potent feelgood chemical produced naturally by the body in response to stress and accompanied by other mood-altering hormones. It’s legal and free, and the high it produces is very desirable. Junkies crave the next ‘fix’ and create situations that lead to the release of this powerful substance. Their lives are filled with stimulants, drama, challenges, crises, and often danger. Even mundane events transform into big deals to them in order to trigger the flight or fight response created when the adrenals pump out their soothing euphoria. “Like it or not, many people are addicted to adrenaline and the increased vitality, delayed pain and deep euphoria it offers; and we live for the thrill it adds to everyday living,” says psychologist and professor Dr Archibald Hart. “No longer relegated to the exclusive domain of professional athletes, the risk of addiction is high for individuals who have difficulty relaxing. …” His books Thrilled to Death (2007) and Adrenaline and Stress (1995) examine the reach of this addiction and its ramifications for both physical and mental health. Just as ‘hooked’ on this free and legal, addictive and mindaltering substance is the ‘Type A’ personality, the driven, wired, busy or intense person, the CEO whose life is filled with racing from one meeting to another, quenching corporate fires. Type in ‘adrenaline addiction’ as a Google search term and at the top of the list are discourses on the adrenaline addiction of business executives. Then there’s the procrastinator who waits until the last minute, sweats through a project, heart racing because it’s down to the wire, the fitness freak who can’t function without a substantial workout at the gym at least five days a week, or the mother of six, for whom there is always an emergency or soccer practice or music lesson or meal to prepare. She has to find a way to make it all work. November 2011

Both Todd and Hart say recovery can be difficult, especially because the condition is socially acceptable in our culture and sufferers don’t want to give up the benefits of the addiction. They see it as a way to meet their goals, be in control and multitask effectively. For these reasons, Todd and Hart agree that professional help is generally required, often for the family as well. Todd, who says it is generally difficult for adrenaline addicts to accept the fact that they are dependent, that the need for the rush has taken over their lives, uses a cognitive treatment program. The issue is treated as a behaviour, the sessions and client work are very structured, and specific new behaviours are developed to replace the harmful old ones. It takes patience and commitment to succeed. For hard-core adrenaline junkies, help could mean the difference between a successful marriage and divorce, mental health and disability, enjoying life one activity at a time or pushing oneself to the ultimate high— the precarious moment between life and death, or beyond (Harkleroad 2006). References Askew, G and Smith-Stoner, M 2001, The Pharmacy Assistant (Clinical Allied Heathcare Series), Clifton Park, NY: Thomson Delmar Learning Harkleroad, IA 2006, ‘Adrenaline addiction: Hormonal rush creates chemical dependency linked to health risks’, Lynx, accessed 3 August 2011 at http://www.pvc.maricopa.edu/puma/apr06/addiction.html Hart, A 2006, Adrenaline Junkies’, Focus on the Family Magazine, cited in (Harkleroad 2006). Stedman’s Medical Dictionary 2007, 28th Edition, Philadelphia: Lippincott Williams & Wilkins

Laura Daniel BA, JD is a Sydney-based freelance writer and editor, and Editor of CQ: The CAPA Quarterly. She would like to acknowledge the cited article by journalist Irene Harkleroad as the main source of the material in this article, quoted with permission: © Maricopa County Community College District. Harkleroad’s principal source, Dr Michael Todd, could not be located in time for his direct input into this issue of CQ. A separate article by her other informant, Dr Hart, appears as a companion piece in this issue.

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Eating Disorders

A Search for Wholeness

At the heart of every eating disorder, whether it is compulsive eating, bulimia or anorexia, there is a cry from the deepest part of our souls that must be heard. It is a cry to awaken, to embrace our whole selves … It is a cry to deepen our understanding of who we really are. It is a longing to know ourselves in mind, body and spirit. Normandi & Roark 1998: 119

In psychosynthesis—the holistic, integrative and psychospiritual approach that I draw upon—eating disorders are understood as a process addiction whereby the person, often but not always a woman, is “caught in a compulsive pattern that seeks to establish self-worth in the face of worthlessness” (Firman & Gila 1997). While historically women have outpaced men in the development of eating disorders, men are catching up. Mission Australia’s largest youth survey to date reports that one in three females and one in four males cite body image as their number one personal concern (2010, cited in Butterfly Foundation 2011). My own work focuses on women. From the psychosynthesis perspective, food addiction, disordered eating and eating disorders are a complex way of managing biographical, existential and spiritual crises (Gale 2008, 2010), all of which are seen as having a spiritual context lying at heart of them. Exploring the spiritual dimension is associated with better healing outcomes as spiritual issues are significant in both the etiology and recovery of eating disorders (Richards, Hardman, & Berrett 2006). Holding a spiritual context is by no means a new idea; however, it is still neglected and at times misunderstood. Spirituality can be understood in the following ways (Richards, et al. 2006; Southard 2010): • oneness with God, spirit, nature, the land or the universe • expansion of identity, enlightenment or transcendence • transpersonal qualities such as harmony, love, gratitude, connectedness or hope • search for the sacred • life energy or essence • pursuit of value, meaning and purpose in life. Holding a psychospiritual context, the psyche, in Greek meaning the soul, consists of body, feelings, mind, sexuality and spirituality. Therefore, eating disorders are classed as ‘soul sickness’, not as diseases, mental or psychiatric illness: all terms used within the medical model. The person’s symptoms are not in need of a ‘cure’ or a ‘fix’; rather, they are sought to be understood as a call from the higher or spiritual Self towards growth and wholeness. In Women, Food & God, Geneen Roth (2010) suggests that a woman suffering with an eating disorder 14

is attempting to fix something that has never been broken— our job as therapists is to provide a therapeutic environment where she is free to discover and awaken to her wholeness. A History of Eating Disorders and Psychopathology Throughout history, eating and starving have been associated with religious and spiritual experiences. In Ayurvedic texts— flexibility, breathing and diet were seen as essential for controlling the mind and emotions. Fasting saints were regarded as miracles and their ability to survive without food as a sign of their holiness. In secret however, many of them were caught out sneaking to the kitchen, gorging on food, and were found to be hiding meat and salt under their beds. Starving has been used by those wishing to express Christ’s suffering, avoiding demonic food to ward off danger and to allow dreams and visions of higher meaning to enter (Vandereycken & van Deth 1994). To this day, religious beliefs inform regulations around food; some Christians eating fish rather than other flesh foods on a Friday, some Buddhists’ avoidance of killing and eating animals, and Muslims’ daytime fasting during Ramadan. Eating disorders are not new phenomena. Bingeing and bulimia—from the Latin, ‘boulimia’, meaning ‘ox-hunger’— were practiced by wealthy Romans and Greeks. Having gorged on feasts, they would tickle their throats with feathers to make way for more feasting. A kind of ‘Cabbage Soup Diet’, was used to cure scurvy in the Roman era, and Hippocrates often spoke of a cure for obesity suggesting an olden day version of the ‘Atkins Diet’, slimming exercises, and punitive measures such as sleeping on hard beds (Vandereycken & van Deth 1994). During the 18th century, bewitchment and demonic possession were seen as popular causes for starving and purging. Increasingly though, Satan was no longer blamed, as a medical, physiological and pathological approach emerged. Rather than starving, many religiously inspired women turned to teaching, charity and care as an alternative (Vandereycken & van Deth 1994). Where women’s curvaceous bodies were at times admired by artists such as Rubens, Botticelli and Leonardo—and viewed as wealthy and fertile if they were obese—by the late 19th century, the middle classes were erring towards an emaciated look. The science of dietetics dictated basic nutritional standards and the body became just one more soulless machine (Lowe 2008). The Capa Quarterly


Jodie Gale

Food has long been associated with social rituals, communication, identity, class, status and power. Increasingly, people’s relationship to food was linked with moral meaning. In the Victorian era, strict rules and manners—punishing, withholding and controlling methods—were increasingly used as a form of oppression of women’s sexuality. Women were often punished by force-feeding or being given no supper at all (Vandereycken & Van Deth 1994). As medical sciences became commonly practiced, eating disorders were increasingly seen as pathological. In the late 19th century, the psychodynamic perspective on secret eating and food stealing was suggested as being an expression of impulsiveness, ambivalence or rebelliousness (Vandereycken & van Deth 1994). Freud was not terribly interested in eating disorders, although he noted that a loss of appetite equalled a loss of libido. By the late 1800s, women with eating disorders were diagnosed as hysterical and insane. Photography and magazines materialised and, amusingly to customers, weighing scales emerged in public places around this time. Mirrors became ubiquitous household objects: “They became critical judges and silent witnesses with which women had a dialogue of delight or dismay” (Vandereycken & van Deth 1994: 213). At the turn of the 20th century, the “battle against fatness had started, obesity was the enemy and the physician had the weapons” (Vandereycken & van Deth 1994: 211-212). By the late twenties, fatness was completely out of fashion, and magazines were exploiting thin women. The biological view had been most prevalent until this time—largely interested in metabolic and hormonal disturbances. More recently, the stomach has been thought of as a second brain, with disturbances in the gut linked to depression (Pallardy 2006) and, in the brain itself, serotonin levels may create a physiological vulnerability for eating disorders (Richards, et al. 2006). Subsequent to biological dominance, the psychoanalytic view dominated theories around eating disorders; in psychiatry, it still does. Wulff (1932) described bulimia as an “oral symptom complex” in which the patient regressed to obtain a “pure oral erotic satisfaction … almost a sexual perversion” (Barton, Blinder, Karin, & Chao 2001). The women were seen to be afraid of their female growth and sexual maturation, their development hampered in order to lead a physically and mentally childish, asexual life. Seeking self-esteem, holding back suicidal impulses, dependency and the somatisation of feelings are other themes explored from this perspective. The twelve-step model for addiction used in Overeaters Anonymous was founded in the thirties by Bill Wilson. Schaub and Schaub (1997) suggest that its form of spirituality reflects 1930s Protestantism … and that even Bill Wilson, the November 2011

most well known of the founders of Alcoholics Anonymous, ranged far beyond the twelve steps in his spiritual search. They suggest that this model is not effective for everyone; for some, the contemplation of the rest of one’s life in recovery holds no new promise. The concept of abstinence for a person suffering with food addiction has received criticism, as abstinence and restriction of foods is often a precursor to bingeing and purging. Concurrently, learning and behavioural theorists such as Skinner suggested that one is rewarded for being thin, and positive or negative attention is paid towards the sufferer. It wasn’t until the forties that bulimia and anorexia were classified as two separate illnesses. Laxatives were widely used, and body shape and selfimage became typical indicators of eating disorders. Systems theory, widely used with eating disorders, emerged in the fifties, suggesting that an eating disorder within a family is a sign of disturbed structures and interactions within that family. The member suffering with an eating disorder is often the emotional barometer, sensitive and tuned in to how everyone else feels. Subsequently, the sufferer acts out what is wrong within the family system and expresses the family story through body and eating disorder. Thinness became a symbol of independence and selfcontrol in the sixties. With model Twiggy’s arrival on the scene, the desire for slimness reached an unprecedented high. Simultaneously, there was an increase in the medical and psychiatric recognition of eating disorders, with higher numbers of women diagnosed with anorexia or bulimia. Eriksson’s theories on psychosocial development suggested that eating disorders were a complex interaction of various predisposing, precipitating and perpetuating factors—a mix of biological, psychological and social aspects. Emerging feminist theories proposed that eating disorders were “a sign of a male society submitting women amidst abundance to an ever more emphatic ideal of slenderness” (Vandereycken & van Deth 1994). It was not until the arrival of humanisticbased theories in the sixties that eating disorders were linked with self-esteem. In the seventies, art therapy, although traced back to the early 1900s, made its way into the realm of self-help groups and is still widely used today. It is an important tool because it provides a creative outlet for self-expression and is a move away from the medicalisation of symptoms and ‘fix-it’ type therapies. Using art allows the client’s symptoms, her soul suffering and her eating disorder, to have a voice. In Pythia Peay’s (2010) ‘Interviews with contemporary Jungian analysts’, Marion Woodman suggests that “images are pictures of the soul and can be used to bridge psyche and the body—the whole body can be integrated by working with them”(2010). 15


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Images of slender women, fad diets and dieting articles dominated magazines throughout the seventies and into the eighties. The lid on eating disorders exploded in 1983 when Karen Carpenter’s death was attributed to anorexia. The nineties saw another surge in feminism. In The Beauty Myth, Naomi Wolf (1991) wrote, “Dieting is the most potent political sedative in women’s history, a quietly mad population is a tractable one.” In an article written in Esquire in 1994, a poll of 1000 women between 18 and 25 said that 54% would rather be run over by a truck than to be fat, and in 2004, an article by the BBC reported that 13 million people in the UK are on a diet all of the time (Mintel 2004). In Australia, “a study of 2000 girls by the Royal Children’s Hospital in Melbourne found that an alarming one in ten females aged 15 to 17 exhibited symptoms of a serious eating disorder ... ‘Beyond Stereotypes’, a 2005 study commissioned by Dove, surveyed 3,300 girls and women between the ages of 15 and 64 in ten countries. They found that 90% of the women surveyed worldwide want to change at least one aspect of their physical appearance, with body weight ranking the highest” (EDV 2011). Vandereycken (1994) suggests that slenderness has become the new shackles of women and has thus become a substitute for the corset, a psychosocial straitjacket. Fat rejects this straitjacket and is perhaps one of the reasons that some women find it difficult to let go of their weight. Ideals have become taller and slimmer but, in reality, as a nation we are fatter than ever, a tension that we are left to manage, and one that is being exploited by the diet industry. In binge-eating disorders, every pathway to the illness mentions dieting as a major contributing component. Fairburn (1995) proposes that most people who diet also binge; dieting often precedes binge eating in the development of binge-eating disorders. Recently, a beautiful young woman on a television weight loss show spent months extreme dieting, excessively exercising, then walked out on stage to show off her new body; a few hours later she was filmed hiding in the fridge, bingeing. Shows where contestants are tyrannised for being fat then encouraged to temptation after extreme dieting and exercise exploit and shame people who are already vulnerable. Fairburn (1995) suggests that reducing the tendency to diet is a goal in most treatments of eating disorders. The Butterfly Foundation (2011) advises that restrictive dieting, 16

body dissatisfaction, and low self-esteem are major risk factors for developing an eating disorder. Eating disorders are on the rise, not only in Western cultures but also in the Pacific Islands, African, and Eastern cultures, due mainly to the widespread use of technology and the internet (Maine 2004). Being overweight in today’s society is viewed as gluttonous and with disgust, reminiscent of some medieval paintings, where sinners were portrayed as fat and heavy but the saints were slender (Angier 2000). “Fat bashing remains a common occurrence, and weightism arguably remains one of the last socially acceptable prejudices” (Matz 2011: 9). Matz also highlights that in some recent studies people who fall into the overweight category live longer than those in the ideal range and suggests that society needs to focus on size acceptance and health at every size (2011). The July 2011 cover of Italian Vogue depicts three plus-size models. One can only hope that change is on the way! Throughout time, eating disorders have been linked with Satan, lovesickness, melancholia and hysteria; often related to a malposition of the womb. The woman suffering with an eating disorder has been ridiculed and labelled as insane and mentally ill. This is the history, the suffering and the shame that the modern-day woman carries transgenerationally and expresses through her body. Seeking solace in food and expressing her silent voice through her body is the only way she knows how to speak her suffering and her truth. Susie Orbach suggests that eating disorders are an unconscious solution to a “complex personal response to a set of interpersonal, intrapsychic, social and political phenomena that structure the woman’s relationship to self and other” (1993: xv-xviii). Furthermore, it is the most brutal internal struggle, directed at suppression of needs. Her eating disorder is her daily, even hourly attempt to keep her needs, herself and her desires under wraps. Ferentz suggests that the worst way to start therapy with clients suffering from an eating disorder is to focus on behaviour, food journals, calorie counting and weigh-ins. The woman is already at war with herself; the last thing she needs is for us to impose our rules on her. Besides, her problems are to do with “pervasive long-standing emotional pain, not primarily about food” (2011: 5). Geneen Roth (2010) classifies two types of eaters, the ‘permitter’ who uses food to numb herself and the ‘restrictor’ who uses food to control her life and body. She suggests that our relationship to food is our entire world on a plate: hopelessness or hope, fear or love, doubt or faith. Marion Woodman, in Addiction to Perfection writes that “many people in our society are being driven to addiction because there is no collective container for their spiritual needs. Their natural propensity for transcendent experience, for ritual, for connection to some form of energy greater than their own, is being distorted into addictive behaviour (1982: 29). She reminds us all to reconnect with the feminine, our love of nature and our bodies as part of nature, to take time for spontaneity and slow time, to honour our inner realities and give value to our feelings, to examine the symbolic meaning of our addictions and to ask: ‘What am I really hungry for?’ (Peay 2010). A Holistic, Integrative and Psychospiritual Approach Psychosynthesis theorist Joan Evans asserts that the debate around psychological health is traditionally viewed as The Capa Quarterly


a breakdown in health and well-being and is viewed as psychopathology (2004). A holistic approach holds the context that every crisis contains within it the seeds for transformation and growth. We cannot avoid all suffering in life, but through suffering, we can “enter into relationship with the world of soul and the potential richness of its wisdom” (Sorrell 2009). In psychosynthesis, we draw from a range of theoretical perspectives as no single theory can explain the complexity of an eating disorder. They might include: • psychoanalysis, object relations and self psychology • existential and humanistic theories and techniques • feminist, social systems and ecological approaches • transpersonal, Jungian and spiritual disciplines • psychosynthesis models such as ‘body, feelings, mind’, ‘subpersonalities’, the ‘inner child’, the ‘triphasic model: the ego, I and the Self’ (Evans 1997) and the ‘act of will’. This allows the therapist’s choice of approach to be inclusive of the best of Western psychology and Eastern and Western spiritual approaches for health and wellbeing. A Search for Wholeness The woman suffering from an eating disorder has an insatiable hunger and a deep craving for an unknown missing ‘something’ (Grof 1993). She searches to fill the void, her suffering, her loneliness. She searches for love, for connection, for acceptance. She searches for relief from the tyrannical inner ‘critic’, ‘saboteur’, ‘perfectionist’ and the high expectations she has of herself. She searches for her identity in the perfect body. She gathers her sense of self from the distorted messages that bombard her through super-skinny, airbrushed celebrities on magazine covers, television and the internet. The dilemma is that she searches in all the wrong places. No amount of food will fill her, so eats more to soothe her pain, to punish herself, to reach for the love she so desperately longs for. Benson (2002) writes of those suffering crisis: “a terrible conflict which centres around longing to love and be loved, while being afraid to love and dreading being unlovable.” She lacks self-love (feminine) and will (masculine)— her life energy is trapped in the downward spiral of her eating disorder. Underlying is a search for wholeness, to know and awaken to her true spiritual identity. Her spiritual hunger, however, can never be resolved on the physical level (Roth 2010). This would be akin to attempting to fill a ‘belonging’, ‘esteem’ or ‘love’ need with a ‘basic’ need (Maslow 1954). Nourishing the Soul The woman is more than her body and her eating disorder. We seek to understand the emerging spiritual value, meaning and purpose underlying her symptoms. We need to follow them gently because they will lead us to her soul’s suffering. Moore writes that “when soul is neglected … it appears symptomatically in obsessions, addictions … and a loss of meaning” (1992: ix). The woman’s fat might be protecting her from something, or shouting to the world ‘see me’. Her use of food could be the only source of sweetness and nourishment in her life. It might be the only way she can communicate with or separate from her family. At the core, each symptom has a healthy impulse towards wholeness and, if removed without working to realise its value, November 2011

meaning and purpose—short-term compliance and symptom switching are probable outcomes. Her ‘permitting’ or ‘restrictive’ thoughts and behaviours will permeate her life in other ways. We need to find out all we can because, at some level, her eating disorder has served her. The woman’s work is to find new ways of nourishing her soul and spirit. Mindfulness Mindfulness and meditation as spiritual practice can nourish the soul and bring the woman home to her authentic and intuitive self. Assagioli, the founder of psychosynthesis, published his ‘body, feelings, mind’ meditation—originating from the Buddhist tradition—in his core text, Psychosynthesis (1965); it is now widely used in mindfulness- and acceptancebased modalities. It is practiced by many psychosynthesis practitioners as part of their spiritual practice and is particularly useful for those suffering with an eating disorder. When a woman is trapped in the cycle of an eating disorder, she is either stuck in the past or is obsessing about her next ‘fix’—“there is an inability to accept whatever is being felt in the present moment” (Goldstein 2009). Mindfulness allows her the space for choice; each time she is able to create that space, it provides a sense of hopefulness and she becomes “stronger, more confident and in control of her own life” (Goldstein 2009). Evidence suggests that mindfulness meditation decreases binges from 70% to 18% (Kristeller & Hallett 1999). As part of a self-care plan, mindfulness can help to manage stress and sleep management; this is essential as sleep disorders are linked with anxiety, depression and obesity (APSS 2011). Ultimately, to gain a healthy, balanced relationship with food, she will need to learn to trust her intuition, be kind to herself and eat mindfully! It is important to remember that mindfulness alone, as with cognitive behavioural techniques, addresses only part of the story. Ven Dr Chonyi Taylor advises “… any program that does not address pain is doomed to fail. As the underlying pain becomes manifest, then the urge for the addiction resurfaces.” Furthermore, “Buddhism, like psychodynamic therapies, is more concerned with finding out why … seeking to dig deeper and deeper to find the causes …” (Taylor 2010: 100). Like psychosynthesis, Ven Dr Chonyi Taylor is optimistic in her proposal that there is an end to suffering—this goes against the age old adage of ‘once an addict, always an addict’. Conclusion Our clients who suffer with an eating disorder need to know that they are loveable at any size. As therapists, reflection upon our own judgements and attitudes regarding dieting, food and weight is a must if we are to build a therapeutic relationship filled with acceptance, compassion, empathy and, most of all, love. Neuroscience evidence suggests it is the power of the therapeutic relationship which contributes to healing (Stratford, Lal & Meara 2009). While it is beyond the scope of this paper to fully explore the complexities of food addiction, disordered eating and eating disorders, hopefully a soulful and optimistic context has been provided—one where the woman suffering with an eating disorder is not pathologised and whereby she has the ability to fully awaken to the love, beauty, creativity and wholeness that already resides within.

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Trauma and Substance Use Over recent decades there has been increasing recognition of the important role that trauma plays in the development and maintenance of substance use disorders (Mills 2009). Exposure to traumatic events is far from uncommon among people with substance use disorders (SUD). In the Australian general population, it has been estimated that more than threequarters of individuals with alcohol or other drug use disorders have experienced a traumatic event (Mills, et al. 2006). Among those entering treatment for their substance use, trauma exposure is almost universal (Mills, et al. 2005, Dore et al. in press). Not only are individuals with SUD more likely to experience trauma, they also experience a greater number of traumas, and tend to have experienced their first trauma at a younger age compared to the general population. Given such extensive exposure to trauma, it is not surprising that the prevalence of post-traumatic stress disorder (PTSD) is also elevated in this population. It is estimated that close to half of those seeking treatment for SUD are also suffering from PTSD (Mills, et al. 2005, Dore, et al. in press). In comparison, the population prevalence of current PTSD is 6.4% (Slade, et al. 2009). There are many pathways that might explain the common co-occurrence of substance use and trauma/PTSD (Chilcoat and Breslau 1998); however, the predominance of the literature suggests that self-medication plays a role (Brady, et al. 2000). Findings from retrospective and prospective studies indicate that in a substantial portion of cases, PTSD precedes the onset of SUD (Breslau, et al. 2003, Stewart, et al. 1998). Furthermore, studies examining symptom interplay have found that increases and decreases in PTSD symptoms are closely paralleled by shifts in substance use (Bremner, et al. 1996, Brown, et al. 1998, Back, et al. 2006a). While the onset of trauma and PTSD often predates the development of SUD, intoxication and the substance-abusing lifestyle (particularly that which is associated with the use of illicit substances) also places individuals at greater risk of re-traumatisation, particularly in the form of interpersonal violence (Darke & Duflou 2008, Mills, et al. 2008). Thus, a cycle of trauma and substance use is often established. It is easy to understand why a person would turn to substance use, or increase their use, following exposure to a traumatic event. Regardless of whether the person goes on to develop a traumarelated psychiatric disorder such as PTSD, the consequences of trauma can be devastating. In the short term, substance use can be a very effective way of containing adverse reactions to 18

traumatic experiences. In the long term, however, substance use only serves to perpetuate these symptoms. Repeated avoidance of trauma-related symptoms is one factor that has been associated with their persistence (Dunmore, et al. 2001). People with SUD often report that their trauma symptoms come back or increase when they cut down or stop using, making it difficult for them to maintain abstinence or reduced use. It is therefore, no surprise that clinicians find clients with comorbid substance use and PTSD more difficult to treat (Back, et al. 2009). Moreover, the clinical profile of this population is often further complicated by the presence of other mental health conditions (e.g., depression, anxiety, and personality disorders), physical health problems (e.g., hepatitis, cirrhosis), cognitive impairment, and a plethora of difficulties in other life domains (Mills, et al. 2005). It is important to recognise, however, that clients with both SUD and PTSD can benefit just as much as those without PTSD from substance use treatment (Mills et al. 2007, Ouimette, et al. 1999). This is a real credit to treatment providers, considering the severe clinical profile of those with this comorbidity who present to treatment. However, in order to impact on the PTSD and its associated disability, trauma-specific interventions are needed. Due to the interrelatedness of substance use and PTSD disorders, there is consensus in the literature that where the two present together, they should be treated in an integrated fashion (Ouimette & Brown 2003). That is, both disorders should be treated at the same time by the same clinician. Patients also indicate that this is how they would prefer to receive treatment (Ouimette, et al. 2003). In reality, however, very few people receive such treatment. Despite the pervasiveness of trauma and PTSD in substance-using populations, it is rare that either is recognised, largely because clinicians do not routinely ask such clients about exposure to trauma. Routine screening is essential so that the client may be provided with, or referred to, appropriate treatment. A number of integrated treatment protocols have been developed to treat this comorbidity, and a growing number of studies are being undertaken to evaluate their effectiveness (Back, et al. 2006b, Desai, et al. 2008, Brady, et al. 2001, Donovan, et al. 2001, Najavits, et al. 2006, Najavits, et al. 2005, Najavits, et al. 1998, Triffleman 2000, Zlotnick, et al. 2003, Morrissey, et al. 2005, Hien, et al. 2004). Existing treatment models may be divided into two types: Past-focused and present-focused therapies (Najavits 2006). Past-focused The Capa Quarterly


Disorders

Common Co-occurrence therapies typically involve techniques which expose the person to the traumatic memory. Such exposure-based treatments have long been considered the ‘gold standard’ in treating PTSD (Bisson, et al. 2007); however, anecdotal evidence suggests that clinicians have been reluctant to use these techniques with SUD patients due to concerns that the distress evoked may be too overwhelming, and could lead to relapse or increased substance use. Two uncontrolled pilot studies provide support for the safety and efficacy of these techniques in patients with SUD (Najavits, et al. 2005, Brady, et al. 2001), but their use in this population requires further investigation. A number of randomised controlled trials have recently been completed or are currently under way (Foa & Williams 2010, Mills, et al. 2010, Sannibale, et al. 2010). Present-focused therapies focus on providing the patient with coping skills to manage their substance use and trauma symptoms in the present without revisiting the traumatic memory. These therapies have also demonstrated their usefulness in producing improvements in outcomes across a number of domains (Hien, et al. 2004, Desai, et al. 2008). In conclusion, trauma and PTSD are highly prevalent among people who present for substance use treatment. Although this client group present therapists with a number of challenges, positive treatment outcomes can be achieved. There are also a number of new treatment options being trialled for these people, which will inevitably lead to improved interventions, and quality of life for this very deserving population.

Katherine Mills

Breslau, N, Davis, GC and Schultz, LR 2003, ‘Posttraumatic stress disorder and the incidence of nicotine, alcohol, and other drug disorders in persons who have experienced trauma’, Archives of General Psychiatry, 60: 289-94 Brown, PJ, Stout, R and Gannon-Rowley, J 1998, ‘Substance use disorder-PTSD comorbidity. Patients’ perceptions of symptom interplay and treatment issues’, Journal of Substance Abuse Treatment, 15: 445-8 Chilcoat, HD and Breslau, N 1998, ‘Posttraumatic stress disorder and drug disorders: testing causal pathways’, Archives of General Psychiatry, 55: 913-7 Darke, S and Duflou, J 2008, ‘Toxicology and circumstances of death of homicide victims in New South Wales, Australia 1996-2005, Journal of Forensic Science, 53: 447-451 Desai, RA, Harpaz-Rotem, I, Najavits, LM and Rosenheck, RA 2008, ‘Impact of the Seeking Safety Program on Clinical Outcomes Among Homeless Female Veterans With Psychiatric Disorders’, Psychiatric Services, 59: 996 Donovan, B, Padin-Rivera, E and Kowaliw, S 2001, ‘“Transcend”: initial outcomes from a posttraumatic stress disorder/substance abuse treatment program’, Journal of Traumatic Stress, 14: 757-72 Dore, G, Mills, K, Murray, R, Teesson, M and Farrugia, P In press, ‘Post-traumatic stress disorder, depression and suicidality in inpatients with substance use disorders’, Drug and alcohol Review Dunmore, E, Clark, D and Ehlers, A 2001, ‘A prospective investigation of the role of cognitive factors in persistent posttraumatic stress disorder (PTSD) after physical or sexual assault’, Behaviour Research and Therapy, 39: 1063-1084 Foa, E and Williams, M 2010, ‘Methodology of a randomized double-blind clinical trial for comorbid posttraumatic stress disorder and alcohol dependence’, Mental health and substance use: dual diagnosis, 3: 131-147 Hien, DA, Cohen, LR, Miele, GM, Litt, LC and Capstick, C 2004, ‘Promising treatments for women with comorbid PTSD and substance use disorders’, American Journal of Psychiatry, 161: 1426-32 Mills, K, Teesson, M, Barrett, E, Merz, S, Rosenfeld, J, Farrugia, P, Sannibale, C, Hopwood, S, Baker, A, Back, S and Brady, K 2010, ‘Is exposure therapy for post traumatic stress disorder (PTSD) efficacious among people with substance use disorders (SUD)? Results from a randomised controlled trial’, Drug & Alcohol Review, 29 (suppl 1): 20 Mills, K, Teesson, M, Ross, J and Darke, S. 2008, ‘Predictors of trauma and PTSD among heroin users: A prospective longitudinal investigation’, Journal of Drug Issues, 38: 585-600

References

Mills, KL 2009, “‘Between pain and nothing, I choose nothing’: trauma, posttraumatic stress disorder and substance use’, Addiction, 104: 1607-1609

Back, S, Waldrop, A and Brady, K 2009, ‘Treatment Challenges Associated with Comorbid Substance Use and Posttraumatic Stress Disorder: Clinicians’ Perspectives’, American Journal on Addictions, 18: 15-20

Mills, KL, Lynskey, M, Teesson, M, Ross, J and Darke, S 2005, ‘Post-traumatic stress disorder among people with heroin dependence in the Australian treatment outcome study (ATOS): prevalence and correlates’, Drug & Alcohol Dependence, 77: 243-9

Back, SE, Brady, KT, Jaanimagi, U and Jackson, JL 2006a, ‘Cocaine dependence and PTSD: a pilot study of symptom interplay and treatment preferences’, Addictive Behaviors, 31: 351-4

Mills, KL, Teesson, M, Ross, J & Darke, S 2007, ‘The impact of post-traumatic stress disorder on treatment outcomes for heroin dependence’, Addiction, 102: 447-54

Back, SE, Waldrop, AE and Brady, KT 2006b, ‘Evidence -based time-limited treatment of co-occurring substance use disorders and civilian-related PTSD’, Brief Treatment and Crisis Intervention, 6: 283-294

Mills, KL, Teesson, M, Ross, J & Peters, L 2006, ‘Trauma, PTSD, and substance use disorders: findings from the Australian National Survey of Mental Health and Well-Being’,[see comment] American Journal of Psychiatry, 163: 652-8

Bisson, JI, Ehlers, A, Matthews, R, Pilling, S, Richards, D. and Turner, S 2007, ‘Psychological treatments for chronic post-traumatic stress disorder. Systematic review and meta-analysis’, British Journal of Psychiatry, 190: 97-104

Morrissey, JP, Ellis, AR, Gatz, M, Amaro, H, Reed, BG, Savage, A, Finkelstein, N, Mazelis, R, Brown, V, Jackson, EW and Banks, S 2005, ‘Outcomes for women with co-occurring disorders and trauma: program and person-level effects’, Journal of Substance Abuse Treatment, 28: 121-33

Brady, KT, Dansky, BS, Back, SE, Foa, EB and Carroll, KM 2001, ‘Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: Preliminary findings’, Journal of Substance Abuse Treatment, 21: 47-54

Najavits, LM 2006, ‘Present- versus past-focused therapy for posttraumatic stress disorder/substance abuse: A study of clinician preferences’, Brief Treatment and Crisis Intervention, 6: 248-254

Brady, KT, Killeen, TK, Brewerton, T and Lucerini, S 2000, ‘Comorbidity of psychiatric disorders and posttraumatic stress disorder’, Journal of Clinical Psychiatry, 61 Suppl 7: 22-32

Najavits, LM, Gallop, RJ and Weiss, RD 2006, ‘Seeking safety therapy for adolescent girls with PTSD and substance use disorder: a randomized controlled trial’, Journal of Behavioral Health Services & Research, 33: 453-63

Bremner, JD, Southwick, SM, Darnell, A and Charaney, DS 1996, ‘Chronic PTSD in Vietnam combat veterans: course of illness and substance abuse’, American Journal of Psychiatry, 153: 369-75

Najavits, LM, Schmitz, M, Gotthardt, S & Weiss, RD 2005, ‘Seeking safety plus exposure therapy: An outcome study on dual diagnosis men’, Journal of Psychoactive Drugs, 37: 425-435

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Gambling:

Recreation or

Gambling is a popular and enjoyable form of entertainment for a significant percentage of the population in Australia. Following liberalisation of the gambling industry in the 1990s, its growth was rapid. By 2008–2009, turnover from the gambling industry was over $19 billion and more than half of that turnover was spent on poker machines in clubs and pubs. The Productivity Commission (2010) estimated that around 600,000 Australians (4% of the adult population) played Electronic Gaming Machines (EGMs)—poker machines—on a weekly basis. Problem Gambling It is estimated that up to 30% of weekly poker machine players are either problem gamblers or at moderate risk of problem gambling. In fact, it is only 15% of the gambling population that provides 40-60% of the gambling revenue. Some 115,000 poker machine players are estimated to be problem gamblers and a further 280,000 are at ‘moderate risk’ of problem gambling. The 18–24-year-old age group, is more likely to experience problems with gambling (particularly males), and make up 40% of all problem gamblers. Although many forms of gambling are available, poker machines are most likely to cause problem gambling and, indeed, problem gambling increased significantly after poker machines became more widely available. Definition of Problem Gambling

Gambling Research Australia (GRA) describes problem gambling as being “characterised by difficulties in limiting money and/or time spent on gambling which leads to adverse consequences for the gambler, others, or the community” (Neal, Delfabbro & O’Neil 2005). Problem Gambling is currently included in the Diagnostic and Statistical Manual (DSM)‑IV‑TR as an Impulse Control Disorder. Proposed changes for DSM‑V include reclassification of gambling into a new Addiction and Related Disorders category, creating a new category of behavioural addictions in which gambling would be the sole disorder. Problems common to Substance Use Disorders and along a continuum are recognised (Gambino 2009). Also, Substance Use Disorders are significantly higher amongst problem gamblers and approximately one fifth of problem gamblers are estimated to experience Substance Abuse problems (Kessler, Hwang, LaBrie, Petukhova, et al. 2008). 20

Impacts of Problem Gambling

The impacts of problem gambling can be devastating, and troubles can continue for years after the problem behaviour has ceased. Problems range from personal and mental health problems, such as anxiety and depression, loss of trust, family breakdown, child health problems, to financial problems, such as bankruptcy, or employment and productivity problems. Legal problems are not uncommon and risk of suicide is increased. Pathways Model of Problem Gambling

Problem Gambling is recognised as a complex multidimensional activity with multifaceted causes, and it appears that gamblers are not a homogeneous group (Moodie & Finnigan 2005). There appear to be three distinct pathways into problem gambling (Blaszczynski & Nower 2002). The first pathway is through behavioural conditioning. It is characterised by bad judgment or poor decision-making and the absence of specific pre-morbid psychopathology (co-morbid psychopathology can develop as a symptom of problem gambling). The second pathway is through emotional vulnerability and is characterised by a desire to regulate mood or other psychological needs. This group of gamblers does not express emotion effectively and uses gambling to escape or for emotion-based coping. They gamble, for example, to alleviate boredom or to escape painful emotions, stresses or conflicts. These gamblers tend to show higher levels of pre-morbid psychopathology and there is often a history of gambling in the family. The third pathway is through biological dysfunction and antisocial impulsivism. These gamblers appear to show different responses to reward and punishment, seek out rewarding activities, show symptoms of attention deficit disorder, find it difficult to delay gratification, and have a diminished response to punishment. Gamblers in this group are less likely to seek help (Blaszczynski 2000). Common influences for all pathways include: situational or ecological factors (such as availability of gambling facilities), the principles of conditioning and reinforcement, and irrational cognitive schemas that shape illusions of control and an optimism bias. Common amongst problem gamblers is a misunderstanding about probability, as well as superstitious thinking that results in a belief that the odds of winning The Capa Quarterly


Behavioural Addiction? Jeanette Svehla

are somehow better for the problem gambler personally (Blaszczynski & Nower 2002, Wood & Griffiths 2007). Motivation to gamble and the effect of gambling on the gambler may also differ (Petry 2003). Treatment for Problem Gambling The different characteristics of problem gamblers suggest that different treatment plans might be appropriate. However, research on treatment for problem gambling, its effectiveness and efficiency is relatively recent (Jimenez-Murcia, et al. 2007). Also, a “wide range of outcome domains and measures” has made reliable comparison of treatment options unrealistic (Walker, et al. 2006, p. 504) and not much is known about the effectiveness of particular treatments for problem gamblers (Toneatto & Dragonetti 2008). Many studies do not meet standards required for clinical evaluation of specific psychological intervention. Further, only a minority of problem gamblers seek treatment. The Productivity Commission (1999) estimated that as few as 5% of problem gamblers seek help. They are often the most desperate or problematic cases, who seek help only when they reach crisis point and might differ in significant ways from problem gamblers who do not seek treatment (Petry 2003). Of the small group seeking treatment, half will drop out before completion of their treatment. In one study, impulsiveness was associated with dropping out of treatment, suggesting that gamblers who drop out might do so without thinking through the consequences (Leblond, Ladouceur & Blaszczynski 2003, Jimenez-Murcia, et al. 2007). Current Interventions

Interventions currently being funded in NSW include cognitive behaviour therapy, financial and other counselling, and these are considered best practice, given all the available evidence. Regardless of the type of treatment provided, most clients benefit (Productivity Commission Report 2010). Other than behaviour therapy, cognitive therapy and cognitive behaviour therapy, another commonly used technique is motivational interviewing. Behavioural therapy techniques address the ‘behavioural’ addiction of problem gambling. Cognitive therapy techniques address decision-making processes, lack of knowledge about gambling, attitudes towards gambling, and processing of information about gambling. November 2011

These techniques aim to identify and challenge commonly held irrational or erroneous beliefs common amongst problem gamblers, such as their beliefs about control over gambling outcomes, the involvement of skill and luck in gambling, and theories about probability, chance and randomness. Some commonly held beliefs are known as ‘the optimism bias’ and the ‘illusion of control’ because gamblers interpret events in a biased manner and believe that the odds of them personally winning are higher than for others (Le Blond, Ladouceur & Blaszczynski 2003). Cognitive techniques then aim to replace erroneous beliefs using gambling education and other strategies to develop a realistic understanding about gambling, gambling behaviour, and the positive and negative reinforcements associated with gambling behaviour. For behaviourally conditioned problem gamblers, recommended interventions include psycho-education programs that focus on changing erroneous beliefs about chance and luck, and provide education about probability and the random nature of

Possible Image?

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gambling as well as cue exposure using imaginal desensitisation and/or in vivo exposure. For emotionally vulnerable problem gamblers additional interventions include: stress management techniques, problem solving skills, coping skills, confidence building and self-esteem skills, and conflict resolution skills, as well as information about emotional vulnerability and addictive behaviour. For impulsive gamblers, as well as dealing with emotional vulnerability and developing better problem solving and coping skills, additional interventions are directed towards attention and organisational deficits (Blaszczynski 2000). Recent research findings may illuminate and influence choice of treatment interventions. One study showed that both cognitive behaviour therapy and Gamblers Anonymous to be effective treatments that can reduce frequency of and amount of money used for gambling (Toneatto & Dragonetti 2008). A combination of cognitive and behavioural strategies was effective in reducing gambling behaviour. Behavioural techniques, including relaxation techniques, reduced the association between gambling, arousal and excitement (Comans, Evans & Burrows 2005, Taveres et al. 2003). (See realted articles on Pages 10 and 12.) A better understanding of the relationship between chance and gambling encouraged adherence to treatment (Taveres et al. 2003). Autonomic arousal appeared to motivate people to engage in and continue gambling behaviour (Moodie & Finnigan 2005). Gamblers tended to lack coping strategies necessary to manage cravings and were likely to subsequent relapse (Comans et al. 2005). Gamblers are tempted by smaller short-term rewards suggesting difficulties in understanding the long-term implications of their choices (Wohl, Young & Hart 2007). As well as developing an understanding, of faulty beliefs, it is also important for the gambler to be aware of high-risk situations for relapse such as negative mood, interpersonal conflict or social pressure as well as an awareness of the outcome expectancies of gambling, such as stress-reduction effects or mood-elevating effects (Holub, Hodgins & Peden 2005). During recovery, a lapse into gambling is normal. Normalising potential lapses decreases their stigma and the gambler’s sense of embarrassment and promotes understanding about high-risk situations and triggers for relapse. A lapse can also promote healing and education about obstacles to recovery. As a result, motivational interviewing is useful at many stages during treatment. It helps to engage participants, strengthen readiness for change and reduce the dropout rate from treatment (Wood & Griffiths 2007). Greater treatment attendance appears to be correlated with better gambling outcomes and development of effective coping strategies, although it might also be related to greater motivation to change and better insight into the problem behaviour (Toneatto & Dragonetti 2008). Objectives of Treatment Interventions

Current research into treatment intervention options aim to develop knowledge and understanding about the gambling industry and gambling behaviour through psycho-education, as well as to provide skills and strategies for coping with highrisk situations. Developing those skills and strategies includes 22

using cognitive strategies to address common misperceptions about gambling and the illusion of control and behavioural strategies that reduce the association between gambling, arousal and excitement, using imaginal desensitisation, in-vivo exposure and stimulus-response modification. It also involves social skills training, development of effective coping skills to promote task-oriented coping, problem solving skills and other relaxation strategies as goals of treatment (Taveres et al. 2003, Wood & Griffiths 2007). Improvement along the problem gambling continuum can be measured subjectively by a decrease in frequency of gambling behaviour, a decrease in perception of control, a reduced desire to gamble, and perceived self-efficacy (Tavares, et al. 2003). Effective treatment should show both a reduction in frequency or intensity of gambling behaviour, and a decrease in problems caused by gambling, as a direct result of treatment (Walker, et al. 2006). Measures are important on completion of treatment and at follow up. A Pre-Commitment Scheme for Gambling The Productivity Commission (2010) found that making changes to poker machines would be the most likely way to minimise problem gambling harm. As a result, a proposal to introduce a uniform pre-commitment scheme for gaming machines across States and Territories is currently being considered by the Federal government and is widely debated by various interest groups. Revenue from poker machines provides venues and governments with an important source of revenue and this influences their approach to proposed changes. The advertising campaign by clubs against the pre-commitment scheme indicates that clubs are concerned about the proposed changes. A pre-commitment scheme would require each player to personally set ‘limits’ around playing gaming machines. It might involve a daily spending limit, a bet limit and/or a time limit in relation to playing on the gaming machines. Currently, there is no consensus about the best ways to deliver a pre-commitment scheme or what the details of the scheme should be. Current research provides some insight into factors that cause poker machine players to exceed their intended expenditure (Schottler Consulting 2010). Attractive features of gaming machines include number of playlines, bonus features, and the ability to play low cost machines (1-, 2-, and 5-cent machines). The research suggests that players are more likely to exceed intended expenditure as a direct result of the following factors: • EGM play dynamics such as increased number of free spins • being deeply absorbed in play • strong urges to continue to play • the experience of excitement after receiving features during play • EGM spin rates • life events experienced by players. Also, trends indicate that players at risk of developing problem gambling are more likely to have a faster rate of play than players not at risk. Machines played at high intensity can easily cost $1500 an hour. Non-problem gamblers generally tend to play at a lower intensity. In other words, particular characteristics of poker machines influence excess expenditure. Problem gamblers bet more credits per line and play for longer each session. Also, they prefer a maximum line and minimum The Capa Quarterly


bet per line strategy of play because of a desire to obtain bonus features. It has been suggested that limits on note acceptors and maximum bet size may play a useful role in reducing excessive expenditure. A pre-commitment scheme could be either voluntary or mandatory; however, it is apparent that a voluntary scheme would not work for gamblers in the process of chasing losses and caught up in the excitement of playing poker machines. Even some low-risk players, who normally show a high degree of control, gamble more time and money than intended when they are caught up in the excitement of the play. To ensure that the pre-commitment scheme applied to problem gamblers, it would have to apply to all gamblers and all venues. It would in fact, have to be universal (Productivity Commission Report, 2010). ‘Limits’ would have to apply for a set time period, 24 hours for example, to be effective in preventing players from moving between venues after reaching their limit in one venue. Arguments Submitted to the Joint Select Committee on Gambling Reform

Those against implementation of a precommitment scheme are: • Problem gamblers often continue to play until their funds run out and this is relevant to the risk that players would set a high pre-commitment limit, ‘just in case’, and to give them more flexibility to gamble. • Players might increase their limits if they believe they have just missed out on a big win because they had previously reached their pre-commitment limit. • Confidentiality, inconvenience and other issues might arise from use of a gambling identification card. • The gambler’s ability to set a reasonable limit in the first place is questionable, considering that many problems gamblers do not seek or want help and do not appear to have insight into their problem gambling behaviour. Informed and rational choice is often difficult for problem gamblers because of faulty cognition, lack of control over behaviour, failure to appreciate risks, and other individual vulnerabilities. Such players are unlikely to set appropriate and effective spending limits (Productivity Commission Report 2010). Alternative Strategies to a Pre-commitment Scheme

Those suggested to the Joint Select Committee on Gambling Reform are: • Lowering the limits on the poker machines so that potential jackpots are lower and less attractive. • Removing ATMs from gaming floors or from gambling venues entirely, so that gamblers have to leave the floor/ premises if they want to withdraw more money to continue to play; or a setting a daily cash withdrawal limit from ATMs in gambling venues. • Limiting transactions so that players can only place bets up to a certain limit (lower than is currently available on high intensity machines). • Appropriate signage and/or reminders that bring attention to time and money spent gambling and other gambling behaviours. November 2011

Online Gambling Further issues arise for problem gambling as online gambling increases, making gambling opportunities even easier to access. Australians are already estimated to be spending $300 million annually gambling on line. Although the Interactive Gambling Act (2001) makes it an offence to provide interactive gambling services, it is not an offence to use those services. Community concerns are that younger people will access more and more gambling on line, particularly if they are interested in technology, making it increasingly important to address harms caused by problem gambling. Counselling problem gamblers continues to be one effective way to reduce the harms associated with problem gambling for those prepared to seek help. (See related article, Page 24.) References Blaszczynski, A 2000, ‘Pathways to pathological gambling; identifying typologies’, e-Gambling: The Electronic Journal of Gambling Issues 1: 1-11 Blaszczynski, A and Nower, L 2002, ‘A pathways model of problem gambling’, Addiction 97: 487-499 Coman, GJ, Evans, BJ and Burrows, GD 2005, ‘An innovative cognitive strategy to assist problem gamblers’, British Journal of Guidance and Counselling 33: 129-140 Gambino, B 2009, ‘Should gambling be included in public health surveillance systems?’ Journal of Gambling Issues (23): 156-176 Holub, A, Hodgins, DC and Peden, NE 2005, ‘Development of the temptation for gambling questionnaire: A measure of temptation in recently quit gamblers’, Addiction Research and Theory 13: 179-191 Jimenez-Murcia, S, Alvarez-Moya, EM, Granero, R, Neus Aymami, M, Gomez-Pena, M, Jaurrieta, N, Sans, B, Rodriguez-Marti, J and Vallejo, J 2007, ‘Cognitivebehavioural group treatment for pathological gambling: analysis of effectiveness and predictors of therapy outcome’, Psychotherapy Research 17, 544-552 Kessler, RC, Hwang, I, LaBrie, R, Petukhova, M, Sampson, NA, Winters, KC, et al. 2008, ‘DSM-IV pathological gambling in the National Comorbidity Survey Replication’, Psychological Medicine 38(9): 1351- 1360. Leblond, J, Ladouceur, R and Blaszczynski, A 2003, ‘Which pathological gamblers will complete treatment?’ British Journal of clinical Psychology 42: 205-209 Moodie, C and Finnigan, F 2005, ‘A comparison of the autonomic arousal of frequent, infrequent and non-gamblers while playing fruit machines’, Addiction 100: 51-59. Neal, P, Delfabbro, P, & O’Neil, M 2005, Problem gambling & harm: A national definition, Adelaide: South Australian Centre for Economic Studies Petry, N 2003, ‘A comparison of treatment seeking pathological gamblers based on preferred gambling activity’, Addiction 98: 645-655 Phillips, JG & Blaszczynski, A 2010, Gambling and the Impact of New and Emerging Technologies and Associated Products, Victoria, Gambling Research Australia Schottler Consulting Pty Limited 2010, Factors that influence gambler adherence to precommitment decisions, Brisbane, Gambling Research Australia Tavares, H, Zilberman, ML and el-Guebaly, N 2003, ‘Are there cognitive and behavioural approaches specific to the treatment of pathological gambling?’, Canadian Journal of Psychiatry 48: 22-27 Toneatto, T and Dragonetti, R 2008, ‘Effectiveness of community-based treatment for problem gambling: A quasi-experimental evaluation of cognitive-behavioural vs. twelve-step therapy’, The American Journal on Addictions 17: 298-303 Walker, M, Toneatto, T, Potenza, MN, Petry, N, Ladouceur, R, Hodgins, DC, el-Guebaly, N, Echeburua, E and Blaszczynski, A 2006, ‘A framework for reporting outcomes in problem gambling treatment research: the Banff, Alberta Consensus, Addiction, 101: 504-511 Wohl, MJA, Young, MM and Hart, KE 2007, ‘Self-perceptions of dispositional luck: Relationship to DSM gambling symptoms, subjective enjoyment of gambling and treatment readiness’, Substance Use and Misuse 42: 43-63 Wood, TA and Griffiths, MD 2007, ‘A qualitative investigation of problem gambling as an escape-based coping strategy’, Psychology and Psychotherapy: Theory, Research and Practice 80: 107-125

Jeanette Svehla, BA Psychology (Hons), PG Dip, Appl Psych, is a registered psychologist. She works at Lifeline Harbour to Hawkesbury (LLH2H) in the face-to-face personal counselling team. She is also the coordinator of the RGF problem gambling service, funded by the NSW government to provide counselling and support services for problem gamblers, their families and others. Jeanette also sees clients presenting with a wide range of issues including depression & anxiety, substance abuse, relationship problems, and life transitions and adjustments. She has trained recently to facilitate the REACH depression group in partnership with the Blackdog Institute.

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Hooked On Line Internet technology has transformed the world in many ways and has provided many benefits to its users. It has also developed a downside. Some people become so preoccupied with the internet that they are unable to control their use of it, thus jeopardising employment and relationships. The concept of ‘internet addiction’ has been proposed as an explanation for uncontrollable, damaging overuse of this technology. Symptoms are compared to the criteria used to diagnose other addictions, and the literature has characterised internet addiction as an impulse control disorder comparable to pathological gambling because of overlapping criteria. This paper reviews both the conceptualisation of internet addiction—including the proposed criteria for the diagnosis of Pathological Computer Use to be used in the revision of the DSM-V—and the various forms that internet addiction can take, including online sexual compulsivity, internet gambling addiction, and addictions to chatting and gaming. Also examined are the treatment implications for working with internet-addicted clients. Healthy use of the internet can be very productive, people can surf for information, make vacation plans, book airfares, do research, chat with friends, shop and bank online. Not all internet use is unproductive or non-legitimate. The issue for treatment becomes moderating and controlling compulsive use while retaining a healthy balance between productive computer use and other aspects of a client’s life. Once the larger issue of conceptualising and diagnosing the problem has taken place and it is brought into the treatment arena, the issue becomes how to help clients find that balance when we rely on computers in our daily lives. History of Internet Addiction Studies on internet addiction originated in the US. As early as 1996, the first paper on internet addiction was presented, at the American Psychological Association conference held in Toronto, by Dr Kimberly Young, who had studied over 600 cases studies of individuals who appeared addicted to online activities. The compulsive behaviour identified was significant enough to cause problems in relationship function, family cohesiveness, work performance, and school performance. Further studies began to identify similar patterns of addictive and compulsive internet use resulting in a loss of impulse control among frequent online users (Young 2004). 24

More recent studies have documented internet addiction in a growing number of countries such as Italy (Ferraro, Caci, D’Amico, & Di Blasi 2007), Pakistan (Suhail & Bargees 2006), and Czech Republic (Simkova & Cincera 2004). Reports also indicate that internet addiction has become a serious public health concern in China (BBC 2007), Korea (Hur 2006), and Taiwan (Lee 2007). A nationwide study conducted by a team from Stanford University’s School of Medicine had estimated that nearly one in eight Americans exhibited at least one possible sign of problematic internet use (Aboujaoude, Koran, Gamel, Large, & Serpe 2006). While time is not a direct function in diagnosing internet addiction, early studies suggested that those classified as dependent or addicted online users were generally excessive about their online usage, spending anywhere from forty to eighty hours per week, with sessions that could last up to twenty hours (Young 1998). Sleep patterns were disrupted due to late night log-ins, and addicts generally stayed up surfing until the early morning hours then faced the reality of having to wake up on time for work or school. In extreme cases, caffeine pills may be used to facilitate longer internet sessions. Such sleep deprivation causes excessive fatigue, impairing academic or occupational performance, and also increased the risk of poor diet and exercise. Researchers have likened internet addiction to addictive syndromes similar to impulse-control disorders on the Axis I Scale in the DSM and have used various forms of DSM-IV-based criteria to define Internet Addiction. Of the all the references in the DSM, Pathological Gambling was viewed as most akin to this phenomenon. The Internet Addiction Diagnostic Questionnaire (IADQ) was developed as an initial screening instrument for diagnosis (Young 1998). The following questionnaire conceptualises patterns associated with the disorder: 1. Do you feel preoccupied with the internet (think about previous online activity or anticipate next online session)? 2. Do you feel the need to use the internet for increasing amounts of time in order to achieve satisfaction? 3. Have you repeatedly made unsuccessful efforts to control, cut back, or stop internet use? 4. Do you feel restless, moody, depressed, or irritable when attempting to cut down or stop internet use? The Capa Quarterly


The Lure of the ’Net 5. Do you stay online longer than originally intended when you began the session? 6. Have you jeopardized or risked the loss of significant relationship, job, educational or career opportunity because of your internet use? 7. Have you lied to family members, therapist, or others to conceal the extent of involvement with the internet? 8. Do you use the internet as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression)? Answers evaluated non-essential computer/internet usage such as for non-business or non-academically related use. Subjects were considered ‘dependent’ when answering endorsing five or more of the questions over a six-month period. Associated features also included ordinarily excessive internet use, neglect of routine duties or life responsibilities, social isolation, and being secretive about online activities or a sudden demand for privacy when online. While the IADQ provides a means to conceptualise pathological or addictive use of the internet, these warning signs can often be masked by cultural norms that encourage and reinforce online use. Even if a client meets all the criteria, signs of abuse can be rationalised as, “I need this for my job” or “It’s just a machine” when, in reality, the internet is causing significant problems in a user’s life. Most recently, the American Psychiatric Association has discussed including the diagnosis of Pathological Computer Use in the DSM-V (Block 2008). Conceptually, the diagnosis is a compulsive-impulsive spectrum disorder that involves online and/or offline computer usage and consists of at least three subtypes: excessive gaming, sexual preoccupations, and e-mail/text messaging/social networking. All of the variants share the following four components: 1) excessive use, often associated with a loss of sense of time or a neglect of basic drives, 2) withdrawal, including feelings of anger, tension, and/ or depression when the computer is inaccessible, 3) tolerance, including the need for better computer equipment, more software, or more hours of use, and 4) negative repercussions, including arguments, lying, poor achievement, social isolation, and fatigue. This classification of internet addiction defines the behaviour in a comprehensive manner that includes major components associated with the compulsive behaviour. November 2011

Kimberly Young

Types of Internet Addiction Internet addiction can manifest itself in various ways. In this particular condition, internet addicts can become hooked or addicted to different aspects of online use. Subtypes of internet addiction have been identified that vary dependent upon how the problem has been presented. Online Sexual Compulsivity

The first and most prevalent form of internet addiction is online sexual compulsivity. Adult websites comprise the largest segment of online development and electronic commerce catering to a wide variety of sexual interests. Given the extensive availability of sexually explicit material on line, individuals with this condition typically engage in viewing, downloading, and trading online pornography or are involved in adult fantasy role-play rooms. Online sex chat rooms allow multiple users to discuss various sexual fantasies and have various sexual themes, which activity in turn opens the door for further exploration. Due to the anonymity of online interactions, the user may secretly begin to explore and experiment with his or her sexuality online without the fear of being caught. Users may feel encouraged and validated by the acceptance of the cyberspace culture and, especially when cloaked behind the anonymity of the computer screen, may feel less accountable for their actions over the internet (Cooper 1998). Cooper suggested that three primary factors—anonymity, accessibility, and affordability— are associated with compulsive online sexual behaviour, or what he coined as the Triple A Engines that serve as risk factors for those who already have a problem with sexual compulsivity or to those who have psychological vulnerabilities rendering them at risk for developing such compulsivity (1998). Young (2008) stated that “computer-enabled fantasies are highly reinforcing and the addict’s preoccupation with sexual arousal stems from his own imagination and fantasy history.” The association of the internet with sexual arousal can be so potent that it transforms the internet from a practical business or research device into a modern-day sex toy. A curious person may be completely unprepared when he or she steps into one of many sites specifically designed for the purposes of facilitating sexual experimentation. Titles such as the ‘Hot Sex Room’, the ‘Fetish Room’, or the ‘Bisexual Room’ may intrigue a casual browser who is initially shocked, but at the same time titillated by the 25


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permissiveness of others engaged in virtual sex. Such virtual environments may be more seductive than most users anticipate, providing short-term comfort, distraction, and/or excitement. Users may begin to dabble in darker or more deviant sexual material or themes. Online experiences occur in the privacy of one’s home, office, or bedroom, facilitating the perception of anonymity and of internet use as personal and untraceable. Online Gaming

Massive Multi-user Online Role-Playing Games, or MMORPGs as they are often called, are one of the fastestgrowing forms of internet addiction, especially among children and teenagers. Like an addiction to alcohol or drugs, gamers show several classic signs of addiction (Griffiths 2006). They become preoccupied with gaming, lie about their gaming use, lose interest in other activities just to game, withdraw from family and friends to game, and use gaming as a means of psychological escape (Leung 2007). Yee (2007) suggested that hardcore players show a tendency toward neuroticism or may suffer from emotional problems or low self-worth and -esteem. He suggested that individuals who have other emotional problems may be more at risk of developing an addiction to interactive gaming. In the game, these interactive environments allow individuals to experiment with parts of their personality, they can be more vocal, try out leadership roles, and new identities. The problem arises when players rely upon these new online personae and the distinction between what is real and what is a fantasy becomes blurred. Gamers can join groups, guilds, lead battles, or win wars in a virtual fantasy world. A large part of gaming is about creating social relationships. Gamers make friends with other gamers who help them learn the ‘ropes’ of playing the game (Kolo and Baur 2004). Multi-user role-playing games often include interactive features and options such as chat rooms and places to virtually hang out with other gamers. The social aspect is a primary factor in many game addictions (Leung 2007). Many adolescents have trouble with social relationships and feel lonely, as if they have never truly belonged. This feeling can be especially powerful among children and adolescents who haven’t felt a sense of belonging in their real lives and often their only friends are fellow gamers. Parents who try to put time limits on the game may find a child becomes angry, irrational, and even violent. Gamers who can’t access the game experience loss. They want to be on the game and they miss playing the game. This feeling can become so intense that they become irritable, anxious, or depressed when they are forced to go without the game. As their feelings intensify, they stop thinking rationally and begin to act out towards others, especially a parent or anyone who threatens taking the game away. Even highly educated and competent professionals may get so caught up in electronic recreation that their ability to perform is impaired. For example, a Pennsylvania lawyer was recently suspended from the state board for three years for letting “his video game addiction interfere with his ability to perform as a lawyer”(AP 2011). An interesting examination from the addict’s perspective comes from a professor who last year published a personal account of his “journey into the dark world of video game addiction”, an 80-hours-a-week activity 26

that caused him to neglect both his family and his work and took him to the brink of suicide (Van Cleave 2010). Though some of the psychological problems he relates pre-date his battles in—then with—War of the Worlds, his case provides interesting insights into the types of individual histories that may predispose a client to internet addiction and the issues that arise for those whose gaming activities do take over their lives in this way. Internet Gambling

Another form of internet addiction is compulsive online gambling. Through gambling websites, users can gamble using interactive devices and mobile phones as well as computers. The convenience of 24-hour access, the ease of setting up an online account, and the variety of sites from traditional betting to casino gambling to lotteries makes internet gambling very appealing (Petry 2006). Individuals who start experiencing a problem with internet gambling become preoccupied with gambling, creating a disruption in the personal, family, and social aspects of their  lives. Petry (2006) found that teenage internet gamblers were more likely to have a serious gambling problem than other gamblers. She found that teen-aged internet gamblers were more likely to suffer from health and emotional problems such as substance abuse, circulatory disease, depression, and risky sexual behaviours. According to the National Gambling Impact Commission, young children and teenagers are at the greatest risk of developing a problem. They estimated that 11–18-year-old males comprise 4‑7% of internet gamblers, a significant increase with advent of online casinos (www.ncalg.org). Social Networking

Finally, as demand has increased for mobile devices, PDAs, and mobile phones with internet access, problem mobile device use has increased, especially among the younger generations (Bianchi & Phillips 2005). As a result, e-mail, texting, Facebook, and Twitter overuse has become a growing social and clinical problem. The more time spent texting or checking Facebook, the less time is spent with one’s family and friends. Individuals who suffer from low self-esteem, who feel lonely, restless, or withdrawn, seem more at risk of developing an addiction to electronic communication in order to cope with their feelings (Morahan-Martin & Schumacher 2003). Socially awkward or emotionally troubled individuals may find it easier to engage in internet relationships than to risk the face-to-face rejection of a real person (Ferris 2001). However, the anonymity associated with electronic communication can also increase the online user’s feeling of comfort since there is a decreased ability to look for, and thus detect, signs of insincerity, disapproval, or judgment in facial expression, as would be typical in face-to-face interactions (Morahan-Martin & Schumacher 2003). Among people married or in exclusive relationships, this can lead to online affairs (Whitty 2005). Electronic communication allows individuals to feel less inhibited, which accelerates perceived intimacy, allowing married/committed users to email, text, chat, or Facebook to find support, comfort, and acceptance The Capa Quarterly


from a romantic online partner in a non-threatening manner, nearly always kept secret from the actual life-partner. Forms of Treatment Internet addiction is a relatively new psychological condition. We have yet to fully determine how best to treat this patient population. Early researchers have suggested that moderated and controlled use of the internet is most appropriate to treat internet addiction (e.g., Orzack 1999). For similar compulsive disorders—such as intermittent explosive disorder, pathological gambling, and trichotillomania—Cognitive Behaviour Therapy (CBT) has been shown to be an effective treatment (Hucker 2004). CBT has also been effective in treating substance abuse, emotional disorders, and eating disorders as well. With this in mind, CBT has been used to treat internet-addicted clients. Behaviour therapy is the initial focus of recovery, examining both computer behaviour and non-computer behaviour. Computer behaviour deals with actual online usage, with a primary goal of abstinence from problematic applications while retaining controlled use of the computer for legitimate purposes. For example, a lawyer addicted to internet pornography would need to learn to abstain from adult web sites, while still being able to access the internet to conduct legal research and to e-mail clients. Non-computer behaviour focuses on helping clients develop positive lifestyle changes for life without the internet. Life activities that do not involve the computer such as offline hobbies, social gatherings, and family activities are encouraged. Similarly to food addiction, wherein recovery can be objectively measured through caloric intake and weight loss, online addicts can objectively measure success through maintaining abstinence from problematic online applications and increasing meaningful offline activities. In one of the first studies to examine treatment outcomes, Young (2007) found that CBT was effective among 114 internetaddicted patients. Each patient received 12 weekly sessions of CBT. The study used assertion training, behavioural rehearsal, coaching, modelling, and relaxation training as part of CBT. Treatment also addressed the catastrophic thinking often associated with addictive behaviours such as overgeneralising or catastrophising, negative core beliefs, and cognitive distortions. Using a Daily Internet Log to evaluate computer behaviour, results showed that 80% of patients were able to abstain from problematic online applications and achieve controlled use of the internet for legitimate purposes. In the long term, patients were able to successfully moderate their online time over a sixmonth period post-treatment. To pursue such effective recovery programs, continued research is needed to better understand the underlying motivations of internet addiction. Future research should focus on how psychiatric illness such as depression or obsessivecompulsive disorder play a role in the development of compulsive internet use. Longitudinal studies may reveal how personality traits, family dynamics, or interpersonal skills influence the way people use the internet. Lastly, further outcome studies are needed to determine the efficacy of specialised therapy approaches to treat internet addiction and compare these outcomes against traditional recovery modalities. November 2011

References Aboujaoude, E, Koran, LM, Gamel, N, Large, MD, & Serpe, RT 2006, ‘Potential Markers for Problematic Internet Use: A Telephone Survey of 2,513 Adults’, The Journal of Neuropsychiatric Medicine 11: 750-755 Associated Press 2011 ‘Pennsylvania Lawyer Suspended, Blames Video Game Addiction’, dated 19 August 2011, http://philadelphia.cbslocal.com/2011/08/19/pennsylvanialawyer-suspended-blames-video-game-addiction/, accessed 28 August 2011 BBC News 2005, ‘China imposes online gaming curbs’, accessed from the BBC on June 7, 2011 at http://news.bbc.co.uk/1/hi/technology/4183340.stm Bianchi, A & Phillips, J 2005, ‘Psychological Predictors of Problem Mobile Phone Use’, CyberPsychology & Behavior 8: 39-51 Block, J 2008, ‘Issues for DSM-V: Internet addiction’, American Journal of Psychiatry 165: 306-307 Cooper, A 1998, ‘Sexuality and the Internet: Surfing into the new millennium’, CyberPsychology & Behavior 1: 181-187 Ferraro, G, Caci, B, D’Amico, A, & Di Blasi, M 2007, ‘Internet Addiction Disorder: An Italian Study’, CyberPsychology & Behavior 10: 170-175 Ferris, J 2001, ‘Social Ramifications of Excessive Internet Use Among College-Age Males’, Journal of Technology and Culture 20: 44-53 Griffiths, M 2006, ‘Is internet gambling more addictive than casino gambling?’ Casino and Gaming International 2: 85-91 Hucker, SJ 2004, ‘Disorders of impulse control’, In W O’Donohue and E Levensky (Eds.). Forensic Psychology, Elsiner Academic Press, New York Hur, MH 2006, ‘Internet addiction in Korean teenagers’, CyberPsychology & Behavior 9: 14-525 Kolo, C & Baur, T 2004, ‘Living a Virtual Life: Social Dynamics of Online Gaming’, The International Journal of Computer Game Research 4: 1-10 Lee, M 2007, ‘China to limit teens’ online gaming for exercise,’ accessed on June 7, 2011 at: http://www.msnbc.msn.com/id/19812989/ Leung, L 2007, ‘Stressful life events, motives for Internet use, and social support among digital kids’, CyberPsychology & Behavior 10: 204-214 Morahan-Martin, J & Schumacher, P 2003, ‘Loneliness and social uses of the Internet’, Computers in Human Behavior 19: 659-671 Orzack, M 1999, ‘Computer Addiction: Is it Real or is it Virtual?’, Harvard MentalHealth Letter 15: 8 Petry, N 2006, ‘Internet gambling: an emerging concern in family practice medicine?’ Family Practice, 23(4): 421-426 Simkova, B & Cincera, J 2004, ‘Internet Addiction Disorder and Chatting in the Czech Republic’, CyberPsychology & Behavior 7: 536-539 Suhail, K, Bargees, Z 2006, ‘Effects of Excessive Internet Use on Undergraduate Students in Pakistan’, CyberPsychology & Behavior 9: 297-307 Van Cleave R 2010 Unplugged: My Journey into the Dark World of Video Game Addiction, Deerfield Beach, Florida: HCI Books Whitty, M 2005, ‘The Realness of Cybercheating, Social Science Computer Review 23: 57-67 Yee, N 2007, ‘Motivations of Play in Online Games’, CyberPsychology & Behavior 9: 772-775 Young, KS 1998, ‘Internet addiction: The emergence of a new clinical disorder’, CyberPsychology & Behavior 1: 237-244 Young, KS 2004, ‘Internet Addiction: The consequences of a new clinical phenomena’, in Psychology and the New Media. K. Doyle (Ed). pp. 1-14, American Behavioral Scientist: California. Young, KS 2007, Cognitive-Behavioral Therapy with Internet Addicts: Treatment Outcomes and Implications, CyberPsychology & Behavior 10: 671-679 Young, KS 2008, ‘Internet Sex Addiction: Stages, Risk Factors, and Treatment’, in: American Behavioral Scientist; Psychology and the New Media K. Doyle (Ed.), 2: 21-37

Kimberly Young, BS, PhD (Clinical Psychology), an internationally known expert on internet addiction and online behavior, serves as the clinical director of the Center for Internet Addiction Recovery, founded in 1995, and travels nationally conducting seminars on the impact of the internet. She is the author of Caught in the Net, the first book to address Internet addiction, translated in six languages, Tangled in the Web and her most recent, Internet Addiction: A Handbook for Evaluation and Treatment. She is a professor at St Bonaventure University and her research has been featured such news outlets as The New York Times, The London Times, USA Today, Newsweek, Time, CNN, CBS News, Fox News, and Good Morning America. Visit www.netaddiction.com for articles and more information on Internet addiction.

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First Person

Working in Drug and Alcohol Rehab Beate Zanner I offered to write about my experiences working in a drug and alcohol rehabilitation (D&A rehab) facility as I had found in it a world that I never knew existed—challenging, exciting, rewarding—in which I never stopped learning, where people in our country can get help for drug and alcohol misuse, learn about themselves and their impacts on others and, hopefully, begin to lead better lives. In Australia, as a society, how lucky and privileged we are that such services exist in our communities and are provided by our governments. Some of us really do not realise how our governments look after our people on so many different levels. Drug and alcohol rehab is certainly one of the areas where support is given for people who require help with substance abuse. Substance misuse behaviours are symptomatic of underlying life issues that people are struggling to deal with as a result of traumatic experiences in childhood—trauma which, I’ve discovered, means that some people who come for help have difficultly connecting with people due to experiences of sexual, physical, and emotional abuse and neglect. Using alcohol and/ or other drugs exacerbates their feelings of disconnectedness, being unattached and not belonging. Many models are used to assist in dealing with such issues—from attachment theory, developed by Bowlby and Ainsworth (Gleitman 1995), through completing timeline tasks, to family of origin exploration (Kerr & Bowen 1988) looking for patterns and insights. The core thread I discovered while working in D&A rehab is that every person who comes for help, voluntarily or involuntarily, has experienced trauma or neglect in childhood, and the impact of those early experiences has led to a life of hardship, misery and struggle. All these clients yearn to find who they are, what they want from life. For many, they know what to say but not what to do. Some people don’t need to consider these big questions as they are living life. For others, these questions are a huge consideration, as connection and being able to matter, the sense of belonging and meaning (Frankl 2000) are missing for them. I wonder how many of you are thinking, ‘Yes, but they know what they are doing, as they do criminal activities, do terrible things to their families and society. They are rotten to the core and junkies!’ This is the perception portrayed by the media, believed by many, used politically—especially with regards to being tough on crime—inferring if not stating outright that these people do not deserve help. Their problems come to matter only to those whose family is affected; until then the stigma prevails. When I talked about working in a D&A rehab with peers with whom I’d graduated, I found that some were surprised I could work with such people. Indeed this is common with people I meet in everyday life. For some reason, drug users are seen as less than human, and alcoholics are seen as having a problem that will get better in time. For some affected people D&A rehab is the only place where they can learn so many different life foundations, a bit at a 28

time. Rehab is a place to build foundations that include: daily routine, hygiene, how to cook, wash up, wash clothes, pay bills, build communication skills, engage in activities of interest, learn how other services can assist them … and the list of required foundational skills continues. Hence people need to keep returning to rehab as it takes time to learn what are the foundations, and time again to build each layer. I’m talking about a cohort of people whose addiction to alcohol and other drugs ruins their lives and who need newly built or re-built foundations to be able to stop using. To replace the addictive behaviours with fully living life! Rehab is a microcosm of society for people who live by no rules, who feel they are alone, that they don’t fit in, that no one cares about them. They come into rehab and are surprised that there are other people in rehab who feel just like they do. They reconnect, and laugh like they haven’t for a very long time. They are in an environment where they cannot use drugs or alcohol, and they learn things about themselves. This is a major requirement! Doing individual work, people tend to bend the truth and can pretend everything is going well when it is not. By being in an environment of not using, slowly but surely the individuals begin to regain the real parts of themselves. For some, this can be feeling good about themselves, as they are feeling positive and hopeful in what they are doing and achieving. For others, it is very scary not to be using, as they are not ready to give up the substance-saturated lifestyle. All of a sudden, by not using, buried feelings come up again and are overwhelming in the extreme. The mind is now very active and grinds a person down with feelings of shame and guilt. All the negative thoughts are working overtime, and people feel like giving up, leaving D&A rehab and using again. Many do leave, to quieten the mind down, to avoid dealing with feelings and to begin again the cycle of numbing themselves with drink and drugs. Clients who stay in rehab can receive support from staff, can talk about what is happening for them and work collaboratively to master strategies to get through a tough time. Clients are taught Cognitive Behaviour Therapy to help them deal with their feelings and emotions, so they can see the choices and the outcomes of the decisions they make (Corey 1996). I’m sure we are familiar with the Model of Change by DiClemenet and Prochaska (1982) and the different levels where people can be on the wheel. Learning to understand the different levels where a person can be is helpful. For example, the precontemplation stage assisted me in learning not to try solving the problems of another person’s journey. Some people who come to the D&A rehab are involuntary admissions and are in the precontemplation stage; if they have not willingly engaged in the program by the second week, they usually leave and go back to jail or to their families and continue causing havoc. I realise what a good model the Model of Change is—a boundary for a therapist The Capa Quarterly


to walk with the client rather than imposing a point where the therapist thinks the client needs to be. Importantly for clients, D&A rehab is an environment where they are supported by staff, have a structure, and are offered alternatives for living life. People in rehab are assigned a D&A worker who does individual casework. Casework includes the self-report scale called DASS21 (Psychology Dept UNSW), which is done twice whilst they are in the program. The differences after the first week and the third week were amazing! Clients went from Extremely Severe with depression, anxiety and stress ratings to Mild and Normal ranges. Using the DASS21 is such a great tool as it shows within a couple of weeks the changes being made in the D&A Rehab environment for people with drug and alcohol issues. I was blown away by the results of their not using drugs and/or alcohol at all, as the environment so significantly assisted in lowering clients’ stress, depression and anxiety. Some people have the opportunity to be assessed by a psychiatrist in order to evaluate their mental health issues. For some people it is the chicken-egg question: Are they using drugs or alcohol because of mental health symptoms or do they have mental health problems because of the drug or alcohol abuse? Being in D&A rehab and not under the influence of any substances allows a person to learn how to use medication properly. Many people come in continuing the behaviour of wanting medication of some sort. It was important to figure out the drug-seeking behaviours, and there was a learning curve; clients will go to extremes of manipulation and dishonesty to gain extra medication. At the beginning, and being green in experience, I believed everything a client said. Big mistake, as not challenging their behaviours and beliefs does not help clients. At this D&A rehab, clients are given the opportunity to attend Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings. This is a space for people to share their stories, to listen to others’ stories and to take what they find resonant with their own needs to assist in their recovery journey. This is also handy place for clients to get extra, unauthorised medication, to get things passed onto them without a staff member knowing. We rely on honesty and others to keep the rehab safe (an aside from the last paragraph). The important thing about clients going to the AA and NA meetings is that most clients have burnt their bridges with friends and family. They need to link back into a community and society again, and this space gives them a place to belong, to speak, to learn and gain support. AA and NA meetings, which use the total abstinence model, exist all over the world. Some people in our world just cannot take the risk of having even one social drink, and going to a meeting helps them remain abstinent. Again, we are looking at the power of group work, how peers and what they say assists others more than does input from staff members. Practically every day at D&A rehab, group work is run for the clients, and this is very rewarding, especially November 2011

when the group runs the group, as they are curious and share their worlds with each other in a safe environment. There are group rules, facilitated by the questions asked; the structure is psycho-educational within specific topics. Clients get to explore anger management, conflict resolution, self-esteem, relapse prevention; and various specialists come in as well and give talks on sexual health and mental health, for example. The clients live together and the feedback they give to each other greatly assists in cutting down dishonesty and shows how they really come across. Positive feedback on the work they do is also invaluable to clients. All these groups facilitate normalising feelings, teachings ways to deal with life, encouraging self-growth and determination. Yalom would call these groups encounter groups (1995). For a rehab situation, they do exactly what is needed for people who come in empty—emotionally, physically and spiritually. It gives great pleasure to see clients learning from the groups and making connections, becoming aware of how their behaviours have impacted others, and discovering alternative ways to deal with a variety of situations in the way they communicate, and understanding how to get their needs meet in positive ways. Within all the experiences of participating in a group, they cease to feel like they come from the planet Pluto, no longer feel alone, and are now taking responsibility. The other topic I would like to address about working in a D&A rehab is transference and counter-transference. It just amazes me how important it is to be aware of the person’s transference and my own reactions (counter-transference). Working in an environment where there are ten clients or so, all wanting different things, having their own agendas, different ways of communicating, different ways of manipulating and different follow-up requirements—and at the same time being aware of the program to be run and working with other staff members, who also have their own styles, and working together in an environment—can be difficult at times! Clients will not want to follow the program. They are used to running their own show, so coming into rehab is a huge change and a difficult adjustment. Some clients will be very convincing about why they cannot participate in an activity. It is much easier to let the client avoid participation than it is to use motivational interviewing (Miller & Rollnick 1991) skills to help them see the benefit in doing the activity. Fortunately, this is not an option for the client as they have signed up (or been signed up) to do the program. What I realised with the transference was how it can affect the way I operate because I have taken on the client’s story or feelings. This impacts the way I communicate with staff members, and I could also react inappropriately with counter-transference. I think I needed to listen to colleagues more when they were concerned about me, as they picked up what was going on for me earlier than I did. Now I speak up and reach out for support.

(continued on Page 35) 29


Professional Development

The Needs of Gender Variant Children Elizabeth Riley is a counsellor, supervisor, and educator specialising in sexuality and transgender counselling and a Senior Educator at the Australian College of Applied Psychology. A PhD candidate, she has been part of a team researching the needs of gender variant children and their parents. She is also a counsellor, consultant and trainer for the St James Ethics Centre and works in private practice in Sydney. Elizabeth has presented papers and workshops, both locally and internationally, in the areas of Sexuality, Gender Identity, and Ethics.

After the AGM on 13 August 2011, Elizabeth Riley presented her PhD research on Gender Variant Children and Their Parents. We were privileged to hear this presentation before Elizabeth’s presentation of the same material at the World Conference of Psychotherapy in August in Sydney and at the Biennial Symposium of the World Professional Association for Transgender Health in the US in September 2011. Elizabeth worked in the Gender Centre in Sydney for seven years as a counsellor, and at that time there were no specific courses on gender variant people in Sydney. No research had yet been conducted in Australia and, being one of the few workers in this field, Elizabeth was offered the opportunity to conduct such research as her PhD topic. Elizabeth’s experience at the Gender Centre most likely contributed to making this research genuine, realistic and very valuable, as it incorporates her personal understanding and experience of working with transgender populations. Elizabeth started her presentation by showing a video of selfreports by several persons describing their experience. The first story was of a middle-aged person of female appearance, born as a male, who for many years tried to meet societal expectations while feeling painfully uncomfortable with his own physicality and the social expectation that attended his birth gender. It was only when he heard another person describing exactly how he felt that he was encouraged to proceed with his own transformation. This led to some surgical and hormonal

adjustments congruent with the gender identity. This person retained the male voice despite female appearance. Another story described how Elijah has gone through many life experiences that were completely incongruent with his gender identity. He was born female, married, and had a son. It was not until the son was eighteen years old and Elijah was in his early forties that he decided to affirm his gender identity as male. Another transsexual person described living as a heterosexual man with a wife, children and grandchildren. His wife’s support for cross-dressing at home saved his ‘sanity’ for a while but eventually all the efforts to keep secrecy about crossdressing led to panic attacks and therapy. Eventually, in the ’60s, this person learned to feel comfortable ‘wearing’ the female appearance openly, without shame. The last episode presented the experience of a young black person born male saying, “There was a femaleness about me” and “when I made love to a woman, it was lesbian love” and “when I made love to a man, it felt right”. These stories only touched upon the actual trauma these individuals lived through, but hearing the unsaid, I could feel a sense of bitterness for having had to pretend being who they were not and, at the same time, denying their yearning to let the world know who they were deep inside, without any shame. Elizabeth’s research examined experiences of gender variant persons during their childhood and the impact these experiences had on their adult choices and behaviours. She also

2012 Professional Development Events On 6 March 2012, Dr Alexander Blaszczynski, Professor of Clinical Psychology and widely recognised expert on problem gambling, will give a PD presentation at the Crows Nest Centre, 7-9pm. Full details of the program will appear in the next issue of CQ. On 6 June 2012 at the Crows Nest Centre, 7-9pm, Elisabeth Shaw, for the past three years Chair of the PACFA Ethics Committee, will give a presentation on Ethics in Counselling, further details to follow. Suggestions from members for future PDEs are welcome. We are selective with the choice of presenters and invite only those who have qualifications adequate to garner PD credit for attendees. Topics are under negotiation as most presenters do not like to commit too far in advance, and there is always a risk that they may cancel, sometimes at short notice. 30

The Capa Quarterly


and Their Parents

Review by Juliana Triml

explored experiences of their parents, and finally, experiences and attitudes of professionals. Part of this presentation was also experiential. We were asked about our exposure and experience with transgenderism. Most of us had little experience, and those who had some had learned from their clients. Elizabeth then asked us: “If a preschool boy wanted a Barbie doll, would you give it to him?” and then “Would you let him take it to school?” and “If he wanted girl’s clothes, would he get them?” Some people said that many children go through a stage of experimenting, and dressing up is part of it, but most retain their birth gender. However, Elizabeth noted, most gender variant persons exhibit strong and significant signs of this variance since early childhood. Elizabeth’s presentation touched our hearts and challenged most of us in some way. I personally realised that whilst I am perfectly open-minded and non-judgmental when a client tells me his or her story, the thought that my three-year-old grandson might make wearing (my) high-heeled shoes a common thing made my

heart skip a beat. Under some circumstances, we see dressing up as funny, but at other times it can challenge parents’ values. I imagine that parents of gender variant children inevitably go through a process of emotional adjustments of their own, from shock to, hopefully, acceptance. Unfortunately, and Elizabeth agreed, some parents have difficulties with accepting their child being who she/he is without wanting the child to meet their own expectations, and thus deny the child the basic support that is needed at those very difficult times. You are invited to challenge your own fears, expectations, etc. whilst imagining being a parent of a gender variant child, juxtaposed to being a counsellor of a transgender person.

Juliana Triml is the CAPA NSW PD Coordinator. If you have any suggestions regarding future professional development events, please contact her at: capa.pd@hotmail.com

November 2011 CAPA NSW Professional Development Event CAPA NSW members must complete twenty hours of approved professional development each year. To help members meet this requirement, CAPA is hosting a PDE on the following date: Wednesday 22 November 2011, 7.00 pm–9.00 pm, PD hours: 2

Mary Sawyer Acceptance & Commitment Therapy—Six Core Processes

Acceptance and Commitment Therapy (ACT) is a new model of behavioural treatment that emphasises acceptance of internal experience while maintaining a focus on positive behaviour change. This approach is designed to address maladaptive avoidance of internal experiences associated with many problems in functioning while also focusing on making and keeping commitments. ACT uses a variety of verbal, experiential and homework techniques to help patients make experiential contact with previously avoided private events (thoughts, feelings, sensations), without excessive verbal involvement and control—and to make powerful life-enhancing choices. Empirical evidence suggests that ACT techniques may be broadly useful for intervening with multi-problem patients dealing with issues such as anxiety, depression, epilepsy, substance abuse, pain management, psychotic disorders. In addition to an overview of empirical and research findings on ACT, this event will address some techniques of ACT interventions, including the six core processes of ACT, and the evolution of ACT as the third wave of behaviour therapy and the ACT theory of change. Mary Sawyer RN, BA, MApp Psych, MAPS, MCN, has a private psychology practice in Sydney. Before entering private practice, she lectured in psychology and psychosocial care at ACU National in Australia and Hong Kong. One of the foremost ACT therapists in Australia, she has over 150 hours of professional development with expert ACT clinicians and has trained with leading ACT researchers and clinicians in Australia, New Zealand, the UK, the Netherlands and the USA and has presented ACT workshops at International Conferences. She is the first Convener of the Australian Psychological Society (APS) ACT Interest Group and has been actively involved in promoting ACT in Australia since 2003 and facilitates ACT workshops in Sydney and rural areas of New South Wales. Mary uses ACT working with a variety of psychological problems such as; depression and anxiety, grief and loss, post traumatic stress disorder, all addictions including gambling, alcohol and other drug problems, adult survivors of sexual abuse and relationship, separation and divorce issues. She has provided clinical supervision for Alcohol and Other Drug workers in the NSW Department of Corrective services for 10 years and is now a clinical supervisor for St Vincent’s Hospital Sydney Alcohol and Other Drug Service and Homeless Health Outreach Workers, using ACT as the predominant therapy. Bookings: (02) 9235 1500 or office@capa.asn.au Please book as soon as possible. Spaces are limited due to Occupational Health and Safety requirements. Cost: Free for CAPA members. $30 for non-members Venue: Crows Nest Centre, 2 Ernest Place, Crows Nest, Sydney (unless otherwise stated) If you have any suggestions for future PDEs, contact CAPA’s PD Coordinator, Juliana Triml, on pde@capa.asn.au CAPA is also exploring more convenient options for members in rural and regional areas. Please email the Regional and Rural Committee with your suggestions regional@capa.asn.au. November 2011

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Features (continued) (continued from Page 17) References APSS 2011, ‘Sleep’, paper presented at the 25th Meeting of the Associated Professional Sleep Societies LLC, Minneapolis Assagioli, R 1965, Psychosynthesis, London: Thorsons Barton, J, Blinder, MD, Karin, H and Chao, BS 2001, ‘Bulimia nervosa/obesity overview’, retrieved 5 January 2008 from http://www.ltspeed.com/bjblinder/ publications/bulimiahistory.htm Benson, J 2002, ‘Gain, loss and change as journey and exploration in psychotherapy’, Institute of Psychosynthesis Handbook, 3 Butterfly Foundation 2011, Training Manual: Free to Be: A Body Esteem Resource, Crows Nest: Butterfly Foundation EDV (Eating Disorders Victoria) 2011, ‘Key statistics’, retrieved 18 June 2011 from http://www.eatingdisorders.org.au/media/key-reserch-a-statistics Evans, J 1997, The Triphasic Model, Year 3 Training Manual, London: The Institute of Psychosynthesis Evans, J 2004, ‘Foreword’, in Essays in Psychospiritual Psychotherapy, London: The Institute of Psychosynthesis Fairburn, C 1995, Overcoming Binge Eating, New York: The Guilford Press Ferentz, L 2011, ‘It’s not about the food: The truth about eating disorders’, retrieved 25 February 2011 from http://www.psychotherapynetworker.org/magazine/ currentissue/1211-its-not-about-the-food

Mintel [Market Research Analysts] 2004, ‘Many people diet most of the time’, retrieved 14 January 2008 from http://news.bbc.co.uk/2/hi/health/3454099.stm Moore, T 1992, Care of the Soul, London: Piatikus Normandi, C and Roark, L 1998), It’s Not About Food, New York: The Berkley Publishing Group Orbach, S 1993, Hunger Strike, London: Penguin Group Pallardy, P 2006, Gut Instinct, London: Rodale Books Peay, P 2010, ‘Jungian analysis, eating disorders and the ‘great work’: Interview with Marion Woodman’, retrieved 1 June 2011 from http://www.huffingtonpost.com/ pythia-peay/jungian-analysis-eating-d_b_578890.html Richards, S Hardman, R, & Berrett, M 2006, Spiritual Approaches in the Treatment of Women with Eating Disorders, Washington: American Psychological Association. Roth, G 2010, Women, Food and God, New York: Scribner. Schaub, R and Schaub, B 1997, ‘Advanced recovery: Emotional strength and spiritual recovery’, retrieved 9 August 2010 from http://www.newyorkpsychosynthesis.org/ pdf/advanced_recovery.pdf Southard, M 2010, ‘The connection between mental health and spirituality’, retrieved 18 June 2011 from http://www.mhspirit.org/uploads/2009%20conference%20 Dr%20southards%20speech-byline.revMJS060710.pdf Stratford, T, Lal, S and Meara, A 2009, ‘Neurophysiology of therapeutic alliance’, Gestalt Journal of Australia and New Zealand, 5(2): 19-47

Firman, J and Gila, A 1997, The primal wound, New York: State University of New York Press

Taylor, VDC 2010, ‘Enough! Undoing addictive patterns’, paper presented at the Mind & Its Potential conference, Sydney

Gale, J 2008’, Call off the search: Eating disorders, a symptom of psychospiritual crisis. Institute of Psychosynthesis, London

Vandereycken, W and van Deth, R 1994, From Fasting Saints to Anorexic Girls, London: The Athlone Press.

Gale, J 2010, ‘Addiction: A psychospiriual perspective’, The CAPA Quarterly, Journal of the Counsellors and Psychotherapists Association of NSW, 4: 20-23.

Wolf, Naomi 1991, The Beauty Myth, New York: William Morrow

Goldstein, E 2009, ‘Mindfulness and Addiction, Part I’, retrieved 25 February 2011 from http://blogs.psychcentral.com/mindfulness/2009/02/mindfulness-andaddiction-part-i/ Grof, C 1993, The Thirst for Wholeness: Attachment, Addiction and the Spiritual Path, New York: HarperCollins Kristeller, JL and Hallett, CB 1999, ‘An Exploratory Study of Meditation-Based Intervention for Binge-Eating Disorder’, Journal of Health Psychology, 4(3): 357-363 Lowe, M 2008, ‘Eating’, retrieved 2 March 2008 from http://www.answers.com/topic/eating Maine, M 2004, Father Hunger, USA: Gurze Books

“LEARNING IS FOREVER” “LEARNING IS FOREVER”

Matz, J 2011, ‘Recipe for life: Is attuned eating the answer to diet failure?’ retrieved 25 February 2011 from http://www.psychotherapynetworker.org/magazine/ currentissue/1213-recipe-for-life

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Woodman, M 1982, Addiction to perfection, Toronto: Inner City Books

Jodie Gale MA Psychotherapy, Dip Therapeutic Counselling, CMCAPA, PACFA Reg. has a wealth of personal and professional knowledge in the field of addiction and eating disorders. Her experience includes a Master’s thesis on eating disorders, training in addiction and ‘women’s business’, work experience in the ‘Eating Disorder Unit’ at Great Ormond Street Hospital in London, the Eating Disorders Foundation and Women’s Health NSW. She is an ‘approved service provider’ for South Pacific Private Addiction and Mood Disorder Treatment Centre and works in private practice on the Northern Beaches. www.psychosynthesis.net.au www.facebook.com/psychosynthesis

EXPLORE AN EXISTENTIAL APPROACH WORKSHOPS THAT WORK WORKSHOPS The Anxious Client

GROUP WORKSHOP Skills for Coaches

28 & 29 October 2011

22 & 23 December 2011

2-day Workshop

2-day Workshop

Advanced Existential Theory & Practice 5-day Workshop

21 - 25 November 2011

2012 - NEW EXCITING PROGRAM INCLUDING *PHILISOPHICAL EVENINGS*CREATIVE SERIES*LEARNING GROUPS* *SUPERVISION ON SUPERVISION* AND LOTS MORE*

For more information The Centre for Existential Practice admin@cep.net.au www.cep.net.au Telephone: 0431 401 659

The Capa Quarterly


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Upcoming themes in The CAPA Quarterly Send expression of interest to editor@capa.asn.au as soon as possible in order to ensure inclusion.

Sex ~ Issue Two 2012 Peer reviewed submissions due: 1 October Non-peer reviewed submissions due: 1 November Mail out: February Belief Systems in Therapy ~ Issue Three 2012 Peer reviewed submissions due: 1 October Non-peer reviewed submissions due: 1 November Mail out: February

Najavits, LM, Weiss, RD, Shaw, SR and Muenz, LR 1998, ‘“Seeking safety”: outcome of a new cognitive-behavioral psychotherapy for women with posttraumatic stress disorder and substance dependence’, Journal of Traumatic Stress, 11: 437-56 Ouimette, P and Brown, PJ 2003, ‘Substance use disorder-posttraumatic stress disorder comorbidity: A survey of treatments and proposed practice guidelines. Trauma and substance abuse: Causes, consequences, and treatment of comorbid disorders, American Psychological Association: Washington Ouimette, PC, Finney, JW and Moos, RH 1999, ‘Two-year posttreatment functioning and coping of substance abuse patients with posttraumatic stress disorder’, Psychology of Addictive Behaviors, 13: 105-114 Sannibale, C, Sutherkand, K, Taylor, K, Visser, A, Bostock-Matusko, D, Peek-O’Leary, M, Teesson, M, Mills, K, Sitharthan, T, Creamer, M and Bryant, R 2010, ‘Does integrated treatment improve outcome among people with alcohol use disorder and post-traumatic stress? Results of an RCT of cognitive behaviour therapy’, Drug & Alcohol Review, 29 (suppl 1): 66 Slade, T, Johnston, A, Oakley Browne, MA, Andrews, G and Whiteford, H 2009, ‘2007 National Survey of Mental Health and Wellbeing: methods and key findings’, Australian and New Zealand Journal of Psychiatry, 43: 594-605

Dealing with Dementia ~ Issue Four 2012 Peer reviewed submissions due: 1 October Non-peer reviewed submissions due: 1 November Mail out: February

Stewart, SH, Pihl, RO, Conrod, PJ and Dongier, M 1998, ‘Functional associations among trauma, PTSD, and substance-related disorders’, Addictive Behaviors, 23: 797-812

NOTE: ~P  eer reviewed submissions are due four months ahead of the issue month. ~ Non-peer reviewed submissions are due three months ahead of the issue month. ~ A ll submissions are due on or before the 1st day of the month.

Zlotnick, C, Najavits, LM, Rohsenow, DJ and Johnson, DM 2003, ‘A cognitivebehavioral treatment for incarcerated women with substance abuse disorder and posttraumatic stress disorder: findings from a pilot study’, Journal of Substance Abuse Treatment, 25: 99-105

Contributor guidelines: http://thecapaquarterly.blogspot.com/p/contribute.html or contact editor@capa.asn.au. Advertising enquiries: http://thecapaquarterly.blogspot.com/p/advertise-with-us.html or contact advertising@capa.asn.au

November 2011

Triffleman, E 2000, ‘Gender differences in a controlled pilot study of psychosocial treatments in substance dependent patients with post-traumatic stress disorder: Design considerations and outcomes’, Alcohol Treatment Quarterly, 18: 113-126

Katherine Mills, PhD, is Senior Lecturer and NHMRC Research Fellow at the national Drug and Alcohol Research Centre, University of New South Wales. Currently, Dr Mills is coordinating a NHMRC funded randomised controlled trial examining the efficacy of an integrated intervention for PTSD and illicit drug use disorders. Her other research interests include the epidemiology of substance use disorders, comorbidity, treatment outcomes, and substance use disorders among youth populations.

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Features (continued)

You don’t want to write an academic paper? We welcome more informal anecdotes from your practice. Topics could include:  A client who changed my practice (or my life) T  he most valuable lesson I learned in the therapy room  Ideas that inform my practice  My most important therapeutic mistake S ome things I wish I knew before becoming a therapist Send your submissions to editor@capa.asn.au

Advertising a course, workshop or conference?

Apply for CAPA PD endorsement Increase your potential audience by submitting your event outline for CAPA Professional Development (PD) assessment. If your event meets the criteria, your ad will be highlighted with the CAPA seal of approval, and the number of CAPA PD hours it attracts. And it will appeal to more CAPA members. To take advantage of this service, email CAPA’s Membership Chair at membership@capa.asn.au. Assessment fee: $150.00 Submission date: event outlines are due at least two months before the relevant advertising deadline. (Please note that submitting your event to this service does not guarantee endorsement).

Ma k the mo e s of your t ad 34

The Capa Quarterly


(continued from Page 29)

Reflection since no longer working in D&A rehab has highlighted for me how important it is to look after myself by debriefing, having regular supervision—both individual and group—taking holidays, being social and having interests in other activities, just so I can be myself and operate at a good level with clients. As we all know, transference/counter-transference really does require reflection and supervision, so we do not take on our client’s load and do not react to a client’s world, so a client feels supported and held. Too many times I’ve heard clients relate how a therapist or counsellor was not able to deal with his or her story or emotions and the client was told, ‘I’m not able to help you!—or was left feeling bad and confused. Hence clients may be left feeling what they share with another is too much, and so continues the journey of hell for them. In looking at what I have written, I realise how much I have learnt by the experience of working in a D&A Rehab. I learnt the dangerous levels of harm caused by drug and alcohol abuse to the users and people important to them. How families suffer in silence due to the stigma of reaching out for help, as it does not come easily. How it takes time, a lot of time, for some people to get what is required, and how some don’t make it, end up dead through the awful life of addiction. On the whole, when people reach out, they want help right there and then. Unfortunately, or fortunately, there is a required process of assessment, needs and vacancies. In the end, everyone involved in assisting people to lead a better life is doing something valuable in our society: assisting another human being. I have left out much of what D&A rehab work offers. What I have included is what has stayed with me: the different models, tools, scales, psycho-educational group work, the need to look

after myself and colleagues. Most of all, though, I remember the people I have worked with, the clients, who have taught me much, allowed me into their painful worlds, to see them take hold of their lives and to join society rather than feel an outcast. In the end, we all need help at some stage or other in our lives, and it is the people who cross our paths, who might say just one thing, and that is enough for a person to take hold of his or her life, to take a better direction. As a graduate from Jansen Newman Institute I was oh! so green to work in a D&A rehab! The opportunity to work at the Watershed Drug and Alcohol Education Centre gave me skills that I would not have learnt doing individual work alone. What a great privilege. Thanks for the opportunity to share part of my world in a D&A rehab between 2004 and 2009. References Corey, G 1996, Theory & Practice of Counseling & Psychotherapy (5th Edn), South Melbourne: Thomas Nelson Australia Frankl, VE 2000, Man’s Search for Ultimate Meaning, New York: Perseus Publishing Gleitman, H 1995) Psychology (4th Edn), New York: W. W. Norton & Co Inc. Kerr, ME & Bowen, M 1998, Family Evaluation, Markham, Ontario: Penguin Books Canada Ltd. Miller, WR & Rollnick, S 1991, Motivational Interviewing: Preparing People to Change Addictive Behavior, New York: Guildford Publications Prochaska, JO & DiClemente, CC 1982, ‘Transtheoretical therapy: Toward a more integrative model of change’, Psychotherapy: Theory, research and practice, 19: 276-288 Yalom, ID 1995, Theory & Practice of Group Therapy (4th Edn), New York: Perseus Publishing www.2.psy.unsw.edu.au/groups/dass.over.htm

Beate Zanner, BA, Dip Psych, is a psychotherapist and counsellor in private practice at Exploring Possibilities in Wollongong and is currently Acting Team Leader for Aftercare’s Personal Helpers and Mentors Program. She is also Membership Chair for CAPA NSW Inc. Feedback would be appreciated and welcomed. email: bkzanner@hotmail.com

We can help you help them through crisis: •We Alcohol drugyou addiction Mood through disorders • crisis: Relationship issues •PTSD canand help help •them We canand help you help •them through • Alcohol drug addiction Mood disorders • crisis: Relationship issues •PTSD Call Rhoda now on (02) 9466 6201 southpacificprivate.com.au • Alcohol and drug addiction • Mood disorders • Relationship issues •PTSD Call Rhoda now on (02) 9466 6201

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May 2012 – Sex

Calls for Contributions

In our multicultural society and global community, many people have personal and societal challenges around sexuality—sexual attractiveness, sexual performance, sexual orientation, and sexual identity, as well as sexual abuse. Such issues often find their way into the therapist’s rooms as clients search for clarity and resolution, comfort and confidence. Sex can be a tricky subject, but it is fundamental and can arise in many contexts for both children and adults. Sexual issues can also be buried—hidden behind other issues more amenable to revelation and discussion. Clients may suffer anxiety or depression, or may even act out violently in response to unresolved sexual issues of one sort or another. Some therapists specialise in sexual issues; others prefer to avoid them. Does best practice necessarily include dealing with the subject of sex? How does a therapist identify such issues when the client doesn’t voice them? How are the varieties of sexual issues best approached and discussed in therapy? Join the discussion with a contribution to the May 2012 issue of CQ: The CAPA Quarterly. Peer reviewed papers due by: 1 January Non-peer reviewed due by: 1 February

August 2012 – Belief Systems in Therapy

It is probable that many of us hold some beliefs that do not serve us well, even some that are contradictory. Every client walks into the therapy room with a set of beliefs that define and drive who he thinks he is and how he fits into the world. Every therapist also has a personal belief system. How does the therapist find ways through these systems or sets of beliefs, and how do those of the therapist and those of the client interact in the therapy room to build trust and a working relationship that can achieve positive results for the client? How do you as a therapist first discover and identify then work with or change those beliefs toward resolution of the issues the client has brought? How do you set aside your own when the need arises? The August 2012 issue of CQ: The CAPA Quarterly holds a space for discussion of this tangled web. Peer reviewed papers due by: 1 April Non-peer reviewed due by: 1 May

November 2012 – Dealing with Dementia What is dementia? Where does it come from? How does one cope with growing evidence of its erosion of the person we know—either the self or a loved one? How can the therapist assist someone who has dementia? How can carers cope with the gradual disappearance of the person they have known and loved? What special skills and insights can illuminate such situations in the therapy room? As people live longer and dementia becomes a more common experience, what do therapists need to know to enhance their ability to help in this circumstance? Share your insights and experience with a contribution to the November 2012 issue of CQ: The CAPA Quarterly. Peer reviewed papers due by: 1 January Non-peer reviewed due by: 1 February

February 2013 – Open Forum Do you have an insight to share about the practice of therapy, but haven’t been able to align it with any of the announced themes for CQ: The CAPA Quarterly? Now we have an Open Forum each February so that articles on any aspect of therapeutic practice can be welcomed. Share your knowledge with your peers and open up discussion on topics of importance to you. Peer reviewed papers due by: 1 October Non-peer reviewed due by: 1 November

Deadlines are for articles that have been accepted, not for new ideas. Please send expressions of interest as soon as possible, to maximise your chance of inclusion. For Contributor Guidelines contact editor@capa.asn.au

Advertising rates for 2012 Ad size

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Book your ad for a year (4 issues) and receive a 12% discount Booking deadlines February issue 1 December May issue 1 March August issue 1 June November issue 1 September Artwork/copy deadlines February issue 1 January May issue 1 April August issue 1 July November issue 1 October

For advertising specifications and bookings, contact our Advertising Coordinator at: advertising@capa.asn.au or 02 9235 1500

36

The Capa Quarterly


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Classifieds

A free service for CAPA NSW members, contact advertising@capa.asn.au

Rooms for Rent Brookvale New building behind Warringah Mall, suit counsellor, coach, psychologist. Room available most days, half day or full day. Client parking available. Call Peta on (02) 9938 5860 or email jangrant@optusnet.com.au Crows Nest Modern, bright, fully furnished room and large, fully equipped group room available in an established practice on the Pacific Highway. Metered/free parking nearby. Half, full and multiple day rates available. Contact Eve on 0412 011 950 Crows Nest Well presented consulting room in brand new clinic located in the heart of Crows Nest. Excellent parking and public transport. Sessional and permanent rates. Also available: group space for up to 14 people. Fair rates. Please contact Sabina on 0419 980 923 or sabina@wellforlife.net.au Glebe Warm and inviting, well-presented consulting rooms available for reasonable rates on a permanent, weekly or part-time basis. Large, pleasant waiting room, good facilities and great location on Glebe Point Road in the midst of Glebe village. Public transport at the door and ample off-street parking. Contact Lee on 0407 063 300 Glebe Inviting and warm consulting room available for hire on Mondays and Wednesdays; other days negotiable. Spacious and welcoming waiting room. Easy access on St Johns Road, Glebe. Public transport at the door and ample on-street parking. Contact Gay on 0409 986 740 Lane Cove Rooms/room available to rent on a daily basis in a beautifully renovated health care clinic. Ideal for a Professional Health Care Provider. Flexible lease agreement. Unrestricted and ample parking. Please contact Peter on (02) 9427 1785

Please contact Eva on 0411 498 468 or eva@ardstrom.com.au Parramatta Four airconditioned and well appointed counselling rooms and a group room are available at hourly casual rates (from $25) or on a permanent basis. Rooms are located in George St, Parramatta and room bookings can be made on our website www.lifexplored.com.au. Contact John Carroll on 0419703410 or john@lifexplored.com.au Sydney CBD Stylish consulting rooms in landmark Macquarie St building, in Sydney’s prestigious medical district. Polished wooden floors, air conditioning, waiting area, kitchen amenities and printer/ copier/phone/fax. Bright, leafy outlook and nearby public transport. Opportunities for crossreferral and cross-promotion. Full day, half day and casual sessions. Photos available. Contact Susie on (02) 9221 1155 or beingcounselling@iprimus.com.au Woolloomooloo – CBD Two comfortable, spacious consulting rooms to choose from. One room complete with sandplay tray and figures. Large group/ workshop/training space also available. Close to transport and ample parking. Photos available on our website under Room Rentals. www.gloo.org.au Full day, half-day or weekend rental available for workshop venue. Contact Tanya on 0425240928 or email tanyadawson@iinet.net.au

Supervision Supervision – Penrith and Richmond Experienced supervisor and adult educator offers supervision for counsellors, group workers, community workers etc. Penrith and Richmond..PACFA Reg. Contact Jewel Jones on 0432 275 468 or email jeweljones@iprimus.com.au Web: www.jewel-jones.com.au

Lilyfield Bright, sunny, unfurnished room available at the Lilyfield Psychotherapy Centre, established practice. Very reasonable room rental. Convenient location close to public transport and cafes. Contact Jen Fox on (02) 9560 0719 or (02) 9799 3387

Supervision – Disability and Sexuality Individual and group supervision for counsellors, group leaders and those supporting people with a disability or Asperger’s syndrome. Twenty years’ experience working in disability field; seven years in relationships and sexuality counselling and education including working with victims and perpetrators of sexual harassment and assault. CMCAPA. Burwood and Newtown. Contact Liz Dore on 0416 122 634 or lizdore@bigpond.com Web: www.relationshipsandprivatestuff.com

Mosman Beautiful practice room at the heart of Mosman, close to public transport and easy parking. Available on a daily basis with good rates.

Supervision – Newtown Available for those doing individual, couples and group work. Over twenty years of clinical experience. Accredited in Professional

November 2011

Supervision (Canberra Uni), Registered member PACFA. Contact Vivian Baruch on (02) 9516 4399 or email via www.vivianbaruch.com Supervision – Brookvale and Glebe Experienced supervisor for counsellors and group leaders. Qualified trainer and supervisor, CMCAPA, Registered member PACFA. Call Jan Grant on (02) 99385860 or email jangrant@optusnet.com.au Supervision – Chatswood West Supervision for individual, couple and group work, including counselling, psychotherapy and coaching approaches. Flexibly designed to suit your needs. Over twenty years of clinical experience. Clinical Member CAPA/Reg. PACFA. Contact Gemma Summers on 0417 298 370 or email gemma@goodmind.com.au. Web: www.goodmind.com.au Counsellors/Hypnotherapists Just graduated and looking to go into private practice? Supervision and business coaching available to help you on your way. Also rooms for rent on sessional/permanent basis. Contact Lidy@northernbeachescounselling.com.au or phone (02) 9997 8518 or 0414 971 871. Supervision for working with Adolescents and Parents – Coogee and telephone Individual and group supervision for counsellors, educators, allied health workers, group leaders and parents. Fifteen years in private practice as psychotherapist/counsellor; eighteen years working with pre-teen/teen girls and their parents, addressing developmental issues and popular culture/media’s impact on girls’ body image. Registered clinical member PACFA. Contact Shushann Movsessian on (02) 96654606. Web: www.shushann.com and www.letstalkgrowingup.com.au Supervision Experienced supervisor. Registered member PACFA. Accredited supervisor with Australian Association of Relationship Counsellors (AARC). Available for psychotherapists, counsellors and group leaders. Caringbah. Contact Jan Wernej on (02) 9525 4434 or email janwernej@optusnet.com.au Counselling, Psychotherapy and Supervision For personal and professional development, self-care and mentoring. Thirteen years’ experience in private practice. PACFA Reg.20566. Location: Mosman. Contact Christine Bennett on 0418 226 961 or email christine@caring4couples.com.au Web: www.cb-counselling.com.au and www.caring4couples.com.au 37


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Journal of the Counsellors and Psychotherapists Association of NSW Inc ABN 50 035 123 804 If undeliverable, please return to: CAPA NSW Suite 134 / Level 13 183 Macquarie Street Sydney NSW 2000 Phone: +61 2 9235 1500 Email: office@capa.asn.au Web: www.capa.asn.au Changed your address? Please notify CAPA NSW

Looking for a Conference? To include your free conference listing here, contact editor@capa.asn.au

Some prominent psychology conferences in Australia and elsewhere this year are listed below. For a more comprehensive list of psychology conferences worldwide, visit http://www.conferencealerts.com/psychology.htm

Date & Location

Organisation/Conference

Contact

7-8 November 2011, Sydney

Mind & Its Potential

http://www.mindanditspotential.com.au/index.stm

26-28 January 2012 , San Diego

13th Annual Meeting Society for Personality and Social Psychology

http://www.spspmeeting.org/

26 January 2012, San Diego

SPSP Pre-Conference on the Psychology of Religion-Spirituality

http://www.baylor.edu/psychologyneuroscience/index. php?id=76186

13-14 February 2012, Singapore

Annual International Conference on Cognitive and Behavioral Psychology

http://www.cognitive-behavior.org/

1-2 March 2012, Sydney

Happiness & Its Causes 2012

http://www.happinessanditscauses.com.au/

8-11 March 2012, Palm Springs

Association for Women in Psychology

http://www.awp2012.org/

18-20 April 2012, London

British Psychological Society Annual Conference 2012

http://annual-conference.bps.org.uk/

8-10 June 2012, Macau

5th International Conference of Analytical Psychology and Chinese Culture ‘Dreams, The Symbolic Language of the Psyche, Nature and Culture’

http://iaap.org/conferences/2012/v-analytical-psychologychinese-culture.html

27-27 June 2012, Paris

8th International Conference on Applied Psychology and Behavioural Science

http://www.waset.org/conferences/2012/paris/icapbs/

17-21 July 2012, Stellenbosch, South Africa

21st International Congress – International Association for Cross-Cultural Psychology

http://www.iaccp.org/drupal/

22-17 July 2012, Cape Town

30th International Conference of Psychology ‘Psychology Serving Humanity’

http://www.icp2012.com/index.php?bodyhtml=home.html

23-25 March 2012, Tirane, Albania

International Conference on Human and Social Sciences

http://conference.researchbib.com/?eventid=11963

CQ 2011-4 Addictions  
CQ 2011-4 Addictions  

Addiction: the Big Picture ~ Peter R. Martin & Laura Daniel Addiction to Adrenaline: Thrilled to Death? ~ Archibald D. Hart The World’s Most...

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