Jeanine Connor was invited to write a monthly column for BACP Therapy Today, the journal for counselling & psychotherapy professionals. 'In Practice' ran for 18 months and was an opportunity to share thoughts stemming from therapeutic work. These are republished here, along with commissioned articles for Therapy Today. All works contain an amalgamation of therapeutic experiences, events and individuals are unrecognisable. 

Keeping up with our clients: a response to the new ethical guidelines

‘My foremost aim is to promote the client’s wellbeing and protect them from harm. For me, these are the guiding principles of my work and for my clients that is good-enough’

When was the last time you read the BACP Ethical Framework? In my experience, formal documents such as these are read on a need-to-know basis: something goes wrong, or has the potential to go wrong, and we turn to an official lodestone for succour. But the Ethical Framework also has a role in our learning and development within the wider social and political context. It helps ensure that things go less wrong in the future.

The section ‘Our commitment to clients’ in the new Ethical Framework for the Counselling Professions serves as a reminder that our overarching aim is to do good, not harm, and there are some interesting amendments here. Previously, the Ethical Framework was couched in terms of ‘alleviating personal distress and suffering’; now we are committed to alleviating the ‘symptoms of ’ personal distress and suffering. I facilitated a training day about mental health and asked participants to respond to the statement, ‘I see it as my role to cure my client’s symptoms’. The unanimous consensus among the 40 BACP-registered counsellors was discomfort with the words ‘cure’ and ‘symptoms’, both of which were initially perceived as pathologising. But as I encouraged further consideration of the statement in small groups, I witnessed a gradual shift in perspective. Most counsellors remained uncomfortable with ‘cure’, which developed into something more like ‘alleviate’. As their explorations continued, I observed less abstract thinking and more reflection on tangible clinical experience.

One counsellor spoke about a client he’d been working with for many months who had presented for counselling
with chronic anxiety and social phobia. The counsellor admitted an initial urge to make things better for his client –
a desire to ‘cure’ him. With the support of the group, he was able to reflect on 
the work, which up until now had felt hopeless, and reframe the counselling objectives. As a result, he would return to the counselling room with an increased robustness that would feel enabling for his client. The exercise had achieved its aim of bringing alive our commitment to alleviate the symptoms of distress and suffering in an authentic and meaningful way. If time had allowed, it would have been pertinent to replicate this application for each of the commitments outlined in the new Ethical Framework. This would be valuable CPD.

The new framework states that well-founded ethical decisions should be strongly supported by one or more of six ethical principles: trustworthy, autonomous, beneficent, non-maleficent, just and self-respecting. In my experience, the most difficult dilemmas arise when there is an impasse between two or more of these principles. A common example from work with young people are requests for information. Parents and guardians are commonly asked to provide blanket consent for professionals to share information about their children’s development, education, health and social care. What this means is that an adult with parental responsibility may have consented to this information being shared some considerable time ago, long before the current involvement, and/or may have given consent even though the child did not agree to it. Ethically, medical professionals, including counsellors and psychotherapists, should also seek consent from the young person themselves, according to the law of Gillick competence,1 so valuing and respecting their right to be autonomous and self-governing.

A difficult ethical dilemma can also arise when consent has been given yet the counsellor believes that to share information would be detrimental to the client’s wellbeing. When ethical dilemmas such as these arise, as they so often do, my foremost aim is to promote the client’s wellbeing and protect them from harm. For me, these are the guiding principles of my work and for my clients that is good enough.

Where the previous Ethical Framework contained 10 personal moral qualities to which we were ‘strongly encouraged to aspire’, now there are 11. Some of the old ones have been cut and others have been added (care, diligence and identity). I think they are all worth considering, both individually and in supervision. They provide a solid framework for the consideration of clinical issues.

For example, I have supported supervisees in considering how they can remain resilient in their practice without diminishing their own needs, how they can deal with colleagues honestly and how they can manage their fears and uncertainties in a profession where there is very little that is certain.

The ‘Good practice’ section of the new Ethical Framework has had a major overhaul and is clearer, more comprehensive and promotes greater inclusivity. We are no longer being instructed in what practitioners should do; instead the statements read like a pledge: ‘We will work with our clients... We will do all that we reasonably can... We will collaborate with colleagues.’ This engenders a sense of ownership that should promote useful self-reflection.    

There were a couple of statements that stood out for me as particularly pertinent to my work with young people. For example: ‘We will... recognise when our knowledge of key aspects of our client’s background, identity or lifestyle is inadequate and take steps to inform ourselves from other sources where available and appropriate...’ (22f ). I am forever being reminded of my inadequate knowledge about social media, gaming, popular music, sexual practices and its accompanying terminology, and I domy best to educate and inform myself. My Google search history makes fascinating reading. I continue to despair at colleagues’ beliefs in the inherent dangers of ‘new’ apps such as Facebook and Snapchat: Snapchat has been around for five years and Facebook for 12. We have to accept they are here to stay and that we need to know about them.

Another area where I have had a lot
to learn is in relation to physical illness. I have no formal medical training but have developed a decent understanding about some conditions because I’ve worked with clients who have had these diagnoses, and I needed to understand them. Similarly, I know about the effects and side effects of common drugs such as Risperidone, Sertraline, Quetiapine and Aripiprazole. And I can pronounce them. Being informed of the facts doesn’t replace getting to know what the condition feels like for the individual; that’s always a very idiosyncratic, personal thing that can be explored
in therapy. But it does provide a shared language that helps us to connect.

My guess is that many people will interpret this clause of the ‘Good practice’ guidelines in a different way, perhaps focusing instead on culture, religion or sexuality. I recently attended a meeting of counselling practitioners where we discussed a young person who identified as transgender and pansexual. Most of my colleagues were unfamiliar with the terms. Some perceived them as ‘fads’. There was a conversation about gender identity and bisexuality being ‘all the rage’. I applaud the inclusion in the new Ethical Framework of the statement ‘We will... inform ourselves’. My fear is that those colleagues with the most to learn do not know what they do not know. I suppose it’s our collective responsibility to gently nudge them.

Another clause that stands out for me is: ‘We will ensure that... reasonable care is taken to separate and maintain a distinction between our personal and professional presence on social media’ (33c). In my experience, the worst offenders fall into one of two camps: they either use social media indiscriminately, blurring the boundaries between personal and professional, or they shy away from it completely. I was commended recently on my ‘media presence’ by a counselling training provider who had accessed my services via my professional website and who follows me on Twitter. She spoke about the widespread reluctance among counselling and psychotherapy professionals to make use of social media and her consequent difficulty in making contact with any of us. I’m aware of this reluctance. At a training I attended, one prominent facilitator proudly announced that he has no internet presence whatsoever! How does he get work? I use Twitter to share pertinent reflections and links to my published work and newsworthy items from the world of counselling and psychotherapy. I follow professional organisations such as BACP, as well as psychotherapists I hold in high esteem. It’s a way of keeping in contact, maintaining my professional profile and keeping my knowledge up to date. This is another of the professional standards outlined in the ‘Good practice’ section.

My website includes details about my qualifications, experience and private practice. I’ve outlined my therapeutic model and included a contract and referral form – all in line with the BACP Ethical Framework. Rather than merely telling potential clients that I abide by the Association’s professional standards, I use my website to demonstrate how I do this. And I share nothing there or on Twitter that I wouldn’t share in the therapy room. The social media forums I access for personal use are separate and I’ve learnt to check the privacy settings regularly to maintain this. If clients request to ‘friend’ me on Facebook, I remind them about the therapeutic boundaries and that they exist to protect us all, and that this applies to the virtual world as well.

If you haven’t already read the new Ethical Framework, then you should do so now. I also urge you to have a notebook and pen to hand. Better still, review and discuss it with your supervisor
or a colleague. Don’t look at it as a dry, directive document. Instead, transform each clause into a question and reflect on how it applies to you and your clinical work. Really engage and be honest about your practice. Think about the times when something went wrong, or could have gone wrong, and use the framework to help you to consider how you would respond differently if a similar dilemma arose in your work tomorrow.

The new Ethical Framework won’t tell you what to do or remove your clinical responsibility, but it will provide you with a robust scaffolding to support your decision-making, as any good framework should.

1. Gillick v West Norfolk and Wisbech Area Health Authority [1985] (1985) 3 All ER 402 (HL). 

first published in BACP Therapy Today,  July 2016

 First dates ...

Ten years ago I arranged to meet a woman I didn’t know in an unfamiliar part of town. A mutual friend set us up and thought we’d get along. I remember the trepidation as I decided what to wear for our first meeting and the nervous anticipation as I rang her doorbell.  During the hour we spent together I gradually relaxed. The conversation flowed and she seemed interested in getting to know me. She encouraged me to open up in a way that nobody before her had. She was older than me, witty, attractive and dressed in a similar style to my own. We were a good match and our relationship thrived for five years. Did we fall in love? Perhaps a little.

Choosing a therapist can be like choosing a lover and a first session is much like a first date. The introduction might be arranged by a well-meaning friend or the date self-selected from the Internet using whatever criteria seems important at the time. It’s a risk. It’s anxiety provoking. And it can be ever so slightly exciting.

I remember Stanley, an outwardly confident eighteen-year-old full of swagger. He announced his arrival at our first session by hammering so loudly on the door I thought he might punch a hole through it. Once inside, he relaxed onto the couch not waiting to be invited and started chatting almost immediately. Stanley talked about his college course, family, aggression, scrapes with the authorities and the hour flashed by. Stanley shook my hand enthusiastically and swaggered off. I’d found him intriguing and looked forward to us working together. The following week I waited for Stanley and as the minutes ticked by the realization struck me that he wasn’t coming. I tried unsuccessfully to contact him, leaving messages saying I was thinking about him and wondering if he was coming back. He didn’t reply. On reflection, that first session with Stanley had been the therapeutic equivalent of a one-night stand.  He’d charmed me with his stories and faux intimacy but it had all been bluster and our relationship had no future. He wasn’t ready to commit.

Samantha was in her mid-teens and, like Stanley, engaged enthusiastically in our first session. She had many questions; about what therapy is for, how long I’d been a therapist and what I enjoy about my job. Her questions didn’t feel intimidating they felt fair enough, and I was delighted she had the confidence to be so openly curious. 

The following session Samantha arrived a few minutes late and with much less gusto. She responded monosyllabically to my wonderings about her week and after about seven minutes she fell asleep, a state she occupied for the remainder of the session.  our first meeting Samantha hadn’t told me anything about herself at all. Instead she’d employed a sophisticated form of defense disguised as engagement. Her catatonic state was less subtle and her communication loud and clear. Samantha was testing out levels of intimacy and control that would feel comfortable enough and I needed to respect these if we were going to have a meaningful therapeutic relationship; which we did, for about a year. sessions, like first dates, contain a wealth of information about how the relationship is likely to pan out, contained in our feeling response to the other person in the room. It’s mostly a gut instinct that experienced therapists (and serial daters) learn to trust. 

Lexi telephoned me prior to our first appointment. She’d read the therapeutic contract on my website and wanted to ‘get a few things straight’. The telephone call left me exhausted and dreading our initial meeting. Lexi was a compact, buttoned-up woman who was always prompt and didn’t take a breath as she recounted her life of woe. She told me she had been let down by countless ‘people like you’ and had low expectations. I remember thinking – ‘I’ll show you; let therapeutic battle commence!’ but what I was feeling, despite the formidable, highly defended woman in the room, was that I really wanted to help her to have a happier and more fulfilling life. And against the odds I did. Lexi and I worked together for a year and she never missed a session. Ours was an intense relationship full of passion and hate but we survived it together and eventually love thrived. When we finally parted, Lexi thanked me for bearing her and I thanked her for allowing me to. It’s always a privilege to be chosen. 

Published in BACP Therapy Today,  July 2015 

 Why dads matter...

We live in a patriarchal society. Yet it remains a sad irony that many young people will not be sending a father’s day card this month because they have no dad they know about to send one too. They might have a father figure in the form of a step-parent or family friend, while a male teacher or counsellor can provide an adequate male role model too. But there is a fundamental difference between a father figure and a dad proper that goes beyond the biological.

I ran a Thinking and Feeling group for 8/9 year olds. Jack was angry because his mum had a new boyfriend and he was angry because he didn’t have a dad. Lenny told the group he was sad because he didn’t see his real dad anymore. Skye said, matter-of-factly, ‘oh I know what that’s like; my dad isn’t my real dad either’. I encouraged the group to consider what a real dad is. Millie knows her dad is her real dad because he’s in photos she has of herself as a baby. Lenka has been DNA tested to prove whether her dad is her real dad and whether her mum is her real mum. The children’s naivety, in an absence of accurate explanation, had left them feeling confused. So we struggled on, trying to make sense of their nonsensical, father-less worlds.

One of the things about dads is that they anchor us and give us a sense of belonging. Even for younger children who are unacquainted with the biology of paternity, there is a recognizable, yet nameless feeling associated with having a dad that is ‘real’ that makes us feel real too.

Nell, a woman in her forties, reflected with me on a father-less childhood and a lifetime of not-knowing. She was three when her parents separated and Nell’s father was described by her mother as a wannabee, a dreamer and a weak man who remained living with his mother into adulthood rather than living in the real world. The real world involved being Nell’s dad and he’d opted out.  

Nell remembered her mother’s words so precisely because they were all that she had of her father. She’d never seen a photograph of him and her memories were depleted. Nell grew up believing she wasn’t good-enough, a certainty instilled in her by her mother’s story. 

As a consequence, she worked hard and excelled in academia and in her career.  despite her successes, she had never felt like she fitted in and had an enduring sense of not being good-enough. She struggled to get along with female bosses – replicating early maternal rivalry, and felt let down by male ones, mirroring the father who disappointed her. She opted eventually to work freelance, taking care of herself as she had learned to do from a young age. Unsurprisingly, Nell had a history of failed relationships. She chose good-enough men, who she left when they fell in love with her, so as to deny them the opportunity of repeating her father’s abandonment. Nell told me ‘I just don’t know who I am’. 

I think about the adults the children in my Thinking and Feeling group will become; perhaps adults like Nell with a fragmented sense of self, endlessly striving for perfection in an imperfect world. Fathers offer an alternative perspective to mothers, as well as support and equilibrium. Children without a dad have a sense of something missing and are likely to internalize that sense so that they feel inadequate too. They blame themselves (or are blamed) for their father’s absence and go on searching for what isn’t there, never really knowing what it is they are hoping to find. Knowing about our real dad helps us to recognize and consolidate our real self. We are a part of them and they are a part of us; biologically, emotionally and psychologically. That’s why dads matter.

Published in BACP Therapy Today,  June 2015 

I’m judged therefore I am...  

recently facilitated a workshop for trainee counsellors and, despite years of experience, suffered the familiar pangs of performance anxiety: am I interesting/ knowledgeable/entertaining enough? Have I pitched it right? Should I have worn lipstick? I gradually got into my groove and enjoyed a stimulating day; my superego was tougher than my audience, but I have no doubt that they judged me; they always do. 

At the start of the day we negotiated our group boundaries and the first suggestion was that we strive to be ‘non-judgmental’. I challenged the group to contemplate the term we bandy about so freely, and I challenge you to do the same. What are we asking of each other and of ourselves, and is it even possible? I think the answer is no. It’s in our nature to judge; evolutionary theory supports this, our survival depends on it and anyone who suggests otherwise is misguided. You’re judging me now. You may even go to the bother of sharing your judgments. The positive and polite judgments will go to Therapy Today; the others seem to come directly to me. It appears that critics feel shamed into anonymity. 

The theme of judgment recurs repeatedly in therapeutic practice. Parents feel judged on their capacity as parents, work/life balance and social status. Children sense judgment on their popularity and appearance. Adolescents perceive judgment on everything. To rehash a familiar flippant phrase, just because you’re feeling judged, it doesn’t mean people aren’t judging you. The fact is, they probably are. 

 I perceive clinical judgment-making to be an important therapeutic responsibility. I’m carefully attuned to the depressed mother so that I can make judgments about her ability to care for her children. When she accuses me of judging her an unfit parent, I tell her truthfully that I’m wondering if she can be a good-enough mother at a time when her struggles are so overwhelming. 

Much of my work is with adolescents, many of whom feel judged about their lifestyle choices and coping mechanisms. I do my best to comprehend their internal struggles. They tell me that taking drugs or alcohol or cutting their skin helps to keep them alive. 

They tell me that taking drugs or alcohol or cutting their skin helps to keep them alive. I don’t judge their choices but I do make judgments about their capacity to keep themselves safe and I say so.  

Working with children who have been neglected or abused, I’m often asked to share my clinical judgments in meetings and court hearings where decisions are made about their welfare. I share my judgments honestly and always with the families involved before anyone else. Do these families feel judged? Of course they do, but I assure them that my role is to help to make sense of their situation and communicate their needs so that they may access the support they deserve. 

Every therapeutic encounter invites multiple hypotheses about a client’s state of mind, safety and physical needs. Therapists are trained to be analytical and what is analysis if not a type of judgment? Not discriminatory or disparaging judgment, but considered, exploratory judgment couched in theory and clinical experience. 

It’s time to rethink judgment and overturn its bad rep’. To be judged is to be noticed. As a writer, I sit tapping at a keyboard, not knowing how or even if my constructions will be received. When judgment arrives in the form of a letter or comment I know that someone else has had a reaction to something that I did. I’m judged therefore I am! 

So let’s harbour this notion. Let’s not fool our clients or ourselves into believing that we are non-judgmental. Instead let’s share our judgments honestly and without shame. I judge you because I have noticed you and had a feeling response to you. I judge you because I care. 

Published in BACP Therapy Today,  May 2015 

Behind the shades of grey

I read book one of that trilogy when it was first published and shared my thoughts in a column in the December 2012 issue of BACP Children & Young People. At the time the general consensus was that the books were a ‘good thing’ because they revived sexual experimentation and this was seen as liberating for women in particular. I didn’t read anything that questioned the protagonists’ relationship, which I had perceived as dysfunctional and abusive.

Since the film’s release there have been varying reviews, including psychosexual psychotherapist Julie Sale’s critique in this journal last month, and so I’m taking the opportunity to revisit, and perhaps refine, the reflections I made previously.

Fifty Shades of Grey went on general release on Valentine’s Day and is being flaunted as a romantic love story with beautiful actors having lots of erotic sex. Everyone remotely attached to the film has been interviewed and photographed looking sassy and gorgeous. Author ELJ has transformed her image from frumpy, middle-aged mum – ‘Look, I’m just like you!’ – to vampish sex kitten – ‘Hey, you can be just like me!’ All this has made me feel rather queasy. But my overwhelming emotion has been indignation at the widespread ignorance about themes touted in Fifty Shades – the books and the film.

The lead actor, Jamie Dornan, got his break in the television drama The Fall, where he played an athletic, sexy, charismatic professional, a counsellor actually, with a disturbing second life. So far, so Fifty Shades. His character was a predator who hunted beautiful young women before tying them up for his own sexual gratification. Again, very Fifty Shades. The Fall challenged the viewer’s perceptions and caused us to ask, ‘How can I be attracted to this man who I know to be depraved?’ But when the character murdered the women he stalked, our desire turned to repulsion. I find Dornan’s casting as Grey quite chilling.

For those who still don’t know, Christian Grey is a handsome, charismatic billionaire who is partial to BDSM-style sex. He is a dominator, in and out of bed, who seduces virgin Ana with luxurious dates and expensive gifts. 

He is a dominator, in and out of bed, who seduces virgin Ana with luxurious dates and expensive gifts.  virgin Ana with luxurious dates and expensive gifts. Ana takes up the role of sexual submissive and relinquishes control of her life. Christian decides what she wears, who she sees and where she goes. We learn that Christian’s sadistic desire is the result of childhood abuse – an ominous plot line.

I recognise the narrative from my work with victims of domestic abuse who tell me their partners want to have them to themselves. They are told to dress attractively to please him and are rarely allowed to see their friends. He earns and controls the money. Some women tell me it’s romantic and chivalrous. I recognise too the justifications: ‘It’s not his fault, he had a terrible upbringing’ and ‘He does it because he loves me’ – a displaced responsibility that saddens me.

Arguing that a relationship like Ana and Christian’s is consensual is akin to saying that women who remain in abusive relationships and are beaten or those who dress provocatively and are raped are ‘asking for it’. They are not; the culpability always lies with the perpetrator. Fifty Shades peddles a belief that women fantasise about being dominated by men. Some do, but there is a distinction between fantasy and reality, and it has become blurred. Fifty Shades has reached an adolescent audience, and so has the notion that women want to be physically and psychologically controlled by men. Jokes about domination, sexual abuse and rape have become mainstream. This film legitimises abuse. The sex is just a smokescreen. Take it away and you’re left with manipulation, misuse of power, violence and exploitation.

Not old-fashioned romance but old-fashioned abuse.

Published in BACP Therapy Today, April 2015 

It’s time to speak up for the sake of our clients

            When the weather is inclement and the evenings short I find myself more aware than usual of what’s in the news. As I write this we are approaching the awards season (I will have been overtaken by events by the time you read this, I know) and there’s an air of anticipation surrounding the nominations for the Oscars, Grammys, Globes, Baftas and Brits, all weeks before the actual awards ceremonies take place, when there’ll be another consignment of frenzy. The entertainment industry likes to honour its heroes. Among the show biz glitz, healthcare industries have been a regular focus of our news too. But they’re not being awarded, rewarded or regaled: quite the opposite in fact. 

             Images of failing services are beamed into our homes, with accompanying narratives about scandal, abuse and exploitation. The names we recognise belong to those who have failed the most vulnerable members of our society. We hear nothing about the successes. Hospitals and GP surgeries deemed inadequate by the Care Quality Commission (CQC) have been named and publicly shamed, while those graded good or above remain anonymous. Waiting times are up, patients are treated in corridors, staff are overworked and underpaid, blah, blah, blah. The names of the worst ‘offenders’ are touted. This is the antithesis of what happens in the entertainment industry, where achievement is publicly applauded and ineptitude ignored. 

             I spoke recently to a senior practitioner in occupational health for a large NHS trust. He told me the department is inundated with referrals for mental health clinicians who are on the verge of collapse. They have become a kind of ‘squeezed middle’: pressured by management to treat more patients in less time while quantifying every move on electronic databases that aren’t fit for purpose; pressured too by patients who demand and deserve to be treated according to their needs. 

             

I heard that stress, anxiety and depression have seeped into the system so that mental health clinicians are now just as likely as their patients to receive such diagnoses. I also heard about the upsurge in referrals relating to bullying. We hypothesised that the NHS has become a (top) dog eat (under) dog world, with the bullies marking their territory at the top of the tree by nonchalantly pissing on those below them. It seems that individuals with an unconscious desire for power and control are the very people most likely to rise to the top in organisations set up to support the needs of the vulnerable, exploited and abused, so that the system itself becomes abusive. Professionals on the ground feel neglected by supervisors and abandoned by managers who are preoccupied with the business of accounts rather than accounting for the quality of their team’s work. In organisations where numbers matter more than people, clinical safety feels dreadfully precarious. 

            The majority of clinicians who work in the healthcare sector do so because we are passionate about implementing positive change for those entrusted to our care. Could this be the reason that professionals in these industries have so far put up and shut up? But perhaps the wind is changing. We’ve heard in the news that NHS organisations are to be required to appoint guardians to protect whistleblowers from the fallout of speaking up about bullying and clinical safety issues. So I wonder how long it will be before someone, somewhere blows the whistle loud enough for a media kingpin to hear. Lips are pursed, but many remain too depressed to blow. 

Published in BACP Therapy Today, March 2015 

The games people play

Did you hear the one about the MP caught playing Candy Crush during a Commons committee meeting? He said he’d try not to do it again. For those that don’t know, Candy Crush is an apparently addictive game accessible via mobile app. Players match rows of brightly coloured sweets accompanied by tinkley music. It resembles something designed for a three year old but the typical player is aged 25 – 45. The best selling games of 2014 were FIFA 15 (Xbox 360 rated age 3+), Grand Theft Auto V (PS4 rated 18+) and Minecraft (Xbox 360 rated 7+). Time was that families would sit together and play a board game. Old fashioned perhaps; but Monopoly, in its various guises, remains the best selling game of all time.

As ever, cultural trends, fantasies and fears are reflected in my practice. Among my therapeutic resources I have a selection of twenty or so board games. Some have survived from my own childhood while others were sourced from charity shops. When I first set up in private practice I had a few games ‘just in case’ and soon discovered their popularity among clients of all ages. I also realised their therapeutic worth and so my collection grew. 


I recently completed a period of therapy with a girl of 11, an only child who presented as precocious and pseudo-adult. Evie’s parents had strong moral and religious values and placed high emphasis on educational success. Evie was unquestioningly bright but I had a sense of a lost childhood. During our first session, she noticed the games inside a glass-fronted cabinet and told me proudly that she was a ‘Scrabble champion’. Surprisingly then, she opted to play Snakes and Ladders for the duration of her six week therapy. This game is more about luck than skill and can be incredibly tedious. As Evie wriggled about excitedly (like a snake) I commented on her enjoyment of playing, and about the going-ups and going-downs of the game. Evie learned that my observations about the game also signified recognition of her own internal ups and downs.  

 Ethan, a boy of 13 struggled to read or write. He’d been terribly neglected and I suspected he’d been abused. He couldn’t make eye-contact or express himself verbally and didn’t like to draw. Ethan selected Junior Monopoly, a game based on the original and designed around a fair with fairground ride assets and ticket booth properties. We played it every session for the duration of Ethan’s therapy. The game has low stakes. You earn £2 pocket money for passing GO and pay to ride the attractions. We spent eight weeks playing together in/on fair ground while reflecting unconsciously on the unfairness of Ethan’s external world.         

Tom was a sullen 18 year old on the brink of exclusion from college and caught up in gang culture, drug use and theft. He noticed my ancient Solitaire and wanted to know what it was. We dipped in and out of playing the game designed to be played alone, together, taking turns under Tom’s instruction to jump over marbles with other marbles, working collaboratively to accomplish a mutual goal.   

 

The sessions with Evie, Ethan and Tom were often monotonous and I wondered about the value, in monetary as well as therapeutic terms, of what we were doing. But each of them displayed progress in their capacity for reflection and expressed emotion, inside the therapy room and externally. Parents reported calmness where there had been chaos, calamity was replaced with creativity, isolation with connectedness. In short, the therapeutic process had been effective. The games we played together provided consistency, stability and containment and there just isn’t an app for that.


Published in BACP Therapy Today, February 2015. 

So this is Christmas


It’s Chriiistmaaas. Actually, it’s early November but I’ve already heard Noddy Holder’s screeching pronouncement half a dozen times and by the time this goes to print he’ll be laughing all the way to the bank for the 41st consecutive year. Many readers will have decked their halls, stairs and sitting rooms to a festive soundtrack, while others will have opted out depending on the meaning of Christmas where you are. I won’t assume I know what that is, how could I.

 

When people talk about the true meaning of Christmas we assume they’re referring to Christianity in varying degrees. The nativity is re-enacted in schools across the land where girls as young as three compete for the chance to play Mary. What they understand about the virgin birth and the doll in the feeding trough is contestable but their sing-songing to you and your king (sic) about morning being night (sic) suggests significant confusion. In reality, the true meaning of Christmas is far from cheerful for many families as evidenced by the Office for National Statistics*. There are 20% more deaths in December than any other month, commonly caused by road traffic accidents, fires, falls and poisoning. Women are 12% more likely to be murdered in December while for men the probability increases by 5%. Figures for matricide and infanticide rise by 25% in the two week period between Christmas Eve and Twelfth Night, while there are 33% more incidents of domestic abuse on 25th December alone than on any other day of the year. We know that alcohol is a significant risk factor and consumption is almost double in December (+41%) than in any other month.  These figures make for grim reading but they also illustrate what I already know from my therapeutic practice; everybody’s not having fun.

 

One young man found his way to therapy in early December suffering from a severe bout of depression. He lost his mother when he was 15. She was killed on Christmas day by her partner who was found guilty of murder. My client’s family encouraged him to focus on his studies and he’d achieved significant academic success. But he described an emptiness that these accomplishments failed to fill as well as a series of unsatisfying relationships with older women at university.

 

  


 

My client was tormented by all-things-Christmas and the extended festive period at home was experienced by him as a living hell. I hoped that my metaphorical ‘holding’ would convey something of my understanding of his desire to be mothered.    


An adolescent attended a short period of psychotherapy. She said nothing and barely moved. Often she allowed her head to drop forwards as if detached from her body. She slept deeply for most of the session most weeks. Being in her presence felt bleak and disturbing and I experienced the silent sessions as a deadly part of my week. I knew from the referral that the girl’s father had hung himself on New Year’s Day. My client gave me a sense of what it must have felt like to discover her father’s lifeless corpse and to bear a physical memory of that experience in her own body. I work therapeutically with young people in residential care and for most of them Christmas is a cruel reminder of everything they have lost. It’s a time for family; but they are alienated. A time for presents; but they receive a generic token. A time for extravagance; but they reside in underfunded institutions. A time for parties; but they receive few invites.  The tendency for these children to act-out at Christmas proliferates dramatically. Reprimands, restraints and runaways escalate as the young people demonstrate their desire to be contained, nurtured and loved ‘the same as everyone else’ – a meagre wish I hear often. 

 

So I urge you to be mindful of the true meaning of Christmas for each of your clients as you say goodbye for the holidays. Before the festive greetings fall unbidden from your lips take a moment to consider what the next two weeks might be like for them. Yes it’s Christmas, but I’m certain everybody’s not having fun.


Published in BACP Therapy Today, December 2014


Personal disclosures

I've been interviewed three times this week. Enquiries were made, in varying degrees of interrogation, about my professional and personal experiences, my age, marital and parental status as well as whether or not I smoke or like Iggy Azalea. The impromptu interviews came about during therapy sessions and my adolescent interviewers were not easily gratified. Individual counsellors and psychotherapists have their own rules about personal disclosure which are informed by their modality and individual inclination. Very few, especially of those working with young people, occupy the traditionally psychoanalytic blank slate, and mercifully few share everything. So how do we inhabit a space that feels comfortable on the personal disclosure continuum? 

Working from my therapy room at home, clients often enquire about the rest of the house. These are simple enough questions which I answer willingly to illustrate the therapeutic boundaries. Some clients want to know why we can’t sit in the garden (obscured by an opaque window) on a sunny day, and I have to work harder to explain about physical and therapeutic containment. I hear about previous counsellors, real or fantasised, who invited clients to accompany them on dog walks, smoked with them and offered a lift home. I’m judged harshly against my unboundaried predecessors and accused of not caring, if I did I’d let the session run over when my client arrives late. I try to explain that the opposite is true; I care very much about my client and also about honesty, reliability and integrity.   

When I’m asked about my own life (or not) during a therapy session it always tells me something about my client. One young man was particularly interrogational. He’d grown up in the care system with a belief that decisions were made for and about him rather than with his consent. He’d witnessed domestic abuse as a child and been raped during adolescence. He’d suffered a lifetime of intrusion so obviously his questioning felt intrusive as he projected these experiences onto me. He told me it wasn’t fair that I wanted to know all about him while he knew nothing about me. I commented that his therapy was supposed to be about him but he wasn’t satisfied. In fact he was really un-fucking satisfied and I knew he wouldn’t come back after session one if I didn’t change tack. 


 So I attempted to negotiate. I said it made good sense for him to work out if he thought I could help him and in order to do that he needed to know about me. He visibly relaxed but held onto a healthy dose of scepticism, wanting to know why I was a psychotherapist dealing with other people’s shit. Could I deal with his shit was the implied anxiety but it was too soon for smart interpretation.

I've realised that what I'm willing to share is what’s on my CV, information that’s readily available via Google to anyone who can spell my name. Nowadays we call this public domain information and I'm comfortable with it being known. But to simply provide facts-and-figures type stuff to clients without facilitating exploration is to miss a trick. The questions are always more revealing than the answers.  I was asked during my training, fourteen years ago in case you’re asking, how I could be a child psychotherapist when I didn't have my own children. In response I wondered aloud if a male gynaecologist would be judged on his lack of a vagina. He wouldn't. It’s insulting and ignorant. Reproductive assemblages do not influence medical aptitude anymore than parental status influences therapeutic ability. The most important thing is a capacity to empathise, both with my client’s experiences and with their curiosity about mine. So I’m always willing to explore why it matters if my parents are alive, whether or not they abused me, or if I’ve ever taken MDMA. I don’t share anything that my clients couldn’t find out for themselves and that becomes more bearable as they learn to understand that I mean what I say; the sessions really are all about them.   

Published in BACP Therapy Today, November 2014



 

Thinking about dying 

I live in a small town close to a slightly larger town in a semi-rural part of the UK. Yet despite my whereabouts, I can’t travel far without passing an impromptu shrine apparently marking the site of a recent fatality, forcing personal loss into the public domain. I write this piece in the wake of the actor Robin Williams’ suicide with images bombarding our screens of floral tributes outside his Californian home, on the Hollywood Walk of Fame and at various film locations around the US. Meanwhile, social media is awash with homages to the ‘acting genius’ mostly from people who never met him.  There is no escaping Public Displays of Grief (capital letters merited) the most striking example of which followed the death of Princess Diana in 1997. Images of waist deep stacks of bouquets remain indelible in the minds of all who witnessed them. This seemed to set a precedent and signify a new cultural norm; but to what end?

Grief is a deeply personal emotional state, so the desire to demonstrate it publicly seems paradoxical. Perhaps the laying of floral tributes externalises, and therefore splits-off, those feelings of personal grief that are too painful to contain.  Maybe the shared mourning of a celebrity creates a socially acceptable outlet for the expression of individual loss, discouraged in our typically buttoned-up society.

We have heard much about Robin Williams’ struggle with depression which is in contrast with the more familiar face of the ‘comic legend’. Millions of people identify with this and with the urge to self-harm or to attempt suicide.  When someone takes their own life, opinion rages and those who do so are branded as brave and tormented or insensitive and selfish.  And all this in the context of another debate currently being contested in the public sphere; that of assisted dying. The associated moral, ethical and legal considerations are too vast for the constraints of this column, but they do highlight issues which cannot be avoided; issues about how we manage death, personally, publicly and in practice.   

 Benjamin Franklin wrote in 1789: ‘In this world nothing can be said to be certain, except death and taxes.’ Death is certain of course, but the where and when and how is rarely known about in advance. 

 

How could we live with certainties about our own demise despite knowing, cognitively, that we and our loved ones are mortal? Some of our patients have fewer unknowns; those who live with terminal illness, their own or their families’, and those who are contemplating assisted dying or suicide. This raises a further paradox in that although these issues are in the public domain, personal suffering too frequently remains hidden – few spoke about Robin Williams’ depression prior to it being cited as the cause of his death.

I have worked therapeutically with many patients for whom death is an ‘alive’ reality. Their ages and circumstances vary enormously but all are beset by physical and/or psychological pain, often accompanied by a heavy dose of shame. Talking helps. Having a space to verbalise fears, fantasies, what-ifs and if-onlys helps. Not being judged, persuaded, discouraged or emotionally blackmailed helps. Humour helps. Of course I have an urge to keep my patients alive physically, but the crux of my work is to facilitate psychological aliveness. I have witnessed transformation in the most fragile individuals as they gradually become more robust. I have rejoiced as, after numerous overdoses, a patient begins to make alternative, safer choices to manage their despair. I have reflected on life after death with children whose parents have completed suicide and who thought there was no alternative for them. I have explored treatment choices and decisions to terminate treatment with those who are terminally ill. I have helped manage the psychological ache of termination. One very ill young man summed up our work with a metaphor: ‘There’s a tonne of bricks hanging over me. You haven’t taken them away, but you’ve climbed under here with me and are helping me hold the weight. I’m ready now. I’m ready to go.’

Published in BACP Therapy Today, October 2014 

Seeds of hope and 

potential

This year, 6 June marks the 70th anniversary of the D-Day landings, the beginning of the end of World War II. While 4 August marks the centenary of the outbreak of WWI. Summer 2014 has a distinctly commemorative feel. Until a few years ago, my knowledge about WWI consisted of sketchy memories of war poetry I’d studied reluctantly at school. So it was with some ambivalence that I took the opportunity to visit the Somme area of France. During my stay I became immersed in history, desperate to improve my meagre understanding of the atrocities of WWI. I visited countless cemeteries and gazed with awe at immaculate row upon immaculate row of war graves. What I found most striking about the Somme was its vastness and its immense beauty. It is truly breathtaking how vile and bloody battlefields have been transformed into the serenely exquisite memorials that stand in their place today. The experience of bearing witness to this was the epitome of poignancy.

And of course there are poppies.

Papaver rhoeas (field poppy) has an innate capacity for survival. Every flower head contains over 1000 seeds, each with the potential to become a new plant. Those seeds, once dispersed, lie dormant in fields and craters until they are disturbed and exposed to light. Perhaps this is why the poppy has long, literary associations with sleep, oblivion and homoeroticism. One hundred years ago the Western Front was reduced to mud and trenches. But when fighting ceased, hidden seeds germinated creating miraculous swathes of red poppies. Their colour mimicked the bloodshed and the Royal British Legion adopted the poppy as its ubiquitous emblem.

There is much symbolism in the imagery of war that feels pertinent to my therapeutic work. Often when I meet families they tell me about the battles at home, the fighting, futility and hopelessness. They express despair and despondency. They describe separation and splitting without hope of reconciliation. I hear about verbal attacks and abuse as well as physical assault, rape and violence. Some clients describe the internal war raging within them, and the tireless fight against psychological demons that are an omnipresent enemy.  

It is human instinct to turn away, not to listen or want to learn about other people’s bitter experiences, just as some people turn away from images of conflict. But therapists in practice have a different instinct which encompasses a desire to hear our client’s stories and visualise their awful realities. We are curious and empathic. We can hear the unspeakable and we do ponder the unthinkable. And we are rewarded with the opportunity to facilitate change, to awaken the latent hope that we know must be hidden somewhere beneath the hopeless devastation that our clients share with us.

The poppy would make a fitting emblem for therapy, or rather for clients in therapy. Not because of its connotations of bloodshed and oblivion but for its extraordinary robustness and its potential to endure suffering, regenerate and survive even the most ferocious experiences. Within each of our clients there are minute seeds of hope and potential. There is also an innate instinct to survive, emotionally and psychologically as well as physically. When our clients come to us, the seeds of hope are often dormant and buried deep within. Our role is to unearth them (sometimes by shaking things up a little!) We shed light by illuminating our client’s realities; their strengths and difficulties, what can change and what is unchangeable. We fertilise their potential with care and attention. We bear witness as the seeds flourish and our clients emerge psychologically and emotionally more robust, ready to survive and shape the future.

So as we commemorate the two World Wars this summer, let us also be reminded, in the symbolism of the poppy, of our client’s battles and of the journeys we accompany them on through devastation, depression and dormancy to something alive and hopeful. This summer, and always, let us remember them all. 

Published in BACP Therapy Today, July 2014

Parents & online safety

My reputation for blaming gaming for the rise in ASD and ADHD is based on a distortion of my article ‘Where Lunatics Prosper’ (¹). I maintain that children living in an environment furnished with chaos and violence are likely to present as chaotic and violent or emotionally shut-off and socially isolated and I remain troubled by the popularity of 18+ games in under 18s. However, the rumpus surrounding my previous article focused on a misunderstanding of my thoughts. I explored off-screen chaos and violence too but it was my reference to the computer generated stuff that got people’s goat.  Those in the gaming camp felt illegitimately attacked, while the anti-gaming posse jumped on the overcrowded bandwagon pedalling the notion that the internet is the root of all evil. And that seems to be a theme; technology fuels the terrifying headlines while external reality remains worryingly unthought-about.  

 

Take Facebook, now in its 10th anniversary year. Conversations I’ve had with adults about it usually go one of two ways. Either (a) they prohibit access to under-13-year-olds because it’s illegal. Or (b) they prohibit access to over-13-year-olds because it’s unsafe. Both perspectives demonise technology and shut down thinking. There is a third position; the perilously uninformed one of turning a blind eye. Those who ban Facebook ignorantly assume that prohibition will alleviate the much-hyped problems associated with it. It won’t; children will just keep shtum.

 

I don’t understand why the 13+ age restriction is clung to so vehemently by adults who veto Facebook yet turn a blind eye to children as young as 5 playing 18+ games. Have you seen those games? They contain violence and sex, sometimes violent sex, all in graphic technicolour. They have a chat function too so while your child’s avatar is killing and having sex s/he can link up with ‘friends’ who are killing and having sex too. Their online friends might be of similar age or they might be over 18s playing perfectly legitimately. Is that comforting? The paradox is that the main reasons cited for prohibiting young people from accessing Facebook are fears about cyber-bullying and sexual grooming. Warning: these risks exist outside Facebook. And anyway, the 13+ age restriction has nothing to do with safeguarding and everything to do with US advertising laws in relation to minors. Surely everyone knows that? 

Consumer reports estimate that of Facebook’s 900 million+ users, 8 million are under-13 and 6 million are under-10(²). These figures are likely to be underestimated because many under-13s are too scared (or too savvy) to own up. I don’t think it will be long before Facebook lowers their age restriction and there is talk of linking children’s profiles to those of their parents. That’s an interesting proposal; making children’s online safety the responsibility of their parents and carers. I wonder if it will catch on.  

One boy I talked to was being bullied via Facebook. He finally told his dad who threatened to report him to the Police because he was only 11! Will this boy stop using Facebook? – Probably not. Will he confide in his father if he gets into a sticky situation online again? – Ditto. Meanwhile, a 12-year-old told me she’d used her mother’s login details to access Facebook and ‘see what people were up to’. She found sexually explicit messages between her mother and a family friend as well as photos of them semi-naked. It’s impossible to un-know something like that or to un-see those images. She knew she’d be in trouble if she admitted using Facebook but she did admit it to me during a therapy session and we were able to think it through together.

 

Lots of young people ‘bring’ Facebook to therapy, sometimes literally. In these examples, as in countless others, Facebook isn’t really the concern; it’s simply the vehicle of expression for real-life issues such as bullying, betrayal, secrecy and sexuality. Is this an appropriate use of therapy? Totally. Why? Because the client has asked for help to explore something that’s troubling them in a non-judgemental, safe, thoughtful and contained way and that’s exactly what I seek to do. 

 

1.       Where Lunatics Prosper, bacp Children & Young People, September 2011

2.      Consumer report figure quoted in BBC News Technology, 4 June 2012


  • Published in BACP Therapy Today, June 2014

 The human need for connection

We don’t get a second chance to make a first impression. This paradigm runs through my mind as I write my first column for Therapy Today. In practice, we learn a lot from first impressions of new clients. I arranged a first session with 15 year old Henry who’d been described by school and parents as un-teachable, unreachable and uncommunicative. Henry’s father ‘forgot’ to bring him and I sat in my therapy room thinking about Henry in his absence. When I did eventually meet him I was able to state honestly that I had held him in mind. He struggled, unsurprisingly, to comprehend this or to communicate his thoughts and feelings. Nevertheless, he attended ten therapy sessions where he experienced being in the presence of an attentive other and something shifted. He began spending time with his family instead of in his room. He invited a friend home for the first time in eight years and his academic performance improved dramatically. I was informed that therapy had done its magic!  I think the ‘magic’ encompassed what Winnicott termed ‘maternal preoccupation’¹ which can feel quite magical.  

Therapy fulfils a human need for connectedness. It does other things too but the relationship is fundamental and evidence supports this. By connectedness I mean actual, in-the-moment connectedness. It feels nice to be with someone who wants to be with you. When we are, we often face each other, attuned to each other’s facial expressions and micro-communications. We listen and we hear what is said and what is implied. We recall previous shared conversations and experiences. We laugh, we cry. We experience things together, at the same time and we hope we will do it again.

Well sometimes it’s like that. Sometimes I meet people and within moments their eyes glaze over as if they’re not really present, not connected with me at all. I perceive a twitching in their hyperactive fingers that aren’t used to staying still for so many seconds. Temptation gets the better of them and within minutes they are checking their phone to see if anyone has texted or tweeted or updated their status. ‘What about my status? ‘What about what I’m doing?  Right here, right now!’ I want to yell as I metaphorically wave my arms in their vacant faces. I don’t want to jump up and down to gain their attention; why should I? But I have a need to be attended to, to reassure myself that I am cared about. That’s what Henry and all our other clients need too. They need to feel attended to and connected and cared about.

I witness a miserable lack of connectedness happening to all kinds of people in all kinds of places. Doctors review patients by staring at computer screens, avoiding eye contact with the person in the room.

 Highly skilled and highly paid professionals idle away meetings tapping on phones secreted under their notebooks. Counselling sessions are interrupted by the all-too-familiar ‘ping’ that serves to inform client [or in some cases counsellor!] that someone, somewhere else, has just uploaded a picture of their dinner. People like Henry experience this too. It’s the antithesis of maternal preoccupation, the epitome of un-connectedness and it’s depressing.  

Therapy offers the possibility of a real, live person who is totally preoccupied with just you. Little wonder that some clients, adolescents in particular, find this baffling, especially if their earliest experience of being mothered was less than good-enough. It is the norm for most of my young clients to have hundreds of online ‘connections’ but the idea of being connected with someone whose primary concern is them for almost an hour can feel alien. But it can also feel exquisite. That sense of feeling connected, once they are attuned to it, can indeed be magical.

In my first column for CCYP two years ago I quoted from T.S. Eliot’s Little Gidding – ‘the end is where we start from’In this first column for Therapy Today I am again borrowing from literature. The opening of Ruth Ozeki’s novel A Tale for the Time Being contains the following: ‘A time being is someone who lives in time, and that means you, and me, and every one of us who is, or was, or ever will be’.  As therapists we are attuned to the here-and-now of our client sessions; the relationship in time between the two beings in the room and in the transference as well as the ‘ghosts’ of many other beings from our client’s internal and external worlds. But we must be mindful, particularly in first sessions, that our clients may not have experienced being attended to, as infants or adults, in the way that we attend to them. They may need time to adjust to this kind of connectedness. And when they do, it will feel magical.

 

  1. Winnicott, D. (1956) Primary Maternal Preoccupation, London, Hogarth
Published in BACP Therapy Today, May 2014

Where Lunatics 
Prosper

(First published in BACP Children & Young People 2011, republished in Therapy Today)


A growing number of young boys are being referred to CAMHS because they are unable to concentrate, failing academically and have no impulse control. Jeanine Connor argues that computer games are partly to blame for a marked increase in young male aggression and age-inappropriate sexual behaviour. 


The title of this piece is the tag-line from Grand Theft Auto (GTA) III (1), a console game marketed at young men aged eighteen and over. Regrettably, the appeal of this, and similar games, covers a much wider demographic and is the primary pursuit of many children as young as eight years old. One of the mainstays of this type of game is violence; injury and death is portrayed in graphic detail as dying bodies hurl through the air and bullets cut through flesh, splattering blood across the screen. The character in Call of Duty (2), for example, opens fire in a busy airport killing innocent bystanders in order to progress to the next level. I was informed of this by a boy of eleven who, reflecting on his hobby in a therapy session, told me; ‘I don’t know what I would do if I was ever in a real airport with a gun’. God forbid, I thought. The latest blockbuster in the Call of Duty series is Black Ops (3) which sold more than 7 million copies within 24 hours of going on sale. In this game, the marketing hype informs us, players are able to ‘turn down the blood and turn off the profanity to suit their needs’. There can be no argument that the amount of blood and profanity a child ‘needs’ is zero, yet the prepubescent boys who spend their free time playing these games seem most unlikely to censor them.  Equally as concerning is the sexual content of many console games played regularly by young children. In GTA III the character acts out sexually explicit scenes. In GTA IV (4) he picks up prostitutes and selects from three levels of service; masturbation, fellatio, and full sexual intercourse. Many of the boys who access these games are still in junior school and spend several hours a day playing them in bedrooms, behind closed doors, often with their parent’s knowledge and consent. I wonder if these parents would be as consenting to their young sons watching pornographic films.    

 

A recent study of ten and eleven year olds conducted by Bristol University found that playing computer games for more than two hours a day increases the risk of mental health problems by 60% (5). This is a scary statistic but, like most statistics, it does not really mean very much to most people. My own observation is that players of [most] console games are rewarded for action, speed and progressing to higher levels by fair means or foul [legal ‘cheats’ are readily available online]. I hear from countless parents and teachers about their children’s inability to concentrate, about their uncontrollability and about their academic failings. I wonder aloud about the link between their computer habits and observable behaviour. I also hear about children who are described as violent to siblings and peers, who use sexually explicit language and who seem devoid of empathy. I speak to children about their interests and learn that they enjoy games in which they are vicariously rewarded for killing and that the role of female characters is merely to provide visual and sexual gratification. 

 

I hear the argument touted vociferously that there is no direct link between the playing of console games and violent behaviour, but my clinical experience highlights numerous risk factors. As with most experiences, context is paramount. Many of the children I work with have grown up in families where boundaries are, at best, permeable. Many have witnessed aggression and violence and have experienced trauma, neglect and abuse of all kinds. These children are twice as likely as those who are not deprived or disadvantaged to develop a formal mental illness. In order to escape their despicable realities, many of the children I meet in the consulting room have retreated into a fantasy world of console games. In doing so, they form identifications with fantasy characters who are fighters, killers and abusers, in order to defend against their own vulnerability. With a gun in their (virtual) hand and a (virtual) female companion to provide sexual gratification at the push of a button, these children can, at last, feel truly omnipotent.           

 

Child and Adolescent Mental Health Services (CAMHS) are receiving a growing number of referrals of violent and aggressive boys who are unable to concentrate, are failing academically and have no impulse control. In many cases, the referrer is seeking a diagnosis of and treatment for Attention Deficit Hyperactivity Disorder (ADHD). A similar, yet distinct, type of referral relates to children who are described as destructive, aggressive, and lacking in empathy, obsessional, hyper-vigilant and overly-sensitive. The referrer in these instances is often seeking a diagnosis of Autistic Spectrum Disorder (ASD).  In both types of referral, a mental health diagnosis is sought in order to explain the child’s behaviour and, in many cases, a drug to control it. And I can see why. These children present with the clinical symptoms learned by professionals by rote from diagnostic screening tools and manuals such as DSM-IV (6) or looked up on the Internet by baffled parents. I recognise and support the merits of thoughtful, accurate diagnosis and treatment, but to label a child in haste is tantamount to imposing one’s own version of reality onto an already identity-confused individual. To do so is, in effect, saying ‘I shall view you and define you in this particular way and completely ignore your own experience of who and what you are.’ (7). It is also worth noting that Fetal Alcohol Syndrome, a widely under-diagnosed condition, looks very much like ADHD and in some cases ASD. In my opinion, any mental health assessment is incomplete if we ignore the child’s family and environmental experiences. To do so may result in a neat diagnosis, but it is also likely to leave the child exposed to further risk and potentially irreversible damage. 

 

I am lucky, as are the children whom I assess, in that I work as part of a multi-disciplinary team of mental health professionals. During thorough assessment, we have noticed remarkable similarities in the family backgrounds and experiences of the children I have begun to think of as ADHD-like and ASD-like. The majority of ADHD-like children we meet, predominantly latency aged boys, have witnessed domestic abuse and been allowed to play age-inappropriate console games. The same is true in many of the ASD-like children referred to our service. This suggestion is not the result of subjective, self-serving research; it is a clinical observation which has presented over time from the ordinary case-load of referrals made to an ordinary CAMHS service. My guess is that similar observations are being made in clinics up and down the UK.  

 

What follows is a clinical case study which is an amalgamation of dozens of children I have assessed for therapy. It is presented as an amalgamation for two reasons; to maintain the anonymity of the children detailed and because their stories are so similar. Darnell is a nine year old boy referred to CAMHS for a mental health assessment by his GP. The referral letter states that Darnell meets every one of the criteria for ADHD and is so extreme in his presentation that a diagnosis is inevitable. Darnell is described as hyperactive and inattentive. He is alleged to bully his peers, particularly girls, with sexualised language and aggression. He cannot be left unattended with his younger sister, Jess who is four. He is failing academically and has been suspended from school on numerous occasions and faces permanent exclusion if his behaviour cannot be tamed.

 

At assessment, we met with Darnell, his mother and Jess. Mum was heavily pregnant and showing signs of bruising to her face. We were told that Darnell is uncontrollable and that he refuses to do as he is told; telling his mother he hates her and that she should ‘fuck off’ and is ‘a slag’. He has said that he wants to kill her and also that he wants to die. Darnell’s mother confided that ‘he has always been like this’ and that even as a baby he was ‘difficult’, whereas Jess is, and was, much easier. Jess did indeed remain calm and unusually quiet throughout the two hour assessment. Darnell sneered and groaned. He broke some of the toys and devoured a packet of tissues by chewing them up and spitting them out. We learnt that Darnell was an unplanned baby. His mother was eighteen and had been in a relationship with John, Darnell’s father, for only a few months when she discovered she was pregnant. We wondered if John had been supportive and were told that ‘he did what he could’ but that they lived separately with their own parents for most of the pregnancy until they moved into Social Services funded accommodation prior to Darnell’s birth. His mother told us that John drank a lot ‘because of stress’ and would sometimes become aggressive. He once punched her in the stomach when she was pregnant and she gave birth with a black eye. She believed that John loved her and wanted their baby. Following Darnell’s birth, the violence ‘got really bad’. The relationship ended when John drove their car, under the influence of drink and drugs and with baby Darnell and his mother as passengers, under a truck. She thought they would all die. John went to prison for ‘driving under the influence’ but she thought it was important to maintain contact between Darnell and his father and so regularly took him for prison visits in his early years.  

 

Darnell’s mother began a relationship with John’s friend, Jason, who ‘was really supportive at first’ while John was in prison. But he raped her and she became pregnant with Jess, telling no-one the details of the conception. She has been in her current relationship with Jamie for eight months and he is the father of her unborn child. Jamie was described as ‘like a third child’ and Darnell’s mother admitted that they have heated arguments and sometimes ‘use each other as punch bags’ to ‘let off steam’. When I spoke to Darnell alone he told me that he hates Jamie because he is mean to his mum and he is lazy and won’t play football. Darnell has learnt that if he is naughty at school he gets to go home and that way he can make sure his mum is ok. Yesterday the Police came again because Jamie had hit his mum because he thinks the baby is not his. Darnell said he tried to be good because he is frightened he will be taken into care like his older brother, a child I had not been aware existed, but who I later learnt was in foster care due to emotional and physical neglect. I expressed my concern about Darnell’s situation, stating very clearly that it is not ok for grown-ups to hurt each other or to make children feel frightened. Darnell admitted that he sometimes feels sad, but ‘not frightened because I’m not gay!’ I asked Darnell what he likes to do when he isn’t at school and was given the inevitable response of ‘x-box’. Fearing the answer, I asked Darnell which games he likes to play. I noticed him become excited and animated for the first time during the assessment. He said he likes the GTA and COD games and had just got Black Ops for his ninth birthday. I commented on how lively his expressions had become and wondered aloud what it was that Darnell enjoyed about these games. He said simply, ‘sex and killing’.

 

‘Darnell’ is illustrative of countless young boys whose lives consist of real and virtual violence and who often present as ADHD-like. Their lives are messy, unsafe and without boundaries and so it should be no surprise that they present as chaotic, at risk and uncontrollable. These children ‘create havoc at home and school... as if they were spilling out all over the place’ (8). Children like Jess are also damaged by their experiences and remain at risk but, unlike Darnell, many of them go unnoticed. These children are compliant and expend their energy ensuring that there is no mess and no chaos as an antithesis to their messy and chaotic lives. They are often hyper-vigilant to noise and notice everything. As they get older they may switch off emotionally and end up in GP surgeries and CAMHS clinics presenting as ASD-like.      

        

Children are damaged beyond measure by exposure to violent and sexual imagery and language; be it in the home or on the screen. Adults who allow this to happen are guilty of social and emotional neglect, or what has recently been termed ‘urban neglect through technology’ (8). Psychodynamic literature emphasises the importance of infant-caregiver attachment, yet for many children, early ‘care’ is provided by a screen portraying sex and violence. For many children, this provides a mirror to their external lives so that fantasy and reality become inextricably tangled. In the absence of a suitable father role model, the process of identity formation for pre-pubescent and adolescent boys becomes enmeshed with on-screen characters who are an exaggerated version of themselves (9). These boys crave ‘raw, loud and angry... because they need it to be strong enough to match and master their [own] anxiety and anger (10).

 

However, society is, on the whole, turning a collective blind-eye. Instead, the media spotlight highlights the potential impact of provocative clothing for young girls which, it is argued, leads to their premature sexualisation. Yet the spotlight has merely flashed over their male counterparts who, while their female peers play dress-up, are simulating oral sex and bloody violence. If this trend continues, trials for murder, rape, paedophilia and domestic abuse are more likely to draw attention to female attire than male console game addiction. This feared future will indeed be a place ‘where lunatics prosper’ (1).   

 

References

1. Grand Theft Auto III (2001) Rockstar Games, New York 

2. Call of Duty (2003) Activision, California 

3. Black Ops (2010) Activision, California

4. Grand Theft Auto IV (2008) Rockstar Games, New York

5. Bristol University study conducted by Dr A. Page et. al (2010) 

6. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (2000) American Psychiatric Association

7. Mollon, P. (2001) Releasing the self: The healing legacy of Heinz Kohut, Whurr, London 

8. Jennings, S. (2011) Healthy attachments and neuro-dramatic-play, Jessica Kingsley Publishers, London  

9. Taransaud, D. (2011) You think I’m evil, Worth Publishing, London 

10. Jones, G. (2002) Killing monsters: Why children need fantasy, super-heroes and make-believe violence, Basic Books, New York