Association of Counsellors and Psychotherapists in North London (ACPNL)

23 10 2014

I’m really honoured to have been invited to be a guest speaker by the Association Of Counsellors and Psychotherapists in North London (ACPNL). I will be presenting there on Sunday December 14th, from 10am to 1pm, and you can find full details on their events calendar.

acpnl

The title of my presentation will be “Social Emotion Regulation: Bringing The ‘Other’ Into Therapy”, and a brief description is as follows:

“Often in therapy we focus on the internal struggles our clients face, exploring intrapsychic variables such as troubling narratives, conflicting beliefs, or self- defeating messages. We discuss our clients’ emotion regulation strategies, and give them the tools to develop new ones, such as meditation, mindfulness, exercise, awareness of automatic thought patterns, and so on. However, these are all relatively isolated activities, and the social circumstances of our clients’ lives are often left unexplored. In this workshop, Stefan Walters explores the importance of social emotional regulation, and how a sense of being part of a supportive and enriching social network is absolutely vital to good mental health. Stefan looks at the links between self-worth and other-worth, and discusses how we can bring the ‘other’ into therapy, to assist our clients with their issues.”

Tickets are £30 for non-members of the ACPNL, or £20 for members, and can be purchased on the website. I hope to see you there!





Guardian Interview about sex for the over 60s

25 08 2014

A while ago I did a short interview with The Guardian, to discuss sexual health and relationships for the over 60s. It was recently published on their website, and you can read it here.

older couple

Unexpectedly, the story seems to have been picked up by a number of other international sites as well, including this American news site and some blog posts. It’s nice to see the story spreading around, and hopefully this will encourage further healthy discussion around the topic.

I think sometimes there’s a stigma that you “can’t teach your grandmother to suck eggs”; that after a certain age we just get stuck in our ways and refuse to change. So the misconception follows that therapy is reserved for younger people; from teenagers facing problems in puberty, up to married couples in their 50s facing divorce.

But the truth is that it’s always good to talk; no matter what age you are. I see many elderly couples who find it transformative to discuss their relationships and sex lives in therapy, and it’s always rewarding to see the progress they make together. It’s never too late to make a change!





Aviva Insurance

25 07 2014

I’m pleased to announce that I recently became a recognised provider of psychological therapies by Aviva Insurance.

This means that I am now able to receive insurance payments for Aviva Health Insurance customers.

Please do contact me if you wish to schedule an appointment.

aviva

defaqto





Lost Highway

4 03 2012

I’ve been a fan of Lost Highway, by David Lynch for many years. I remember seeing it in the cinema when it first came out and being mesmerised by what I had just seen, although not fully understanding it.

Since then I have watched the film many more times, and last month’s David Lynch retrospective at the BFI recently inspired me to revisit it again.

I’d like to think that I have a pretty good grasp of what the film is about, now, and I get frustrated by all the reviews saying that it is ‘meaningless’ or ‘pure surrealism’, so I thought I’d share my interpretation here. Before I start, I should point out that you should not read ahead if you haven’t seen the film yet – I discuss the full plot of the film here, and my review contains many spoilers.

Right, now that’s out of the way…

In summary, I think it is a film about infidelity and unrequited love, and how they can lead to literal madness. I think it’s a wonderful study of mental anguish, and of dissociation, and personality disorders.

When watching the film, it’s also important to remember that David Lynch is primarily an artist, not a film-maker. He often mixes fantasy and reality, and uses a lot of surreal imagery in his films. Many of his films are wonderful studies of consciousness, dreams, identity, and mindfulness (in fact Lynch runs his own center for transcendental meditation), as well as the primary emotions, including desire, shame, fear, and anger.

Here’s my summary of Lost Highway:

Lost Highway film poster

[At the start of the film a buzzer goes off. A man answers it, and he hears a voice say “Dick Laurent is dead”. Then we hear police sirens in the distance, and the scene fades out.]

We meet our two main characters: Fred Madison and his wife, Renee. They live in a minimalistic, modern house in the Hollywood Hills. Fred is a professional musician and Renee (as we later discover) used to be an actress in the sex industry. Right from the outset, we see that there is a lot of tension in their relationship. They barely speak to each other, and most of the scenes are silent and awkward. One night Fred is preparing to go and play a gig, and Renee says that she’s not going to attend. Fred seems suspicious and asks what she’ll do instead, and the following dialogue occurs:

Renee: “You don’t mind that I’m not coming tonight?”
Fred: “What are you going to do?”
Renee: “Stay home, read.”
Fred: “Read? Read what, Renee?”
Renee laughs.
Fred: “It’s nice to know I can still make you laugh.”
Renee: “I like to laugh, Fred.”
Fred: “That’s why I married you.”

The tension is palpable, and the distrust between them is obvious. Fred is clearly suspicious of Renee. After he comes off stage, Fred calls the house, but nobody answers. We see the phones ringing throughout the house, but nobody is there to pick them up. When Fred gets home later that night, he finds Renee asleep in bed, and seems relieved; momentarily, at least.

It becomes clear that Fred suspects that Renee is cheating on him, and that this is literally driving him crazy. His fear of losing her is so great that it begins to cause him to ‘dissociate’; to split off different aspects of his identity as a means of coping with the trauma, as is common in cases of dissociative identity disorder (DID). During these dissociative episodes he imagines that he is ‘outside of himself’ and is completely unaware of his own actions; almost as if he has blacked out. It is only afterwards that he can remember what happened, by imagining that someone else had videotaped him during that time. Lynch brings these videotapes into the movie as if it they were real objects, but they are metaphorical, and they represent those dissociated parts of Fred’s consciousness; the parts that contain his deepest fears, and which are starting to enter into his daily life as he can no longer push them aside any more.

One night Fred and Renee have sex. It is a frenzied scene, and we see the conflicting emotions in Fred’s eyes as he orgasms, and the emptiness in Renee’s. Fred comes quickly, and as Renee attempts to reassure him, he recounts a dream where he couldn’t find her in the house – he says he saw someone that looked like her, lying in bed, but it wasn’t her. At that moment, the image of a spooky white face suddenly flashes across Renee’s face. This terrifying image represents Fred’s inner demon. The dream suggests that, for Fred, Renee is slowly beginning to represent his inner demon; the source of his deepest fear and rage.

The videotapes start to appear more and more regularly, as Fred is no longer able to prevent these dissociated parts of his consciousness from coming to the surface and entering his daily life. Renee is spooked by them, and they call the police.

Two detectives visit the house, and the following conversation occurs:

Detective: “Do you own a video camera?”
Renee: “Fred hates them.”
Fred: “I like to remember things my own way.”
Detective: “What do you mean by that?”
Fred: “How I remember them… Not necessarily the way they happened.”

This explains why videotapes are such a dangerous metaphor for Fred’s darkest thoughts (and video cameras will later appear as incredibly threatening objects); and why he is struggling so hard to create a coherent narrative for himself. He wants to construct a story that makes sense to him; but which may not necessarily be true.

In one scene we see Fred remembering the night he was on stage at a gig. We see him noticing Renee at the back of the room, and then he sees her leaving through the exit, with a sleazy looking man. He suspects that they might be having an affair.

A couple of scenes later, we see Fred and Renee at a showbiz party at someone else’s house. The camera pans back and suddenly we see the sleazy looking man from the club scene. We learn that his name is Andy, and that he is a ‘friend’ of Renee’s. Renee is drunk and very flirtatious with Andy. They are all over each other. Renee asks Fred to go and get them some drinks. This seems to be the snapping point, which pushes Fred over the edge. He cannot stand it any more. He goes to the bar, and drinks two drinks himself, and then suddenly his inner demon (the spooky white face we saw earlier) appears at the door; his nemesis. The demon approaches, and they talk. This is the first time Fred’s inner demon has ever entered into his waking life. The demon knowingly says “We’ve met before, haven’t we?” and when Fred asks where, he says “At your house” (in a sense, he is saying “I am inside you”). The demon proves his existence via a trick on Fred’s phone, and then leaves.

Fred is understandably distressed by this encounter, and asks Andy who the demon was. Andy says he is a “friend of Dick Laurent’”, which reminds Fred of the very first scene in the film. He looks confused, and the following dialogue takes place:

Fred: “But Dick Laurent is dead, isn’t he?”
Andy, looking angry and threatened: “He is? I didn’t think you knew Dick. How do you know he’s dead?” (The use of the name ‘Dick’ here, and the reminder that ‘Dick is dead’ may also be a reference to Fred’s sexual performance, and his shame from the other night).

Fred is confused and upset and angry, and pulls Renee away from the party. On the way home, he asks her how she met Andy. She says “We met at a place called Moke’s. We became friends. He told me about a job.”. When Fred asks what job it was, Renee simply says she can’t remember; but by this point it’s already too late. Fred is filled with jealousy and rage, and he is convinced that Renee is cheating on him. He can no longer dissociate, or keep it under control. As they approach the house, we see shadows moving indoors. Fred enters the house, and asks Renee to wait outside. He goes into the house and we see him moving amongst the shadows; starting to merge with his dissociative alter-ego.

Renee enters the house, and we later see her calling for him in the darkness. This is the last time we will see her. Later that night (as we will discover through footage from Fred’s ‘videotape memories’) Fred murders her in their bed.

Once out of his dissociative state, Fred has no memory of this afterwards; in fact when the police accuse him of being a murderer, he begs for them to “Tell me I didn’t kill her”. He is sentenced to jail, and execution in the electric chair. In his cell, Fred struggles to make sense of what has happened. He can’t sleep, and suffers from constant headaches. He has short glimpses of memory where he sees what he did to Renee, but still cannot resolve everything in his mind. He needs closure somehow; he needs another chance to make his relationship work, or to understand what went wrong. He has to figure out what happened, and why. He has to know who caused it, and he has to get revenge on those people that corrupted Renee and helped her cheat on him. There is only one way he can do this: by creating an ‘alternate reality’ for himself and entering into a fugue state.

So this is exactly what he does, and from here on everything we see is taking place within Fred’s consciousness, as he attempts to battle his inner demons and make sense of what has happened. Fred imagines himself to be a young man named Pete, and from this point on, we see the movie from this alter-ego’s perspective.

Pete is a young, attractive ladies’ man, who works as a mechanic, and dates a girl named Sheila. Pete ‘appears’ in Fred’s cell, and is set free; with detectives following his movements from a distance. Pete decides to go to work, and here we meet a terrifying character named ‘Mr Eddy’. ‘Mr Eddy’ takes Pete for a ride to fix his car, but whilst they’re out driving someone overtakes them, and ‘Mr Eddy’ rams his car off the road, beats him up, and threatens to kill him. Clearly, ‘Mr Eddy’ is not somebody you should mess with. As they get back to the workshop, the detectives spot them, and identify ‘Mr Eddy’ as Dick Laurent; the man we heard about earlier. Clearly, this man represents the corrupt, dangerous, nasty side of life.

Mr Eddy

The next day, ‘Mr Eddy’ returns with a different car, but this time there’s a woman in it: it’s Renee. Except she has blonde hair, and her name is now ‘Alice’. This is Fred’s way of bringing her back to life; to incorporate her into his fantasy world as some kind of identical twin.

Alice

Pete instantly falls in lust with her, and she seems to feels the same way. Time slows down, and they glance at each other as music plays. Later that night she returns, and asks Pete to accompany her to dinner. Pete hesitates, as he recognises the danger of getting involved with ‘Mr Eddy’s’ girl, but he cannot resist. They go to a motel and have sex. They swap numbers, and start a sexual relationship. They regularly meet in motels and sleep together, and seem to be developing feelings for each other.

Notably, as Pete starts to develop feelings for Alice, reminders of reality start to creep into the fantasy word Fred has constructed in his mind: Pete starts to have headaches, and to become confused about ‘what happened to him’, and there is an occasion where we hear Fred’s sax solo on the radio at the workshop, and Pete quickly has to change it.

One day, Alice tells Pete that they are in danger, and that ‘Mr Eddy’ knows about them. Pete asks what they should do, and she comes up with a plan. She says that she knows a man who “pays girls to party with him” and has a lot of cash. They could kill him and steal the money and run away together. Fred asks Alice how she met this man, and she explains that he works with ‘Mr Eddy’. She reluctantly confesses that she made adult films for them in the past, and explains that their very first meeting was “at a place called Moke’s”. Suddenly it becomes clear that she is talking about Andy. Finally, through Pete, Fred is able to understand the full story of what happened. Pete agrees to Alice’s plan; to kill Andy and run away with her.

But when Pete gets home that night, Sheila is there. She is distraught, and says she knows he is cheating on her. She urges Pete’s parents to tell him something, but they refuse. Finally, she bids him farewell, and says she will never see him again. It’s clear Pete’s time is running short and that his fantasy can’t last forever. Fred needs resolution.

Pete goes into the house and his parents pass him the phone. It’s ‘Mr Eddy’, and he is with Fred’s inner demon; working in cahoots. At this point, the demon still represents Fred’s nemesis, and the source of his darkest fears and deepest anger. Pete talks to the demon, and has the same conversation that Fred has with him at the party. Finally the demon tells him a story:

Demon: “In the East, the far East, when a person is sentenced to death, they’re sent to a place where they can’t escape, never knowing when an executioner may step up behind them and fire a bullet into the back of their head.”

This is of course a thinly-veiled threat against Fred; who already has been sentenced to death, but still awaits the execution itself.

The next day, Pete goes to the address Alice told him about, and murders Andy, as planned. However, what he didn’t expect was to actually have to witness seeing Alice in her adult films. They’re projected onto a wall in the living room, and he cannot avoid them. This is too much for Fred’s psyche to handle, and Pete starts to convulse and bleed. Fred’s fragile alternate reality is falling apart, and suddenly we see a picture, of both Alice and Renee, standing with Andy and ‘Mr Eddy’. Pete asks Alice if they are both her, and she points only at Alice and says “That’s me”; temporarily keeping the narrative of the alternate reality alive. Pete goes upstairs to clean himself up, and when he comes back down there is a short exchange with Alice where she points the gun at him and we once again question whether or not she can be trusted. Finally she hands it to him and suggestively tells him to stick it in his pants.

Alice tells Pete that they must drive out to the desert, to a cabin, so they do. The cabin represents the very heart of Fred’s consciousness.

When they get there, there’s nobody there yet, so they have to wait. Alice seduces Pete, saying: “You still want me, don’t you, Pete”.
“More than ever,” Pete replies, “I want you, I want you.”
Time slows down and they have sex one last time and roll around in the sand. As they finish, Alice towers above Pete, and leans down to whisper into his ear: “You’ll never have me.” Then she gets up and leaves.

Fred’s alternate reality has fallen apart. Even in this fantasy, he couldn’t convince himself that his wife loved him.

There is no need for the alter-ego any more, so Pete has turned back into Fred, and this is who we see stand up, in the middle of the desert. Pete is gone.

Fred walks to the cabin and his inner demon is there, waiting with a video camera; the window into his soul. Fred asks where Alice went and the demon makes it brutally clear: “Alice who? Her name is Renee. If she told you her name is Alice, she’s lying.”

Demon with video camera

Everything is lost. All that is left is for Fred to be executed; but he can still commit one final act of revenge, by joining forces with his inner demon and killing ‘Mr Eddy’. So this is what he decides to do.

He finds ‘Mr Eddy’ in bed with his wife, at the Lost Highway Motel (the ‘Lost Highway’ of the desert represents the journey down deep into his consciousness). He kidnaps ‘Mr Eddy’ and bundles him into the car boot. He drives him out to the desert, and then opens the boot. Suddenly ‘Mr Eddy’ leaps out, and for a moment it seems like Fred will lose the battle, but suddenly someone hands him a knife, and he cuts ‘Mr Eddy’s throat. The camera pans out, and we see that his accomplice is now his inner demon. They have joined forces, and Fred has embraced his innermost fears and rage. ‘Mr Eddy’ dies; one final token act of revenge, and closure for Fred.

We cut to a scene back at Andy’s house, and the detectives are cleaning up the mess. They notice the picture we saw earlier, but this time only Renee is in it. “That’s Fred Madison’s wife with Dick Laurent.” The fantasy world has collapsed.

Finally, all that is left for Fred to do is to run. But he has one last idea; perhaps if he can somehow go back in time, and reassure himself that the evil Dick Laurent has already been dealt with, then maybe he can find happiness with his wife after all? So this is what he does – he flees from the police, and goes right back to the start of the movie; setting a Möbius strip into motion, like a black hole in time.

In the fantasy world, Fred is suddenly submerged by flashing blue lights, and his body starts to shake violently. He screams out. In reality, he is in the electric chair, being electrocuted. These are his final moments.

And that’s the end of the film.

Film stills

Of course, I’m aware that I could be wrong, and that it could all mean something completely different, or even a million different things. But, to me, that’s what makes it such a brilliant piece of art.





Private Practice Made Simple

4 02 2012

My review of “Private Practice Made Simple” by Randy J. Paterson, PhD:

Private Practice Made Simple front cover

There are plenty of books and websites out there offering advice to mental health professionals who want to know how to establish their own private practice. With this new release Randy J. Paterson, PhD offers his own comprehensive take on this popular topic, promising to provide “everything you need to know to set up and manage a successful mental health practice,” from “getting client referrals and creating a positive and comfortable office atmosphere to building a strong and thriving therapy practice that can serve both you and your clients.”

As the 2008 recipient of the Canadian Psychological Association’s Distinguished Practitioner Award, and the owner of a private multiple-provider outpatient practice in Vancouver, Paterson certainly seems to write with a wealth of personal experience in this area. Indeed, what differentiates this book from so many of the others available on the market is that personal touch, as Paterson shares his own journey into private practice, and the lessons learned along the way, explaining that:

No one really teaches you how to manage a mental health or counseling practice. As clinicians we stumble through our careers, gradually picking up shortcuts and strategies that make our lives (or those of our clients) a lot easier. Many of these useful ideas aren’t rocket science and could have been taught to us in an afternoon if anyone had thought about it. That’s what this book is for: it’s nothing more than a collection of useful basic tips … The emphasis of the book is on quick and easy strategies that can save a lot of headaches.

This light, conversational style typifies Paterson’s everyman approach to the topic, ensuring that the book is easy to read and full of accessible ideas for anyone contemplating the possibility of working in private practice.

While some other books might launch straight into the practical side of running a private practice, Paterson predicates this by starting his book with a chapter focusing on the importance of weighing up the pros and cons of running this kind of business in the first place. Paterson lists his ten most frequently-heard arguments both for and against private practice, and I can guarantee that any mental health professional will be able to relate to at least some of this debate.

The arguments in favor are listed as:

1. No Big-Organization Hassles
2. Getting Away from the Medical Model of Distress
3. Increased Accessibility for Clients
4. You Get to See Whom You Want
5. More Money
6. Supplement Your Salaried Income
7. Flexible Hours and Holidays
8. Work Fewer Hours
9. No Commute!
10. A Service Based on Your Own Vision

Whilst the arguments against are:

1. You’ll Never Get Clients
2. You’re No Good at Networking or Marketing
3. Uncertainty About Income from Month to Month
4. You Hate All the Clerical and Business Demands
5. You Don’t Know Enough to Practice Independently
6. Dealing with Fees will be a Huge Hassle
7. You’ll be Helpless in the Face of Insurers or Funders
8. No Retirement Plan or Benefits
9. You’ll Burn Out and Won’t Have a Safety Net
10. You Won’t have a Sense of Meaning in Your Work

Paterson follows this up with a considered appraisal of what is truly involved in the day-to-day running of a successful private practice, and then allows you to make up your own mind as to whether you’re really suited to this type of business. Assuming that you are, this book then serves as a comprehensive guide to everything involved in setting up and maintaining your practice, from such subtle nuances as the ‘olfactory environment’ and placement of clocks, to website design and finance tips.

As Paterson says, many of the ideas in this book aren’t rocket science, and might initially just seem like common sense, but don’t let this be a deterrent. As you make your way through the book you’ll realize there are also countless suggestions here which will leave you wondering “Why didn’t I ever think of that before?” and feeling enlightened. One such example is the section on ‘The Client’s View,’where Paterson explains the importance of the contents of the therapist’s bookcase:

Look at your own bookshelf from the client’s position. Notice where your eye naturally falls. These are the most salient shelves. Banish books that imply you are having significant problems yourself (Avoiding Burnout, The Wounded Healer), your introductory psychology textbooks, the trashy novels you secretly read at lunch, the books on handling problem clients, the self-help books you wouldn’t recommend to your worst enemy, and all the books on managing the finances of your private practice (including this book). Shift those books upward or downward, and replace them with scholarly books on your specialty areas of practice, books on diversity, a book or two on sexuality (this subtly gives clients to put such issues on the table), the self-help books you most frequently recommend, high-level books on practice and therapy, and other books that communicate your expertise, interests, and breadth of knowledge.

Once you’ve thought about it this seems so obvious, but I have seen plenty of counseling rooms where this advice had clearly been sorely missed, and where business may have suffered as a result.

It is these kinds of subtle tips which can make a huge amount of difference to the way a private practice is run, and which might distinguish an outstanding business from a mediocre one. Having all of these ideas listed in one simple book is truly invaluable, and will surely offer numerous benefits to anyone in the mental health profession. I couldn’t think of anything which Paterson had missed from this book, and he even includes a link to free downloads of practice worksheets and sample forms to help you on your way. If you’ve ever considered setting up a private practice, or you’re running one already, then this book’s for you.

3 out of 5 stars.





How To Change Your Drinking: A Harm Reduction Guide to Alcohol

16 12 2011

My review of “How To Change Your Drinking: A Harm Reduction Guide to Alcohol” by Kenneth Anderson:

How to change your drinking front cover

Substance misuse is one of the most common and widely discussed topics within the mental health community, as both clients and professionals debate the most effective ways to deal with addictions and their causes.

In the past, treatment might typically have involved a focus on abstinence as the ultimate goal, through zero-tolerance groups such as Alcoholics Anonymous, or a 12-step program, where clients would be rewarded only for complete sobriety and nothing less.

This has slowly changed over the past decade, though, through the realization that complete abstinence simply wasn’t a realistic or achievable goal for some, and that such a harsh insistence on withdrawal simply wasn’t working. In fact, it is estimated that 60 to 95 percent of clients who enter 12-step programs either drop out or otherwise fail to maintain abstinence from alcohol, and the NIAAA’s statistics suggest that only 7 percent of people who suffer from an alcohol use disorder will typically seek treatment within any given year.

As a result the treatment focus has shifted from simple cold turkey toward an overall emphasis on healthier and safer habits, and lowering risks. This has seen an emerging popularity for modalities such as motivational interviewing, where both the pros and cons of sustaining the negative behaviors are acknowledged. The client is then free to decide how, and at what pace, to proceed.

The HAMS group takes a similar “baby steps” approach. HAMS — the acronym stands for Harm reduction, Alcohol abstinence, and Moderation Support — describes itself as “a free of charge, lay-led support and informational group for people who want to change their drinking for the better.” Founder and CEO Kenneth Anderson is himself a former problem drinker.

In this book, How To Change Your Drinking: A Harm Reduction Guide To Alcohol, Anderson presents a comprehensive summary of the harm reduction approach to drug and alcohol problems, suggesting it could “either be used as a self-help manual for people working on their own or by people who are participating in a harm reduction support group.”

The book begins by introducing the underlying theories of harm reduction, and is written in a nonjudgmental tone that will be reassuring to most readers:

Some folks today want to say that everything fun is an addiction and that everyone had better spend their lives in 12 step meetings talking about their ‘Higher Power’ and holding hands and saying the Lord’s Prayer instead of ever doing anything fun. We beg to differ with these people. Prohibition does not work because there is nothing essentially evil, sinful, or diseased about having fun. There is nothing evil, sinful or diseased about drinking alcohol moderately, and for that matter there is nothing sinful, evil or diseased about engaging in recreational intoxication either.

There is not some specific magical quantity which we can say is too much alcohol – free individuals have the right to make up their own minds about how much they believe is too much for them personally. Occasional intoxication is not a symptom of a disease; it is a choice.

It is this focus on individual choice and empowerment which personifies this book and differentiates it from much of the rest of the substance misuse canon. Instead of focusing on problematic labels or clinical diagnosis as a means of demanding perfect abstinence, the author leads the reader on a step-by-step journey toward deciding what their own goals should be, and offers advice and support on the healthiest ways to achieve and maintain them. There is even a short section titled “Ken’s Story,” where Anderson talks about his own previous drinking problems and near-death experiences in AA. Those led to his resolution to “find a better way” and start the HAMS network.

The opening chapters might seem familiar to many mental health professionals, as Anderson suggests that each reader completes a Cost Benefit Analysis exercise, similar to those used in motivational interviewing techniques:

Miller and Rollnick (2002) say, ‘Often individuals considering changing a problem behavior will concentrate on all the negative aspects of the behavior. ‘I know how bad my drinking is for me,’ they say. In fact, they can often produce a litany of reasons why what they are doing is bad for them. Clinician and client are often baffled by the fact that even with all these negatives, change does not occur. The reality is that if the behavior were not in some way beneficial to the client, he or she would not be doing it. Until the client acknowledges the ‘good things’ about the behavior, they cannot prepare to combat temptation once they make an attempt to change. The decisional balance helps facilitate this process.

It is clear that Anderson has done his research in this field, and even though much of the book features personal stories and experiences, these are all presented within a scientifically supported framework, using clinically proven techniques and offering further resources where appropriate. Later in the book, Anderson explains Prochaska’s “stages of change” model, leading the reader through each stage and explaining the range of thoughts and behaviors that might accompany this process. He offers readers a large quantity of materials to help them along this journey, too, ranging from goal-setting and risk-ranking worksheets, to consumption charts and graphs, to the chemical breakdown of different alcoholic beverages and how they are processed within the body.

The book also addresses the addict’s friends and family. Anderson features chapters on specific topics such as spousal goals, alcoholism’s effects on children, and a study of drinking patterns as affected by ethnic identity and religious affiliation.

There is a wealth of knowledge in this book, but the clear, concise and easy-to-read style ensures that it never becomes overwhelming or difficult to follow. Anderson describes things in layman’s terms and it is doubtless this open, reassuring style which attracts so many of the HAMSters to the harm reduction approach.

As a comprehensive manual to changing drinking behaviors, readers will be hard-pressed to find a better book than this. If you’re looking for support, advice, scientific facts, or recovery tools, you’ll find them all here, clearly laid out for both mental health professionals and clients alike.

4 out of 5 stars.

It is worth noting that alcohol misuse has been a major issue in the British media since I wrote this review; with suggestions of major changes in government policy and the introduction of ‘drunk tanks’ and ‘booze buses’. I have a lot more to say on this topic, and it is one that is close to my heart as I do a lot of work for a substance misuse agency within the NHS in North London; but that’ll have to wait for another time.





Assessing Adult Attachment: A Dynamic-Maturational Approach to Discourse Analysis

10 09 2011

My review of “Assessing Adult Attachment: A Dynamic-Maturational Approach to Discourse Analysis”.

Assessing Adult Attachment front cover

Attachment theory has come a long way since John Bowlby’s paper “Forty-four Juvenile Thieves” was published in 1944. In the paper Bowlby wrote about his work with disturbed youth in London. He theorized for the first time that the nature and security of an individual’s relationships to their primary caregivers during infancy and early childhood equips them with the methods they will use to express their feelings and needs in later life. Those relationships also predict how people will form relationships with significant others during adulthood.

Through further research into Bowlby’s initial ideas – and the invention of the Strange Situation experiment – Mary Ainsworth was able to develop a clear system of classification for this theory, which could be used to identify three unique patterns of attachment: Type A (Avoidant), Type B (Secure), and Type C (Ambivalent).

This rudimentary ABC system has been at the heart of attachment theory since its inception, and has paved the way for a host of psychological texts and theories. Titles such as “Attached” by Dr. Amir Levine and the “Attachment-Focused Family Workbook” by Daniel A. Hughes join countless other attachment-specific books currently on sale, and Dr. Sue Johnson’s research into relationships and subsequent development of her Emotionally Focused Therapy (EFT) program have brought about a revolution in the field of couples therapy. Indeed, a recent issue of the American Association of Marriage and Family Therapy’s ‘Family Therapy Magazine’ was entirely devoted to The Science Of Love, reporting the recent findings of groundbreaking research focused on the understanding of romantic love and adult attachment.

It is clear, therefore, that the ABC classification system of attachment theory has a lot to offer those in the therapeutic field, but it is not without its problems, either. First, it often seems overly simplistic: the classifications can be vague and unreliable, everyone is forced to classify themselves with one of just three basic attachment styles, and there is no option of further classification within each division. Second, it is too limiting: people frequently feel typecast and stuck within one specific attachment style, with no option for change or progress. Third, it is outdated and culturally biased: the system was derived from work in the cognitive sciences in the late 1970s, and based largely on findings from observations of middle-income, low-risk American families. And fourth, it offers very little in terms of a solution: once someone has identified their attachment style, then what?

The main cause of these problems has been the source of the classification data itself: the Adult Attachment Interview (AAI), an interview and coding method developed by Mary Main and Ruth Goldwyn in the 1980s which has been the primary method of collecting and interpreting attachment information ever since. Now, at last, with this book, Crittenden and Landini have provided us with a more up-to-date, efficient and multicultural alternative, which continues to be compatible with the AAI data collection method, but works equally well with other forms of interview, too: their own Dynamic-Maturational Model (DMM) of attachment.

Various theoretical perspectives on attachment can be applied to the interpretation of the AAI. Main and her colleagues developed the AAI based on a version of attachment theory that assumed that (1) by adulthood most adults had a single representation of attachment relationships, (2) this relationship reflected one of the Ainsworth patterns of infant attachment, (3) these patterns were transmitted from mother to child across generations, and (4) frightening circumstances disrupted the organizational process, leading to a state of disorganization in infancy or lack of resolution of the frightening circumstances in adulthood.

In the Dynamic-Maturational Model of attachment and adaptation, none of these four assumptions are made. To the contrary, the DMM approach to attachment theory presumes that adults have multiple dispositional representations, each unique to the information processes underlying it. Second, the array of strategies is developmentally expanded from its roots in infancy, with endangered individuals most often using the later developing and more complex strategies. Third, it is understood that each individual constructs his or her own dispositional representation from his or her own experience. Sometimes this will reflect similarities to the parent’s dispositional representation, but, especially in cases of parental disturbance or inadequacy, children will often organize the opposite strategy from the parent… Finally, exposure to danger is assumed to be the essential condition that elicits attachment behavior, and, across repeated experiences, leads to organized self-protective strategies.

Clearly, the introduction of this model represents a major leap forward in our understanding of attachment and attachment theory, offering a far more detailed and multicultural system of classification than the old ABC model. Over the course of this book, Crittenden and Landini fastidiously lay out a new classification system, with many numeric subdivisions within each individual attachment strategy. In fact, the research is so exhaustive and delivered in such great detail that it seems almost impossible that any clinicians reading this would not recognize each of their clients at least somewhere within the text. The downside to this is that this is not an easy book to read; it is certainly not something you will want to flick through to help you relax at the end of the day. But those who do make their way through the sometimes dense and challenging text will come out feeling incredibly rewarded for their perseverance, armed with a new treatment model for working with their clients and a new understanding of the complexities of adult attachment.

Essentially, what the field of attachment theory has been sorely lacking is its own Diagnostic and Statistical Manual — a modern, flexible, and multicultural tool which will provide practitioners with the common language and standard criteria for the classification of specific attachment styles, and their best-practice solutions. Now, with Crittenden and Landini’s long-awaited book, it finally has it.

Critically, though, this book aims to do much more than serve as just a DSM for attachment theory. As well as a basis for gathering empirical data, the authors provide us with a compassionate new guide for treatment formulation, and there is a chapter – titled ‘But What Shall I Do?’ – dedicated specifically to this cause:

Researchers are happy with a reliable classification, but not so psychotherapists and others who must guide troubled individuals and their families. They need an action plan. In this chapter we describe how one uses an AAI classification, combined with information about the history and current functioning of the speaker and his or her family, to derive a functional formulation. The functional formulation is the professional’s dispositional representation (DR) of the relation between the service structure and the individual and his or her relationships. Like all DRs, a functional formulation is dynamic; it is always changing as new information is integrated into the existing set of information… We describe how to derive functional formulations that can guide treatment both at its onset and, with feedback and updating, across the course of treatment.

Crittenden and Landini then go on to demonstrate exactly how their model can be used as a therapeutic tool, using the initial classification as starting point to guide both the therapist and client toward the resolution of past issues and the reorganization of the thoughts and language that shape both our ideas of self and attachment strategy. Furthermore, this model aims to shift the focus on attachment styles from one of disorder to one of function; from the old deficit-based model to one that is dynamic and optimistic. Rather than an emphasis on diagnosis simply for the sake of identification or labels, the authors stress their hopes that this model might open the doors to new ways of thinking in not just the mental health field, but others as well, concluding that:

When functioning is understood as attempts to protect rather than to damage or harm, alliances between mental health professionals and people in need of care become more likely.

Many say that DMM theory and methods are complex, too complex for working clinicians. After a century of trying to understand and ameliorate mental illness, it seems unlikely that simple theory, simple assessment, and quick manualized treatment will be more successful than our past efforts. It is more likely that theory needs to be sufficiently complex to represent the crucial aspects of the life experiences of people with mental illness. The assessments need to be sensitively attuned to the encrypted communications of very distressed adults, and to be coded by skilled professionals trained to a high level of reliability.

Possibly, the greatest potential of the DMM-AAI is its capacity to focus observation precisely while retaining the openness to expand and change understanding of observations. We hope this book will be used to promote accuracy of observation, clarity of interpretation, and – most important – discovery of new ideas about human adaptation. Psychological tools that yield useful data without restricting thinking are very valuable. The DMM-AAI does more: It opens the door to groundbreaking basic and applied research of as much relevance for the social sciences as for the healing professions.

This is a groundbreaking piece of work, containing a life-span view of adaptation that is both intuitively succinct and simple in structure, yet also completely nuanced in execution. Researchers and clinicians alike will undoubtedly benefit from the wealth of information shared here, and it is a must-have for anyone with an interest in attachment theory, representing a major evolutionary step forward in the field.

5 out of 5 stars.