Tag Archives: counselling

World Suicide Prevention day

It’s world suicide prevention day today so I thought I’d pen (type) a few words on the way in which we can work safely with suicidal clients online.  I’ll be talking about problem gamblers specifically as they’re the client group I work online with.

It will come as no surprise to anyone that problem gamblers can sometimes be suicidal….people who are addicted to gambling are often able to hide the addiction for quite some time, maybe even years, from those closest to them.  If you’re in a relationship with a problem gambler you might get the sense that something is wrong…your partner might be distant, anxious, depressed and even have angry outbursts for reasons you can’t identify but none of these things would necessarily lead you to the conclusion that he or she was a problem gambler.

Thoughts of suicide thrive if the thinker feels no one cares and in their distorted view of the world a problem gambler might interpret a loved one’s lack of understanding as apathy.  Of course it’s pretty difficult to show understanding regarding a situation you know nothing about!  Another contributing factor to the consideration of suicide as an option for many problem gamblers is the fear of being “found out”.  Think about it….you’ve spent a long time hiding your addiction….getting rid of the betting slips…clearing your browser history….taking the bills away and putting them somewhere “safe” before they even have a chance to hit the mat and you’ve managed to keep all of your balls in the air BUT you know that tomorrow you’re going to get caught.

If a problem gambler knows that the secret is going to come out because there is some form of communication on the horizon that can’t be controlled heading in the direction of a partner, such as a call to the bank the partner intends to make to find out just what the hell is going on, they may feel utterly desperate!  The idea of facing someone they love as the extent of the chaos they’ve created is unearthed before they’re very eyes can be too much to bear for some and there only seems to be one way out.

I work for an international online counselling and support site for problem gamblers and sometimes I “meet” people who have reached the exact state of mind I’ve described.  Now, I don’t want to go into the ins and outs of what can and can’t be done to get help to people in distress when working online because although there may be a few things, involving IP addresses etc, they are very limited if you’re working on a “drop in” basis to provide emotional support.  Obviously if you’re working in a structured way, with a contract and details of Doctors and next of kin, which you would have if counselling someone, you have greater control over what you can and can’t do.  So, for the purpose of this Blog, let’s focus on the people who click a button and get through to us without having had any prior contact with our staff team.

First and foremost and in the words of Hitchhikers Guide….DON’T PANIC! If you receive contact from someone who implies or explicitly states that they are suicidal.  The service user is seeking help by speaking to you which is a positive thing.   There’s no empirical or anecdotal evidence to suggest that talking about suicide or indeed naming it, if service user talks about “not wanting to carry on” etc, will increase the likelihood of a suicide attempt.  In fact, quite the opposite is true as many people report feeling relieved at being able to explore their feelings about the subject.

Discussions around suicide should be handled sensitively and if your client hasn’t mentioned the word “suicide” explicitly, word your questions carefully and seek clarification about what they’re trying to tell you.  Questions such as “You seem to be saying to me that you don’t want to be here anymore, would I be right in thinking you’re having thoughts about ending your life?” can offer the client the opportunity to open up because it shows them suicide isn’t a “taboo” subject.  You don’t want the client to think they’ll freak you out if they tell you what’s really going on after all.

When a suicide risk has been identified the first step to take is to find out where they are and who, if anyone, is with them.  The primary aim of the conversation at this point is to encourage the client to get some face to face help…whether that’s from a friend; family member, mental health professional or doctor is irrelevant.  If the caller tells you they’re alone and have no one to turn to it’s important to make sure they have a link or telephone number for services such as the Samaritans or Befrienders (outside the UK) before the call comes to a close.  If you build up a rapport they may even give you an address or telephone number you can use to get help to them if it comes to that, which in my experience it very rarely does.

One thing you can do to take the pressure off both of you is to employ a brief “no harm” contract that applies to that particular session.  This means that the service user agrees not to act on suicidal thoughts during or immediately after the session and they agree to access additional support from a friend, family member or organisation following the session.  Without this commitment from the service user you may struggle to have peace of mind and should decide for yourself if you can be effective with such uncertainty in the air.

Some suicidal thoughts are fleeting and vague and occur only when an individual is in crisis whereas other thoughts can be constant and well considered.  In order to help the service user to better understand their feelings you could ask them to rate the intensity of their suicidal thoughts on a scale of 0 to 10 (0 being no strong thoughts and 10 being a determination to act on their feelings in the immediate future).  This will help you determine the level of risk you’re working with.

Another method of assessing risk is to ask the client whether they feel this way as a result of a prolonged period of depression or whether they may be feeling this way as a response to another situation which will pass.  If the feelings are being driven by current circumstances allow the client to explore the possibility of resisting the feelings until their circumstances change.  The emphasis here should be on the way in which circumstances change, has the service user considered coping strategies that are flexible and can change along with their situation instead of employing such a permanent solution?  You can do this by looking at different scenarios with the service user such as talking to the people in their lives that they find to be supportive and helpful.  If the clients’ feelings appear to be more prolonged, encourage them to access a mental health service or their GP to assess whether they may be clinically depressed and identify potential treatment.  Whether clinical or reactive we know that depression can be treated and the low feelings will eventually pass, so try to focus the client on the fact that however painful, their feelings are temporary and death is permanent so wouldn’t it be more logical to look for ways in which to cope until they pass?

Encourage the service user to look at times in the past when they may have felt this way, ask them about what coping strategies they employed before in order to survive.  When working with our client group we have to be aware that the answer to this question may be “I gambled” in which case exploration of other methods of coping in a healthy way should take place.

Always remember that if someone decides to end their life it’s their decision.  I know it’s sad and monumentally frustrating but there are no magic words we, or anyone else, can pluck out of the air to “fix” anyone.  By letting a person talk about suicide openly and without judgement you’re giving them something very special, you’re accepting them….and maybe that’s what they need.

When ending the call the service user should have a clear idea of what to do next and what methods of support are available to them and you should make a note of your experience so you can talk it through with your clinical supervisor.

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Suspended Grief – A Personal Reflection on Childhood Loss

I sat in front of my laptop and watched the reams of videos flash past my eyes…..a friend, stood in a bucket soaked to the skin complaining as water soaked through to his underwear….another friend clung onto her dog so she wasn’t the only one to get wet…my daughter…shrieking in delight whilst her dad tipped up the bucket wearing a look that can only be described as pure glee.  The ice bucket challenge 🙂 It was all very funny….so why were there tears streaming down my face?

Motor neurones is a horrible disease, it can start in different areas of the body from person to person but the end result is always the same….loss of control over your body, loss of dignity, loss of life.  With my granddad it started in his throat and for a while my older brother and I bought the story that he had a sore throat and that’s why he couldn’t talk.  He moved in with us and we carried on like normal, we just accepted that granddad now wrote notes instead of speaking and eventually had a machine not dissimilar to the old “speak and spell” I had as a kid to communicate with.  It was around that time that the memory hails from….the one that makes me sob like a baby despite the fact that is happened almost thirty years ago.

It was Christmas day and I’d been told off, a none too rare occurrence given the fact that I could be a bit of a brat! I think I’d been ungrateful about a present I’d had or something like that and my dad had had enough and snapped at me.  My granddad was in the room sitting quietly in his armchair watching the events unfold when I decided to storm out of the room with the as much drama I could muster!  But, as I reached the door he reached out his hand and held gently onto my arm.  I stared back at him with annoyance because he’d interrupted me mid flounce!  It’s the look in his eyes though that I’ve never forgotten….you see, he couldn’t let go of me to grab his note pad or “speak and spell” because he knew I’d storm out…but he had something to say and it couldn’t have been any clearer if he’d managed to shout it out!  He seemed to say, “Stop this…it’s silly, you’re being silly and life is too short.  It’s Christmas after all”.  I didn’t hear him,….I wrenched my hand away and stormed out anyway.  I don’t know why this memory fills me with guilt and sadness to this day, but it does.

I don’t want you to think I didn’t like the fact that he lived with us though because even in the midst of this horrific illness he was a funny and a loving man.  I’ll never forget a conversation he had with my younger cousin….(I can’t remember what it was about) I remember he was writing notes on a pad to her and she was writing back.  Then a glint of mischief shone in his eyes as he wrote “Laura, why are you writing to me?  I can’t speak….I’M NOT DEAF!!”  We all laughed…my parents still have the notepad 🙂

I was sheltered from a lot of pain towards the end, it’s only now that I’m an adult I understand the true devastation the disease wrought on my granddad and the truly heroic way my parents cared for him no matter how difficult things became.

So now I come to the title of this blog.  Having felt a rush of sorrow on numerous occasions over the past few weeks I’ve come to the conclusion that perhaps my grief over the loss of my granddad was suspended.  I’m left wondering if as a child the anguish of losing someone so cherished was simply not something I could process.  So I shed a few tears and went about the rest of my life not knowing that I had set aside my sadness to revisit later on when I could fully understand not only what I had lost but how I had lost it……

I am genuinely at a loss to understand why someone lost to me thirty years ago is in my thoughts daily…why my eyes burn when I talk about him….why I’m crying now unless he had been placed in an envelope marked “to be opened at a later date”.   And if this is the case then I’m not sure if that means we should be trying to encourage children to grieve if they seem unmoved by a loss or we should simply trust their system to know when it’s time even if it comes at them out of left field when it is?

Kubler-Ross talks about the five stages of grief:

  • Denial
  • Anger
  • Bargaining
  • Depression
  • Acceptance

Which makes sense to me when talking about adult grief…but from my own experience I guess I would have to posit the idea that maybe children of a certain age undergoing a certain kind of loss skip the initial stages and go straight to Depression and then Acceptance.  Then later in life they revisit those two stages to finish the job…?  I don’t know how this impacts, or even if it impacts on how we work with adult grief over a loss in childhood, but I thought I’d share my thoughts.

I don’t know the answer but I do know something feels unfinished so I’m going to reflect on that for now….I’ll let you know if I reach any conclusions 🙂

 

Take a Punt on Online Support (Unedited version of article published in Therapy Today July 2014)

Working Online with Problem Gamblers

Hi, my name’s Jane Fahy and I’m the Clinical Services Manager for Gambling Therapy, a website that supports roughly sixteen thousand people around the world who either have a gambling problem or are close to someone who does. The work we do in Great Britain involves providing wrap around support for people accessing residential treatment in one of the Gordon Moody Association Residential Treatment Centres. We also educate and support their friends and families. Outside Great Britain we offer a range of services in different languages to supplement the face to face support provided by other agencies. We do this on our forums, in online groups, via e-mail or on our helpline.

The number of problem gamblers worldwide is hard to pin down for a variety of reasons that I won’t bore you with now….but generally speaking it’s accepted that between one and four percent of individuals that gamble have a gambling problem. Working with addictions is tough, ask any addiction specialist! On one hand your client wants to change, they’re desperate to, but on the other hand they are driven by a white hot desire to continue doing what they have always done. After all, it keeps them safe doesn’t it?

Some people struggle to understand how an addiction without the introduction of a foreign substance can hold an addict in its thrall in the same way as an addiction with the introduction of a substance. I mean I get it, why would you do something that cost every penny you had, destroyed your family and left you homeless unless you were high? So I suppose this leads us on to a discussion about what we mean by the term “high”, an altered state maybe….euphoria? Escape? All words I’ve encountered when working with problem gamblers.

How then is it that problem gamblers are unable to stop when they’re not actively gambling because surely the effects wear off quickly right? Wrong, the brain needs time to acclimate to working within a more “normal” range of stimulation, which can take a while! To put it in more simple terms, if you’d spent hours on a roller coaster and adjusted to such a high level of stimulation your head would spin for quite a while after you got off! So the cycle continues, the thoughts become more distorted and the gambler gambles until one day the cost is too high. That’s when I “meet” them 🙂

So how does it all work? Well, it’s kind of like a jigsaw puzzle that people coming to us for help put together themselves to form their own recovery picture. It’s a picture that changes depending on where someone is within their recovery and what they need on any given day. Accessing online services like ours means people can take a dynamic approach to their support and tailor their recovery so it’s personal to them. In practice that means that if the person accessing our site wants to talk to someone who’s “been there”, someone who’s bought the T-shirt they can do that. If people want to talk to a counsellor who can help them to explore the “whys” of their situation, they can do that too…kind of a pick and mix solution!

If we’re looking at the nuts and bolts of supporting problem gamblers online via an established website with a vibrant community, I guess we first need to look at online support in more general terms. What is it, and what is it our clients are getting from it? I view it in terms of the following categories:

  • Accessibility
  • Community
  • Anonymity
  • Flexibility

Accessibility – A client using online support can access that support at any time of the day or night irrespective of the time zone they’re in. Support can be accessed on a laptop, PC, Mac, on a tablet or even a phone. Effective and comforting assistance can be a coat pocket away!

Community – An online therapeutic community is a powerful entity. Many people who have accessed a support group talk about the feeling of acceptance that hit them like a wave when they walked into a room with others in similar situations. Now, imagine that room was a virtual room containing thousands of people from all over the world, all understanding at least part of your story, all wishing you well and offering you a hand across cyber space. Then that feeling of acceptance has the potential to turn into something altogether exceptional…maybe even overwhelming in its ability to wrap an individual up in a blanket of understanding.

Anonymity – As therapists we often hear clients talk about shame, the shame of an addiction, an experience or even a relationship. Part of the work we do is to break through that shame and allow our clients to express themselves freely through their experience of our unconditional positive regard. Understandably it can take our clients time to perceive our lack of judgement and feelings of warmth towards them which allows them to speak freely but what happens if they don’t have to look us in the eye? Kate Anthony, CEO at the Online Therapy Institute and Fellow of the BACP, refers to this as the online “disinhibition effect” a term initially coined by eminent psychologist J.Suler.  Anonymity allows clients to express themselves on a deeper level, perhaps more quickly than they would in a face to face setting and, if managed correctly by the therapist; this can lead to some very valuable work carried out over a relatively short period.

Flexibility – We all respond differently to different kinds of support and different people but sometimes it can be hard for us to be specific about what we need and what works for us. Without the need to maintain premises that can only be open at certain times, staffed by at least two people, usually more, when open for the sake of safety and often held back by physical constraints, online support is often more dynamic, lean and capable of rapid change than a land based practice. The range of services can be adjusted relatively quickly to meet the needs of those accessing them and feedback concerning what those needs are is often frank and forthcoming thanks to the aforementioned disinhibition effect. This means people accessing this form of support can choose from a wide range of help, some in real-time and some where the response is not immediate (as with forums), they can tailor to suit their personality and preference.

So we know why this kind of support works, but what specifically are the benefits and pitfalls of supporting problem gamblers in this way? Human beings are complex and problem gamblers are no exception, so when looking at how best to support them and deliver therapy we have to consider why they do what they do, what are they likely to respond to…most of all WHO ARE THEY?

I’ve come into contact with problem gamblers from all over the world who gamble on everything from poker to scratch cards…online or in a casino or betting shop…games that are legal or illegal…..alone or with others trapped in the same downward spiral. I guess the thing you need to know about problem gamblers is that there are no two the same. But what remains the same with all of them is the pain behind their actions. So, ok they’re all different but that doesn’t explain why supporting problem gamblers online works so well?

Well, let’s not beat around the bush, with addictions to substances there will be many occasions when the people accessing support won’t be in a coherent state, particularly if they’re in their home environments and early on in their recovery. Being coherent is something that’s a basic requirement when it comes to getting help online and, where no dual presentation exists; it’s something that people I’ve supported don’t generally struggle with.

Something that helps problem gamblers in recovery is the use of practical barriers. These can include handing over financial control to someone they trust, self excluding from land based venues or adding blocking software to a PC or mobile device. Many barriers involve the avoidance of triggers and one of the biggest triggers for many is walking past a bookies. For those of you reading this article from within the UK I’m sure you can imagine just how hard it would be in many of our towns and cities to plot a route somewhere that didn’t take you past a bookies? Whilst I don’t object to seeing bookies on our high streets, as I’m aware many people can, and do, enjoy gambling responsibly and recreationally, I have to feel for those that must feel they can’t escape from them. You don’t have to walk past a bookies, a casino, an arcade or a shop selling scratch cards to access help online so in a vulnerable moment the people we support relish the opportunity to connect and talk to us without taking that risk.

Of course it’s not possible to avoid all triggers, emotionally charged situations or vulnerable moments over an entire lifetime so in order to regain a sense of living a “normal” life in which avoiding triggers doesn’t play such a prominent part, problem gamblers may initially use online support as a safe and secure stepping stone back to the life they want. If we revisit the idea of the online therapeutic community that I mentioned earlier, the potential for the community as a whole to role model recovery and a return to normality is vast particularly for those who’ve completed residential treatment because leaving that bubble can be extremely daunting! The community also performs the very valuable function of acting as an ongoing safety net, always there if needed, never judging the individual in need.

Our virtual doors are open to male and female problem gamblers but something that I found surprising when I first started delivering online support was the number of women accessing the support when compared to men. I had wrongly assumed that problem gambling was a predominantly male concern…I guess I had an image of Del Trotter in my head standing outside the bookies clutching a betting slip and proclaiming “This time next year…” Needless to say, that’s not what I found and shame on me for making assumptions J Perhaps because of this common assumption women often hold off on accessing face to face counselling or group support but they seem more willing to engage with therapy online….maybe because they can choose whether or not to even disclose their gender at first. Maybe because they’re not walking into a room full of men, which they could be imaging will be the case, or maybe because they feel less judged online for being women who gamble for the reasons I’ve already mentioned. You might be surprised to learn that out of the 1868 most recent contacts, women made up roughly 46% of the people accessing the Gambling Therapy helpline or online groups.

Styles of gambling vary so much from country to country, as do attitudes towards gambling and the help available to problem gamblers. In countries such as the USA many people are used to getting support for a variety of reasons and help is readily available. However, in some other countries help might be limited and people in need of it may be being actively discouraged from seeking help outside of the family unit. Because we work in the way we do, with people from all over the world, we have to work in a truly transcultural way. We can’t know everything of cultural significance relating to every corner of the globe so we HAVE to work with the person on the other end of the screen without making any assumptions based on where they’re from. We find out everything we need to know about them, from them, and put the individual client at the centre of the process rather than being influenced, however subconsciously, by a cultural stereotype.

As with any personal development work it can be rewarding to reflect on our progress. Some use forums as a journal open for people with similar experiences to read and contribute to. Others use them to pose questions and support their peers. What is ALWAYS useful is to look back during vulnerable moments to see how far we’ve come.

So, that’s all from me, I’m sure you’ll agree that there is value in online support and see its potential particularly in terms of supporting problem gamblers. I hope you’ve enjoyed this small glimpse into our world. Thanks for reading 🙂 TTFN

 

Jane Fahy (MBACP)

jane@gamblingtherapy.org

Clinical Services Manager

Gambling Therapy, Part of the Gordon Moody Association

When Worlds Collide (First Published in TILT Magazine in May 2013)

Ok, so I’m not a techie, not really a techie, although I am married to a techie 🙂 but I do like online gaming and social networking and I have been known to frequent chat rooms in my distant past.  But all of that, well it’s just childishness really, just harmless escapism with no useful application; I wasn’t learning anything or developing any skills whilst engaging in these frivolous activities….or so I thought!

2014-04-08 17.53.26This is me 🙂

But I’m getting ahead of myself. I started my training as a counsellor about nine years ago, before that I worked in banking which is all very dull and irrelevant so I won’t bore you with that! At the time I had an eighteen month old daughter and I was working part time so I thought, well this is it, now or never, let’s do something that I really care about and my foray into counselling began.  I loved it every bit as much as I thought I would but with coursework and placements everything got a little bit stressful and I needed a way to unwind which is when my lovely (techie) husband said “Well why don’t you give World of War craft a go?”

So I did 🙂 by day I was a mild mannered (somewhat) trainee counsellor, mother and wife and by night I was a spell slinging uber mage with a penchant for turning monsters into sheep (Seriously you can’t make this stuff up). I loved the double life, the responsibilities I had for my personal and professional growth and development, for my clients and for my family were tucked away safely in the back of my mind while I romped through a fantasy world where I could be, or do anything.

But what did you learn, I hear you cry? Well my typing speed increased first and foremost! I learnt to work with large groups of people and communicate clearly with them via text.  I learnt that relationships forged online have value, my fellow players were not merely pixels on a screen they were mothers and soldiers and students, they laughed and cried and became frustrated (often with me, because in all honesty I wasn’t that great at the game!) and they were friends.  Eventually however I simply didn’t have the time to dedicate to the game and so with reluctance WoW and I parted ways.

Let’s move on a couple of years….

Having worked with compulsive gamblers for two years in a land based venue I was approached by an organisation that delivered support and therapy to problem gamblers online.  I’ll be honest here, I wasn’t convinced! How could I convey empathy, compassion and understanding via a computer screen?  How could I work with body language without a body to observe?  But that’s when it occurred to me, all of those times when I had understood others that I had only ever met online, I had shared things with those people whilst running away from goblins or trying to stop the zombie apocalypse.  Those connections had been real; those feelings had been real and those relationships had existed beyond and outside of cyberspace. So in that moment I understood that if I could recreate the strength of those connections with clients, albeit as part of a therapeutic alliance rather than a friendship, I could provide effective support and therapy.

I would like to say here that the epiphany didn’t mean that I was magically able to deliver effective online support just because I used to be a gamer.  Far from it! Certain ways of expressing things online are simply not appropriate when you are working therapeutically yet my fingers wanted to type the words anyway so I had to be very aware of that to start off with.  So I reached the decision to do things properly.  Proper training a high level of dedication and a wholehearted belief that I can really make a difference to others by delivering therapy online are what I need and whilst I have two out of three it is the first of these things that led me here.

I look forward to learning more and I know it won’t be easy but this is important to me so I’m prepared or work for it!

This article was first published in TILT Magazine (Therapeutic Innovations in Light of Technology) and I am pleased to say I have since qualified and continue to work therapeutically online.