Online Counselling or Face to Face Consultations in Sydney, Australia

Ash Rehn QindsmI’m Ash Rehn, counsellor, coach and Medicare Provider. Take a look around to find out more about my in-person and online services.

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Treatment for Pornography: From Disease Model to a Response by Men

Young couple in the couch having conflict problemTreatment for Pornography Addiction often focusses on the act of watching pornography and assistance to try to reduce the ‘behaviour’. But if such an approach doesn’t work, what are the alternatives and why don’t we hear more about them?

I’ve been working with concerns about addiction to pornography for a number of years now. When men started to contact me seeking help (and it was mostly, although not always, men who wanted help with porn use) many of them came to me equipped with a glossary of terms from 12-Step programmes like SAA (Sex Addicts Anonymous), SLAA (Sex and Love Addicts Anonymous), SCA (Sexual Compulsives Anonymous) and SA (Sexaholics Anonymous). They spoke of concepts like ‘sobriety’, ‘healthy sexuality‘ and ‘bottom-line behaviours’.

Alternative Treatment to 12 Step Programmes

Some of these men had invested quite a lot of time reading about these models of addiction, understanding the group concepts and attending groups. At the same time, they were consulting me because the groups and 12-step programmes had not completely worked for them: they were still using pornography or were dissatisfied with the amount or type of pornography that they were viewing. Ironically, most of the men who had turned to the 12-step model seemed to want to continue to use the terms and concepts the programme had taught them, despite deciding it hadn’t worked.

It is not always possible to continue to view our actions through the same lenses to which we are accustomed, particularly when those lenses fail to provide us with clarity or vision. One of the difficulties of trying to develop what I call ‘self-agency’ when working within a 12-step model is that the model itself tells the person he is powerless. So it is kind of at odds with the idea of gaining more influence over one’s own life and actions.

The ‘brain chemistry’ model supports a sense of powerlessness as well. If we don’t understand the chemistry of the brain – and perhaps even if we do – we are at its mercy. But dialogue can create meaning. Do we really need to pretend pornography use is all about complex science only specialist medical doctors understand?

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Brain Chemistry or Sobriety? Both are Disease Models of Porn Addiction

Both of these approaches assume that pornography use is a disease. And many people are surprised to find out that there is no diagnosis of pornography addiction according to the major disease classifications,  I realised quite early on that simply accepting that addiction to pornography was a disease would spin off a number of assumptions about a person’s use of pornography that might go unquestioned. So instead of looking at what was the same for these men who were consulting me, I started exploring what might be different for them. And I found many differences. In fact, every man who contacted me had a unique story. While there were some common threads, failing to approach their stories as unique narratives of porn use clearly meant I was missing crucial details about what was significant in each man’s history and the way porn had found its way into his life.

I believe it is disrespectful and fundamentally flawed to use a ‘colour-by-numbers’ approach to concerns about porn use. We need to look beyond the act of a man looking at pornography and instead consider the ways in which that act might be a response. And to what it might be a response. Focusing on porn use as a problem rather than as a response is like simply focussing on cars as the cause of traffic accidents without ever considering transport needs. People watch porn for many different reasons. What I offer is a chance to explore those reasons and investigate how pornography has taken such a place in a man’s life.

But there is another point to be made here. It’s not my place to judge a person’s porn use. The medical model suggests we give ourselves up to the doctor or psychotherapist who presumably knows best. The risk is that the patient or client becomes more or less a helpless victim. When men contact me, I’m interested in their concerns and why they are finding their porn use a problem. I don’t start with an agenda that I know best. So these therapeutic meetings are dialogical: they happen through conversation. They aren’t about instructing men what to do or passing judgement on their actions. Instead we explore the topic brought to the session and develop meaning around it together, in dialogue. That is the way to new understanding and more influence over the choices made in life.

You can contact me if you would like to make an online appointment or meet with me in-person.

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Healthy Sexuality and Sexual Addiction: Two Ideas Worth Exploring

Unhappy couple in bedroomI was recently contacted by a student who was writing a paper about ‘sexual addiction’ for a college course on sexuality. As a counsellor and therapist in private practice, I’m not usually in a position to offer so much assistance to students (I receive many requests and my time with people is my livelihood) but my curiosity was drawn to the theme of his particular course: Healthy Sexuality.

Sexual Addiction and ‘Healthiness’

To date there has not been so much written about the idea of sexual addiction from a narrative therapy perspective. When I saw the course title, what immediately struck me was the lens of healthiness through which sexuality was being judged. I know this is a very common way to consider sexuality because I hear it all the time. And I began my career working in the field of sexuality as a ‘health educator‘. In a state, culture and era when public dialogue about sex was largely taboo, health (and specifically HIV) provided an entry point to talk more openly. The rules were that our sex talk had to be the interests of public health.

When people consult me about sex addiction, they are often describing their actions in terms of whether they are ‘healthy’ or not. These days the concept of healthy human sexuality has become such a norm it is a cliche. It seems to me that, particularly since the onset of AIDS, ‘healthiness’ is the primary lens through which we tend to view sexuality. It is taken for granted that sex and sexuality must be ‘healthy’ first and foremost. And this makes me curious about the division that is made between ‘healthy’ and ‘unhealthy’ sexuality. How useful is this binary? And who determines what is ‘healthy’ and what is not?

It also has me wondering about what happened to other perspectives or lenses through which we might view sexuality. What does sexuality look like, for instance, through a lens of Pleasure? Or a lens of Community? Or a lens of Power? Or Spirituality? Or – dare I say it – ‘Fun’?! What does your sexuality look like if you view it through those lenses instead? Or how about through the lens of Self-Knowledge, finding out about yourself?

Exploring Sexualities and Alternatives to ‘Addiction’

It does strike me that when we start looking at sexuality through a lens of ‘healthiness’ we might also be standing firmly within the disease model. It’s no wonder these fears about addiction figure so strongly when we are viewing ourselves with the presumption of a deficiency or possible health disorder. We lose the context. In the stories I hear, people tell me about the steps they are taking in exploring desire. They describe themselves acting on urges they have had for 30 years but done nothing about due to shame or fear of ridicule. Others tell me about strategies of using pornography for stress relief, or to relieve boredom or to escape from grief that has overwhelmed them. Some people tell me how good they feel when they have sex but say they can’t share this with others because of taboos around discussing sex. I find myself engaged and interested in the courage, skills and abilities of those who consult with me and we draw on all of these in our work together.

history of sexualityIn his book series The History of Sexuality, the French philosopher Michel Foucault claims that the concept of Sexuality itself was developed to ensure power remained with certain people. Sexualities are proscribed in the same way that particular activities or behaviour might be regarded as disordered or pathological or unhealthy. In narrative therapy there is an idea that people can be experts in their own lives. This certainly challenges the standard model supporting doctors, psychologists and psychotherapists as the experts, but it is a way of thinking I personally find exciting and empowering.

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Inspiration in Treatment: The Rewards of Working as a Therapist in 2013

Celebrating 2014How was 2013 for you? What does 2014 have in store? Do you have any New Years Resolutions?

When out socially, I’m regularly told that my work must be demanding, difficult and depressing. It must take its toll on you, people say.

I don’t want to pretend that being a therapist isn’t challenging and personally tough at times. It is. But it is also a vocation full of inspiration and motivation. I thought I would take the time in this post to appreciate and reflect on the meaning and fulfilment I gain from therapeutic consultations and to share some of the most rewarding aspects of my work from 2013.

Therapy as an ‘In Treatment’ Journey

This year, I have met and continued to work with some wonderful people, journeying with them through confusion, uncertainty and change. An ongoing therapeutic relationship is like travelling with someone. You get to know them over time and through different moods and experiences. You see their ups and downs, are privy to their fears and share their relief.

Some of these are short journeys, for example, adjusting to separation or the breakdown of a long term relationship. Others have been over longer periods or are ongoing: helping guys who are coming out later in life; assisting adults responding to memories of childhood physical or sexual abuse; supporting those in grief around the death of their partner or a loss of direction in life.

In both my short term and long term work, I admire the preparedness of those who consult me in treatment. I notice and call attention to their courage or their skills, their abilities. I’m curious about the sense they are making of their circumstances. I hear their stories and draw out the meaning they make of what is happening to and for them.

Sex, Sexuality and Relationships: Inspiration through Counselling

One of the areas in which I specialise is depression experienced by gay men. In these conversations, we often find ourselves pulling apart the way in which their identities as gay men have been constructed and taking a closer look at what might have contributed to depressed feelings. I’m very conscious that most of us seem to develop our identity against the backdrop of heteronormativity (and homonormativity). Many men feel constrained by the way sexuality has been defined in the last 50 or so years, by the prevailing assumptions about sexuality being fixed. For some of my clients, the only word that comes close to their experience of themselves is ‘bisexual‘, but they say this does not really work for them for a number of reasons.

There are also questions of masculinity to be explored and I always find these conversations stimulating because, as quite a few guys have pointed out to me, the representation of masculinity in popular media is quite limited. This year, I intend to develop my site www.GayCounsellor.com.au with short blogs and articles that will be of interested to all men.

Something else that has been on the radar this year has been the return to dating or relationships by both men and women who are in what they might describe as ‘middle age’. It might be that a long term partner has passed away, or that the person is beginning a new life post-separation. I might be speaking with a man who has lived most of his adult life with a woman, raised children together with her, but decided now to take a new direction, one that feels more comfortable and in keeping with his sense of sexual orientation. Or it could be someone who has spent the last 20 years having casual sex, who has decided they want to experience something different.

These new directions can be quite scary and also take some time. People often feel they have ‘messed up’ or ‘failed’ when trying to establish a new relationship. Sometimes they tell me that it is about learning to date again. They say they feel like a clumsy teenager trying to get a boyfriend or girlfriend. Often they end up finding themselves in treatment, recovering a sense of connection with something quite important about themselves they had lost.

Developing Professionally as a Therapist: Some Reflections

Through this year, I’ve also changed and grown from my experiences. I was fortunate to attend an international social work conference in Kochi, India and present a workshop to an international HIV conference in Paris, France. I lived across 2 continents and worked with individuals and couples across the world. Due to my masters studies commitments, many of these conversation have been online over webcam. Colleagues are usually surprised when they hear I have conversations with individuals in cities as far spread as Moscow, Bangkok, Dublin, Stockholm, Baghdad, Perth, Capetown and Tokyo. But online clients continue to tell me that they feel more at ease working this way online. I’m convinced online counselling and therapy has a big future and can exist alongside ‘face to face’ therapy as another option for accessing help and support.

I’m now working in-person in Sydney Australia again, as a Medicare provider while I continue with my online clients. The Australian healthcare system is one of the best in the world, up there with the NHS in Britain and the public health system in Sweden. Each has its limitations but I feel quite privileged to work in cooperation with GPs to improve mental health outcomes for individuals. I am grateful to the AASW for representing my interests as a mental health practitioner.

My hope for the year ahead is to continue as a counsellor-therapist both online and in-person in this rewarding work with people and their stories. Specifically, I’ll keep pursing my professional interest in concerns about pornography ‘addiction’, ‘sex addiction‘ and mental health services for gay men. I plan to continue some supervision of social workers and complete my dissertation on community work with men who have sex with men. I’ll also be returning to my creative writing. I believe we make sense of our lives through telling stories, to ourselves and to others. This is also the therapeutic nature of narratives.

I look forward to more conversations with those currently consulting me and with new people who contact me. They are doctors, nurses, paramedics, software developers, IT engineers, mechanical engineers, teachers, academics, students, lawyers, journalists, artists, musicians, actors, sportspeople, business owners, business consultants, tradespeople and sales professionals. I find inspiration in their different experiences, stories and meanings, their different lives.

I’m grateful for the opportunity I have to journey with people through the toughest times in their lives. Regardless of whether you are in difficult circumstances right now, or you are travelling fine, I wish you well for 2014 and hope that you find peace and contentment in the year ahead.

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Can I see a Medicare Provider for Porn Addiction? Do You Accept Health Insurance?

Man on computer next to a swimming poolAs a counsellor and therapist specialising in pornography use problems, these are questions I am asked often. Both men and women contact me seeking help, either for themselves or their partners, around use of pornography and dating websites. Sometimes they are concerned or convinced there is a mental health or medical condition involved and want to take advantage of the Australian Medicare rebate for psychology consultations. So I thought I should explain how the Medicare rebate works and under what circumstances this and other forms of health insurance are available.

The Better Access to Mental Health Care initiative was introduced to improve outcomes for people with a clinically-diagnosed mental disorder through evidence-based treatment. As a Mental Health Social Worker, I have been assessed and accredited as having specialist mental health expertise to provide this treatment (selected psychiatrists, GPs, psychologists and occupational therapists work are also working in similar ways under the same programme). Medicare has specific criteria used to determine who is eligible to receive these sessions. You need to first be diagnosed as having a mental health disorder and generally this diagnosis is done by a GP or occasionally a psychiatrist. Your GP will complete a ‘mental health care plan’ for you and you can then access up to 10 sessions of focussed psychological strategies (individual therapy sessions) per calendar year meeting me in-person or with another mental health professional*.

Can I be Diagnosed with Addiction to Pornography or Dating Websites?

According to the World Health Organisation, ‘disorder’ is not an exact term…

…but used to imply the existence of a clinically recognizable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions. Social deviance or conflict alone, without personal dysfunction, should not be included in mental disorder…

(source: http://www.who.int/classifications/icd/en/bluebook.pdf)

Cover of ICD 10Despite popular ideas about the existence of ‘porn addiction’, there is no such diagnosis of pornography addiction in the current International Classification of Mental and Behavioural Disorders (within the ICD-10) used by Australian medical practitioners and the British NHS*. This is the manual Australian doctors use to determine their diagnosis under Medicare’s Better Access programme. There is also no diagnosis of ‘pornography addiction’ or ‘sex addiction‘ in the DSM V – the Diagnostic and Statistical Manual of Mental Disorders used by American Psychiatric Association. So technically a GP cannot give you a diagnosis of ‘addiction to pornography’ that will permit you access to Medicare rebates or health insurance for psychological services. (If you want to purchase either of these manuals, click the links to take you to Amazon).

However, my own professional experience is that many people presenting with concerns about what they believe is excessive use of pornography or dating sites will eventually be diagnosed with a particular mental health condition provided they see a GP. Often the diagnosis they receive will be a form of depression or anxiety (or a combination of both), diagnoses related to grief or loss, mood disorders (e.g. bipolar), post-traumatic stress (e.g. PTSD) or adjustment disorders. Very occasionally it could be a form of sexual dysfunction not caused by organic disorder or disease. These kinds of conditions are often present alongside relationship difficulties, work stress, sleep difficulties, domestic violence or a particular physical illness or health condition.

In other words, it’s important to remember that your access to the Medicare rebate may hinge on whether the doctor considers you have an underlying mental health condition rather than how often you are using dating websites or what kinds of pornography you are using and when. Some people look at pornography regularly and do not report any disturbance to their mental well-being. But patterns around the use of sexual images and even sex itself can be a response to psychological difficulties a person is experiencing. Men, particularly, talk to me about their use of the Internet as a way to escape from anger, stress, boredom, shameful feelings or thoughts of inadequacy. People can use sex as a way to avoid sadness or distract from the emotional pain of separation or even a coping strategy when work, a relationship or loneliness is overwhelming them. Some build up a reliance on the Internet or using sexually explicit adult websites which ends up in sleepless nights, arguments with partners, downloading banned material or many wasted hours and time lost at the expense of other priorities. If internet dating or porn websites have started causing you problems, it can be a sign that all is not well with your mental health.

Getting Help for Depression, Anxiety or Other Problems Associated with Using Dating Sites or Porn Addiction

If you are in Sydney, or can travel from other parts of Australia, you can meet with me in person to discuss your concerns. The first step is to contact me, and sending an email is best although you are welcome to call and leave a message. If you think you might have depression or anxiety, an adjustment disorder or another mental health condition, you can either meet with your own GP or I can refer you to competent local medical practitioners in inner Sydney. If you are an Australian resident and meeting with your regular GP, ask for referral to me under the ‘Better Access’ programme. The doctor will generally ask you some questions to ensure your symptoms are appropriate for the referral and then complete what is called a ‘mental health care plan’ for you. What I require at the first appointment is a letter of referral from your GP. This can either be addressed to me or ‘The Mental Health Professional’. Some GPs have existing relationships with other mental health social workers or psychologists, but it is your choice who you see. Unfortunately I cannot meet with you without a referral letter so it is best to ask for it to be addressed to me personally or the generic ‘Mental Health Professional’. Ask the doctor to give you the letter (don’t mail it to me, give it to me in person at the first session). My address for the referral letter is:

Ash Rehn (private and confidential)
PO Box 7798
Bondi Beach NSW 2026

Provided you meet the criteria for the Better Access programme, have been referred and not used all your 10 sessions for the calendar year, Medicare will provide you a rebate that will cover part of the cost of the consultation. To find out more about my fees, please contact me and let me know you are interested in an in-person appointment in Sydney.

If you don’t live in Sydney, cannot travel or simply prefer to meet online over webcam, telephone or through email counselling, we can meet online. Unfortunately, at this stage Medicare does not offer rebates for online counselling or therapy appointments. But many people prefer the privacy and convenience of meeting online. And of course for some people it can feel a lot easier to discuss these kinds of sexual problems online. Take a look at my online counselling and therapy options for more information about the services I offer.

Health Insurance Rebates for Pornography ‘Addiction’ or ‘Sex Addiction’

Once again, as neither Pornography Addiction nor Sex Addiction are officially acknowledged as mental health disorders, health insurers will generally not pay for treatment specifically for these concerns. However they may be satisfied if the appointment was ‘psychology services’. Whether or not your health insurer will pay towards the sessions depends on the insurer. I generally do not mind who pays for the sessions but require payment at the time of the appointment. You will need to discuss payment with your health insurer in advance if you want to be sure. I can provide you a receipt to show you have paid for the sessions but cannot guarantee that your insurer will pay. Some of my clients – both online and in-person consultation – prefer to keep their sessions ‘off the record’. The advantages of not requiring a rebate for private therapy and counselling include:

  1. It’s much easier to get an appointment. You don’t need a doctor’s referral or to meet the eligibility criteria;
  2. I will work collaboratively with you and can be flexible to your circumstances. If you go through the healthcare system, the system determines how many sessions you receive and when your treatment is over;
  3. Funding through both Medicare and health insurers is limited to certain psychological approaches and strategies. You may not find these meet your needs or take your preferences into account. For example, Medicare does not fund relationship counselling, yet many of my clients seek assistance for their relationships and this may require a course of sessions in itself.

How Can a Medicare Provider Help Someone who is Using Porn or Sex as a Response to Mental Health Problems?

Once again, it’s important to stress that using pornography or sexual activity is not necessarily a mental health issue in itself. But if you are having severe mood problems, suicidal thoughts or destructive thoughts, chronic depression or disabling anxiety, and your porn-watching or sexual behaviour is making these worse, it is time to get help.

The focussed psychological strategies that Medicare Providers use include,

  • Psycho-education, including Motivational Interviewing
  • Cognitive behaviour therapy (CBT) including: behavioural intervention, behaviour modification, exposure techniques, activity scheduling
  • Cognitive interventions and cognitive therapy
  • Relaxation Strategies (such as progressive muscle relaxation and controlled breathing)
  • Skills training and
  • Narrative Therapy

Taking the first step is often the hardest and it gets easier after that. The people who consult with me tell me they are glad they made the decision to get help and the first session was much easier than they imagined. So if you have been thinking about doing something positive for your mental health, stop delaying and make contact now. It is the first step towards feeling better.

For more information get in touch with me either by email or phone.

*This information is correct at the time of posting this article.

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