What is this thing called therapy?

If you are a prospective client beginning the search for therapy and a therapist, the various approaches available can lead to much confusion. How to know which method is going to suit you and the issues you want to work through? I will attempt to explain in brief terms, the difference in approach that underpins some of these schools of therapy. [My apologies in advance for what may seem reductive to some!]

  • CBT [Cognitive Behavioural Therapy], DIT therapy [Dynamic Interpersonal therapy], EMDR [Eye Movement Desensitisation and Reprocessing], Solution Focused Brief therapy. These are often time- limited approaches to therapy. Clients and therapists will work in a structured and organised way focusing on particular problems that the client identifies. The CBT therapist may use worksheets and other tools to bring about helpful cognitive and behavioural change in the client. For individuals with OCD, panic disorder and phobia this can be a very useful approach. EMDR is evidence-based as effective in relieving symptoms in people suffering PTSD.
  • Person-centred or Humanistic therapy works from the premise that certain conditions offered by a therapist [warmth, congruence and non-judgemental acceptance] will enable a client to grow and self- actualise. There is a focus on the here-and-now rather than the past.
  • Psychodynamic and psychoanalytic therapy is grounded in the notion that an individual’s presenting difficulties may be rooted in past experience and particularly in early family life. It is curious about the idea of an unconscious, and the theory that we are sometimes unconsciously compelled to repeat dysfunctional patterns of behaviour and relationships. It is an approach that is generally less interested in focusing on ‘symptom management’ than exploring what underlies and creates the need for the symptom. By uncovering what underlies the symptom it is to be hoped that fundamental and lasting change can be effected.
  • Systemic therapy is often utilised by therapists working with couples, families and children. It looks at families and individuals as existing within some kind of family ‘system’. Difficulties in an individual or in a part of the family can be understood as having a ‘ripple out effect’, which negatively impacts others in that system. Trans-generational trauma is of interest.
  • Psychotherapy is generally open ended and for clients who are interested in exploring issues at some depth. Psychotherapists have had a rigorous four- year training which involves having their own long-term therapy and working with clients with complex presentations such as Bipolar disorder, or Borderline Personality Disorder.

Whatever the approach, all the evidence about what makes a therapy effective points to the strength of relationship between client and therapist as key. No single approach is better than another, and many experienced therapists use a ‘cross-modality’ approach where they draw from several models in order to meet the needs of the individual client.

Truly Bipolar

In his excellent book ‘Strictly Bipolar’ the psychoanalyst Darian Leader describes the dramatic rise in diagnosis of bipolar disorder in current times. Almost 25% of Americans are now diagnosed with some form of bipolarity, an increase of some 4000% since the mid-90’s. Leader writes, ‘The question today is not ‘Are you bipolar? But ‘How bipolar are you?’

The burgeoning of bipolar categories into Biploar 1, 2 and 3 and the proliferation of websites and articles online with a kind of checklist of ‘symptoms‘ has encouraged people to self-diagnose. For a person suffering mental ill health there is an understandable longing to find out what is causing their distress. Clients can come into therapy with questions around diagnosis, ‘Am I bipolar?’ Whilst anyone can become low in spirits at times and then elated at others, the extreme experience of true manic- depression is underpinned by a particular mental structure. A good psychotherapist can help clients explore the experience of their illness, better understand themselves and find ways to manage what can feel at times truly terrifying. If the therapist believes their client is truly bipolar they may refer on to a psychiatrist, for only a psychiatrist can give a definitive diagnosis and prescribe the drugs that may help control distressing thoughts and behaviour.

In a manic state the individual often describes feeling truly ‘alive’, intimately connected with other people and the world. Stephen Fry writes, ‘We are kings of the world, nothing is beyond us, society is too slow for our racing minds, everything is connected in a web of glorious colour, creativity and meaning.’

This elated state is intoxicating, yet on the downward spiral these states bring dreadful lows and nightmarish agitation that make sleep and rest elusive. The paradox of bi-polarity is that despite the suffering it may bring, the giving up of the manic states of creative elation may feel too much of a devastating loss. Compliance with medication is frequently poor for these reasons.

The experience of the manic highs and desperate lows of bipolar disorder are truly terrifying for the sufferer. It is a serious thing and with it comes a devastating sense of loss of the ‘self’. Often recovery requires the combination of medication and psychotherapy to help the person integrate the bipolarity so that is part of the ‘self’ without defining or overruling it in ways that are harmful. Whilst a person may fully recover from a depressive episode, bipolar disorder is a lifelong condition. With any devastating diagnosis comes loss, and loss requires mourning so that the individual can move on and have the best and most fulfilling life possible.

Whilst the most obvious aspects of bipolar disorder might be the contrast and disconnection between high and low moods, a psychotherapist will explore with a client the quality of these states of being and the thought processes that underpin them. We are all after all individuals, our stories unique.

Pornography, the Internet and the Couple Relationship

The growth in pornography is linked to the ease of access to the Internet and the sheer volume of online pornography available. Most users are accessing free online pornographic material [80-90%], and 24% of smartphone users look at pornography on their handsets.
The effect upon couple relationships can be devastating and up to 50% of divorce cases cite obsessive interest in pornographic websites as part of the reason for relationship breakdown.

Use of pornography per se is not necessarily the problem; some couples and individuals enjoy the use of pornography and maintain healthy and loving relationships. [The ethics of pornography is beyond the scope of this short article]. However, some individuals are more at risk of developing an addictive and compulsive use of Internet pornography, perhaps as a defence against depression or anxiety, or experience of childhood trauma.

Spiral of Addiction

Unfortunately the guilt and shame that addiction to pornography arouses, leads to further withdrawal, depression and isolation and the couple relationship is neglected and avoided. Partners can feel angry and resentful towards the addict. They may feel rejected and unattractive, humiliated and shamed. For both parties these problems are difficult to talk about with anyone and often such a couple struggles even to seek professional help, so great is their hurt and distress. However, once lines of communication are opened up and help and support enlisted, then positive change can begin.
Once the underlying factors that might lead to an individual becoming addicted to pornography are addressed and understood better then an appropriate and individualised treatment model can be constructed. Often the experience of being supported by a compassionate and non-judgemental therapist is the catalyst for change.

Young People and Pornography Addiction

Young people are exposed to pornography in an unprecedented way. Research shows a significant drop in the current rate of teen pregnancies, suggesting young people are having less sex but engaging in online sexual activity more. The ‘sexual templates’ of young children, laid down before the age of 10, can be distorted by exposure to on screen pornography. Boys that may become fixated on pornography can develop unrealistic ideas of human sexual behaviour and then find that this impairs their experience of ‘real’ sex with partners. Equally girls are growing up with pressures to look and perform like the young women they see in pornography. Again, some adolescents are mature enough to realise that intimate sexual relationships require love, respect and communication on both sides. They may be fortunate enough to have come from an environment that models this way of relating. Other young people are less fortunate.

How Can Therapy Help?

Therapy can help the individual or the couple work out what the underlying causes of addictive use of pornography might be and then think about how positive change might be managed. Unravelling the unconscious aspects of the compulsion can be essential if this change is to be lasting. Addressing any addiction takes courage and perseverance. Working with a trusted and supportive therapist can be the difference between success and failure.

Understanding and Living with Anxiety

To be anxious is to some extent a normative aspect of human experience. If inertia is the opposite of anxiety, then it is clear that some degree of anxiety is in fact helpful in powering the drive to achieve certain goals, and in fact surviving. Yet in modern Western society the term ‘anxiety’ has become synonymous with mental health difficulties. ‘Generalised anxiety disorder’ [or GAD] is a relatively new term, applied by mental health professionals to a person who might present complaining of an anxious mental and physical state with no clear cause. GAD is often characterised by a crippling anxiety that attaches itself to anything and everything and to all aspects of the individual’s life.

Our distant prehistoric ancestors had powerful and quick acting fight/flight responses in order to hunt and avoid becoming the hunted. The modern human brain is still wired to convert anxiety into a physical response, flooding the nervous system with chemical signals such as adrenalin and cortisol. The resulting physical responses, [raised heart rate, breathlessness, skin flushing, nausea and insomnia] are only too familiar to people who suffer heightened and prolonged episodes of anxiety. Our distant ancestors had plenty of opportunity to discharge this flood of fight/flight chemicals through the physical demands of survival. The cerebral and sedentary nature of modern life is far less suited to this method of returning the mind and body to a state of equilibrium.

CBT and Mindfulness techniques go some way to addressing this modern dilemma, suggesting behavioural measures through which anxiety can be controlled and reduced to more tolerable levels. These include easy to master techniques such as breathing and relaxation exercises, taking short breaks from work, from computer screens and phones in order to get up and move around. Becoming aware of the body and using it to engage the senses can be grounding and anxiety relieving.

The therapeutic approach used by psychoanalytic and existential psychotherapy strives to look more deeply into the root causes of human anxiety. People seek out counselling and support when levels of anxiety become too unbearable, and old ways of managing become dysfunctional. Whilst behavioural methods might enable some control over the symptoms, psychotherapy strives to be curious about the more existential aspects of anxiety. What is it to be human, to strive to live a meaningful and fulfilling life? What might make us anxious about the notion of failure as opposed to fulfilment and success? What is it about ourselves that we imagine others might reject or dislike? People today, more than at any other time, have a notion of themselves as having potential control over their lives and the choices they make and this makes them anxious. Anxiety, when raised to crippling levels, can make the sufferer feel that life is difficult to live. The therapist strives to explore with the client what it is that might make life a richer and more pleasurable journey. Understanding and confronting the existential nature of the anxiety can be essential in beginning to enable some mastery over it.

Living with an Alcoholic Parent or Partner

In the UK, alcohol abuse accounts for more deaths and chronic illness than any other single drug of choice.Beyond the effect of alcohol on the individual who drinks, is the insidious and corrosive effect upon family life. For every problem drinker it is estimated that at least five other people are adversely affected.The children and partners of the person who drinks to excess often describe living in a near constant state of anticipatory anxiety and fear, due to the volatile and explosive anger that accompanies prolonged abuse of alcohol.’Walking on eggshells’ in order to avoid ‘setting off’ or triggering rage or abuse from the uncontrolled drinker.Many people who drink excessively do so in order to anaesthetise themselves against the pain and distress of underlying mental health problems such as anxiety or depression.

Most families struggle to manage the problem of the alcholic individual on their own. The partner of the alcoholic may feel guilt that he or she cannot help the loved one get back control of the addiction and come to feel themselves in some way responsible. The silencing effects of shame upon such families may drive the problem deeper underground, but of course it rarely goes away without active intervention.Problems frequently escalate until relationships are at breaking point. Treating the drinker without also helping the family often makes treatment less effective.

Sadly for the children who grow up in this atmosphere of fear and uncertainty the accumulative effects amount to a chronic and persistant trauma.Children describe the need to be alert at all times, vigilant for signs of mood changes and loss of control from the parent [or parents] who drink. Children develop strategies to avert disaster, but many times these prove insufficient.

The support group Al-Anon [http://www.al-anonuk.org.uk] provides help for anyone whose life has been affected by someone else’s drinking, whether that person is still drinking or not. It offers another group Alateen for children and young people who are able to get support from sharing their experiences with others.The wounds may run deep in those affected by a loved one’s alcoholism and even years later an individual can struggle with relationships and trust.  Groups such as Al-Anon, or individual counselling , may offer the chance of a reparative experience.Often the simple act of being heard  and of someone else bearing witness to distressing and traumatic experiences, can reduce the power and potency of these experiences over the rest of the individuals life. In this way a new story becomes possible, one in which alcohol, addiction and abuse need not have a place.

The Pattern of all Losses

Often it seems that people turn to therapy in response to an experience that confronts them with some kind of loss.Certain losses are profoundly disturbing, resisting relegation to that dark internal corner of the mind marked,’To be thought about later.’ Human nature is to defend against the reality of death and the separation and loss of the loved one that a bereavement brings. Other losses may be less acute or traumatic.The loss of a relationship, a job, a friendship or some other treasured and nurtured aspect of  life that may for some time have defined you. People mourn the loss of their youth, their children growing up and leaving home. They mourn lost opportunities, paths not taken on their journey through life, decisions and choices made. In her review of CS Lewis’s ‘A Grief Observed’ Hilary Mantel succinctly describes how the ‘pattern’ of all loss mirrors that of the gravest losses, leaving the sufferer to struggle with the physiology of mourning, plunged into grief and fear.It can feel as if we are in an endless cycle of attachments made and lost.

‘Disbelief is followed by numbness,numbness by distraction,despair,exhaustion.Your former life seems still to exist, but you can’t get back to it;there is a glimpse in dreams of those peacock lawns and fountains, but you’re fenced out, and each morning you wake up to the loss over again.’

Freud observed that in a symptomatic and unresolved grief, where the working through  of mourning had not been achieved, the sufferer remained in a kind of melancholic and backward looking state, unable to fully disengage from the lost person. Western culture promotes ideals of the desirable mental state as one of resilience, contentment and happiness. There is a societal dread of protracted states of sadness or depression in the individual and an increasing tendency to offer medical ‘diagnosis’ for states of mind that are perhaps an appropriate response to loss and grief.In his book ‘The New Black’ Darian Leader writes;

we should see what we call depression as a set of symptoms that derive from complex and always different human stories. These stories will always involve the experience of separation and loss,even if sometimes we are aware of them.’

Current losses evoke old losses.Losses that have been stacked up and left unattended can be revived, triggered perhaps by some especially powerful event.The resultant existential crisis may leave us with no option but to fully engage with our sadness and the question of what it is to be human and endure such separation and loss. Therapy does not, [or rather should not], offer a quick ‘fix’ to the process of loss and mourning.Therapy offers a secure and safe space, one in which the therapist, another mind, can walk along side of the individual whilst they  make the difficult journey towards some kind of acceptance and assimilation of whatever it is that has been lost to them. Human life is inevitably overshadowed at moments by loss. Perhaps we do not so much ‘get over’ our losses as learn how to make them a part of our story, however difficult or painful, in order that we can continue along the path of life.Hope may be hard won, but it is on hope that the foundations of therapy are built.

CS Lewis ‘A Grief Observed’.

Darian Leader ‘The New Black’.

Hilary Mantel ‘My heart and body are crying out’ Guardian Review 27th December 2014

In Praise of Small Pleasures

We construct the stories of our lives around the significant events that might seem, [at the time], to define us;  birth,deaths first loves,relationships, marriages, jobs,moving house and so on. If you look back over the last few years of your life, something will undoubtedly emerge that constituted a fairly major event because it necessitated change.Even when such change is looked for and anticipated, it can bring with it a sense of loss. As we are constantly bound to move forward through the trajectory of our lives, the yearning to return sometimes to an earlier time is an understandable fantasy, but also just that, a fantasy. As adults we can envy the ability of the young child to exist in the moment, absorbed in play, free of the  gnawing existential anxieties that can plague later life. The child’s ability to engage fully in small pleasures , [an ice cream, fallen leaves in Autumn],  can transport them to a place of internal wonder. Can you remember when you last lost yourself in a small pleasure like that?  And yet, I suggest, it is such small pleasures that might sustain us through the worst of times .A precious half hour snatched in a busy day to read a book or listen to music, to drink an espresso, read a newspaper. These moments, if treasured and looked out for, can offer some respite from the relentless onslaught of contemporary life. Small pleasures, after all, can stay the same when all else around you seems in a constant state of change.If you used to love to read a book, the chances are that you still might. Can’t think of a small and wonderful pleasure that is just yours? Then it might be worth really thinking about where your pleasure and desire is located. Sometimes we need to do things in relation to other people, but if we can locate what it is that we can enjoy and achieve on our own, then we are better equipped to get by when we find ourselves alone.Find your small pleasures and then fight for them.The rewards will be exponential.

Attachment and Loss and the Work of Mourning. A Boy’s Story.

A teenage boy I know well, [son of a good friend], has been in mourning over this Christmas holiday period, bereft by the death of his beloved and long-lived hamster. This little pet has been his support and confidante through some stormy years. ‘I miss having something to look after’ he tells me. I wonder also that the hamster [a’ she’] was, in her constancy and her silent acceptance of him, a secure and safe space where he could feel himself looked after also. The little hamster was a Christmas present herself, several years ago, and this fact seems to compound this boy’s awareness of a lost part of himself, the child who used to be so excited and transported by Christmas. He cannot get his little hamster back, and neither can he turn back the clock and become again, even for Christmas, the boy he was before adolescence struck.

‘How long is he going to be miserable for?’, his exasperated mother asked me ‘‘This has been going on for days now!’’  She feels the loss of her son to her. Where once she could seem to make things ok for him, now he seems beyond reach. For both mother and son there is a dawning realisation of the temporal nature of childhood and of life itself. Our attachments to others are what make this existential reality, at times, so exquisitely painful. How indeed are we to ever recover from the loss of those so beloved to us? We are thrown into the work of mourning.

I am struck by this boy’s awareness of his need to engage in the process of grief. With the wisdom of youth he intuitively does what he feels will help him to make sense of this. He has buried his hamster and built her a cross, planted some flowers. He rejects the attempts of his parents to engage him in social activities, explaining that he will re-engage with friends when he goes back to school. He is quite insistent that to do this before he feels ready will be a burden for him and for others. How many adults would be able to resist the social pressures to hasten the process of grief and mourning in order to make themselves more acceptable to others? ‘I wish I had known how much I loved her before she died’, the boy explains. It bothers him that she might not have known the extent of his love. It seems a universal irony, that it is only with the loss of something or someone that we are made aware of their true value to us.

I have no simple answers to this mother’s question of ‘How long?’ The process of mourning for each of us is complex, bound up with our individual personalities and the nature of the bonds and attachments we make to others. ‘Allow him Time’ I suggest to my friend . Should we perhaps appreciate this boy’s engagement with loss, rather than rush to bring him to a position of normative ‘happiness.’? This experience of a lost attachment will be some preparation for the next loss. He will recognise this experience and know that it can be endured and integrated.  Only by becoming ill with grief can we experience the joy of health and recovery.

New Year, New You?

So it’s that time again, New Year’s Eve.  Standing poised between the closing hours of the old year and the opening hours of the new, we may, if we are lucky, snatch some moments to reflect back on the losses and gains, the high points and the low points of the year that is drawing to a close.

Amidst the pressures of family life and work it can be difficult to take the opportunity that this holiday time might bring to stand still for a moment and note one’s own state of mind and body. There is a cultural and social drive to keep moving on, to accumulate more money, experiences, relationships and possessions.  Yet in order to be open to make good use of these potential experiences and relationships on offer, we need to struggle to achieve the kind of self-awareness, insight and equilibrium, which will enable these experiences to be truly valued and transformational. This notion of self knowledge as the key to something transformational is hardly new. As Marcel Proust wrote, ‘The real voyage of discovery consists not in seeking new landscapes, but in having new eyes. ‘

So, how has the past year been for you and what are you left with at the end of it? What might you hope for yourself in the years ahead and are you going to need to do something differently in order to achieve it?[And  doing something differently might involve less, rather than more, action.] The challenge posed here is two-fold.

Firstly, it requires an awareness and acceptance of your own needs, hopes and desires. Many people have internalised a notion of their needs and desires as somehow shameful or invalid. Self denial and self disgust are frequently high on the agenda as the New Year begins. Resolutions centre on the need to somehow achieve validation through the ‘losing’ of things; chocolate, food, wine, weight, cigarettes. How often though are diets begun or substances given up only for the resolution to be broken in one of those ‘Oh f*** it!’ moments? On a dark, wet and windy January night the short term benefits of a take-away and a bottle of wine may heavily outweigh the long term gains of abstinence.

What may not get addressed is how these pleasurable substances fulfil and how instantly they are on hand to feed and ‘nurture.’ If you are going to take them away, with what are you going to replace them?

The second aspect of the challenge is that to get what you hope for, need or desire may involve Change, and as human beings [on an unconscious level at least] we seem highly resistant to change. Freud noted that his patients began analysis with him stating their conscious desire for change, but would then in the course of their treatment utilise all kinds of defence and resistance in order to ensure such longed for  change would not take place. Sometimes the painful self sabotage we are engaged in seems safer and less unsettling than the new or unknown. Change after all involves loss. Loss of the way of life that we have become accustomed to. Otherwise it would be so simple , wouldn’t it? You want to be thin? Go on a diet, run! You want to save your liver? Stop drinking! These straightforward instructions seem so satisfying, so linear and clear. That’s why diet books sell. Alan Carr sells. And yet people slip back into their old ways of being, because the loss involved in giving up these behaviours and ways of being in the world have not been addressed somehow.

Perhaps we could begin the New Year thinking on what we might want to add to our lives, rather than what we should take away. By shifting the focus from self denial to self  care, it may be that fear of change and loss can be confronted in a rather different and more generative way.