Friday, 23 January 2015

Working with Addiction Part Two

In working with addiction, if long term change is to be achieved, it is important to consider what encouraged the development of the addiction in the first place. A theory that many clients find helpful is the concept of the cycle of shame. The idea here is that the client may have had experiences which established a sense of deep inner shame, often in childhood. It is possible to create a distinction between guilt, a feeling resulting from the perpetuation of a regretted act, and shame, a conviction of being intrinsically bad at the core of your being. The second could be produced in childhood by physical, emotional or sexual abuse. The psychology of a child makes a young person inclined to attribute all that happens to his or her agency, and this is reinforced by parental and societal behaviour. If you do something disapproved of, you may have to sit on the naughty seat or be sent to bed without anything to eat; if you do something approved of, you may get praise or even a reward of some sort; this creates a Pavlonian response of linking what happens to you to your own behaviour. Of course, this is cemented in if the parent is abusive. Children who are abused are both enjoined to secrecy-a shame-inducing procedure-and also told that their own actions or manner is to blame for the abuse; for example, they can be accused of seductiveness, told that their own beauty is to blame, or be instructed that they show they enjoy the abuse. It is not impossible that abused children exhibit an autonomous response akin even to pleasure, for purely physiological reasons. All of these circumstances can lead to a child suffering a sense of being "dirty" - of shame. 

You can see that another factor here is that the abused child sometimes has a motive to avoid being angry with the abuser. It is often not safe to be angry with an abusive parent for fear of triggering more abuse or even worse; there can be, and not always without cause, a fear of being attacked, abandoned or even killed. If anger cannot find its natural target, it tends to be internalised and to boomerang, taking the shape of a profound sense of shame.

Nor are these the only circumstances which can be associated with shame. Being routinely disliked or bullied, being on the receiving end of name-calling, being emotionally deprived and unloved, can all produce a fundamental sense of unworthiness. 

Furthermore, shame, like measles, can be caught. A child who accompanies an alcoholic parent to a restaurant, for example, may feel deeply ashamed of the adult's behaviour, perhaps because he or she senses the disapproving attention which the parent's loud behaviour might be attracting. 

In the circumstance above, and in others, a keen awareness of humiliation may be present. Neurological research suggests that humiliation may be one of the most powerful and enduring sensations we can experience.

For many people, a negative body image may be a source of shame. Poor skin, being small, skinny or fat can produce feelings of inferiority, especially likely to be present if there is teasing or bullying. I have noticed that attractive people can be very liable to be bullied out of envy, the victims often accepting that they are unattractive, the exact opposite of the reality. People who are different, odd or eccentric, alongside people of exceptional intelligence and precocity, can also be shunned and excluded, losing in the process a feeling of belonging and acceptance. In England, finding yourself displaced socially or geographically can lead to being on the receiving end of snobbery or inverse snobbery. 

Those who have arrived from another country or find themselves socially isolated can suffer from the bigotry and prejudice of others. Racism, anti-Semitism and Islamaphobia can induce a sense of shame.

It is worth dwelling upon the difficulties faced by people who realise that their predominant sexuality is not heterosexual, especially if they encounter entrenched hostility to homosexuality in the family, school or religious group. Here they can be pressured to feel intrinsically wrong, even sinful.

For people, then, alcohol can be a refuge, a safe place, from which the ever-feared awareness can be banished. Perhaps, the prototype of a refuge is the womb, and the act of drinking, a profoundly oral act, can resemble the sucking on a breast which provides comfort and security after we have been thrust into the world. Within the cocoon of partial or near-complete loss of sensibility, other sensations can also be avoided. The most obvious of these are social awkwardness, shyness and insecurity.

With the first of these states, shame, it is usually much easier than the client might anticipate to dispel it. Very often, a discussion of the originating circumstances can enable the client to realise that there was no reason to feel shame at all, and, if there was anyone in the situation who might properly experience shame, it might be a parent, adult or group-anyone, in fact, except the client who has taken it on.

With anxiety of every kind, it is important to know that alcohol, like all other stimuli, is subject to the law of diminishing returns. A first drink may help, a second will help less and a third may be a hindrance. Here, the research evidence is quite conclusive; more than a small quantity of alcohol increases rather than reduces anxiety. This may be, as clients have suggested, because people feel ashamed of their reliance upon alcohol but also because anxiety is produced by the effort required of an intoxicated person to appear sober. The evidence suggests that drinking even a small amount of alcohol at night induces anxiety and enhanced tremelousness the following day. More to come.

Thursday, 13 November 2014

Working with Addiction : Part One.

This piece is an argument about how to deal with addiction. It contains an account of the main strategies that have been suggested to help clients cope with addictions. It does not accept that Cognitive therapy by itself is the best approach. It firmly sides with an Integrative therapeutic view rather than the strategies of Alcoholics Anonymous. I do not accept the blanket statement, which is at the core of the approach of AA and similar organisations, that "we are powerless in the face of our addictions" and therefore have to call upon the aid of a "higher power" to resist them.

Nor do I think it remotely convincing to claim that the Twelve Steps can be retained but reinterpreted with a personal idea of a "higher power."  The steps clearly imply a beneficent, omnipotent God. At AA meetings, religious ideas often predominate.

At the risk of losing most of my readers early on, I need to say that, although I have religious views of my own, I have worked with non-religious people who have combated their addictions with massive effectiveness by using psychological means, and so I am advocating a psychological rather than religious view of addiction work.

The way in which I have seen people gain control over their addictions is by thinking effectively about the addictions but also about themselves and their entire lives. For an addict, this might seem woefully inadequate and weak. Most have recognised that their behaviour is self-destructive but have not yet stopped it.

The key word above is 'effectively'.

My argument is going to be that the existence of modern technology enables therapists to think about doing addiction work in new ways- ways that bridge the gap between Humanistic, on the one hand, and more cognitive and directive therapies on the other. These can be used in the service of improving the effectiveness of established therapeutic techniques.

There are at least six ways in which the effectiveness of thinking can be enhanced: firstly, it can become more focussed. Secondly, it can make greater use of psychological principles. Thirdly, running alongside the first despite being very different in character, it can be more freely and deeply exploratory. And, fourthly, it can get to the psychological maintaining factors on an emotional level. Fifthly, it can be directed towards greater life satisfaction which can remove much of the motivation to escape. Sixthly, it can put an emphasis on becoming more of an engager and less of an avoider, thereby attacking the denial and ostrich-like behaviour which often characterises the drinker and drug-taker.

If it is possible to maximise the effectiveness of our thinking, and therefore the degree of control we have over our behaviour, then the next question is " What can a therapist do to enable the client to use his or her thinking to improve their lives?" This question takes us into the realm of discussion around how best to do therapy. 

My argument here is that therapy debate has become a university-led fight over paradigms, and that it would be much better to focus debate around different difficulties faced by clients and how best to help them to move forward. Much debate about addiction involves different and competing schools of therapy. For example, cognitive therapists often have a horror of therapist behaviour which departs from their manuals. They stigmatise this as "paradigm drift".  But this is sectarian thinking; on the contrary, it makes sense that, if a focussed way works, and a deep exploratory way works, then combining the two will work at least as well as either of the approaches on their own. And, if the integrative therapist believes in such an approach, it may be particularly powerful. 

One reason why I am convinced of this is because I think that the person who can understand his or her own behaviour on both the micro and the macro level is especially well placed to change it.

If we consider any field of human endeavour, excellence depends on combining the general and the particular, the broad sweep and the vital detail. This is as true of therapy as it is of any other area of human endeavour. A competitive cyclist needs fitness, stamina, motivation and quick reactions but also needs to know the route and watch out for potholes. 

For that reason, I believe in a comprehensive approach to addiction. Firstly, I believe that, as far as alcohol is concerned, the addict usually has a choice between abstinence and cutting down. This is because it seems that something that can be learned can be unlearned, and can be unlearned by the same set of psychological principles that governed the initial acquisition of addiction. These principles, collectively, are known as "learning theory".

Yet, in therapy, the wishes and experience of the client has to be paramount or the therapy will not work. The client may discover, by experience, that cutting down does not seem to be a relevant option, and this may be particularly true of those clients who like a drink and who are also addicted to cocaine. Alcohol interferes with the functioning of the part of the brain which specialises in rational thinking and so, after a few drinks, the strategies and considerations which enable the client to resist cocaine may become unavailable. Yet I have also met clients who drink liberally but abandon cocaine use, so I would not like to be dogmatic about this. My own experience of clients is that cocaine is so physically and psychologically addictive that the addict is not able to return to occasional use but even here I have encountered an exception.

Therapy can most usefully begin by encouraging the client to establish the reality of his or her own addiction. This should be a factual rather than a moral matter, and challenging the client's view of the facts needs to be done, if at all, sparingly and diplomatically or a tendency to retreat into denial could be exarcebated. Nothing could be more unhelpful than the "demon drink" approach. 

At the moment, probably the majority of addiction therapists are themselves former addicts who have been through twelve-step programmes, see themselves as being "in recovery", continue to attend AA or similar meetings, and who use twelve-step methods with their clients.  While it is beyond doubt that these traditions can be incredibly helpful to some clients, I believe that others find them outdated, puritanical, excessively spiritual, and involving the replacement of one addiction with another: an addiction to meetings.

The essence of the early sessions embraces the "motivational interviewing" technique of Miller and Rollnick and the "drinking diary". As part of this, the client is encouraged to record the circumstances in which the craving originated and the associated feelings and thoughts and thereby spot what patterns are occurring. This is a way of introducing one of the most important strands in addiction treatment-namely engaging the client totally in the process of therapy by making use of the client's capacity to think and innovate. This is where what person-centred therapists call " the actualising tendency" comes in. This should not be regarded as the preserve of humanistic therapists alone. D.W. Winnicott noticed this tendency in the people he worked with, calling it the tendency to " grow towards the light". 

Therapists here have the opportunity to exploit the benefits to addiction therapy provided by new technology. 

For example, as part of the Cognitive approach to addiction, clients have been encouraged to produce a "decisional analysis" summing up the advantages and disadvantages of their own addictive behaviour. By keeping this on their mobile phones, it is possible for clients to keep this  continually under review, to keep on modifying it, to keep it continuously relevant and continuously accessible. The benefit of this to the client is that it becomes interwoven with his or her daily life instead gf being an unchanging piece of paper kept separate from it.

In the past, it was never even remotely practical to keep a drinking diary using paper and pen during a drinking session but now that it is perfectly normal and acceptable to consult your mobile phone during a conversation, it has now become possible to make a "real time" record of your drinking while you are doing it. You can also use Excel to make a tabular record of your progress, so you can record the pattern of your drinking. For emphasis, it is possible to colour code this, so that you can see how many "red" days there have been in comparison with "green days". Moreover, you can record a motivating talk to yourself in relation to your drinking; as people know their own psychology well, this can be very effective. The very act of writing this talk, with its drafting and even re-drafting, can be very effective in strengthening the motivation of the client. The client can also record messages to themselves encouraging some degree of restraint at crucial points during hazardous situations-say, after drinking five pints during an evening with an old friend; this might be a good moment to tell yourself that you have enjoyed a relaxing and pleasant evening, and, if you stop now, you will have a good day tomorrow. You can also keep on your mobile phone a set of encouraging images.
For example, clients often do not decide to give up an addiction while keeping the rest of their lives unchanged. Indeed, there is some evidence that continuing to resist an addiction is most likely to achieve long term success if you also establish a more rewarding life for yourself. You can use your mobile phone to record and store motivating images. For example, a client who loved cycling could use an image of a cyclist - or a personal photo- which reminds the client that, if he or she goes home now, there will be an opportunity to go cycling tomorrow instead of staying in bed with a hangover. A picture of a partner or child might remind a client of a motivation to keep drinking within reasonable bounds. At the same time, you can also store the written word on a phone and this, crucially, could include reminders about forgiving yourself for your imperfections and failings. Clients can also be asked to give a presentation to the therapist, using PowerPoint software, on the physiology and neurobiology of addiction. Google is a blessing in this regard; there is so much information available. I have found that clients are good at coming up with strategies for using technology, so the therapist can harness the client's creativity, only adding to the ideas in a mutual brainstorming session.

If the client wants to cut down on an addiction, then they may need encouragement in certain skills. Resisting addictions is quite a complicated business, and so it is unreasonable to expect the client to "re-invent the wheel". I think that some person-centred therapists have such a horror of being thought of as experts that they set themselves up, in practice, as enemies of knowledge. But the therapist does not have to substitute a pedagogical role for a therapeutic one. The beauty of Google and other search engines is that the therapist does not have to train the client in assertiveness skills which might help a client whose "friend" is bemoaning the client's reluctance to drink alcohol. The client can look up assertiveness techniques and can apply them to his or her own situation.

There is no limit whatsoever to the usefulness of new technology in addiction work. Clients can be encouraged to make their own lists of the reasons they give themselves for drinking, alongside an all-important list of the fallacies involved and of alternative behaviours which could be substituted. A client who rewards himself for getting through a hard day by buying himself a bottle of whiskey could substitute an alternative treat- downloading a movie or whatever.

The learning theory approach involves being aware of addiction as a behaviour learned in response to a variety of cues. For example, getting off a train may be associated with heading for the pub nearest to the station. Awareness of this helps the client to become aware of the link and make a new decision to break it. These cues may be very numerous but unconscious, such as the beginning of the news on the television; quite clearly, certain people and situations can act as the stimulus in a stimulus-response chain. Once these have been identified, ways of coping with difficult situations can be adopted. The anticipation of difficulties helps the client to acknowledge and cope with them.

By encouraging the client to look forward and anticipate, the therapist is tackling two mental habits which can distinguish addicts from non-addicts. One is a tendency to think in the short term. The cocaine addict, for example, thinks of the high, which may last for hours rather than the comedown which may consume days.

The second is a tendency to engage in ostrich-like behaviours. Psychologists have identified the categories of "engagers" and "avoiders", addicts tending towards membership of the second group. Addictions function as tools of avoidance. Hence, if addicts realise that they can find solutions to their problems, they have less incentive to use an addiction to avoid them. (Continued in Part Two)

Friday, 11 October 2013

Working with Anxiety

Anxiety is, to some extent, inevitable. There is much to worry about: death, illness, money, how we look etc. Some of these may be more realistic than others. Anxiety becomes troublesome when it creates a serious barrier to happiness and inhibits our ability to live creatively and courageously.

It is important to accept its naturalness, as an emotion which we are biologically and neurologically prone to experience.

Anxiety itself can be generalised, confined to certain areas of life, or funnelled into specific phobias. Whatever its form, there is usually serious insecurity. This has often begun in childhood, perhaps caught from anxious parents or the consequence of experiences that the young self finds hard to process such as bereavement or bullying. Abuse- physical, emotional or sexual- sends a message that   
people and the world cannot be trusted. Obviously, a lack of love and warmth implies a life in which needs may not be met. 

By sharing these experiences with a humane therapist, it is possible to feel less lonely in them. Unpleasant experiences can become a source of a sense of being understood. By re-visiting a childhood bereavement, you can be released from the sense of responsibility which, as a child, you assumed. If you suffer from a sense of guilt, anxiety will accompany it. I think it is helpful to become conscious of the sources of your insecurity. By reminding yourself of them, you will be placing some distance between your anxieties and your sense of the world.  You will become conscious of the contribution of your inner world to your anxieties.

Anxiety also seems prevalent in people who are very hard on themselves. Some people deeply feel that they are undeserving of happiness and so send themselves a never-ending series of anxieties as a sort of 'spoiler' or as a way of sabotaging themselves. It is possible to address a harsh interior voice and to learn to extend to oneself the compassion and understanding that you give to others. It is possible to work on a lack of self-esteem in therapy both through focused work and through a more free-ranging approach. I incline to the view that trying to identify what you like about yourself-and learning that-can be valuable in acquiring a sense of ego strength.

When feelings of guilt and shame are examined in therapy, they rarely seem proportionate to the offence and it can appear that anger at another person's actions might be more appropriate. This reduces fearfulness as well.

Especially, but not exclusively, when clients present with work stress, anxiety is often produced by having excessive expectations. One client would work weekend after weekend so that members of the team he managed could enjoy their spare time. Another insisted upon 'prepping' perfectly for meetings, involving reduced sleep. Realising that these self-sacrifices don't make for high performance  but often lead to depression, stress and anxiety can set a client on the road to a more personally satisfying life.

It is also possible to consider in therapy lifestyle factors such as eating well, scheduling sufficient sleep and rest, breathing deeply, and being aware of alcohol consumption and taking exercise, all of which can have implications for anxiety levels.

There can also be psychological mechanisms of a subtle and individual kind. 

There is a great deal to be said in favour of the attitude of 'facing the fear and doing it anyway'. An attitude of avoidance can intensify fears because it sends the unconscious mind the message that the fear is realistic.

There are many cognitive interventions which can reduce or even abolish anxiety. For example, if you think that a small mistake at work could lead you to be sacked, you may be doing what cognitive therapists call 'catastrophising'; replacing such notions with less extreme ones might impact directly upon anxiety. The tactic of 'graded exposure' may assist in dealing with a phobia.

In working with anxiety, it is important to be guided by the client in terms of the nature of the therapeutic relationship and the approaches employed.  In dealing with anxiety, it can become possible to live more confidently, bravely and truly.

Friday, 4 October 2013

Working with Depression

Depression can be so severe that it can undermine all pleasure in life,and involve feelings of powerlessness, worthlessness and despair. In extreme cases, it can lead to attempts at suicide, some of which succeed.

For some time, there has been a focus upon pharmaceutical approaches but, increasingly, the research on which these are based has been called into question. Although tablets help some people, I believe that psychological ways of accounting for, and treating, depression are better at getting at the root of the problem.

What is depression? As so often, its name gives an important clue; to 'depress' is to push down. This suggests that depression is less an emotion in its own right as a low mood resulting from the pushing down of another emotion-say, anger or guilt. Moreover, depression can be the consequence of being 'pushed down' as a person. For example, criticism by a spouse can be a potent cause of depression. In many cases, the pushing down occurred in childhood as a response to a critical and guilt-inducing parent. In adulthood, a client may push himself or herself down by having a highly critical dialogue inside his or her head. Quite a few people call themselves names, behaving towards themselves like a spiteful child in a playground.

This same state, a state of repression, can also result from child sexual abuse, where a real feeling of anger might be repressed, leaving an overwhelming sense of shame. Repression can also become established after the death of a parent in childhood.

Crucially, then, depression is related to the way in which we think about ourselves, others and the world. People who think they are worthless are not likely to be cheerful. Psychologists believe that our thoughts about ourselves, others and the world are not just isolated thoughts but are instead organised into reasonably coherent systems. These are sometimes called 'schemata' or 'schemas'. These schemata are mood-dependent. (We all know how our thoughts change when the sun comes out.)  Thus, we may have one way of thinking about ourselves, others and the world when we are at our happiest and another when we are depressed. I find it helpful to imagine a department store; on each level, we can access different goods. Our thoughts are similar, with different ways of thinking that we draw upon, according to which 'floor' our moods are on.

When we feel low, we may engage the kind of schema which is inherently depressing. The sort of schemas which have the strongest tendency to lead to depression involve our sense of our core selves. If we believe we are intrinsically powerless, essentially worthless, fundamentally weak and feeble, or we deserve to feel permanently ashamed, we are almost certainly going to suffer from deep depression.

These negative ways of thinking may be triggered by particular events, especially if these are viewed in particular ways. The break-up of a relationship can lead to a sense of failure which could trigger a self-destructive schema; as Cognitive therapists point out, this is especially likely in the presence of modes of thinking which intensify the negative emotions. For example, Cognitive therapists employ the idea of 'catastrophising', by which they mean a tendency to select the most disastrous possible outcome of a given situation, and then think about it as the most likely one. For example, if the end of a relationship leads to the conclusion 'I will never be able to make a successful relationship', then this is more likely to lead to depression than the thought 'I will see what I can learn from this experience so my relationships work better in the future.' You can see that the former position is also far more likely to bring into play a schema based around the idea of powerlessness.

It is important, too, to pay attention to experiences in early life which can also have a bearing upon later     emotional states. There is reason to believe that people tend to set their happiness levels in childhood, and have a tendency to maintain them. Events such as divorce, the death of a parent, persistent bullying and emotional, physical and sexual abuse can all have effects which continue to make their presence felt even decades later.

This takes us to the beauty and flexibility of the psychotherapeutic approach to depression. It engages with the real and individual experiences of each person. One common factor is the therapeutic relationship which is, according to research, the main curative factor in psychotherapy, after the level of the client's motivation. You can see that an atmosphere of warmth, empathy, and non-judgementalism directly address some of the issues already mentioned. The therapeutic relationship is also important as, within it, a sense of trust can arise which can facilitate a client in talking about painful feelings and experiences and so can enable them to be thought about clearly and in new ways. Even the act itself of admitting to feelings of embarrassment and shame can help them to diminish. All good therapy is a species of cognitive therapy.

It is possible to use ideas from cognitive therapy to look at some of the modes of thinking which can lead to depression and can trigger negative schemas. Catastrophising-an ugly coinage but graphic-has already been mentioned. Another is 'thinking in extremes'- e.g. If my essay isn't brilliant, it (and I) are hopeless. Another is to view life selectively, emphasising the negative and minimising the positive. A further one is to personalise, so that you obsess over the reactions of others which might have occurred entirely through the internal processes of another person. In Cognitive therapy, the aim is to replace these cognitions with modes of thinking which promote your interests more successfully. In the Humanist Integrative approach in which I believe, my intention would generally be to enable you to work out your own ways of thinking, so that you feel in charge of your own therapy. At the same time, I cannot, and should not, promise that therapy will be without challenge. We all have our blind spots, and, although it is rarely comfortable to have attention drawn to them, if done sparingly and helpfully, this can be therapeutic. After all, it is a sign of openness to give consideration to the issues which we find hardest to contemplate.

In all this, there is often an issue of regarding oneself with a lack of compassion. The promotion of compassion towards oneself, learning to forgive oneself for one's errors and failures, and accepting oneself as a very valuable, if fallible, human being, plays a vital part in overcoming depression.

Tuesday, 10 September 2013

Working with women who love abusive men.

One of the most difficult and sensitive issues which arises in my sessions occurs when women are loyal to abusive men. Despite bruises, cuts, public humiliations, hospital visits, the advice of friends and social workers, abusive men can exert a magnetic attraction

Why is this? Part of the answer lies in the narrative. Abusive men do not start a relationship by being abusive. Often, they are initially very charming. Having charm is often an unrecognised sign of having been emotionally, physically or sexually abused. A child who has been brought up in a happy and accepting home will not be afraid of anger, of expressing a contrary opinion or being challenging. A charming man can be a person whose real self has gone into hiding. Anxious to please, the charmer can be a chameleon, and so can present himself as an ideal partner, one who shares the opinions and interests of his victim.

Having been accepted as a partner, the first task of an abusive man is to detach his partner from her friends and colleagues. This may be done on the pretext of closeness or self-sufficiency - now we've got each other, we have no need of others. As Dr. Johnson said, friends are people whose faults we ignore; the abusive man sets about remedying this omission.The woman's friends are represented as irresponsible, bad influences, immature and outgrown, or else as over-serious, no fun. The last has especial appeal if the abuser has a drug or alcohol problem. Only a prude, surely, could object to a couple of bottles of whiskey now and then? 

Or it could work in the opposite direction: a puritanical abuser-abusers are often harsh to themselves as well as others-may argue that friends are loose, immoral, alcoholics, bad influences. In a way, the arguments are immaterial. What counts is the intention-and that is to place the abused person in a position where no outside influence is allowed to provide a friendly standpoint from which the abuse can be perceived for what it is.

In the early stages, the abuser will be on best behaviour. At the beginning of a relationship, this is quite normal, and so there is nothing yet to arouse suspicions. Everyone starts a relationship trying to be their ego ideal, their best self, and also tries to please the other. This is not sustainable, and so there comes the inevitable day when the woman challenges, criticises or displeases her man. He lashes out, perhaps hitting her across the face. At this point, if she takes the advice of domestic violence experts or the Twitterati, she would leave. However, the outburst seems so out of character; the man is so obviously repentant; and surely everyone deserves a second chance? Flowers and chocolates descend from the sky; eternal love is invoked, and a pattern has been set.

After this, there is a recurring pattern. The abuser knows he is skating on thin ice, and so showers the recipient with love and attention. The intensity of it is intoxicating. Even the abuse comes to seem like proof of the reality and sincerity of the abuser's passion. A woman who would have recoiled in horror at the situation she is now in becomes reconciled to it. 

Another vital tactic of the abuser contributes to this. At all costs, he must lower the woman's self-esteem. In one form, this is a subtle business. He must not appear too obviously critical. The art is to suggest that the woman is lucky to have him, is not attractive enough to appeal to anyone else, and yet has special qualities which he alone can appreciate.

The second method is more obviously-to an outsider-vicious. It is the tactics of the Iraq War: shock and awe. The criticism is so strong, so relentless, so frequent and so comprehensive that the woman becomes worn down by it. It helps if the criticism is delivered in angry, eloquent, uninterrupted harangues so that the woman is denied space to refute and consider. Tragically, women can sometimes accept these criticisms as authoritative and true, thereby destroying any semblance of self-confidence and self-esteem.

Amongst the women who have succumbed to these tactics have been some of the most shrewd and intelligent academics and business women. When described, the processes must seem transparent but they are more insidious when you are caught up in them.

As the relationship progresses, what happens becomes increasingly horrific; by this stage, the phenomenon of Stockholm syndrome may come into play, though with domestic abuse rather than kidnapping. Apparently, when a person is taken hostage by someone who treats them badly, an occasional kind act produces a feeling of overwhelming gratitude very much akin to love. This is so overwhelming a sensation that it becomes a central memory. Hence, we might say that there are two ways to win love: one is to be loveable, the other is to be unloveable but occasionally to do a kind act. This is confirmed by a very strange fact-when people are debating in therapy whether to stay in a relationship or not, it is those who have been hospitalised by domestic violence who are most likely to cry out, as the clinching, unanswerable argument 'But I love him, and could never love anyone else as much!'

Situations such as these challenge both therapist and client. The client overtly wishes to explore her relationship, perhaps seeking an ally in her efforts to break free. The most obvious counter-transference is for the therapist to side with the woman as a victim and experience a disorientating hatred of the abuser. Therapist even-handedness may seem pointless or immoral and might run the risk of collusion with the abuser or with the part of the client that sides with the abuser. However, there is a good chance that, by now, the client feels that it is her and her partner against the world, and so the therapist is in danger of joining that dull, unimaginative, jealous group that wishes to destroy a love to rival that of Romeo and Juliet. 

If, on the other hand, the therapist adopts a traditional psychodynamic stance of strict neutrality, the client may compare this with the hostility towards the abuser of her friends. Then the client might suspect the therapist of being unsympathetic towards, or indifferent to, her sufferings, or even to be quietly endorsing a condoning attitude towards the abuser.

In the sociology of organisations, it is well known that workers like to debate endlessly the characters of their bosses, and it is thought that this is a way of understanding them and predicting their behaviour. There is a parallel in abusive relationships. The women involved would like to find a way of conceptualising the abusers, and so take to obsessing over the abuser's motives, both with their friends and their therapists. This could have the dangerous effect of feeding an obsession with what might look like intrinsically fascinating complexity.

I have come to believe that the best way of working with women in this situation is, first, to make sure, as far as possible, that they are safe. This may mean seeking and establishing a place of safety within the house or outside of it-some arrangement with a friend, for example, which can be called upon if needed. If a safe word can be established within the relationship, so much the better, but this is neither always possible or respected. It may be that raising the issues of safety and self-care may be enough to persuade the victim to leave.

A second strategy can be to encourage reflection on the nature of love-love as an emotion which involves kindness and consideration and respect for the boundaries of others.

A third can be to consider the character of the abuser, and what might constitute reasonable expectations of someone whose behaviour is problematic.

A fourth is to attempt to restore or enhance the self-esteem of the victim.

A fifth is to look at the upbringing and family culture of the victim, and see whether it might offer some clues as to the difficulty in breaking free. For example, for a woman whose parent was alcoholic, love may smell of alcohol, and so the abuser may wear a seductive perfume.

I also think it is helpful to realise that breaking away from an abusive partner, like giving up smoking, might involve several attempts before liberation is achieved.

There are many other tactics which the therapist can adopt. This list is neither prescriptive nor universal, and, as always, the client frequently devises approaches superior to any the therapist could have brought to bear. I have come to believe that it is important to directly discuss the therapeutic relationship, and its bearing on the abusive relationship.

If you would like to discuss the contents of this blog, I would be happy to do so. If you are interested in having therapy with me - which, obviously, could be unconnected with its contents-please get in touch. Richard Thomas, September 2013.