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.