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19th August 2018 

A route out of trauma: June 2018

What do you think of when you think of trauma? For many, it is the aftermath of a devastating terrorist attack or natural disaster, and the vivid, distressing psychological fall out of flashbacks, insomnia and anxiety. But in my work, I see a lot of trauma, and while some of it comes in the form we expect, for others trauma is a response to prolonged abuse, growing up with a toxic parent, or even a reaction to mental illness.

To some extent, we have most of us experienced a mild version of trauma: a car accident, the sudden and violent loss of a friend or family member. So we are all familiar with the way in which trauma relives itself. Who has not had an upsetting experience and found themselves replaying the event, telling and re-telling the story?

The granddaddy of psychoanalysis, Sigmund Freud, talked about repetition compulsion, which is the way that the mind will repress overwhelming trauma on a conscious level, and then the subconscious will play it back again and again through flashbacks and dreams in an effort to gain mastery over the experience.

From my work, I have come to learn that this is trauma's nature: it replays itself over and over again like a film loop in the hope of healing.

For me, the challenge with clients -- and the core of much of the work that I do with them -- is helping them to find a way to relive trauma so that it is processed and healed, rather than simply replayed in a way that retraumatises them. We know that trauma work is working not when the film loop changes, but when the response to it goes from distress or numbing out, to one of "I don't need to tell that story anymore".

Trauma, as with so many mental conditions, effects not just the mind, but also the body. It has a dramatic effect on the Autonomic Nervous System -- the part of the nervous system responsible for control of the bodily functions not consciously directed, such as breathing, the heartbeat, and digestive processes. When we experience trauma it triggers the Sympathetic Nervous System, which is the fight or flight - or freeze - response. This trigger is what enables us to think fast and act furiously, run away, or play dead, in the face of danger. It is an essential survival mechanism.

The problem is when we then are left with trauma, each flashback reactivates the SNS, and we can find ourselves with a racing heart, sweating palms, and a desire to run: or we can find ourselves zoning out, and what we psychotherapists call, dissociating. Both reactions are distressing, and researchers have discovered that they tend to simply repeat the trauma in an endless chain.

Luckily, from the point of view of healing, and overcoming trauma, we also have a Parasympathetic Nervous System. The PNS is the counter nervous system to the Sympathetic one: where the SNS arouses, the PNS decreases the heart rate, breathing and blood flow. It is the body's internal soother.

What psychotherapists such as Babette Rothschild -- who wrote a seminal work on trauma called The Body Remembers -- have identified is that trauma work works best if you can keep the client in a window of tolerance. The aim is that if the client becomes over-aroused, or dissociated (too much SNS) that you can use the PNS to help lower the arousal, and process the trauma.

She says: "It's also important to keep the traumatic hyper-arousal at a level where the client can digest the therapy; if arousal goes too high the client's not going to be able to think and integrate their experience. That's what I call 'putting on the brakes'".

To do this, Rothschild talks about helping clients to identify signs of nervous system arousal and also nervous system relaxation so that they can know what's beneficial to them, and what is detrimental to them. One way she does this is by giving clients resources, such as a safe space, that they can switch into if they feel over-whelmed. A safe space could be a place that you have visited that you love, or a place in your imagination that feels safe and soothing.

I will often use this method of helping clients to regulate themselves as they are reliving their story. After some weeks or months of revisiting and replaying the trauma story, and digesting it by using the nervous system's relaxation response, clients can get to a place of no longer needing to tell their story again.


Quieting the monkey mind: May 2018

The take-away headline for me this Mental Health Awareness Week is that a poll found that almost three quarters of adults have at some point over the past year felt so stressed they felt overwhelmed or unable to cope. That's a huge proportion of the nearly 5000 people interviewed for the poll, and suggests that our hyped-up, frenzied 21st century lifestyle is leaving the vast majority of people feeling frazzled.

Many of the clients I see come into my consulting room saying they feel stressed, and that their symptoms are an inability to concentrate and a racing mind.

It is almost as if our 21st century minds have been wound up so tightly by the constant flow of information, celebrity gossip, social media, 24/7 on-line activity and work demands, that they are revolving as fast as the virtual worlds we are increasingly inhabiting.

Buddhists have long understood the nature of the thinking mind to swing from thought to thought, snatching at memories, and creating fantasy futures and have labelled it the monkey mind. They understand it to be capricious, excitable and given to often aimless chattering: much like monkeys.

But, while the mind has the capacity to behave in this way, my experience is that stress - and anxiety -- can send it into overdrive.

The effect of stress on the mind is often compounded by - and hard to distinguish from - anxiety. Indeed, the two terms are often used interchangeabley: clients will often say I feel stressed and anxious. But in my understanding the two are different, and it can help to tease out the difference between them.

In simple terms, stress is the body's response to anything that is perceived to be a threat, or a major change. The father of stress research was a physiologist called Dr Hans Seyle, who, in the 1930s, noted the changes the body undergoes when faced with stress. He found that heart rate, blood pressure and breathing quicken in order to supply the muscles and brain with more oxygen. At this point, our minds might either start racing or become laser sharp, depending on how we perceive the threat.

According to Dr Seyle, there are two types of stress: eustress and distress. Eustress, or good stress, is when our stress response enables us to rise to the occasion, to pass an exam or make a speech. The second, distress, is when we feel that the threat is overwhelming, and beyond our ability to cope.

I find that people often think in terms of threats as something terrible that happens to them: such as a job loss, divorce or bereavement. But my experience is that modern life can throw up all sorts of "threats' to our sense of self: from the pressure to make enough money, to tumultuous politics and what can feel like a constant barrage of bad news, to the social-media fuelled competition to depict yourself as having the "perfect" life.

All of these can lead to the stress response that sends the monkey mind into a frenzy of activity, with thoughts that spin around leaving people feeling dizzy, drained and exhausted.

What is complicated is that anxiety can also cause the same symptoms. However, anxiety is different from stress, in that it tends to be more diffuse, and less focused. It tends to bring with it a feeling of unease, of apprehension, of not knowing exactly what it is you're worried about, even of impending doom and, as a kicker, you can even start to feel anxious about being anxious. Somebody once described anxiety as a reaction to stress: and in my experience chronic stress can morph into anxiety. Indeed, the report into stress I quoted earlier in this blog, found that 61 per cent of the respondents who felt stressed reported feeling anxious.

So why is it useful to understand the difference between stress and anxiety?

In simple terms, I tend to think as one as more external, and one as more internal. I find it useful as a therapist to understand the stressors in my client's life so we can think together about ways of reacting to those stressors, whether that is changing a job, or grieving a profound loss. With anxiety, we think about how the emotional response to those stressors have got caught up in a negative feed-back loop, that expresses itself as a pervasive worry.

But there are also certain practical steps that you can take if your monkey mind is out of control:

1. Ground yourself: this is so that you can take your energy and attention out of your spinning mind, and bring it back into your body. The breath works really well as an anchor to do this. I encourage my clients to use the breath to draw their attention away from their monkey mind, and into the breath in the body. It doesn't need to be a long session of breathing, simply bringing the attention to the body and breath for a few minutes can help to slow down the spinning wheels of your thoughts.

2. Use mindfulness meditation: this is similar to breath work, in that you are taking your attention away from your racing thoughts. With mindfulness meditation, we focus on what is here, right now, in the present moment. This can be the breath. Or it can be studying an object in great detail. Or listening to a piece of music. The aim is to focus on one thing, while thanking your thoughts for being there, then letting go of them, and returning to the object.

3. The neutral observer. I find this can be a profound way of stepping away from being caught up in tangled thoughts. The idea here is to locate the part of you that watches what is going on at all times inside you: it's the voice that says, oh look, I'm angry, or I'm tired. Once you have located this neutral voice, you use it to watch your thoughts, and you can watch as they come and go. I think of the neutral observer as like the sky, and the thoughts are like the weather that passes through them. The trick is to identify yourself as the sky, and simply, openly and curiously watch the thoughts move through.

4. Loving kindness meditation: here the emphasis in the meditation is to focus on the heart, and bring into your awareness thoughts of compassion, and kindness. These can be aimed at those around us, and towards ourselves. The idea is to conjure up the feeling of love, almost like a gigantic hug, that can bathe us in emotional warmth. Again, the idea is to shift the energy from the head to the body, in this instance, the heart.

To my mind, it is no coincidence that in this frenetically paced modern world, mindfulness has been growing in popularity. It seems that what the Buddhists understood millennia ago, we are only truly beginning to understand now: that peace of mind is essential for our happiness, but also for our mental health.


Are you in a bad relationship with yourself? April 2018

There are as many different reasons for seeking therapy as there are clients who come through the doors of my consulting room, as each cause of anxiety or sadness is as individual as the person in front of me. But, like shame, which I wrote about in my last blog and which appears to be common to us all, a lot of my clients are entangled in a very bad relationship - with themselves.

One of my clients even, half-laughingly, described themselves as in a bad marriage with themselves - with no option of divorce. As in a bad marriage, this dysfunctional relationship with the self can lead to conversations that veer from internal remonstration to sometimes horrible cruelty and even abuse.

It is not uncommon for people with a highly developed internal critic to talk to themselves in ways that are normally associated with abusive relationships, with an internal monologue that says things like "you are completely useless", "why did you screw that up?", "you can't do anything right."

And like the verbal conflicts in a failing marriage, the use of such language leaves the person feeling depleted, stressed, undermined, miserable and, in some cases, depressed.

So why do we do it? How do we get into such a bad relationship with ourselves?

Psychotherapists believe that we internalise the voices we hear as we grow up. I often see clients who had parents who were sharply critical, or who had a teacher who undermined them, or kids who bullied them at school. As children, we are busy building a representation of reality: and so when we hear those messages, we build them into our reality. On a childlike level, we can believe they are true.

On top of this, we in the West live in a society that prizes individual choice and achievement, so if we don't attain our chosen goals, we feel we have only ourselves to blame. On some level, we believe that if we just tried harder, worked longer hours, concentrated more intently, that we should always be able to succeed.

Then, if we fail, we can turn on ourselves in the most vitriolic way.

In her seminal book, Self-Compassion, Kristin Neff writes about how we can get trapped vacillating between feeling ourselves to be superior to others ("he may be richer than me, but he's losing his hair") and feeling worthless. The low-level hum of insecurity we can experience in life, causes us to big ourselves up at other's expense to ward off feelings of not being perfect, or even sometimes, just plain good enough. But, as she says, such one-upmanship does not ultimately make us feel better, as it leaves us feeling negative, and disconnected from others.

In an ironic twist, she argues that we can also turn this desire to feel superior on ourselves. As our concept of self is multi-faceted, we can identify simultaneously with different aspects of ourselves, so we can be both the attacker and attacked. If, for instance, we are unkind to someone, we can tell ourselves that yes, we were unkind, but we are really just and fair, so we will punish ourselves mercilessly.

The result of all this harsh self-talk is that not only are you trapped in a bad relationship with yourself, but it impacts on your relationship with others. Research shows that people who are highly self-critical find romantic relationships harder, because they tend to assume that their partner is judging them as harshly as they judge themselves. Fairly anodyne comments from a partner are then pounced on as evidence that the partner is being hyper-critical, putting a huge strain on the relationship, and intensifying the feelings of insecurity, and unloveability.

So given that divorce is not an option from oneself, how do we change our relationship with ourselves? How do we become our own best partner?

To do that, just like in a struggling relationship, we need to start thinking about how we treat somebody: in this case, ourselves. We need to start thinking of our relationship with ourselves as the most important relationship we will ever have. It is the one that will last until the day we die. And we need to think about how we talk to ourselves. Kirstin Neff talks about learning self-kindness, a way of talking to ourselves that is loving, patient and kind.

That can be challenging, as it can mean changing a life-long habit of self-criticism. Harvard psychologist William James in his 1890 book The Principles of Psychology wrote that "in most of us, by the age of thirty, the character has set like plaster, and will never soften again" in what is thought to be the first time modern psychology introduced the idea that one's personality becomes fixed after a certain age.

However, luckily, one of the amazing things that neuroscience has recently discovered is that the brain is "plastic". More than a century since James's influential text, recent research has discovered that the brain has the capacity to change and grow by creating new neural pathways -- all the way through our lives.

As David Gelles writes in his book Mindful Work, one of the earliest and best-known studies on neuroplasticity looked at London cab drivers. Researchers discovered that the "grey matter" in their hippocampus, an area found at the base of the brain, literally grows when they do the Knowledge, the gruelling test of knowing the location of each London street.

Like London cab drivers, we all have the ability to grow new neural pathways. It's a little bit technical, but in simple terms: neurons are nerve cells that are connected by synapses, which transmit nerve signals around the brain. The more those neurons fire, and communicate through the synapses, the stronger that neural pathway becomes. As the saying goes: neurons that fire together wire together.

Imagine your neural pathways like a stream that starts out as melt water from a glacier, pouring down the ice. As the ice melts, the stream swells to become larger and faster, cutting a groove through the glacier, that gets wider and wider over time, until eventually there's a river where the stream was, chiselling its way through ice and rock with the force of the water.

This is similar to neural pathways: they strengthen with use. So if you are used to talking to yourself in an unkind, critical way, your brain has literally been shaped by the habit of negative self-talk. But as you begin to talk to yourself in a kinder, more compassionate way, you can literally reconfigure your brain.

So what's the down-side? Like all habits, it takes significant conscious effort, and a lot of repetition to change the structure of our brains. To learn new habits, you first need to enlist your pre-frontal cortex, the thinking brain, and apply awareness. When you stop paying attention because you're distracted or stressed, your brain reverts back to its old habits. But when you pay attention you can start to alter the way you think.

So, if you're thinking to yourself, this all makes sense but what do I actually do?, then here are 4 steps you can try:

1. Pay attention to how you speak to yourself: is your internal voice kind, loving, gentle and supportive? Or is it shaming, critical, unkind and even cruel?

In therapy, the first place we start is by becoming conscious. Quite a lot of us are not even aware that we are our own worst enemy, so ingrained is the habit of self-criticism. So with my clients, I encourage them to listen in to their inner voice, and if necessary to jot down the things they may say to themselves. Once we are aware of the negativity of this voice, then we are in a position to begin the processing of changing how we talk to ourselves.

2. When you notice yourself talking to yourself in a harsh or critical way, pause, and replace it with another more loving, kinder voice. This step can be difficult, because we can start to beat ourselves up for beating ourselves up!

If you are grappling with the critic that can't be quiet, thank it for being there and then let it know that you don't need it anymore. The chances are that you adopted this critical voice at some stage of your life to protect or defend yourself. Let it know that you no longer need it. If you can't find your own inner voice of kindness, think of the voice of a loving mother, a supportive friend or a kind teacher.

3. Challenge the voice that says I'm not worth making all this effort for: one part of us will often resist change. The unknown is unfamiliar, and therefore we can often go to great lengths to avoid change. Let yourself know that not only are you putting in effort, but you are also being courageous.

If you are really struggling with changing the way you talk to yourself, it might be worth seeing a counsellor or psychotherapist who can help you to challenge a deeply-held belief system, that is causing you distress and preventing you from actively learning to love and support yourself.

4. Be patient with yourself. It takes time and effort to unlearn habits and replace them with new habits. It took time for your negative, self-abasing thinking patterns to develop and deepen, so it will take time to replace them with new neural pathways that need to be trodden and retrodden until they become second nature.

Ultimately, the rewards of learning self-compassion, and building a loving, supportive relationship with ourselves are as positive as being in a good marriage with someone else: it will boost your happiness, free you to live a contented life and hopefully make you live longer too.


The shame paradox: how speaking shame can transform it. March 2018

If there is one emotion that I can pretty much guarantee will come through the door with a new client, it is shame. And it is usually the last emotion to arrive. We will work through grief, make space for the expression of anger, gently probe at sadness, and, finally, if all is going well in the work, like the kernel in the nut, we will arrive at shame.

So why is it always there, and why is it so hard to talk about? The renowned shame researcher, Brene Brown, argues that shame is a universal emotion: we all experience it. But, she says, it is the hardest emotion to talk about: "shame is so powerful that we sometimes feel shame just by talking about shame".

I was thinking about shame as I was doing an interview for a book project I am working on on being childless-by-circumstance. (That is when you would like to have a child, and believe yourself to be biologically fertile, but because of the circumstances of your life, that has not happened, or has not happened yet.) I was talking to the author, Tessa Broad, who wrote a moving account of her attempts to have children in her book: "Dear You: A letter to my unborn children", and she talked about her childlessness as feeling like she had "a dark, shameful secret".

This made sense to me as I had written my MA thesis on circumstantially childless women, and how they experienced psychotherapy, and what I discovered was that my participants didn't really experience their circumstantial childlessness in psychotherapy - because they didn't talk about it. One of them said she didn't raise it with her therapist because she was too ashamed.

I was blown away by this discovery. Here was this enormous life experience - not having children when you wanted them -- which now affects 1 in 5 women who have reached the age of 45 and my research participants found it so hard to talk about, they couldn't even bring it up in the therapy room. I realised that shame - and the social taboo around involuntary childlessness -- had the effect of silencing many women who do not have children.

In the light of my research findings, I decided to specialise in working with this group of women in my psychotherapy practice and so a number of these childless women -- along with a few childless men -- find their way into my consulting room. They are aged from their mid 30s upwards and want to have children, but for one reason or another due to the vagaries of their lives it is not happening - and they fear it will not. Underneath the layers of anxiety about time running out, and grief at failed relationships, I sense there is often a barely articulated question: is there something wrong with me?

This is the pulsing heart of shame: the sense that we are in some way at fault. It eats away inside us, making us feel as if we have in some way failed, that we have uniquely screwed up our lives. It is a noxious, undermining, consuming and devastating emotion that ends up making people feel isolated and alone. Brown defines it like this: "shame is the intensely painful feeling or experience of believing we are flawed and therefore unworthy of acceptance or belonging".

Rather than mollify these feelings, society magnifies them. Unlike biological infertility, dealing with a failed relationship, and the dashed hopes of having a child, in your late 30s and 40s, are not socially recognised. There are no words of comfort directed at the 40-year-old woman who thought that she was on the road to becoming a mother when her boyfriend walks out: no public recognition of the scale of that loss. Instead, many women I have spoken to for this book project report that if they dare to discuss their sense of loss, they were met with comments like: "You shouldn't be so picky about men." "You could always adopt." "Have you had your eggs frozen?". There is a feeling of being outcast, of being on the outside of society

It is any wonder then that against this social backdrop, buried beneath all of this, when you are scrambling to find a partner and settle down, and conceive, in the decade long window of waning fertility from 35 to 45, there is a sense of shame?

Like every other emotion that enters the therapy room, the first step is to identify its existence. And, in the case of shame, that's hard, because it tends to lurk in the shadows of our mind, where it unconsciously drives thoughts, feelings and behaviours. Such is the power of its pain, many of us avoid acknowledging that we experience it at all. In her seminal work on shame, "I thought it was just me (but it isn't)," Brown talks about the importance of recognising our shame triggers.

We can only transform our shame and vulnerability when we are able to give it words, and to be able to do that, Brown argues, we need to accept that acknowledging our vulnerabilities is an act of courage. When we can feel the visceral, pulsing discomfort of shame, and label it as shame, we are in a position to express it, process and manage it. Before then, we tend to stuff it down inside ourselves where it festers, leaking out as doubts about the value of our very existence.

Once we become adept at labelling our shame triggers, we can also begin, as Brown explains, to put it into critical perspective. Like a camera lens, when we are focused on our shame, it is zoomed in on ourselves, but if we begin to zoom out, we begin to see that we are not the only ones. So it is with circumstantial childlessness. 1 in 5 women hitting 45 without children equates to 1.5 million women, and that doesn't include the 1 million or so women who are 35 + and are childless. Once you begin to see it like that, you begin to realise there is a whole tribe out there.

It also helps to understand why. Jody, Day whose brilliant book, "Living the Life Unexpected" has done so much to give voice to childless women, talks about this generation as the "shock absorbers for the sexual revolution": women who were often brought up to go into tertiary education, pursue a career, and find a partner, and then expected to conceive all before the age of 35. On top of which, there appears to be a shortage of "high-status" men for these women to marry. We realise that we are dealing with a social phenomenon, not a personal failing.

This is important because the power of shame lies in remaining undetected: it seeks silence and secrecy - Broad's "dark, shameful secret". In writing her book, Broad, in an act of courage, reached out and shared her story of battling to have children and then ending up without them, with the world. She told me that she felt lighter afterwards: "I did have this feeling that at last people got me and that felt rather nice". The act of writing it and exposing her vulnerability acted as a powerful antidote to the secrecy of shame.

This is speaking shame: and Brown argues that if we really want to change our relationship with shame, then we must learn to speak shame. There is, of course, a risk inherent in this, a risk that we will be judged or shut down. But Brown argues that it is worth the risk. When we speak shame, and we feel heard and supported, we transform our experience of shame. We no longer feel isolated and alone, we feel we belong. In my work, I try to help clients find words to express the squirming, excruciating feelings of shame, and share them - to tell their own stories -- so that they can go from thinking is there something wrong with me? to knowing that there is not.


Should therapists tell their story? February 2018


The conundrum many therapists face is how much of themselves should they reveal. Click here for my thoughts on this tricky dilemma.



You're a psychotherapist: what is it you actually do? January 2018


In the first of my blogs, I write about what psychotherapists actually do. Click here to read my blog.