I sat in front of my clinical supervisor for my fortnightly meeting in which I was supposed to talk about how I was coping, and how my work helping others was going. “I’m feeling really stressed at the moment.” I started off by saying. This was not an unusual way for me to start supervision sessions. I was hesitant to even bring this up, because I’d talked about my work stress often before and things didn’t seem to be any better for doing so. “How would you rate your stress from 1-10 at the moment?” She asked me in response. “I’d say an eight.” “Eight’s pretty high.” She said, then asked: “What are you doing for self care.” I rattled off a few things I was already doing, meditation, running, spending time in nature. All of the right answers, but I was already doing these things, and was still feeling stressed, and truth be told, pretty unhappy. I quietly despaired, pretended that I’d have a go at the further suggestions for self care that she made, and changed the topic to the work I didn’t want to do with drug and alcohol addicted citizens of West Auckland, who mainly didn’t want to get state mandated help from me, either.
Eventually, sick enough of the work and the workplace that skipped over the surface of the real social and personal issues, I left, a decision I never regretted for an instant. Looking back, I see this experience of so-called self care as actually being the managing of both clinicians and citizens - a substitute for real connection and healing, and certainly a substitute for addressing the disempowerment of both workers and the poor of West Auckland.
Read the rest of the article by Michael Apathy here...
This post isn't about some new idea in psychotherapy or counselling, or about the psychology of the social or environmental issues we collectively face. It's about the afternoon that I spent yesterday taking some of my own medicine - a dose of ecotherapy. The first thing I want to say is that it's so strange, that it takes getting a bit sick and run down and feeling like I have to stop running in the rat race, to actually give myself something different.
Weaving through traffic and the unexpected traffic jams, I felt like I was making a prison break. I half expected that some last work commitment or emergency would stop me from getting to the start of the trail I was headed to at the base of the port hills. In hindsight I was actually worried that I'd flake out without a good excuse, and then have to face having sabotaged my own aspiration without even having an external barrier as a justification.
As I began to walk up the gentle (and then steep) uphill start of the trail, this slightly urgent anxiety to escape began to relax as I felt committed to the trail and direction I had selected. Soon this commitment began to shift to excitement and desire to see the view from the next crest of the hillside. I could feel my empty physical and emotional gas tank begin to refill. Pausing often, to turn around look behind, I began to get perspective on the city. No longer a trapping and limiting, stress and anxiety provoking maze through which I madly run, Christchurch had become a sweeping vista.
As I continued to climb, being an ecotherapist, I kept tuning in to the mental and emotional shifts that were happening inside of me. I noticed that as I began to sweat and glow from the climb, I began to feel more robust and confident, feeling my own capacity to work and progress and rise up over my previous foul mood. By the time I had reached the top I had also reached within myself a strong feeling of gratitude. This gratitude was towards myself, for having given myself this experience and worked for it, but also for having the amazing geography of the port hills so close by. The thought occurred to me: "I am made for this." And I think that's true. I, and you, were made to move through landscapes and to work physically, roam, to find new paths, and to trust the instincts of the body rather than a schedule or a fluorescent office environment. I don't happen to believe that a personal deity came along and made this world to suit my needs, but it's a pretty good moment when I spontaneously find myself feeling that evolution made me to enjoy walking, looking out at views, and feeling the wind on my face.
The descent felt less ecstatic, but still important. I'm not going to live the rest of my life (or even much of it) out on a hillside, as much as I can love it for a while. The impulse to escape the city had shifted to a readiness to return, a sense of warmth and tolerance towards the people and activities that I had needed a break from. Descending is not about ecstasy, it is about careful details of placing a foot in such a way that we do not slip or turn an ankle. As much as the details of my life persecute me at times, it was good to feel ready for rather than resistant to the painstaking detailed work of descending.
I'm glad to be able to share this experience with you through this blog post, but I'd like to take this further. A hell of a lot of research and my own experience tell me that those of us who struggle with issues such as anxiety or depression will find this sort of experience at least as beneficial as sitting in a therapy room with me. I look forward to starting up ecotherapy experiences this spring, so stay tuned for that!
When Psychotherapists and Counsellors start their training, usually the first thing that they're taught to do is to listen to what their clients say, and then to give succinct summaries back to the client, so that the client can hear what they've just said, and that they've been heard. In worst case scenarios, this leads to experiences of sitting down with a therapist, pouring out one's heart to them, and hearing back in a some-what parrot-like way, the gist of a the problem for which one so desperately is seeking a solution. Of course, it's important that your Counsellor or Psychotherapist actually does listen to you, and certainly that is better than simply having one's feelings shut down, or covered over by advice. That said, I do think that in a way, therapists still do listen too much.
The reason why I say this, is that we all use the defences that I've written about in previous posts, practically all the time. Furthermore, it is usually the use of some of these defences, that are actually creating the problem in the first place. Frequently, even at the start of a first session, a client's defenses will stop them clearly describing to me what the problem is that they'd like me to help them with. For instance, when I ask during an initial session what the problem is that my client would like me to help them with, they may reply with the defence of projection (of their will) by telling me (indignantly) that their psychiatrist thinks they have a problem! Or they may reply whilst using the defence of withdrawal, telling me about the problem in such a small tone of voice, and without making eye contact, that it's as if they're miles away from me. If we can't clearly agree on what the problem is that we're trying to address through therapy, it's unlikely that we're going to be able to work together effectively on dealing with that problem.
According to intensive short term dynamic psychotherapy (ISTDP), it is our defences that creating our problems, and therefore are hurting us. It's my job to (with the client's permission) to interrupt their automatic and unconscious use of defences. For instance, withdrawal and isolating is often part of what perpetuates depression. By helping a person to see in a session how they withdraw from me by not looking at me, mumbling, or talking in a small tone of voice, I can help them to begin to experiment right there and then with making some of the changes that will help alleviate the depression that they wanted my help with.
This brings me in a roundabout way to the title of the post. Psychotherapists and counsellors need to do more than just listen. Sometimes actually helping a client is to interrupt them, and help them to begin to express the emotion that they need to deal with, rather than spin around helplessly getting nowhere because they're using a defence without even realising it. I'm not suggesting a tactless of callous form of therapy. To skillfully interrupt a client's defence in the right way at the right time is an act of caring, and healing. The people who come to me for therapy usually don't know the technical information about defences and different styles of therapy, but they can feel the sense of relief when their use of defences has been interrupted and they can actually feel themselves again, and begin to choose a more healthy way of relating.
Somatising is a controversial defence mechanism for a number of reasons. Overall, somatising is not understood well by many professionals, including psychotherapists, counsellors, and psychologists. Somatising is often confused with hypochondria (a preoccupation with or fear of signs of illness), which though a real mental health issue in it's own right can be misunderstood as a manipulative or silly bid for attention.
In essence, through somatising we fend off a disturbing reality or painful feeling and instead experience it as a physical illness. When the unconscious underlying pain is fully felt and acknowledged, the symptoms of the somatising - the psychosomatic illness, reduce or disappear.
Over time society has become more sophisticated in it's understanding of how mind and body interrelate. It is a mainstream and accepted idea that stress and anxiety can contribute to physical illnesses. Somatising, however, is more complex than this. At Lucid Psychotherapy and Counselling we are influenced by a form of therapy called ISTDP - intensive short term dynamic psychotherapy. According to ISTDP, anxiety or stress per se, does not make us sick. What is crucial is the way, or pathway, through which we experience anxiety. Though nothing in this blog can or should substitute for medical advice, if your experience of physical illness seems to be connected with your degree or anxiety or the anxiety provoking situations in your life, you may be somatising.
It was with great sadness that I heard today of the closure of Relationships Aotearoa, something only decided upon this week as talks between the Government and Relationships Aotearoa broke down. RA is New Zealand's largest psychotherapy and counselling provider, with 60 locations, 183 employees, and 7000 clients. Furthermore, they have been known as specialists in relationships and couple's counselling, having trained many other practitioners in Emotionally Focused Therapy for couples.
Minister of Social Development Anne Tolley has explained the government's position by focusing on dysfunction within RA, and has said that it is not the taxpayer's responsibility to take up the slack for poor financial management by RA.
Unfortunately this is a scenario that I have witnessed repeatedly under National Governments. Rhetoric about efficiency and hostility towards the public sector from the National Government has put immense pressure on social service and health organisations. I am convinced that the effect of funding and contract uncertainties, and closures, is anything but efficiency.
It has become normal within counselling and psychotherapy agencies to function under the considerable stress of funding uncertainty, and for the individual employees, loss of livelihood. The National Government would like us to think that this is the market delivering us taxpayers efficiency, through healthy competition.
What I have seen and heard about in many counselling and psychotherapy agencies is clinicians becoming debilitated by dealing with this additional pressure on top of dealing with the stress and pain that their client's bring them to work with. Research on burnout in mental health professionals includes various studies, a UK study showing that 21% to 41% of professionals at any one time report high levels of emotional exhaustion. When these staff burnout, they become more physically and mentally sick, less effective, and become more rejecting and judgmental of those that they are supposed to be able to help. I have seen agencies waste countless hours of their staff's time managing the stress of financial pressures, rather than be able to do what they do best - help their clients. Clients get switched between clinicians due to closures or difficulty with staff retention, often negatively impacting their emotional healing. In summary, clinicians are hurt and are less effective due to constant funding uncertainty delivered by the National Government.
By Anne Tolley's own admission, these sorts of "efficiencies" are likely to continue. Whilst the RA closure is nation-wide, Christchurch is particularly in need of steady and effective support whilst in post-earthquake recovery. Tolley mentions the shift of funding to families and young children. While this is supported by our increased understanding of developmental neurobiology, what we have also learned from this field is that babies and young people do not develop in isolation. I am sure that the clinicians at Relationships Aotearoa have helped thousands of young New Zealanders by ensuring that they never have to be impacted by their parents abusing each other or physically fighting.
Mental Health professionals play an absolutely vital role in New Zealand society. We rightly expect high standards of them, when the lives or the happiness of those we love are at stake. Do we give them the support they need in order to fulfill our expectations?
This post we'll look at the defence mechanisms of idealisation and devaluation, and how these manifest in psychotherapy and counselling.
In this defence, either self or other (or both) are seen unrealistically. In the case of idealisation, a person's good characteristics are exaggerated, and in the case of devaluation a person's worst characteristics are exaggerated. Like many other defence mechanisms, this is understood in popular culture. For instance, most of us could think of people we know who put others up on a pedestal, then complain bitterly to their friends when that person disappoints and becomes devalued as the lowest of the low. Celebrity gossip mags also illustrate this process, idealising celebrities to god-like status, then tearing them down in quick succession by critiquing their bodies, relationships, personalities, or fashion sense.
As with other defence mechanisms, uncomfortable feels are being warded off through this process. You'll have to bear with me as I get a little bit into psychoanalytic technical distinctions, to explain what those feelings typically are. The first group of people who particularly use the defence of idealisation and devaluation are those with narcissistic personality styles. The fundamental issue for narcissistic personalities is a difficulty with self love, or self esteem (though it should be emphasised that one does not need to be narcissistic in order to struggle with self esteem!) A more grandiose narcissist will idealise themselves and devalue others, to avoid their painful lack of love for themselves. An opposite, more depleted sort of narcissist will devalue themselves and idealise others. (This may seem more counter-intuitive as s strategy for avoiding self hatred, but by maintaining some form of connection to the idealised other, a depleted narcissist manages to scavenge some scrap of love for themselves via association.) The use of this defence tends to take a heavy toll on relationships.
The second type of personality that is known for using the defence of idealisation and devaluation is the histrionic personality style. This is a character style less well known then narcissism. Histrionic personalities tend to be warm, dramatic, strongly emotional, and sensitive in general, and particularly sensitive in regard to abandonment. Here the idealisation and devaluation functions not so much to ward off painful self hatred (as with narcissistic), but to fend off the fear of abandonment by establishing an omnipotent idealised rescuer, who may even be able to rescue the histrionic if they become helpless when emotionally overwhelmed.
A word of caution, if you're reading this and think that you recognise yourself in either of these personality styles, please don't jump to any conclusions and diagnose yourself! Most of us exhibit some of the above dynamics some of the time. Psychotherapists and counsellors tend to hold the above distinctions lightly, with a grain of salt, so please feel encouraged to do the same, and don't use any of this as an opportunity to beat yourself up!
A counsellor or psychotherapist may draw their clients attention to moments in which they use the defence of idealisation or devaluation. In my experience, it is rarer for therapists to draw attention to this defence, then some of the other defences that I've blogged about. I'm not sure why this is the case, but if you've got some thoughts about it, please let me know in the comments section.
Our series on defence mechanisms in counselling and psychotherapy continues with this post on the defence of dissociation.
Compared to some of the other defences, dissociation is less well known amongst the general public, despite it being very common (at least in mild forms.) We dissociate a little bit when we zone out, and become mentally absent from the situation in which we are physically present. The association between our mental presence and physical presence is disrupted - hence dissociation. More severe dissociation can lead to actual physical numbness, inability to feel one's body. As emotional and mental life become seperated, in dissociation we may also not be able to feel our emotions. We may feel unreal, or quite distance from a situation unfolding around us. Another variant of this is de-realisation, in which the situation around us begins to feel unreal, like a dream or a movie.
Like other defences, we use dissociation to distance ourselves from uncomfortable emotions. Often people who dissociate are aware of a link between their anxiety building up, and beginning to dissociate. Possibly the strongest form of dissociation is the controversial diagnosis of dissociative identity disorder, in which parts of one's identity become separated off from other parts. This was once called multiple identity disorder, which would be the topic of a whole other post.
When the client begins to dissociate in a psychotherapy or counselling session it is usually a sign that anxiety has become too intense to tolerate in other ways. Hopefully your psychotherapist or counsellor will notice this, or, it may be helpful to tell your therapist if you notice that you're beginning to dissociate. Most clinicians know basic grounding exercises that they may talk you through at this point, to help you reorient yourself to being aware of your body in the present moment, or perhaps to re-orient yourself to the external reality of the room in which you're sitting at that time, by noticing things such as the walls or the furniture around you. For most people this quickly helps reduce the dissociation, and is a useful practical skill to learn to deal with dissociation in one's daily life.
This is part of a series of posts on defence mechanisms in psychotherapy and counselling. Today we'll tackle the defence mechanism of intellectualisation.
Intellectualisation is considered one of the more mature or advanced defence mechanisms, but like the other defence mechanisms, it can still sometimes become unhealthy. When we intellectualise, we rely exclusively on reason, thereby distancing ourselves from or entirely blocking out disturbing feelings or anxiety. It is not merely the use of the intellect, but a "flight into reason", away from pain.
Sometimes the pain that we might avoid through intellectualisation is associated with a difficult decision, in which case the intellectualisation becomes a repeated analysis of the logical aspects of the difficult choice. At times this may be helpful, even of survival value, as we may need to remain "cool headed" and may not always benefit from deciding out of our feelings. However, people who intellectualise a lot tend to not only not decide out of their feelings, but tend to ignore the feelings altogether. This can cause problems. It can cause us to ignore our intuition, to ignore an opportunity to consider what this feeling might be telling us about the most beneficial course of action, can cause us to ignore factoring our happiness (an emotion!) into the decision, and by deactivation our emotional response can reduce our motivation to act on our decision. I read a book (an unfortunately cannot remember which book!) that talked about a true case of a judge who due to a very specific form of brain damage was unable to feel emotions. This judge ended up retiring himself, because he believed that without the input of his emotions his judgement was impaired.
Apart from decision making, intellectualisation can cause us other problems. People who overly rely on intellectualisation can be boring, even if they are smart and knowledgeable. This is because part of what we respond to in other people is their emotions. An interesting idea stripped of emotions often doesn't stay interesting. Related to this, people who intellectualise a lot may become so wedded to analysis that they forget how to play. Without playfulness, our relationships tend to suffer. Humour (considered an even more advanced or mature defence mechanism than intellectualisation) may be the antidote for the dryness of rampant intellectualisation.
Psychotherapists and counsellors should, by virtue of their training, be able to spot intellectualisation in their clients, and work with it constructively. Often, for me this means pointing out to a client that when I asked them what they felt, they told me what they thought, and then inviting them to consider the feeling. Sometimes that may mean exploring the cost of excessive intellectualisation, in terms of loss of intimacy in relationships, or the general loss of aliveness that comes from turning off feelings.
At times however, in the psychotherapy or counselling process, intellectualisation can be helpful. Part of what therapists offer to clients to help deal with emotional overwhelm, may be a set of ideas that give them a safe point to step back into and from which to view the emotional chaos. Sometimes intentionally changing gears into the intellect provides the necessary respite, and helps things to feel safely understandable, so that the client can once again return to the necessary therapeutic task of learning to bear their feelings.
Continuing this series of posts on defence mechanisms in counselling and psychotherapy, today we'll look at the manic defence. For more information on defence mechanisms, check out the first post in this series.
Very broadly, the manic defence is an attempt to do things or think things quickly, to create a sense of busyness that shuts out unpleasant feelings. More specifically, often the feelings that are being shut out are feelings of powerlessness or hoplessness, which are often being shut out with the contradictory feelings of euphoria, goal oriented activity, and control or mastery. Like other defence mechanisms, there really is an intelligence to this, it is very hard to feel hopeless whilst energetically pursuing a meaningful goal. It works. In my opinion the manic defence is also one of the most widespread defences, at least in Western culture where being busy and constantly doing are a virtue.
For many people powerlessness and hopelessness in the extreme can manifest as depression, including lack of energy and pervasive sadness or numbness. The manic defence is often thought of as a defence against depression, though many consider the manic defence to be different from bipolar - or what was once called manic-depression.
In the psychotherapy or counselling process I most often notice the manic defence when a client talks a lot. In particular, when the client's talk is tangential, and is a response to us beginning to talk about painful feelings. When appropriate, I might notice this with a client, by saying something like: "Do you notice that just now as painful feelings began to rise up, you began to get anxious, and you distanced yourself from these feelings by talking fast and changing the topic?" In such a situation, with a client who is ready and willing to work on their defence mechanisms, it may be an act of kindness for the psychotherapist to actually interrupt their client's torrent of words and to help them see their manic defence in action. Thought it may be painful in the short term, experiencing painful feelings rather than shutting them down through mania may at times be a better long term choice. The cost of overusing the manic defence can be exhaustion, spiralling anxiety (because the problems are not dealt with), and difficulty connecting emotionally with others.
For those who are actively working with their own defences of mania and busyness, mindfulness can be an effective practice. Usually this will start with moments of mindfulness in the psychotherapy room, such as the above example when the psychotherapist helps the client to be mindful of their reaction to painful emotions in the moment. Some may take up mindfulness practice in their daily life. By just noticing and not amplifying the flow of thoughts, over time the thoughts slow down, and the usual experience is relief at the lifting of a burden that couldn't even be fully recognised until it lifted. Mindfulness practices that involve being still (rather than for instance walking mindfulness practice) have the advantage of creating physical as well as mental stillness, which further helps with the manic defence.
An interesting Australian article here discusses use of the manic defence by mental health professionals. An example given in the article is the use of antidepressants by GPs and psychiatrists to treat depression. Here the response is to do something, to prescribe something that stimulates rather than to deal with the painful feeling directly. Though I cannot personally comment on prescribing, and don't discourage use of antidepressants, this article is thought provoking. Amongst psychologists, psychotherapists, and counsellors, I see the manic defence at work at times, when the clinician out of a sense of helplessness or anxiety throws behavioural tasks or exercise at a client. Once again, though behavioural interventions aren't bad (I use lots of them myself), when they are being given to clients as a reaction to the clinicians own anxiety, I believe that the client on some level can feel the emotional disconnect, and is affected by it.
For an introduction to defence mechanisms in counselling and psychotherapy, please read earlier posts in this series. If you're familiar with these ideas, or have already read earlier posts, please read this post about the defence mechanism of acting out.
Compared to some of the more subtle or slippery defence mechanisms that we've discussed, such as projection, acting out is generally fairly easy to recognise. In fact, usually when people act out, it is with fairly extreme behaviours that are difficult not to notice! Acting out involves behaving in an extreme way as an alternative to feeling and tolerating an uncomfortable emotion.
Common examples include people who act out by cutting themselves, to avoid overwhelming feelings, or to avoid a feeling of numbness. (People also cut for other reasons, but acting out is commonly part of the dynamics of cutting.) Another example is that of a person who hits their partner, rather than feel and tolerate anger, powerlessness, or shame.
Acting out is a defence mechanism that a counsellor or psychotherapist will often, in one way or another, help their clients to change, simply because acting out can cause a lot of suffering both to the client and to those around them.
As with other defence mechanisms that are easily noticed and potentially destructive, acting out can bring with it a lot of shame. The normally polite person who acted out by drunk dialing their boss and abusing them will feel mortified the next day, and will probably find it very difficult to get help from a therapist. It is important that the therapist does not avoid talking about the destructive behaviour (because it really is a problem that needs to be dealt with), but it is also important that the therapist conveys a lack of judgement or condemnation.
Given that most of us at times resort to the defence of acting out, and given that often the acting out will be something we later regret, what helps? One of the most common things that helps with acting out is learning to use words rather than actions to express our feelings. This may sound simple, but often it's not.
To use words to express our feelings we need to first be able to identify what we're feeling. Learning to identify what we are feeling can be difficult. It may help to have a therapist who can express what we might be feeling, so that we can decide if that fits or not, and we can learn the language to fit the emotion from how the therapist has been talking to us.
Perhaps we know what we're feeling, but don't feel confident about expressing it. A psychotherapist or a counsellor may help with this by helping us to find clear and assertive language, or to deal with the fear of how others might respond to our expression of feeling.
So, to summarise the above, therapists can help us with acting out by helping us to use words rather than actions to express ourselves. However, this may not be the most important approach for everyone. Some people know what they're feeling, and how to find words to express this, but when under stress find it difficult to avoid acting out anyway. Such people may find a DBT program helpful, particularly skills such as mindfulness that help regulate impulsivity and the intensity of the emotion that is at risk of being acted out.
Through mindfulness practice we let go of the impulse to judge or analyse or act on thoughts and feelings. We do this in mindfulness each moment, when we notice our distracting thoughts or feelings, and bring our attention back to whatever we're focusing on, whether it be our breath, body sensations, a view out the window, or a piece of music. Mindfulness has been shown to be effective in reducing the impulsivity even of violent and impulsive offenders, so it clearly really does work.
Not only can mindfulness help us to not impulsively act out an overwhelming feeling, but we also find that through accepting rather than judging our emotions, we begin to feel soothed and the painful emotion reduces in intensity. There are many styles of psychotherapy and counselling that integrate mindfulness into the therapeutic process, including DBT, ACT, and MBCBT.
Some people seem to fear that through learning to regulate their emotions rather than act them out, they will lose the dramatic or creative aspects of their personality that they value. My experience is the opposite. I have found that through doing this personal work people boost their creative or dramatic potential by being able to add a degree of measured skillfulness and control to the spontaneity that they so value.
So, if you're thinking about changing your habit of acting out, you have everything to gain, and nothing to lose. That said, you may need to learn to assert yourself more, because it is possible that your habit of acting out developed because that's what worked to get people to understand that you needed help.