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.
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.
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.
To understand more generally about the concept of defence mechanisms, and how they relate to psychotherapy and counselling, please read prior posts in this series. To learn more about the defence of this post: sexualisation, please read on.
When we use the defence of sexualisation we imbue something (or someone) with sexual significance in order to avoid our anxieties around feelings such as aggression, dependence, or loss. Like other defence mechanisms, there is something remarkable about our capacity to do this. We not only avoid experiencing something painful, but through the pleasure we receive through the sexual association, we may actually be able to make that experience pleasurable. In general, a psychotherapist or counsellor will only confront a client with their defence if it is hurting them. This seems worth pointing out given our propensity to make judgements around sexuality. Sexualisation isn't bad, and is not something to be ashamed about, but sometimes it gets in the way of living a fulfilling life.
To clear up another possible misconception, the defence of sexualisation is quite a different concept from the concern about people (usually children or women) becoming sexualised. According to Duchinsky this different and later use of the term sexualisation developed in the USA in the 80s, to describe a maladaptive form of socialisation which causes a premature entry by the child into adult forms of sexual subjectivity and desire. It seems likely that many of those who have been prematurely sexualised in this later sense of the word will then resort to the use of sexualisation as a defence mechanism, but they are different ideas.
To bring this out of the heady realm of theory, it might be useful to give a couple of common examples of the defence mechanism of sexualisation. Because men are often taught that we must be independent, many of us feel uncomfortable with dependence. But, inescapably, being social animals, we are dependent on others for social connection. When men who are uncomfortable with their need for dependence feel lonely or disconnected they may sexualise this threatening sign of dependence. Instead of seeking out intimate emotional connection, they may go out on the town looking to "get laid" and having the sort of sex that leaves them feeling more empty and alone than ever. (This pattern is not restricted to men, but seems more common in men due to masculine socialisation to be independent.) In extreme form this can result in men (or women) seeking psychotherapy or counselling for sexual addiction or other sexual problems that are really problems with emotional intimacy.
A more common example of the defence of sexualisation amongst women can arise in women who have been taught in one way or another that women are weak and men are powerful. Such women, being afraid of powerful or aggressive men, may sexualise this fear to the point where they instead feel attracted to powerful or aggressive men. Another side effect of this is feeling understandably envious of the power that men are perceived to (and may actually) have. This form of sexualisation is actually the basis of Freud's much maligned and misunderstood concept of penis envy, which (depending on how you interpret Freud) can be seen as a sympathetic and understanding view of the terrible impact on women of patriarchy. Women (or less frequently men) who sexualise in this way often come to psychotherapy or counselling having had a string of very painful relationships with men.
Most of us find talking about sex uncomfortable, perhaps especially if we're talking about a difficulty that relates to our experience of sex and desire. This means that often in therapy I've noticed that clients talk about everything other than sex. Therapists may be hesitant to ask about sex, out of fear of this being interpreted as dirty or seductive or leading by their clients. On the other hand, because of many of our shyness about discussing sex, if a therapist doesn't ask, often a client won't talk about sex. It's difficult. In couple's therapy, talking about sex can be particularly complicated, as sometimes the sexual topic that one couple feels they need to bring up, is the source of great shame for the other. There is no easy fix for this, but having a therapist who feels comfortable talking about sex, does help.
So far in this series of posts on defence mechanisms we've covered the defence mechanisms of withdrawal and sublimation, and we've talked a little bit about how this relates to the counselling or psychotherapy process. For background, read prior posts. Otherwise, please read on for today's post on the defence mechanism of projection.
In popular culture in the West today, most of us have a basic understanding of the concept of projection. When faced with an impulse within ourselves that we see as unacceptable, we may project it out on to the other. This allows us to perceive the other as having that impulse, and thereby relieves ourselves of the conflict we feel over having an unacceptable impulse.
Whereas the defence of withdrawal, depending on severity, may range from unhealthy to fairly healthy, and sublimation is generally a healthy defence mechanism, projection is generally understood as a somewhat or very unhealthy defence mechanism. Projection has the capacity to significantly distort our view of reality, and our capacity to relate to others. Many counsellors or psychotherapists will try to help their clients to project less, and sometimes to instead adopt more healthy defence mechanisms. An example of this is someone who has become familiar with their tendency to project, and is able to reflectively question the truth or falsehood of their projection based on the facts of the present situation. This would be an example of replacing the defence of projection with the generally more healthy defence of intellectualisation.
Some defences are used heavily by particular personality types. Projection is a good example of this. People with paranoid personality styles frequently project, in particular they project their anger and sense of judgement or hostility on to others. The paranoid person's tendency to vigilantly scan for any sign of untrustworthiness in others, and tendency to interpret facts in line with their projections, can make them very hard to establish intimate and trusting relationships with. On the other hand, a paranoid person is so sensitive and vigilant to signs of untrustworthiness in the other, that they can be excellent when this is an asset, such as in detective work or other jobs involving detecting fraud.
Another example of projection at work is in the case of bullying, in which the bully projects their own feared sense of vulnerability onto another, and then persecutes that other person. It can be useful for the bully and the bullied alike to understand what is being projected, and to not get tricked into missing the strength of the person being bullied, and the vulnerability of the bully.
As a psychotherapist, I often notice my clients projecting things on to me. (Though it is important to remind myself that often there is a grain of truth in a projection, so that I don't disown my own imperfections!) Usually, a client who projects something on to me will also project that same thing on to others, and that is usually part of the cause of the problem for which they sought therapy. Depending on the situation as a therapist I might help my client to see the inaccuracy of their projection, or, I might instead help my client to explore the full extent of this projection that might be harder for them to learn about in another context outside of the therapy room.
It is not uncommon for clients in therapy to project boredom, judgement, criticism, or anger on to their therapists. By naming these perceptions to a therapist who is confident in working with projections, you may be able to significantly benefit your own therapeutic work. Sometimes people also project positive aspects of themselves such as generosity and competence on to others, because it may be disturbing to recognise these qualities in ourselves if we have a strong self image to the contrary. Though projecting our positive qualities on to others may not seem as problematic as projecting our negative qualities, it may have a negative impact on our self-esteem.
Though it's not developing at the break-neck speed of the physical or biological sciences, research is developing our understanding of what helps relationships to work, and why. As a couple's counsellor or therapist I was reading the research summarised below to help me to help the couples I work with, though you may find that you can directly apply these findings to your own relationship and get some benefits. Research summarised in psychology today affirms that couple's therapy does work, and looks at first factors that give the most benefit.
Though this is a list for couples therapists, none of it is anything that you can't improve on your own. On the other hand, if you would like a helping hand with this, please get in touch with us!
Leaving or needing to leave a relationship is a frequent reason for people to seek psychotherapy or counselling. For some people the process of ending a relationship, though painful, is relatively straightforward, and certainly does not require therapy. However for others, the process is agonising, protracted, and can even be disabling in terms of a person's ability to work, care for themselves, or maintain other important relationships.
Recent research suggests that addictive processes may be involved, for those who struggle severely with ending relationships. Particularly early on, relationships can trigger the dopamine system in our brain - that's the pleasure center that makes us feel really good. Drugs like cocaine similarly stimulate the dopamine center of our brains. The researchers of this study have wondered if the task of leaving a relationship or "falling out of love", for some, might be the equivalent of an addict giving up cocaine.
While I don't know enough about neuroscience to critique the research, certainly subjective addiction related feelings of craving, difficulty with self soothing, and obsessive focus on the substance (or person) of addiction rings true. If leaving an addictive relationship is like giving up a drug habit, then perhaps the following common features of counselling or therapy for addictions might be helpful for some:
Motivational interviewing: The therapist does not take sides about the need to leave or stay in the relationship (in contrast to friends and family who probably have strongly expressed opinions), but helps the client to come to their own decision based on weighing up the alternatives in a personal way.
Relapse prevention: Going back to an addictive relationship is common. Having a relapse prevention plan may help by identifying triggers, such as loneliness or comparisons with others who are in relationships, and making practical plans for coping with these feelings.
A supportive therapeutic relationship: Just as addiction is often isolating, and accompanied by immense shame, sometimes people feel ashamed of their difficulty leaving a relationship, and may have become isolated from supportive friends. A warm and non-judgmental therapeutic relationship can form a regular stable base in a person's life, from which they can make the courageous changes they wish to make.
This is the last in a series of posts on the relational approach to psychotherapy and counselling for common mental health issues. This post covers anxiety issues.
Like other mental health issues, there are different approaches to dealing with anxiety. The medical approach has it's advantages, but as anyone who has become hooked on sedating or anxiety reducing medication can tell you, it is not without its risks. Another approach, that of mindfulness based treatment for anxiety issues, can be very effective. By learning to control our attention through mindfulness, we can empower ourselves to regulate our physiological anxiety responses, and to deal more effectively with anxious thoughts. Neither of these approaches, however, deals with the relational context of our anxiety.
Our experience of panic, generalised, or specific anxieties is often triggered by relationship with others. In particular, we may be anxious of conflict with others, being vulnerable with others, around displaying certain emotions, or around intimacy in general. With the guidance of a psychotherapist or counsellor, we may be able to approach whatever our personal forbidden territory is, that anxiety keeps us away from. Usually when we approach this territory, we discover that it is not what we thought it is, and we can begin to get more familiar and comfortable with the anxiety provoking situation in our relationships.
In particular, as a therapist, I would watch for moments when a client re-enacts an anxiety driven pattern with me, their therapist. For instance, a person who goes to an old pattern of care-taking in relationships, when feeling anxious, will probably do that with me, their therapist, sooner or later. Working with these moments when the issue is "live" between therapist and client can be some of the most potent opportunities for healing and transformation.
Please let me know what you think about this, and stay tuned for further posts on other topics.
The relational approach is hot in the therapy world at the moment, but what does it actually mean, and why would those who are not mental health professionals want to know about it? This series of posts will discuss how we do or don’t think relationally about some common mental health issues, and what the implications of this might be.
First we’ll look at one of the most common mental health issues, depression. This is a significant issue in New Zealand, as probably most of us know due to series of education campaigns and some very useful efforts to reduce stigma. Often, however, campaigns to de-stigmatize mental health issues cast those issues in a medical light, presumably because we tend to feel little shame over other medical issues such as a broken leg or a heart condition. When taken to the extreme, this can lead to thinking that equates depression with chemical imbalances in the brain that are really only the responsibility of our doctor to deal with. Just like I wouldn’t advise a neurosurgeon on how to operate on me, coming from this perspective, I might sit back and wait for the medication prescribed by the expert to do its work on my depression.
I’m not advising anyone against anti-depressants, but I am suggesting that there’s more to the picture of depression than this. Two subtypes of depression involve relationships of abandonment/grief, and of intense self-criticism.
If I am suffering the first subtype, that of abandonment, I may be experienced in relationship as very difficult to reach and connect with, and my (sometimes unconscious) expectation of others is that they will readily abandon me. Others, whether recently or in my childhood may actually have abandoned me. Furthermore, I may now act in ways that sustain this pattern, by for instance, retreating from others into a depressive isolation. From this relational perspective, my depression isn’t only a chemical imbalance in the brain, it is a state of sustained and often unacknowledged grief, loss, and appropriately to this, sadness. If I'm depressed and doing therapy from this perspective, therapy isn’t just about kickstarting my brain's chemistry, but about helping me to grieve, and bringing me back into relationship – often starting with a relationship with a warm, reliable, and empathic therapist.
If I am suffering from the second subtype, that of self criticism, it may be extremely painful for others to witness just how much I disappoint myself. Though others may accept me, and I may even long to accept myself in the same way, it is as if an invisible wall exists to stop any of this acceptance easing my pain. A criticising relationship with myself has been internalised. In order for me to break with my loyalty to this self-criticism, in therapy I may need to explore with my therapist where it came from. What were the earlier relationships in my life in which I was criticised or invalidated, and was this criticism valid? Were the standards or the purposes of this earlier criticism compassionate and guiding, or punishing and unrealistic?
In a nutshell, that’s my brief introduction to a different, more relational, and hopefully more human way of viewing depression. Please let me know in e-mail or comments what you think about this. Check in again soon for the next post in this series: a relational approach to borderline personality disorder.
Post by Michael Apathy at Lucid Psychotherapy and Counselling.