Areas of Treatment
It is difficult to create categories when dealing with complex individuals leading complicated lives. Many of us exhibit a blend of issues that cross over categories, or one issue maybe in response to another. These can vary in intensity and duration depending on a multitude of variables. I have selected eight areas that are frequently bought to sessions and respond well to counselling or psychotherapy.
Abuse effects many of us across the whole breadth of our society. Any deliberate behaviour towards another that causes them harm or upset is considered to be abuse. The aim of the abuser is to have control and power over their victim and is often the result of the abusers own deeply entrenched feelings of shame and inadequacy.
Although abuse can happen at any stage of life we are particularly vulnerable as children. When abuse is experienced in early years it often re-surfaces later in adult life and can change the way we respond to other life events. This latent effect can take the form of emotional or relationship difficulties, addictions, difficulty regulating anxiety, depression, feelings of shame, rage, dissociation or even medically unexplained physical symptoms. Victims may be deeply traumatised and require a gentle, carefully measured, safe and reassuring approach to sharing their ordeal in therapy. It is often the behaviours that we adopt as a natural attempt to limit the immediate impact of the abuse and that result in later maladaptive behaviours. Early years abuse does not have to be dramatically violent to cause serious difficulties, often emotional and psychological abuse that may be subtle, covert but chronic can have an enormously negative impact on our future lives.
The wide range of abuse encompasses both early years and the abuse experienced by numerous adults in their personal relationships daily. It includes emotional, domestic, sexual, religious, physical, racial, verbal, cultural, financial, psychological and online abuse. Other forms of abuse include female genital mutilation, slavery, gas lighting, criticism, stalking, cyber-bullying, humiliation, neglect, sexual harassment and maltreatment.
Sadly abuse related issues are very common indeed, they can be complex and deep-seated. Many people are prompted to take action only when the problems created in their current life by their historical abuse become unbearable. Fortunately they seek therapy before they become more deeply entrenched and unhelpful coping behaviours.
Addiction is often the expression of a separate psychological issue that has not been processed or dealt with adequately and may even remain outside of our consciousness. Addiction provides the perfect escape from dealing with what may be difficult or frightening to face and process. However this is not exclusively the case as occasionally an addiction may develop without any trauma being present and follow a more physical route, in pursuit of biologically rewarding highs; the picture may have been complicated by a genetic propensity or modelling in early life. It can simply begin as an attempt to manage stress, anxiety, boredom, peer pressure or depression and slowly develop without us realising we have formed an addiction that is effecting those around us. Denial is often involved in allowing addictions to escalate out of control, keeping people from dealing with them until they experience a crisis, often around work, relationships, health or finding themselves in A & E as the result of a misadventure. Evidence shows that the earlier we seek help the more successful it will be. Some of the symptoms that an addict may be struggling with are:
- Increased obsession and time spent in acquiring the desired substance or activity.
- Difficulty taking a break from, or limiting the use or activity.
- Failed attempts to control addiction and frequent relapse.
- Attempts at control cause feelings of anxiety or irritability.
- Neglecting responsibilities, relationships and important daily activities.
- Getting into fights, arguments or involved in accidents and brushes with the law.
- Continuing, despite it flying in the face of the increasing negative consequences.
- Risk taking, personality and behavioural changes around the use or behaviour.
- Pursuit of the substance or activity is causing financial strain.
- Increasing tolerance of the substance or activity.
- Denial of any problem, despite reality indicating otherwise.
We tend to think of most addiction involving: alcohol, gambling, drugs or nicotine. Less often we consider the impact of addictions to exercise, love, legal highs, sex, prescription drugs, pornography, food, shopping, work and computer games.
Addiction also raises the issue of co-dependency, when there is an emotional dependence on one partner meeting all of the emotional needs of the other, enabling them to continue with a destructive addictive behaviour. The co-dependent needs the other to make them feel better about themselves, their caretaking and constant self-sacrifice helps them avoid the anxiety of saying no and setting boundaries. They feel responsible for the other partner’s problems and will over-ride their own needs despite them not taking any of their advice or doing anything positive to help themselves. As with addiction, co-dependency responds well to therapeutic support, identifying the root of the anxiety and shame, building assertiveness and self-esteem.
We have all experienced the anxiety of a big presentation, a new job or an important exam and some mild anxiety may even help us to perform at our best, too much and it can easily overcome us, ruining our performance. Certainly when in real danger, anxiety will help us overcome potentially threatening situations, the physiological changes prepare our body for an extraordinary, supercharged life saving effort. When the pathways designed to be activated in the case of extreme threat are triggered on a regular basis it can be life changing as our daily activities become full of fear and worry. Some of us do not realise we are experiencing anxiety; we believe that our highly stressful existence is somehow a badge of honour. We hold the misguided belief that stress and anxiety help us to keep our performance at an optimum level and any attempt to reduce it will result in a drop in performance when in-fact the exact opposite is true. Often we control the anxiety with an addiction to keep it in check, and instead of going for a run or a gym session, we opt for half a bottle of wine or far more dangerous levels of addiction. Mindfulness based approaches are very useful for helping to create some distance between our thoughts and actions, short-circuiting our often automatic behaviours. Anxiety and stress are about fear of the future and a constant mounting up of what has to be done can easily start to become overwhelming. When practised regularly mindfulness can help us to be more aware of our internal and emotional state in the present moment and treat ourselves with more compassion. In cases were anxiety has got to extremely high levels, normal activities, social interaction or even leaving the house can become a very real ordeal.
Some of the symptoms you may experience when suffering with anxiety are; irritability, inability to concentrate, rapid breathing, rapid heartbeat, nausea, dizziness, insomnia, sweating and feelings of panic. Anxiety is at the core of many of the numerous simple phobias such as fear of flying, dentists, needles, blood, heights, germs, vomit, sexual phobias, spiders, small spaces and hoarding. The more disabling complex phobias such as agoraphobia and social anxiety disorder can have an enormous impact, causing increasing isolation and making work and relationships very difficult. Anxiety is often implicated in other areas such as addictions, trichotillomania (hair pulling), dermatillomania (skin picking), body dysmorphia, compulsions and separation anxiety. Probably two of the most well known anxiety related problems are panic attacks and post traumatic stress, both of which respond well to a combination of mindfulness based interventions and psychodynamic work.
It may be that long-term anxiety around many different situations, racing thoughts and an inability to concentrate or sleep properly is Generalised Anxiety Disorder (GAD). GAD sufferers have to deal with a multitude of emotional and physical symptoms on a daily basis with the effects fuelling each other in a loop, again regular mindfulness practice has been proven to be very effective in helping to regulate your anxiety.
Sometimes it is not apparent why we feel low and other times it is abundantly clear why we are suffering. Living with depression is difficult for both the sufferer and the people around them. It can be impossible to find enjoyment in things that you used to find pleasure in. Some days even getting out of bed can be a real challenge and on others you may find yourself able to carry on as usual. You may suffer from feelings of worthlessness or that life is not worth living, your motivation and self-esteem may be on the floor. You may be tearful, indecisive, irritable, worried and unable to concentrate. You may also experience a change in eating and sleeping patterns, loss of libido, slower or faster than normal speech patterns and withdrawing from your usual activities. You may start to feel that you are a failure or that you have let people down. Physically you may even suffer with unexplained headaches, stomach upsets, fatigue or chronic pain.
Some distressing life events cause low mood for all of us, fortunately it soon passes and we start to feel brighter, unfortunately for others depression sets in and we experience low mood that does not go away. Depression is a mental health condition that effects sufferers every day for long periods of time. Sadness comes and goes relatively quickly and easily, depression is constant and oppressive. It can be hard, when we lose a job, go through a traumatic divorce or lose someone close to us, to gauge how much of our low mood is “normal”, the truth is we all differ enormously. Part of the problem is that the very symptoms of the depression prevent us taking the action that would help, including finding and arranging an appointment with a therapist. Difficult life events such as bereavement are a major cause of depression but it may be that childhood difficulties have left you with problems that you are experiencing later in life. You may have feeling of anger or rage about an issue from childhood or in the past that is causing your depression now and you may not be fully aware of it. Other causes may be other health problems that could be viral, hormonal or chronic pain and life threatening conditions. Heavy drinking is also known to cause susceptibility to depression. It is important that you talk to someone as early as possible as depression is a very common and treatable condition.
There are also more specific types of depression such as seasonal affective disorder that usually occurs in winter and is linked to daylight length. Dysthymia is a continuous mild depression that lasts two years or more. Bipolar disorder is a condition that has periods or episodes of feeling low and lethargic and periods of feeling high and overactive, some medical professionals further subdivide the condition into bipolar I & II with I indicating deep mood swings across the scale from mania to depression and bipolar II indicating a prevalence of depression with less severe mania.
Post natal depression commonly affects women and occasionally (up to 1 in 25) fathers. It persists beyond the often experienced 2-week period of feeling tearful, a bit low and anxious immediately after childbirth and develops into full depression. It is also possible to be affected by pre or antenatal depression that can occur during pregnancy.
Depression takes many forms, from mild but persistent low mood or a more severe clinical depression that interferes with daily living and may include thoughts of suicide or not wanting to carry on.
If you are experiencing feelings that you might harm yourself or that you cannot go on, contact someone immediately, if you have no-one available you can walk into A&E. You can see your GP or the out of hours GP service. If you have taken an overdose or cut yourself badly dial 999.
The Samaritans operate a service 24 hours a day, 365 days of the year, for people who are at risk of suicide, call 08457 909090. Or contact a friend, family or someone you trust.
Disorders & Syndromes
There are lots of labels for many different syndromes and disorders, these often cross over and are linked in complex ways within the same person. Some therapists are keener on giving disorders names than others, personally I find the labels limiting and sometimes stigmatising and only occasionally helpful. I prefer working with individuals and their complex behaviours and I place less importance on definitions. For those that like to categorise mental health conditions I note some of the more common disorders and syndromes below. It must be remembered that these labels are a construct and in real life they blend into one another. It may be very difficult indeed to decide how far from the “norm” a personality trait has to deviate before it becomes a disorder and not just a quirky way of being, or an endearing, or perhaps not so endearing eccentricity.
Many conditions are intrinsically linked to anxiety, depression, abuse and trauma or a complex mixture and can vary in intensity and duration. Anxiety related disorders can encompass; obsessive compulsive disorder, hoarding disorder, post traumatic stress disorder, social anxiety disorder, separation anxiety and panic disorders. Eating disorders such as bulimia nervosa, pica, anorexia nervosa and binge eating disorder also may have their roots in depression and anxiety. This may in turn have foundations in stress, societal pressure, biological factors and be even further complicated by substance misuse, attachment issues and personality disorders.
Personality disorders effect how people manage their feelings and relate to others they often involve attitudes, beliefs and behaviours that cause difficulties in daily life, they encompass; paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent and obsessive compulsive personality disorder. Again as mentioned above they blend often into one another and court considerable controversy about how to even define a “personality disorder”.
Attachment issues are common but attachment disorders and specifically reactive attachment disorder is rare and related to severe absence of care during early years when the child’s basic needs for comfort, love and affection are not met and attachments with others, usually the mother are not formed.
Dissociative Disorders are often a natural mechanism to escape the trauma of abuse when you are entirely powerless to defend yourself. The natural response to a massively overpowering abuser is not to be mentally present or to dissociate. Dissociation can also occur as part of other mental health issues or as a side effect of prescribed or other drugs.
It should be remembered that many disorders and syndromes are just names and that some would argue that many people just do not fit into a particular category but may display traits of several at different times in their live or even within the same day. There is also concern that diagnosing, “over-medicalises” and creates “mental illness” from some of the natural experiences we can expect throughout life. Others argue that it is useful for clinicians to mark out distinct phenomena for recognition, research and to indicate treatment approaches.
Emotional issues are concerned with our thoughts and feelings; they encompass a whole raft of problems that many of us experience at different stages of our lives in varying degrees. We may experience; low self-confidence, assertiveness issues, guilt, rage, procrastination, shame, anger, low self-esteem, exhibitionism, grief, nightmares, fighting, fear of abandonment and self-loathing. These issues may even lead to depression, self-sabotage, self-harm or suicidal thoughts.
Many of the emotional issues mentioned above respond well to counselling and psychotherapy as you discover patterns of behaviour and gain insight into how they may have served you well in the past but are no longer helpful. Although understanding the root of these patterns of behaviour intellectually is very helpful, it is not enough for true healing. Counselling and psychotherapy can help to facilitate emotional experiences that can profoundly alter how you relate to yourself and future events in your life.
The life events that we all experience at some time, can be the cause of many of these emotional issues, it may be health anxieties, aging, divorce, bereavement, miscarriage, grief, loneliness, infertility, abortion, terminal illness, parenting problems, adoption issues or existential anxiety about the big questions, such as; why am I here?
How successfully we deal with many of these emotional life events can influence whole passages of our life. It is important to seek help as early as possible, although for many of these events there is no treatment, as aging, death and illness are inevitable. How we manage our perspective on these issues and come to understand how we respond, in context of our past and present life, can be fulfilling. Even in the most difficult times it is possible to overcome seemingly insurmountable difficulty.
Medically Unexplained Symptoms
Counselling and psychotherapy can be helpful with some physical symptoms that have no medical explanation.
I should be clear that experiencing mental symptoms in the body does not mean it is “imagined” or “all in your head” the symptoms are very real indeed. Our brains and bodies entwine to form one complex system, capable of generating real pain and discomfort. We tend to think of the relationship between our mind and body as a “top down” relationship, when in fact we know that our brains and bodies exchange innumerable message every second, both chemically and via the nervous system and in both directions. We are all aware that with training our mind can influence our breathing and heart rate to work at very low levels, slowing our entire metabolism. Equally with little training we can all create a fast heart rate, feeling sick, shaking, dry mouth, sweating, chest pain, headaches, a knotted stomach or rapid breathing.
Some forms of medically unexplained fatigue, unexplained headaches, stomach complaints, heart palpitations, nausea, chest pain, shortness of breath, weight loss, constipation, selective mutism, irritable bowel syndrome, insomnia and fibromyalgia can often respond to counselling and psychotherapy. Sometimes a link with early trauma or anxiety and depression is clearly established and the symptoms respond well. Unfortunately it cannot always eliminate symptoms in every case, it can however usually help you cope much better with the associated pain and the fallout in other areas of your life.
Despite liberal appearances there is still a great deal of shame and ignorance around many sexual issues. Some of the issues that people bring to counselling and psychotherapy include; adultery, chem-sex, STD’s, gender issues, sexuality, sexual dysfunction, sexual identity, impotence, sexual abuse, infertility and pornography, sex or love addiction.
You may just wish to explore your sexuality in a way that supports your right to express and explore in a safe consensual and responsible way. Counselling and psychotherapy can provide a safe and encouraging space for an authentic exchange were you can explore whatever is necessary for you to find a way of being that fits well with your intrinsic, authentic self, free from judgement.
Some of us suffer with difficult paraphilic disorders that involve fantasising or engaging in extreme and atypical sexual behaviour. These disorders are usually focused on a specific act or object and they become dependent on it for sexual gratification. Some of these behaviours are totally harmless to others but many are abusive, distressing, dangerous and illegal. Psychological issues are often at the core of these behaviours and therapy may be useful for exploring childhood events that have resulted in developing the disorder.