blog

Loss

Tue, 09 Jun 2009 12:20:59 +0100

Existential realities are like primal states of being. They are core to who we are and how we act. To understand our existence is to have insight about the emotions we experience and of course, our mental state. Loss is one of these primal states, and its marks on our personal narratives are ubiquitous and often significant. There are the times in which we shiver in response to its lingering touch. From the moment of the neonate's cry for warmth of its mother's womb until the flashes of a life lived and lost in the instant before death. Loss is a statement of our own mortality in which the limits of our lives demand that choices not taken, words not spoken, and opportunities for actions ignored. Loss is the rhetoric that we are constantly in a state of dying. Perhaps the only certainties that I know is that I began and that I will end. In between is a life of action, feeling and thoughts, that are almost always a reaction to the possibility of loss and the impossibility of omniscience and certainty about our world.

Normally, the word loss is associated with death, bereavement, and mourning. But in a sense these three experiences are also relevant to a wider notion of loss: that something or someone undergoes extinction. That an object literally dies and becomes unavailable. It is this unavailability that represents the key definition of loss for me. For neonate, it is the unavailability of the womb and intimate connectedness within another human body. Death is obviously the unavailability of life, and for those who survive one who dies, the unavailability of that relationship.

Bereavement is the experience of loss that Kubler-Ross describes as five step process: Denial, anger, bargaining, depression and acceptance. Getting through the bereavement process depends somewhat our relationship to what is lost and how it was lost. The more distant a relationship, the easier to accept its loss. When the relationship is more intense and the loss perhaps unexpected, then we are more likely to challenge and deny reality of its absence and feel anger at our powerlessness to change the situation.

This process of bereavement is not just about a response to a loved one who has died – but to all objects loved and lost. It applies to divorce and a break up of relationships. Parents experience it when their children are growing up, becoming independent and finally leaving home. The process is even felt when we mourn the choice not taken – especially when the choice that has been made did not turn out as we expected.

The very ubiquitous nature of loss means that it lies ever present in out existential realities. I have seen my two year-old daughter go through this very process of bereavement when it is time to go to bed and her toys become unavailable to her.

How to survive such experiences great and small? How will my daughter survive the loss of her toys? To my daughter I offer empathy and a naming of her sad feelings. I offer hope that she will play with her toys again. I distract her from her loss through giving her bottle of milk and reading her a bedtime story. I offer her an understanding that saying “goodbye” is hard.

Is that all, you might ask? Except it is not so easy as you might think. Freud wrote an essay once called “Mourning and Melancholia” in which he explored the notion that mourning is a natural stage of sadness that once passes through at the loss of someone or something important. Melancholia is when we get stuck and are unable to move beyond the boundaries of our sadness caused by the loss. This often happens when there are unresolved feelings, thoughts and questions about the person or object that has become unavailable. In many instances the child with unresolved relationship issues with their parents, who may have escaped far away from the family, may have the greatest hurdles to jump before passing from melancholia to a mourning state.

We all have parts of our lives that are susceptible to the melancholic. Many people, in the beautiful words of Ernest Becker are in a state of “denial of death” seeking to live eternally through the creations of our hands and minds that will survive human mortality. He conceives of mental illness as being the perception that these eternal creations are insufficient to repel off our mortality and our ultimate insignificance in a universe of almost seemingly infinite objects.

And this ultimately is what all of us need to come to terms with. Our insignificance and mortality. If we could live forever, we could achieve everything and anything. Our mortality is the unavailability of being able to do this. This is the example that I use. Suppose I read one book a week for 70 years or so of live – that comes to 3,640 books. That is not so many books. After all one can buy millions of books from Amazon, and probably 400,000 new books are published in English every year. How does one choose which book to read, when there are so many, and yet there is so little time? For each book I read, I have to survive the paralysis of knowing that there are literally thousands of books that I will never be able to read.

I could be intensely sad about my state of being. That however much I think how well read I am, the reality is that there is always so much more to know and understand. That this learning process will never stop until my dying breath. And sometimes I am sad (and frustrated) about it. But I also see it as something inspiring. My mortality tells me that I need to value each moment in my life. Each moment. Each person. Each book. Each opportunity to grow, love and live. That is the gift of our mortality and experience of loss. Ultimately, it gives us meaning each second, minute and hour of our life.

Uncertainty

Tue, 09 Jun 2009 12:20:49 +0100

Uncertainty is a powerful and nearly all-present state in our lives. Human beings have a wonderful capacity to fill in the gaps – whether it is visual system creating holistic images in our head, or our auditory and language system creating meaning from misheard statements. Our brains are able to fill in the holes and make interpretations that help us to navigate the world. It gives us certainty. But to a large extent this is an illusion. In the same way, our brains fill in the gaps of uncertainty so that we believe that we really know things that generally are unknowable.

Take the future for example. We are able to predict and prognosticate based on previous experiences that we can recall – but although we believe in our own certainties of the what will happen next, the future is fundamentally unknowable. Our certainties are usually based on leaps of faith, that what happened before, will happen again.

Take the people around us – even those who are closest to us. Again, our brain fills in the fundamental gap that exists in all relationships, that we can never truly know, understand and see another person's mind and feelings. There is empathy, but there is no telepathy. Many of the misunderstandings that happen between people come from this sense that we are able to read minds, but we often get it wrong.

What is interesting to me as a psychologist is how each person decides to live with this inevitable state of uncertainty. To a certain extent there is a genetic influence on the differences in individual reactions to not knowing. Some people really do not seem to worry about not knowing, basking in a Buddha-like glow of enlightenment. For some people, uncertainty is a catastrophic state that needs to be conquered and brought into knowable control. Most of us lie somewhere on the spectrum with our reactions to uncertainty influenced by unique combination of personality, situations and events.

Take the different reactions that people have to an event like the 7^th July 2005 London bombings. For example, I was able to travel on public transport the next day paying no heed to the uncertainty of the possibility of being a victim of another atrocity. I am not sure how it was that in this case I did not have any concerns. Perhaps it was because I could rationally evaluate the risks and understand that there was a very low chance of such an event reoccurring. Perhaps also it was my sense of acceptance of my mortality – and my faith in the idea that God decides when I die, so that there is little that I can do about when or how it will occur.

However, there were many people who were indirectly traumatized by the bombings and lost the capacity to deal with the intrinsic uncertainty of whether we will survive traveling on the Underground. Such anxiety can be overwhelming paralyzing. Perhaps these were individuals who had previous experiences that were triggered by the events of the day. Or perhaps individuals who were already nervous about the risks of traveling hundreds of meters beneath the ground.

Anxiety is a normal response to existential uncertainty. We all experience the tension of not knowing sufficient information about a person or situation. When I once treated a woman in her fifties who had not been able to leave her home alone for more than 10 years, it was her imagined fear of what could happen that prevented her from living a normal life. She imagined that she would faint, or fall over, or that people would laugh at her. She imagined being ashamed and embarrassed. These were certainties that her mind had created about what would happen. She had built a seemingly indestructible framework that trapped in her home, but also made her feel safe where it was a controlled and more knowable environment. This was a reaction to a fundamentally uncertain world, in which it was better to be at home rather than risk what might possibly occur outside, irrespective of how likely it was to happen.

Typically, the onset of these kinds of extreme reactions are a reaction to a trigger event or situation. Someone important died suddenly. The house was burgled. A person was involved in a serious car accident. A person fainted because they were dehydrated. The kinds of the events that are difficult to predict and control for.

How we react to such events and our state of uncertainty is often related to our mental health. Fear of the unknown undermines our feelings and desires to be safe. The typical response is to try and create havens of certainty in our lives. Routines. Obligations. Moments to control the situations and the people in our lives. Fixed points of time in our daily lives to eat, watch television, to talk to friends on the phone. Opportunities to occupy and distract from the discomfort of the unknowable reality with in which we live.

This is not about what is a good or bad response. Such judgments are not relevant for most situations. These responses are part of our human existence. There are large number of individuals who experience intense feelings of anxiety – and the time to seek help is when the fears interfere with daily functioning. However, I believe that treatment is not just about extinguishing the anxiety through interventions like cognitive behavioral therapy (even though it has excellent success rates), because for the individuals who are in deep mental distress, the role of therapy should be to understand the states of uncertainty leading to the specific fears, and finding ways to live with not knowing all of the answers all of the time. Therapy in these situations is about learning to live with anxiety and to function without its paralyzing power. Actually, living life is this too: living with our uncertainty and having the faith to trust what happens next. To walk the stepping stones even though we cannot clearly see to where they lead.

Choosing a therapist

Sun, 29 Mar 2009 13:54:38 +0100

When friends ask me about finding a therapist the first distinction I try to make is whether it is for personal self-development, or for treating some kind of perceived condition. By the way, these things are not mutually exclusive. But here's the main reason why I think it's important to distinguish the two:

It's really hard to go to therapy when you are actually unwell.

If it is for some kind of actual mental health disorder, I tend to suggest practical, physical or pharmacological solutions first, and then therapy when there is more stability or equilibrium. Quite often, when a person is in the midst of mental illness, the insight process is the last thing a person needs to begin with. This is important for choosing a therapist that will help address the actual mental illness - or whether a person should see a psyciatrist for medication first, before starting therapy.

Then I tend to ask, without getting into too much detail (after all, they are my friends) about the kinds of issues they might want to deal with. These typically include: marriage/relationship, children, loneliness, life transitions, tension/stress, anxiety, sadness, disappointment/loss, lack of direction, problems at work. There are many others, but these are probably the most common. Actually, that's an important point; these are really common problems that nearly every person will experience at some point in their life. Wanting to see a therapist is often the most sensible act a person can do in many circumstances. Instead, the stigma of being in therapy makes many individuals feel as if they have failed at living. The point is, that some therapist are better than others for certain kinds of problems. No therapist is good at everything. I did some limited amount of couple counseling during my training, so I would certainly not want to offer my services as an expert in that field or with that kind of problem.

So now I have a sense of what they want to talk about. How do I recommend anyone to them? I have seen a few therapists myself – but only two that really made such a wonderful positive impact on my life. I obviously can recommend them. But they live in London – so what about my other friends in different cities and countries. And anyway, they might not be suitable for everyone.

So here is how I go about this task. I ask myself a series of questions like the ones below. For each one, I'll explain why I think it's important quality to think about.

1) Do they have a sense of compassion, warmth and love for other human beings?

I think that being human and humane is critical. Very often, people think of therapists as being 'clinical' – meaning aloof, separate and distant. I think that is usually the opposite of what most people need when they go to a therapist. There should be moments of tears and laughter that are shared between you and your therapist.

2) Is there an insatiable sense of curiosity about other people?

For me, to have curiosity about another person is to care about that person. I try to be very aware of this whenever I am working with someone. Whenever I start clock watching for the end of the session, and realize that my curiosity has diminished – and that I really need to understand what is causing that and to do something about it.y have a guiding set of principles about the way in which they work?

3) Do they have a guiding set of principles about the way in which they work?

The point here is not the kind of principles necessarily, but rather that they are guided by something they know and feel deeply, and have great experience with. Most therapists say that they are 'eclectic' – but I don't know what that actually means. I like it when someone has depth of belief about how they do their work.

4) Are the flexibly minded and willing to go out of the comfort zones of their frameworks when they need to?

But at the same time, a therapist should not be welded tightly to their principles and beliefs. There are times when a therapist needs to try different ways of doing things.

5) Is there more to them than being a therapist? Do they have a wide general knowledge of different things?

This may seem like a strange one – but I am always a bit scared of people who only know about one subject area in their life. I think the more rounded and knowledge-enriched a person is – the wiser they can be. And a therapist needs to try and be wise.

6) Is there a sense of humility, an ability to be aware of limitations and fallibilities?

Therapists are not magicians or wizards, and they are not omniscient and omnipotent. This is often what most scares me about many people in the therapy world – that they do not see their limitations and that therapy itself is inherently limited. Not all the problems can be fixed. Most things cannot be changed easily, if at all. Acceptance of the human condition requires humility.

So these are the questions I ask about myself as a psychologist – each time someone comes to see me, or when a friend asks me for some advice. I am sure that there are many others, but what really stands out as being important to me is the capacity of a therapist for being humane: forgiving, merciful, kind and a desire to alleviate pain.

Six Causes of Tantrums

Sun, 29 Mar 2009 13:28:53 +0100

I was asked to talk about tantrums recently at a parenting workshop. A popular subject. Actually, I think of the two hours, I spent only about 10 minutes talking directly about the causes of tantrums, which is probably the most common and difficult parenting challenge. Most of the discussion was actually a survey of different evidence-based parenting techniques, which could be employed in a variety of challenging situations, including tantrums.

This blog is about the six causes of tantrums that I have identified, because I think that knowing about some of the causes is the first step in planning what to do about them.

1) Tiredness

This is probably the most common reason for why a child has a tantrum. Check out how much sleep they've had in the previous 24 hours. Is the tantrum a signal of exhaustion and wanting to sleep – even though the child might insist they want to stay awake?

2) Hunger

This is another common reason for tantrums – check whether your child has eaten recently. It is possible that their sugar levels are low. Most people become crotchety when they are hungry – and children are no different

3) Anxiety

I have noticed that fear and anger are often closely related. When a child is anxious or afraid, whether about separation from a parent, social anxiety, or even fear of a specific object, there is a tendency to express it through having a tantrum

4) Attention

Many children have tantrums because it is a way of getting parents to do what the child wants. In other words, the tantrum behavior is rewarded and reinforced. Here is a basic rule: all children want attention, and some attention is better than none. And while good attention is the best, children will settle for bad attention than none at all. If you're on the telephone having a chat with a friend, then look out for some bad-attention seeking through tantrums.

5) Emotional expression – not having the words

Tantrums can occur when children are unable to express clearly their needs and wants. Frustration and a lack of patience mean that some children will resort to tantrums as the easiest way of expressing themselves. For many children, tantrums are an inevitable part of developing emotional control – something that the vast majority of us are not born with. Handled smoothly, tantrums are an important way for a child to develop emotional control.

6) Growing independence and self-agency

For many children, tantrum are a way in which the limits can be tested, and represent the child's desire for control over their environment. This is a natural part of growing independence and sense of being able to be an active and causal force in the world. Tantrums can also be a sign of a power-struggle between parent and child, particularly if there are other siblings involved.

One of the most common things that I have heard parents say to me is that a child is being manipulative, which is often expressed through his or her tantrums.

This is a very adult way of looking at the world. A person who is manipulative obtains his or her own goals at the expense of other people by using them, usually in an underhand way. Children's behaviors are far too obvious to be truly manipulative. It is usually obvious what the object of the tantrum is. A truly manipulative person is able to manipulate without anyone realizing. This is just not the case for the vast majority of children.

The trick here is think childlike, and not like an adult. The most obvious explanations are the usually the best ones when it comes to children's behavior.

Ambivalent about therapy

Tue, 10 Mar 2009 08:46:04 +0100

I am ambivalent about the word “therapy”.

For me, it connotes the idea of something to be fixed and to be made better because there is something wrong, bad and diseased. That makes sense when talking about chemotherapy, or drug therapy, or physiotherapy.

Obviously, there many individuals who have experienced or currently has a mental health illness in which the appropriate word could be therapy, which denotes the act of medically caring for someone who is unwell. In this case, the word “therapy” may be apposite, especially when referring to pharmacological interventions. Although, even then, I am cautious about the idea of providing psychological therapy. In my experience, the best time to start talking therapy is not when a person has become mentally ill, but rather when they are stabilized and able to think and reflect safely in equilibrium. At this point, are they really different to the many people seeking a desire to lead their lives differently because there is a recognition that life could be lived better?

If this is the case, then word therapy does not seem to me to be the best word to describe this process. It is a misnomer to use this word to describe the desire for self-development. It also presupposes that there is something “wrong” with a person's life until this moment for desired change. I am little cautious about interpreting life in such black and white manner, and this seems to me to be a risk of the therapeutic process. In my mind, the relationship between the therapist and patient should be about knowing how to integrate rather than reject the past into a person's vision of a future better life. Living with our personal stories seems so much healthier to me than rejecting or suppressing our history.

Often what is discovered in the therapy process is that what worked when a person was a child, adolescent or young adult does not work so well when the individual is an adult. That is not to say that such behaviors are intrinsically bad; after all they served their purpose. It's just that the fit between the old behaviors and current life situation does not work. For many people entering therapy its about finding new ways to adjust and adapt to life changes and transitions. For example, I once worked with a family with a child who had obsessive compulsive disorder related to counting the number times she needed to breathe before starting a myriad of different tasks. What was interesting about this family, was that the parents and siblings all had their own separate mechanisms for dealing with moments of anxiety. For example, during the family consultation, everyone recognized what would happen when the mother was anxious. She would clean thoroughly every nook and cranny of the house in a whirlwind of industry, and it would be almost impossible to communicate with her. This is an example of a safety behavior which is triggered in moments of anxiety and designed to reduce the emotional tension.

Here is the point: from a therapy perspective one can see how all the family had uncommunicated anxieties and each individual had their own method for dealing with it. However, one consequence appeared to be that the child with OCD had been made the representative of the family's anxiety. Traditional therapy approaches would work with the pathologized child – which of course is indicated by the word therapy. But the question for me was how the family itself generated the necessary environment to perpetuate these safety behaviors in this particular chid. I wanted to focus on whole family rather than the child. In this case, the word I preferred using to describe my work with the family, was consultation. The work consisted of providing a safe context for them to explore all of their own anxiety behaviors and to make a decision about how important it was to focus on one child's specific behavior to the exclusion of everyone else's responses to anxiety. The consultation here was about allowing the family to make their own solutions that involved all the members.

And this is the heart of why I find the word therapy to be so challenging. Implicit in this word is the idea that I, as a psychologist, am able to fix someone else's problems. It seems to me, that at the very most I can offer guidance, counsel and consultation. Is it really possible for another person to be the expert of another individual's mind and consciousness.

I struggle with the notion of expertise. I have had many of years of training. I continue to read many books in psychology and neuroscience. I do have knowledge about mental health. But in a therapeutic context, it is possible for this very expertise to interfere in the opportunity afforded in that 50-minute session to really understand the person seeking support and help. This is a particular risk when someone comes to see me with the expectation that I can “fix” a problem in the process of therapy. It is those expectations that place me into the expert role, that I find challenging. It can be irresistible to be seen as an expert. After all, that is what most people want, and what they are paying for.

The family I described above expected me to start offering cognitive behavior therapy to the child with OCD. This would be a natural expectation. However, she had already received six months of CBT a year previously, and the OCD had migrated to different type of safety behavior. This gave me the opportunity to ask them to try a different and more solution-focused approach that got the family talking about their stories of being anxious. I was able to change their expectations about my role as a therapist, and was able to be more of a facilitator to the family's thinking and talking.

I do not think I would have been able to do this if I had been stuck with a more medicalized and fixed notion of therapy and its purpose. The question is what words are better to describe the psychological process of change in an individual or family. What words are better for describing the role of a therapist and the individuals they see? There is a neatness to the terms therapist, patient or client. It describes the roles and expectations clearly. However, that is exactly my discomfort and ambivalence to those words as well.

Introduction to parenting issues...

Tue, 03 Mar 2009 20:20:18 +0100

The purpose of these parenting blogs will be to present some of the questions that I am often asked, both as a psychologist and as a parent.

Many people call or come to see me with high expectations about the kind of advice that I can provide. Many people just want the simplest tools, techniques and strategies. There are a lot of simple tricks that one can try and use, but I want to say two really important things about giving advice, or perhaps more importantly receiving advice:

1) Most of the time, we already have the knowledge of what needs to be done. Parenting is often about confidence in our abilities to manage our children's behavior. There is rarely one simple answer that works for everyone. The tools and techniques have to fit with our overall relationship styles. Actually, that is often where the answers to problems come from - our personality, our family history, our personal stories. I really believe that most of the solutions we need are actually contained within us.

2) It is important to have theoretical framework for providing advice. Theory creates structure and provides a method of understanding behavior. Having ideas about why a child behaves in a certain way can be very helpful for parents, and this knowlege itself can generate solutions. There are many different psychological theories for child development, and this is not the place to say which is better than the other. My orientation is generally a behavior management approach which itself is rooted in learning theory (i.e. how we learn and respond to the environment around us).

I look forward to hearing different ideas and approaches to some of the challenging issues that are raised, and that these blogs will be of use and interest to parents and other people with an interest in psychology.