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Last Monday, 7th January 2013, I joined former Notts County footballer, currently Birmingham coach, Michael (Johnno) Johnson, on Mark Dennison’s Morning Show (BBC Radio Nottingham); the topic for discussion was the impact on non-Premier League footballers, of coming to the end of their ‘shelf-life’, which is approximately 10years from the age of 20ish-30ish. This followed a report in a magazine about high levels of depression amongst men in this situation. Michael had also observed this phenomenon amongst his peers, and explained that, contrary to popular belief, footballers (apart from Premier League), mostly earn good money for a short time, mainly in that 10year window, after which the contracts dry up, and they find themselves replaced by younger men, and searching for new careers. Those wanting to stay in the world of football have to chase the very few posts available in coaching, managing etc…and there are many more ‘surplus’ footballers each year than there are vacancies in those areas.

Suddenly, men who have heard their names cheered by thousands of fans, been in demand for public appearances, autographs etc, are effectively on the Scrapheap!

Unsurprisingly, there can be an impact on confidence, self-worth and consequently personal/family relationships, as income dries up and status changes, from hero to…what now, exactly ? As the former star comes to terms with this, there can be a period of what might be called grieving for a lost identity, which like any bereavement process, will have elements of denial, numbness, anger, fear and sadness; the person may be moody, distant, irritable, lethargic, seeming depressed…..

This is a time of uncertainty. As humans, we have a response to this somewhere on a continuum, ranging from being excited by possible opportunities ahead, to feeling acutely threatened by the unknown. Most of us seem to be towards the threatened end….So it is not really surprising, in this situation, if the ‘ageing’ footballer, starts to show signs of anxiety and tension. 

This time of adjustment could be predicted and planned for – it is after all a fact of footballing life – but all too often, players are so immersed in their familiar lifestyle, in denial about the future, that it comes as a shock.

As a therapist, I have had the opportunity to work with people in the public eye, performers in different fields, sports, film and stage, and the art world. (I have sometimes also worked with partners and other close relatives of sportsmen). The common shared experience is that the ‘star’ has a sense of being only as good as the last performance/output. We live in a competitive, judgemental culture. Those in the spotlight are particularly vulnerable to external evaluation. In therapy, of course, we seek to develop a strong internal sense of evaluation, self-acceptance and autonomy/self-agency, an attunement to what feels right for the person, by  the person, so how other people judge us has less power over us.

We can do this by learning to develop and listen to an internal ‘other’ voice; this one is compassionate, warm, wise, strong and encouraging. It does not ‘whitewash’ as in ‘Don’t worry something will turn up’ (eg without you doing anything), nor does it pretend that there is no reason for concerned attention to this reality. But neither is it bullying or negatively critical, putting you down. This is the voice of someone who loves you whilst understanding your strengths, and ‘weaknesses’ – which are aspects of your way of being which may slow your progress in life or limit your happiness.

As always when someones is grieving a loss, it takes time to adjust. This is a natural process, and we cannot force the pace. However, we can come to an understanding about what is happening, experience the feedback that this is normal, and start to come to terms with our new NOW. I find that people benefit from reading a short book ‘Who Moved My Cheese?‘ by Dr Spencer Johnson. The ‘cheese’ represents whatever you hold dear in life – and identity is very precious indeed, especially when it has been hard won, that is be becoming successful despite all the odds in a very competitive field.

It helps to learn to challenge the negative thoughts that people faced with this experience typically have eg  ‘I’ll never be able to survive outside the world I know best’…..’I’m no good at anything else’….’nobody will rate me if I’m not a footballer/actor/sportsman/successful artist, business person etc’.  This is about recognising that we are all more than what we simply do. We are after all, human beings, not human doings. But all too often, shortly after meeting someone new, we go on to ask or tell what we do…This, of course is cultural, societal, and will not change overnight. However, perhaps we might all start the process of a shift in behaviour by our own new, different choice of words to introduce/describe ourselves…a challenge indeed!

As with all our fears, we do best to face them; like the monster under the bed in a child’s nightmare, they tend to look less threatening and more manageable when we do this. Sometimes they even turn out to be non-existent threats! This is not to encourage worrying in advance over something that might go wrong, or never happen; we need to take sensible steps to protect ourselves  – like insurance, a sort of life seat-belt – but not avoid driving through life, nor focus only on the rear-view mirror, otherwise we surely will crash!

There are lots of strategies clients learn in therapy, and elsewhere, to counter anxiety; from breathing regulation, mindfulness meditation/yoga, guided visualisations of a calm, safe place….to more vigorous forms of exercise. The important thing is not to self-distract from the problem or compensate for the anxiety by blanking it out with alcohol, drugs, food, spending or any other soother. That pathway leads to another type of difficulty, addiction.

Last week we heard about recommendations that people considering elective cosmetic surgery should first have a psychological assessment. On BBC Radio Nottingham’s Morning Show with Mark Dennison, on Tuesday 12th June, we discussed the possible reasons for this.

Most of us have, at some time, wished we looked ‘better’ eg different, in some aspect(s) of our physical selves – face and/or body. When we are feeling at our lowest or most stressed, such thoughts can become more persistent and intrusive, overwhelming even. Some research has suggested that up to 40% of people being treated for anxiety/depression in mental health settings, are also unhappy with their physical appearance and want to change this. Depression and anxiety are usually, fortunately, a temporary mood condition; once people feel back to their ‘normal’ state of mind, although they may still be dissatisfied with some aspects of physical appearance, they tend to view this from a more philosphical perspective and would not usually attempt to alter it surgically.

This is one of the key reasons why a psychological assessment before elective cosmetic surgery is important. All surgery carries risk – things can, and do, go wrong, sometimes. So it makes sense to only undergo it after careful assessment of the pros and cons, rather than impulsively, whilst in the grip of a depressed mind state where we typically feel pessimistic and think negatively about ourselves. Our mood is destined to improve in weeks, or worst case, months, but the changes we have paid to have made to our appearance will be enduring and difficult to reverse/correct if the outcome was not what we hoped for.

Another good reason to have a psychological assessment (i.e via a counsellor, psychotherapist or, indeed, a psychologist) is to identify Body Dysmorphic Disorder (or orientation towards this). BDD is characterised by

– a preoccupation with an imagined defect in appearance. If slight physical anomaly is present, the person’s concern is markedly excessive

–  the preoccupation causes clinically significant distress or impairment in social, occupational, or other important area of functioning.

– the preoccupation is not better accounted for by another mental disorder (eg dissatisfaction with body shape and size in Anorexia Nervosa).      DSM-1V-TR 2000  300.7

Once people experiencing this psychological difficulty start on the road of elective cosmetic surgery, they keep going, never satisfied with the outcome; there is always just one more alteration to be made before they can be happy….In the worst cases, people will be prepared to self-mutilate to try to achieve the desired self-image.  Research has suggested that 6-15% of patients in cosmetic surgery and dermatology settings, could be clinically diagnosed with BDD.

The problems with undergoing cosmetic surgery in these circumstances are obvious: the chances of satisfaction with the outcome are low (expectations will often be unrealistic). The effect of real or imagined ‘failure’ of the cosmetic surgery (one of the risks), is likely to be devastating. And the person is spending money to live in the future, rather than in the present – things will always be better after this, or that, piece of cosmetic correction has been carried out.

Similarly, it is possible to become addicted to improving personal appearance. Like any addiction, it can only be satisfied by yet one more hit, which needs to increase in intensity. In the case of cosmetic surgery, this would start with a relatively minor ‘improvement’ and graduate to larger-scale interventions.  The addiction process often starts through a person feeling that something is not Ok about life; typically, through therapy, this might be identified as a missing relational need. Erskine (1998) proposed 8 key relational needs which we seek from cradle to grave in our significant relationships. (eg security, the need for validation, to express love, make an impact on the other person, etc…). It makes sense to address this deficit with a talking therapy which will work towards reconciliation of this and self-acceptance without surgery…..

Women have traditionally been more interested in pursuing cosmetic surgery than men; however, there is growing media and peer pressure on men to look ‘fitter’ and more virile. This sometimes draws them towards surgery, but more often tempts them to take supplements, typically steroid-type, and often in combination with circuit/weights training at the gym.  This can quickly become addictive, and has its own risks. Again, following the trend slavishly, succumbing to external pressure, are indicators that the person’s sense of self-worth/acceptance and confidence are not as robust as he might wish.

If depression/anxiety or tendencies to addictive personality or BDD are found during psychological assessment, alternatives to cosmetic surgery can be offered. Typically this would be through a talking therapy programme, often Cognitive Behavioural Therapy which would aim to challenge the negative thinking about self-image, perfectionism etc. Other therapies might seek to uncover suppressed/subconscious deficits in relational needs The object of most talking therapies is for the person to become more self-aware and more self-accepting and compassionate to self. As the French say ‘il faut se faire a son visage’ = we have to learn to like the way we are.

Last Thursday 12th April, I once again joined Frances Finn on the Morning Show on BBC Radio Nottingham. We were in Easter holiday mood, discussing why people have arguments and upsets with their nearest and dearest (or perhaps bestest of friends) whilst sharing what should be ‘quality time’ together.

Clients tell me that this often happens to them….and it has certainly happened to me!

There appear to be some common reasons:

1. A holiday, especially, away or far, far away is a change from normal routine. Part of being human is to regard change as potential threat, or loss ….even a change for the better means letting go of something known and familiar. And our default setting for threat is the stress response, ie fight or flight/freeze. So even as we let our imagine roam over mind pictures of sun, sea, sand, fun and relaxation, it is possible that we can also be having suppressed anxious stressful thoughts ‘yes but what if…..I miss my flight, the weather is bad, the room/villa is awful, the children play up on the journey etc’ . If you are an habitual worrier, this will be familiar ground, perhaps something that others have criticised you for, saying ‘stop worrying it will be fine…’ Unfortunately this is likely to have the opposite effect, as you may then think you have to take all the responsibility for thinking about the details, putting problems right etc.  We usually have to find items to take with us, and remember to take particular things with us; interestingly, the part of the brain associated with memory is also a part affected by stress, which, of course makes it harder to remember! This can set the scene for tension between people before the journey begins and the holiday starts…….making mistakes more likely and a blame-game to begin.

2. We mostly work hard for our holidays and may count down to them, treating them as a reward and consequently loading them with expectations: ‘at last some down-time/time for each other/it will be great!’. Even if a staycation is planned there may be a plan to ‘have fun days out/ do lots of things we never get time to do’. There can be a sense of ‘must make the most to this…’ Our mind-picture may represent our own unique concept of blissful perfection.  All too often, unfortunately, life gets in the way: someone gets sick, loses/breaks something, the weather turns for the worse, neighbours are a nightmare, money doesn’t stretch the way it should…and the reality does not match the dream. Disappointment ( a combination of frustration and sadness) makes us tetchy/ over-sensitive, rows brew up and rain down on our holiday….  

3. Another source of stress and subsequent aggression, is our 24/7 exposure to the people we love; for most of us this is a change from normal life. Generally, with work and domestic routines we do not actually spend such a concentrated period with our loved ones or friends. This can be really testing of our relationships – just how much can we tolerate/forgive as individuals pursue their own idea of the perfect holiday in a way that does not synchronise with our own?  If it is a staycation, at least this is happening in familiar surroundings where we feel relatively comfortable (although there might be a suppressed – or voiced – sense of it being unfair that ‘everyone else is going away, but not us’). But when we are adjusting to a different environment in addition to being in each other’s company all the time, the smallest, most apparently trivial issue can trigger individual sensitivities…..‘why do you always have to (do/say/be like) that..?’  We might say that this situation is like being put under a microscope. Unsurprisingly, most of of would fail this sort of examination in some way, as no-one is perfect 24/7.

4. Of course, it might well be that we are not starting our holiday with all issues resolved between us; this is often called ‘unfinished business’, and includes things that have been left unsaid, but not ‘un-thought’, or the elephant in the room that never gets discussed; or perhaps problems which one or other person is unwilling/unable to address. These may seem to disappear into the depths of everyday life for most of the time, but they are lurking below the waterline, ready to wreck the peace. What better time for them to surface than when there is an already stressful or disappointing situation and unavoidable exposure to each other. 

5. Holidays also provide a unique opportunity in a busy everyday life to take time out and reflect; this can provoke challenging questions such as ‘is this it?…is this what my life is going to be like now for always?…is this all I am going to have to look forward to?…. etc..’  Whilst it can be helpful to develop our self-awareness, tune in to our inner voice and reflect on ourselves, our choices and decisions, we may sometimes risk over-thinking, and over-analysing.  This pathway can lead to maladaptive rumination and/or obsessive self-criticism rather than towards inner peace and self-acceptance.  Before we then shut out or snap at our nearest and dearest, we might do well to consider the prayer of St Francis …’for the serenity to accept what we cannot change, the courage to change what we can and the wisdom to know the difference’.  And it might be helpful, of course, to take this to therapy.

6. A further source of falling out, is the disinhibition and other consequences of increased levels of alcohol consumption. Again an attitude of ‘got to make the most of this’ especially in ‘all-inclusive’ holiday situations, may prevail. Rows may stem from one person not wanting to drink as much, upset by the amount consumed by other family members -perhaps due to health worries, cost or embarrassment etc. Or it could simply be the ‘in vino veritas’ issue, where people say what they really think to each other…and regret it when it is too late.

7. Sometimes, the falling out may be triggered by one person’s own insecurities – a kind of personal unfinished business. For example, if someone’s self-esteem is wobbly, perhaps due to poor self-image, he/she is likely to be super-aware of attention being paid (apparently or actually) by their partner, to other people at the holiday location. This might lead to sulky withdrawl or overt accusation, responded to possibly, by reassurance, or, potentially by frustration and denial. It typically never gets completely resolved until the person first deals with their own issues, perhaps through therapy, and then can take a more grounded look at whether the relationship works for them.

HELPFUL STRATEGIES

– identify your own and others’ triggers of stress – then you can offer yourself maximum choice about responding.

– take responsibility for your own emotional stuff/unfinished business – try to say ‘I feel …when you…’ rather than ‘you make me…when you..’  Seek mutual agreement to formally shelve particular ongoing topics

– compare and contrast your mind-pictures of this holiday with those of your nearest and dearest – prepare to make adjustments and compromises in advance

–moderate your expectations – even a perfect holiday will have some elements which could have been better, and even the worse holiday will have a few pluses

– agree and commit to regulate alcohol consumption – you will remember more about the holiday and feel better for it!

– learn to recognise and challenge negative thinking – eg catastrophising, seeing only the negative in the situation and missing the positive, mind-reading, condemning the whole picture on the strength of one small negative detail, emotional reasoning (a thought not a fact), generalising negatively etc/

Following news that the Welsh Government are tackling employee stress with the provision of a subsidised massage service, BBC Radio Nottingham’s Morning Show, hosted by Sarah Julien, invited me in to discuss the subject of work-related stress. (Wed 14th September 2011).

There are some obvious and clearly recognised sources of stress in the work place. For example, bullying/harassment/discrimination, job insecurity (threat of redundancy or dismissal due to disciplinary action), ‘missing’ out on promotion, and change of company culture/business model.

However, people may be less aware of the stressful consequences of extremes of perceived experience; that is, a sense of too much/an excess of something, or the opposite.

Perception of too much/over/an excess

1. Too much to do

2. Too many rules/restrictions

3. Too much (irrelevant) information/communications/meetings

4. Targets too difficult to achieve (eg in time available/with funding limits etc)

5. Too many bosses/hierarchical layers/too much ‘leadership’

6. Over-long working hours

7. Unrealistic self-other expectations (too high) = performance anxiety

8. Overqualified/skilled

Perception of Too little/ under/ a shortfall

1. Too little to do (boredom)

2. Too little structure/too few guidelines

3. Too little communication/ inadequate communication

4. Too few resources to do job adequately

5. Inadequate leadership/inaccessible leadership

6. Not enough time (eg full-time job in part-time hours)

7. Insufficient opportunity for initiative

8. Under-qualified/trained/skilled

Consequences

1. Health deterioration. Examples include headaches/ tiredness/loss of energy/ weakened resistance to colds and other infections. Tendency to rashes/respiratory difficulties/digestive problems and other aches (neck, back etc). Prolonged exposure to stress causes the para-sympathetic branch of the autonomic nervous system to over-ride the sympathetic branch; the long-term effect of this can bring on heart conditions, gastric ulcer problems and other serious illnesses. The tendency is for people to self-medicate with alcohol/ over-eating etc leading potentially to alcoholism and unhealthy weight gain.

2. Mood disorder. People may become noticeably more irritable, tearful, indecisive, forgetful, demotivated to engage with activities previously enjoyed, avoidant of social interaction, withdrawn. They may be diagnosed with depression or generalised anxiety.

Pathways

In each case, an individual approach to problem resolution is needed, but here are some suggestions that have been found by others to be helpful:

1. Communications: as early as possible, identifying what does not feel ok enough and assertively exploring this with someone who can make a difference.

2. Re-evaluating work/life balance. Maxing-up time outside work with fun and interest.

3. Making realistic adjustments in attitude/perspective on work, eg. this is a J.O.B. which pays for lifestyle needs, occupies x amount of daily time, and fulfils a function.

4. Reviewing options and possible changing job either within this organisation or outside.

5. Identifying and facing personal issues re specific extremes; learning self-soothing techniques eg calming breathing/relaxation exercises/strategies such as visualisations, letters/advice to self from a wise, warm, strong and encouraging Other self.

And finally……Prevention is always better than Cure! Check-out a company’s style if possible, before going on board. If, like the Welsh Government and Capital One (whose Head of HR also contributed to this debate), they seem to invest in looking after employees by providing a gym/ access to massage and other therapeutic body treatments/counselling etc, then this may be a good indicator of what to expect if you were to become stressed….

August 2011 may be remembered for scenes of violence and lawlessness in some of our cities which shocked many of us to the core. On Tues 16th August, BBC Radio Nottingham’s Morning Show with Mark Dennison, invited me to contribute to a discussion about the role of social networking media in society today, given some evidence that this was involved in orchestrating what took place. I have an interest in this contemporary phenomen, both in my role as a Magistrate on the Nottingham Bench, and also from the psychological perspective, in my work as a Psychotherapist.

By social networking, I mean, internet sites such as Facebook, MSN,  Chat Forums for special interest groups, dating websites, Twitter…….but also email and texting. 

There are a number of BIG PLUSSES with this instant form of communication; for example, at its most powerful best, the world-wide-web provides fast accurate information 24/7, with maximum convenience. This meets a demand we seem to have, in these times, for ‘answers NOW!’ ….. and then, the pressing desire to swiftly share what we have learned, with others.  With the press of a button, we can upload images to entertain others. Or indeed to sadden, and stimulate to action eg fundraise for disaster-stricken countries. The internet is a powerful lobbying resource for political and other change, via online petitions, for example.  

From my work with clients, I am aware of the importance of special interest chat rooms/forums. They have become a valuable source of support for some people with, for example, disabilities or mental health conditions, and for those coping with other difficult experiences such as bereavement, trauma and addictions….not forgetting parents and carers.    

Another PLUS, for many, is access to Dating Websites; clients recovering from relationship loss, sometimes report finding this a helpful part of moving on; countering loneliness by making new friendships, even if not ‘replacing’ the original loved one. Dating sites, MSN, Facebook, Twitter etc all offer opportunities to engage with others at a distance – without the risks of face to face meeting. For clients experiencing generalised anxiety, and particularly social anxiety, this form of social interaction may provide a safe space for experimenting with meeting others and relationship building.    

Humans are a relating species: there are a range of evolutionary reasons for this, for example procreation and security.  Maslow (1954) identified a hierarchy of needs, with the most fundamental being biological needs. When these are met, our security needs are the next priority, followed by love and belongingness needs. This latter enhances our feeling of security also… And in some ways, a social networking site such as Facebook offers a tempting fusion of security and belongingness at our fingertips, as we accumulate ‘friends’ and, potentially receive a comforting volume of responses to the detail of our everyday experiences  of self, the world and others. ‘Friends are the family you choose’ …

No doubt, there are other PLUSSES too. However, many clients have shared with me more negative experiences of social networking in all its forms.

For example, are these, ‘real’ friends in whom you can place trust? One client told me that she had a sort of mind-picture of her closest friends (in a happy, calm mood), and did not really register the significance of the others picking up her messages – and also did not factor in that the close friends might be having a bad day… A misplaced sense of security can lead to confiding personal information, disclosing secrets, perhaps off-loading a ‘stream of consciousness’, private thoughts, or venting in the heat of the moment….or maybe uploading to U-Tube personally compromising photos.  Within seconds, this naivete can go global, as a ‘friend’ (for fun, or maybe, through malice), pings it onwards……with devastating consequences for the originator, who may be publicly ridiculed, experience shame and a sense of betrayal as personal vulnerabilities are published and available online for the foreseeable future. Some clients have also belatededly become aware that an ex-partner has been spying on their private Facebook account, well-aware of favourite passwords…. 

Bullying is another recognised negative aspect of social networking media.  This can take the form of overt threats or more subtle pressure. It is now thought that some of the participants in the violent lawlessness during August were ‘rallied’ by online or mobile messaging – no excuse for not being there, you must have got the message! (Equally, it is likely that the lure of being part of a powerful group and the stimulation of risking arrest, were factors in the appeal, particularly to young males). Cyber bullying is also, sadly, rapidly becoming one of the most common form amongst schoolchildren.

These experiences have an adverse effect on mental health conditions; for example, bullying can lead to a sense of isolation, which is associated with depression. If someone is already depressed and  ‘friends’ fail to respond as hoped to a text/email/Facebook message (or their responses are misinterpreted!), this can enhance the sense of rejection, and low self-esteem. The ongoing difficulty with all non face-to-face communications, is that we cannot always accurately interpret the senders intent; there is an absence of tone, pause, emphasis, and facial expression/mood indication.

In my observation, as reported from clients, for some people, these social networking systems become addictive; there is excitement as the mobile buzzes again, or the PC ‘pings’ to announce ‘incoming’. This reduces the need for face-to-face contact, and there is a risk that social interaction, eg ‘small talk’ skills will be lost. People experiencing social anxiety may never have the incentive to overcome their fears, and may continue to avoid real relationships. They are also vulnerable to a worsening of their anxiety because of the tendency to find evidence (eg through misinterpretation of non-verbal communciations) to justify and confirm their belief system about the personally threatening, judgemental world.