Blog

Last Thursday, Frances Finn, recently voted UK Radio Personality of the Year 2010 at the Sony Academy Awards, invited me, as resident psychotherapist on her Morning Show at BBC Radio Nottingham, to discuss her experiences on getting back on her motorbike after her horrendous accident last August.

Fran’s memory of the impact and immediate aftermath is blank as she was mostly unconscious, and she has not reported experiencing any Post-Traumatic Stress Disorder (PTSD) symptoms such as feeling like she was reliving the accident or flashbacks leading to panic attacks etc. However, at the time, it was so serious that it was initially thought to be a fatal accident. Fortunately those reports were incorrect and although horribly injured facially, Fran has gone on to heal unscarred and make a full recovery.  For various reasons she has not had opportunity to ride her beloved Fireblade since then and Weds evening was her first attempt.  She recorded her thoughts and feelings and played it on air.

As is typical, Fran was worried about re-visiting the scene of the accident on her motorbike and this triggering a frightening flash of memory out of the blue. (a possible sign of PTSD). This did not happen, and she feels fully confident to get back in the saddle from now on.

On the show, a caller also described his experiences of being injured as a result of an act of deliberate anti-social behaviour (The ladder he was using was shaken to cause him to fall).  He has recovered, but has never felt safe to get back on a ladder.  This avoidance is a common occurrence when someone has experienced a trauma and not fully come to terms with it, and can be one of the signs of PTSD.

A colleague broadcaster also described his experiences; after a serious car accident, he began to behave recklessly, taking potentially life-threatening risks.  This, too, can be an indicator of the continuing impact of the trauma, and PTSD, arising as a consequence of a sense of a foreshortened future – a kind of pointlessness about life. 

Not everyone who has a traumatic experience will develop PTSD. Many, many people come to terms psychologically with a bad shocking experience, naturally with the passage of time.

PTSD can occur when a person’s world view has been turned upside down so radically that the mind cannot adjust. 

Counselling can be helpful. If someone is experiencing the kind of symptoms described above; a course of therapy might focus on gently encouraging the person to gradually relate their story, of what happened, in the safe environment of the counselling room with the warm and understanding presence of the therapist. Together we assess and  monitor  levels of distress each time the story is related, and the changes that naturally occur as the person psychologically processes the experience (rather than avoiding it), and makes new sense and meaning of it, and adjusts his/her view of life.

Behaviourally  a therapist would support the person to face the feared experience, gradually building tolerance to the trigger, eg taking one step further up the ladder and confronting the unhelpful beliefs about what might go wrong at each stage. 

EMDR (Eye Movement Desensitisation and Reprocessing) can be particularly effective.

There is a high level of success in overcoming PTSD ; approx 50% of people make a full recovery in 3 months.

On BBC Radio Nottingham’s Morning Show with Frances Finn today 12th April, we discussed anxiety and panic attacks.

Anxiety stems from fear, in response to danger; the flight part of the Flight/Fight or Freeze response, sometimes called the Stress response.

Everyone feels fear from time to time – could be a near miss situation: you are just about to overtake a lorry when it pulls out in front of you and you brake in the nick of time; or you lose sight of your child in a busy shop….. and we can feel angry afterwards! Anger and anxiety are closely connected.

Fear triggers a bio-chemical response in the body, like tripping an alarm:

1. The hypothalamus in the brain stimulates the pituitary gland to secrete a hormone which in turn releases cortisol from the adrenal cortex
2. Glucose stored in the liver is released for extra energy
3. In the core of the adrenal glands, above the kidneys, the medulla secretes adrenaline (and noradrenaline, raising blood pressure)
4. The sympathetic branch of the Autonomic Nervous System launches into action:

• heartbeat and breathing become more rapid so that blood carrying oxygen and glucose for energy can get to the muscles faster
• we sweat to make cooling more efficient
• digestive processes go ‘on hold’ so as not to waste energy
• all the senses sharpen for greater efficiency (eg eysesight, pupils dilate to let in more light)          

In the appropriate circumstances, this can be really valuable – say you had to dash into the road to save your child from being run over – or defend yourself when no escape was possible…

Typically we use memory and personal experience – filtered through our belief system/values/life rules – to identify whether a threat requires fight or flight. Sometimes, however, we may NOT be able to escape from situations which we find threatening or lash out in anger, because this is socially unacceptable in today’s world, bringing unpleasant consequences – eg it’s not ok to run out of a business meeting/presentation, or physically attack someone who has carved us up whilst driving. But the Autonomic Nervous System is still firing away!!

We often describe this as stress. Sometimes the fear response happens only occasionally, in reaction to particular events, eg taking an exam or getting results of medical tests, and we can usually cope with this type of situation and reason ourselves into controlling the feelings.

Often people limit their own exposure to things they find stressful, or reward themselves if it’s been a stressful day. (Not always in a healthy way – eg by self-medicating with alcohol…)

However, if the same sort of things which ‘stress’ us keep occurring and are unavoidable, we become anxious This can develop, over a long period of time, into chronic anxiety; (The sympathetic branch of the Autonomic Nervous System can’t keep going, and the para-sympathetic branch takes over with slower heartbeat and breathing rate, even though the stressors are still present, sending confused messages through the body, and inducing a range of illnesses: eg depression, allergies, ulcers, heart disease and many others…)

The brain can also deceive us into thinking that there is danger, when this is not so; how does this happen? Sometimes we may have an experience in a situation which was uncomfortable; perhaps we were in a meeting or doing a business presentation and we were asked a question which we couldn’t answer or we got a bit stuck on…..when we replay the situation in our mind later, it might make us cringe and wonder what people were thinking of us – maybe they thought we were stupid, maybe the boss was disappointed in our performance…And so we associate the experience with threat to our well-being. We avoid meetings etc, because we fear this could happen again; our negative thinking contributes to distortion of memory, bigging up the unpleasantness/threat of the experience. Anxiety builds as we contemplate not being able to avoid the next occasion. Faced with the situation, the sensations of the flight response, listed above, intensify, we misinterpret these as harmful to us:

• My heart is beating so fast I must be having a heat attack
• I’m gasping for air, I can’t breathe, I’m going to die
• The room is closing in, I feel so dizzy, I’m going to faint
• My mouth is dry, my throat is constricting, I’m going to choke
• My legs have turned to jelly, I’m going to collapse
• My stomach is heaving, I’m going to be sick
• I need to go to the toilet, I’m going to lose control
• It feels unreal, like I’m not in my body..

As we know, all these sensations can be explained by the activities of the body’s alarm system, but as anxiety escalates, we sometimes panic, and what is called a panic attack occurs. This lasts just a few minutes but feels terrifying. We can dread a repeat experience, and the fear of this makes them more possible. They can sometimes occur ‘out of the blue’ for no apparent reason, eg in the middle of the night. This is usually as a result of underlying ongoing high levels of anxiety. People often think they are going to faint, but this is impossible because blood pressure is HIGH and fainting occurs when blood pressure is low.

Note: it is important to check with your GP whether you are experiencing anxiety, or whether you have a (rare) medical condition which may require treatment. As a general guide, if the sensations disappear when you are relaxing, at home, or enjoying yourself, they are unlikely to be signs of physical illness.

There are a number of different types of specific anxiety, with various origins:

Social anxiety  – people avoid social contact because they fear negative judgements by others, considering themselves inadequate, stupid. This arises from self-esteem problems

Health anxiety – people constantly monitor themselves for signs of illness, fearing developing a terminal illness, dependancy on other whilst in pain or helpless, death. This arises from a need to control uncertainty in an uncertain world which is perceived as threatening.

Performance anxiety – people dread that they may not live up to the expectations of themselves or others in situations where they are being observed, have deadlines to meet etc. This arises from issues of self-identity, and a fear of not being as competent as ‘supposed’ to be, or ‘should’ be.

Separation anxiety – people fear being away from home or close relatives. This arises from difficulties in  attachment in (usually early) relationships.

Generalised anxiety- people are anxious about a range of things, replacing one thing with another as problems resolve and being in a constant state of alertness watching for the next source of anxiety. There are a number of factors producing this kind of mind-state, and it is often associated with obsessive-compulsive behaviours.

Agoraphobia – people fear being away from a place of safety (usually home), and of being trapped somewhere in a public place, eg cinema, restaurant, meeting, bus, where escape opportunities are controlled by other people or circumstances. This can arise due to control issues, as in health anxiety.

TREATMENT

1. Getting to the bottom of what the anxiety stems from – what was the trigger incident, why did it have specific significance to the person? Challenging a person’s learned beliefs about themselves, the world and others. Developing self-awareness and acceptance of self/
2. What is the function of the anxiety, what would this person have to deal with/face, if they were not so preoccupied with this fear? Dealing with unfinished emotional business.
3. Psycho-education on understanding how the anxiety shows itself in the body, the bio-chemistry of the fligh/fight response. A hyperventilation exercise is sometimes used to demonstrate the process.
4. Facing the fear, with graded exposure step by step to the feared situation to prove that the anxiety will naturally reduce by itself when tolerated without avoidance or safety measures.  A different approach is to desensitise the person to the feared experience by creating a new, more positive association, using strategies like slowed breathing. 

Following the highly publicised alleged infidelities of celebrities such as John Terry, Ashley Cole, Vernon Kaye and Tiger Woods, the Morning Show on BBC Radio Nottingham once again included the Kim-on-the-Couch slot, on Monday 15th February, to discuss the psychology of betrayal and recovery.

There are many reasons for infidelity. Here are just a few:

• one person may feel that his/her needs are not being fully met in the current relationship; he/she may be constantly searching (consciously or sub-consciously) for someone ‘to understand’ better – a ‘soul-mate’ out there perhaps…..
• the existing relationship may have become ‘stale’, in that one or both parties take the other for granted, and complacency imperceptibly allows boredom to creep in and creates space for the excitement of intrigue and the illicit affair.
• A couple develop increasingly absorbing interests outside the home, and drift apart, becoming virtual strangers under the same roof…..someone who shares the same interests becomes more than a friend..
• a person’s past deficits of self-esteem and desire for constant reassurance of worthfulness may make him or her vulnerable to, and excessively needy of, admiration/adoration etc Some celebrities may particularly enjoy the feeling of being special, and crave this, like a drug.
• he/she may be have only been in an environment of dysfunctional models of couples relationships in which infidelity featured , so not expect a relationship to last ( self-fulfilling prophecy!) and therefore be keeping their options open….
• a life-changing event (bereavement/trauma) may provoke a spontaneous re-appraisal of what is truly important now to the individual, resulting in a determination to be different, live life to the full, experience to the maximum etc, creating a fertile opportunity for a new love interest to replace the pre-existing one, which is associated with the past, former self. This phenomenon may also occur at key life moments in which self-identity is challenged, eg turning 40/50/60, children leaving home etc, sometimes called ‘mid-life crisis’.
• a person who has experienced the hurt of infidelity, may deliberately set out to punish his/her partner in a ‘tit for tat’ way; and indeed lose so much trust in the viability of fidelity with anyone, that future partners may then also be punished (consciously or sub-consciously) by infidelity. 

However, mostly people who betray the spoken or unspoken agreement of a fidelity to each other, do not set out to hurt their partner. Most expect never to be caught. Some, who end the pre-existing relationship will go to considerable lengths to try to convince their partner that ‘there is no-one else….I’m just not in love with you any more (but I still care about you), and I just need my space etc…’

Such lack of honesty compounds the hurt of the betrayal when it is eventually revealed, and the potential damage to self-worth, as the other person is left wondering what he/she has done wrong, thinking  ‘if only I had been more….’  Although it may seem tougher, most people cope better knowing ‘the worst’, once the decision to leave has been made. Uncertainty triggers our deepest fears and vulnerabilities.  

Recovery time after a relationship ends depends very much on how the person who has been hurt views life generally, and his/her past experience of being let down and loss. Someone who has a history of abandonment, rejection and loss may naturally interpret this latest experience as further confirmation of self as not worth keeping as a partner, undeserving…. he/she may have invested heavily emotionally in this relationship.  There is then a possibility of onset (or return) of mental health difficulties such as depression. Professional help via GP and a talking therapy (counselling) is usually recommended.

Some people are sufficiently emotionally robust to grieve the loss of the relationship (there is likely to be loss even if both parties were drifting apart) much as we grieve when bereaved – typically shock, denial, anger, fear, sadness and eventually resolution and finally acceptance. In due course they will move on and replace the former loved one. They may continue to have the legacy of a diminished level of trust. This can be worked through with the support of the new partner, although may benefit from some professional help, eg couples counselling.

Some couples set out to re-build their relationship after infidelity, and achieve this successfully.  A relationship may be compared to a house; when the trust is breached it is as if there is subsidence, and huge cracks appear in one or more load-bearing walls. Continuing this image, it is not likely to be a satisfactory repair, if the cracks are just filled in. The foundations themselves need major treatment, and ideally the house might be better rebuilt from scratch, perhaps even somewhere new! Couples counselling can be helpful in this process.

It is also worth noting that if the house ultimately has to be abandoned and put up for sale, so that each person can go their seperate ways, working with a couples counsellor in making an ending together, to what was once a happy hopeful dream for both parties, can help the grieving and healing process.

On Tuesday this week, in the BBC Radio Nottingham studio, Fran, the Morning Show presenter, and I, debated whether anybody/everybody might benefit from therapy, at some point in their life-time, or whether getting ‘in touch with emotions’ was unnecessary, and we ‘should just get a grip, show a stiff upper lip’ as in the past – during the last world war, for example.

I was keen to dismantle certain myths: 

• therapy must be a heavy-weight, intense process that last years No! You are in the driving-seat and it can be as deep as you feel you need to go; some people feel much better after just one hour of therapy, and leave at that point.
• if you have a traumatic or tragic experience, you automatically need therapy No! Many people are psychologically robust enough to process these experiences, in a reasonable time, without needing therapy. It all depends on the person’s core beliefs about self/others and the way the world is supposed to be, and what else he/she has gone through in life.
• therapy brings up stuff from the past, you end up worse than you started No! You don’t have to talk about the past if you don’t want to. There are very, very few people who say that therapy did not help in any way…..and masses of people who have benefited, and told others so!

I like to compare having therapy with going to see your GP:

• some people go when they have an ailment they can’t shake off (eg a persistent difficulty they can’t resolve )
• some people go to just check they haven’t got a serious medical condition  (eg ‘I feel like i’m going mad…I think there’s something wrong with me’)
• some people go as a last resort, sometimes under pressure from family/friends, because symptoms have become very obvious (eg a crisis, desperate distress) 
• some people need to go regularly to treat a long-term condition until it is controlled and they can manage it themselves (eg abuse of some kind in childhood, or recent past, or current addiction) 
• some people avoid going ever, unaccepting of any sign of physical weakness (eg ‘there’s nothing wrong with me, I’m ok…it’s other people who have the problem’) 

The most balanced, common-sense attitude is…..seek medical help ( or therapy)  when you need it. In the words of R.E.M ‘Everybody hurts some time’  … and when you do, waiting until the pain is unbearable, or refusing treatment, ultimately negatively affects you, and loved ones.

There are some natural fears:

• I may get really emotional and not then be able to get myself under control again…’Once I start to cry/get angry/talk about it…I’ll never be able to stop, I’ll explode etc’
• Therapy may not work for me, and I’ll be officially a ‘hopeless case’
• I may end up needing therapy like a crutch, when at least before I was wearing a mask and coping
• The therapist may judge me – even though he/she is not supposed to – and make me feel bad/vulnerable/silly/ashamed etc…so I must not let my guard down
• Having therapy is for ‘loopy’ people – I don’t want to be like them, I’m not needy, that’s not who I am

All of these fears are because of lack of understanding of the therapy process, and/or lack of confidence in the competency of the therapist.

Psychotherapists go through 4 years of training, including their own therapy, and attend frequent, regular supervision, to ensure that the process is ethical, safe, confidential and in the client’s best interest , and continuous professional development maintains this. 

In therapy, you find:

• somewhere to make sense of the experiences you are going through or that have happened in the past, and come to terms with these…
• somewhere to gain new perspectives or explore options, make difficult decisions/choices…
• somewhere to disclose  hurt, pain, shame, worry, fear, anger, sadness…..that you can’t, or don’t want to, tell anyone else – and receive empathy, warmth, honesty and understanding …..whilst not being judged
• somewhere safe to work on overcoming depression, trauma, anxiety, low self-esteem, stress, obsessions, phobias, eating disorders, and so many other common human problems
• somewhere to develop self-awareness and insight and learn self-compassion, self-soothing, to cope with what life bounces at you!

So, WHAT ARE YOU WAITING FOR ?!

Post Traumatic Stress Disorder (PTSD) can develop after someone has undergone a shocking experience involving actual or threatened serious injury/near death (or death of another person) which caused him/her intense fear, helplessness or horror. The diagnosis is made by a health professional when the person has specific symptoms; if symptoms start and resolve within 4 weeks, which is common after a traumatic event, the diagnosis is Acute Stress Disorder; when they are of longer duration, eg up to 3 months, Acute PTSD, and longer than this, Chronic PTSD. 

Any such incident does not just affect the individual, but also his/her loved ones, typically a circle of approx 5 people, and to diminishing extent, other relationships, friends etc.  People often ask, therefore, how they can help, what should they say/not say etc to the person going through this difficult post traumatic experience.

Today, on BBC Radio Nottingham’s Morning Show hosted by Richard Spurr, standing in for Frances Finn, we discussed this; it was particularly relevant because of Fran’s recent horrific motorbike accident, for which she was undergoing surgery as we spoke.

Not everyone who experiences trauma automatically develops PTSD; it is thought that some people may be more prone, because of their core beliefs, for example, and/or what has happened to them in their lives, before this particular incident.

When someone is gripped by Post Traumatic Stress, he/she needs professional help, eg Cognitive-Behavioural therapy, other Psychotherapy or Eye Movement Desensitisation and Reprocessing (EMDR). But loved ones, friends and workplace colleagues can back up this treatment; here are examples of what you might typically notice, with suggestions on the most helpful response:

1. Avoidance of thoughts/feelings/activities/places etc which bring back memories of the event – don’t challenge this, the person needs to make sense of it in his/her own time ‘joining up the dots’.  Meanwhile, there may be flashbacks, nightmares and other unwelcome recollection.

2. Diminished interest/participation in previously enjoyed activitities – offer gentle, moderated encouragement. Don’t cajole or insist you know what is good for them! 

3. Feeling of detachment from others, numbness – don’t take this personally! continue to be warm and be yourself (consistency is really important, when someone’s certainty, the world as it is supposed to be, has been rocked on its axis…)

4. Loss of interest in future planning/ a sense of a foreshortened future – frustrating, possibly, but again, offer gentle encouragement, and avoid overt challenging.

5. Sleep disturbance – professional help needed (eg GP), plus empathy and patience!

6. Irritablility – don’t take this personally, be patient, understanding, and consistently warm

7. Difficulty concentrating – avoid challenging, criticising, be understanding and encouraging

8. Hyper vigilance/exaggerated startle response (jumpy, wary, tense) – be understanding, not dismissive.

Many of the above symptoms are difficult to live for partners, family and close friends and colleagues to adjust to; but remember, that with treatment, PTSD usually passes within 3 months, and fortunately you were not the one to endure the original horrific event!