On Wednesday this week, I took part in a discussion about how best to treat depression, on BBC Radio Nottingham’s Morning Show.  News was just in of a fourfold increase in prescription medication for depression, compared with 5 years ago. Frances Finn, presenter of the Morning Show, wanted to challenge Dr Ian Campbell and me about these statistics – are people being prescribed medication by their GP almost automatically, after a quick consultation ?  Wouldn’t a talking therapy (counselling) be better than medication which might become a ‘crutch’ that people learn to depend on and struggle to give up ? And maybe some people are labelling themselves ‘depressed’ and seeking help when if they just ‘got a grip’ and got on with life they could overcome it by themselves.

All interesting points….

Dr Campbell explained the medical origins of depression: it can be inherent in the person, a feature of their psychological/physiological make-up, or it can be caused by a specific event- such as relationship breakdown, redundancy or loss of some kind.

Medication can really help the person to be able to function enough – to keep going at work for example, when it is essential (as they might see it) that they do this. And it can also help them feel ready to tackle the cause of the depression, or underlying issues that have been triggered and have now come to the surface. Selective Serotonic Re-uptake Inhibitors (SSRIs) such as Fluoxetine (commonly known as Prozac) and Citalopram work on restoring the level of serotonin in the brain and maintaining adequate levels of this; serotonin seems to encourage a sense of calm and makes feelings of anxiety and distress less acute and raw. 

Although medication is very effective for many people, the ideal would probably be that those who want counselling as well, or prefer to avoid medication and just have counselling could be offered this ; sadly there are indeed long waiting lists eg 6 months, in some locations, despite the investment made by the previous government in the IAPS scheme (Improved Access to Psychological Therapies) which has seen a dramatic increase in numbers of trained counsellors (usually in Cognitive-Behavioural Therapy). It seems this has been more than matched by the numbers of people presenting with depression. Some reports suggest that 1 in 3 of us has or will have an episode of depression at some point in adult life.

Depression has been described as a Black Dog (eg Winston Churchill). The stigma surrounding it is diminishing due to various celebrities ‘coming out’ – Alastair Campbell, Ruby Wax, Stephen Fry and many others. Most people know that it is characterised by a dark negative mood, outburst of anger or general grumpiness, tearfulness, loss of energy and interest in activities that were previously enjoyed, appetite changes, sleep disturbance and a tendency to want to withdraw and isolate oneself.

In Cognitive- Behavioural therapy the emphasis is on identifying ,monitoring and encouraging activities that bring feelings of pleasure rather than effort and also in challenging Negative Automatic Thoughts.  In other therapies, we also work with underlying ongoing problems, often unfinished emotional business from the past, helping people to come to terms with these, accept the situation or take necessary action, and move on.

Depression certainly can be treated with counselling/psychotherapy, and this process can be supported by medication, which I particularly recommend when someone is in such a distressed state that they are unable to focus and engage.

If counselling waiting lists are too long, there are other local (Nottinghamshire) sources of possible support. Some of these agencies and charities may only ask for a small donation towards the cost of their service:

Nottingham counselling Service – 0115 950 1743

Nottingham Womens Counselling Service – 0115 978 2040

New Dawn  (Christian) – 0115 917 0500

Cruse (bereavement and loss) – 0115 924 4404

Relate (couples and relationship issues) – 0115 856 5205/0115 950 7836 /01623 636553

There also agencies which specialise in alcohol/drug related difficulties including depression/anxiety

For emergencies there is also Samaritans 08457 909090

There are some excellent self-help books available:

I Had a Black Dog – Matthew Johnstone

Living with a Black Dog – Ainsley and Matthew Johnstone

Overcoming Depression – Paul Gilbert

Depression The way out of your prison – Dorothy Rowe

Help online includes websites where you can download free leaflets like northumberland  tyne and wear nhs and various cognitive behavioural programmes.

You don’t have to just ‘get a grip’ – but you do need to reach out for support when you may least feel like doing so!

Some people would prefer to avoid medication of any kind and opt for counselling.

On Friday 1st April, I took part in a debate on Radio Nottingham’s Morning Show about the significance of mothers returning to work after baby is born, leaving fathers to do the nurturing.

My guiding text on this is Sue Gerhardt’s ‘Why Love Matters’ which explains how babies’ brains develop through the bonding with the primary caregiver, usually mother. The key to this is the emotional availability of the parent, expressed through caring touch, holding, eye contact and also verbally. The parent provides soothing for the infant, and he/she starts to internalise a model of how to do this, which becomes a template for life.

I do not feel that only the mother can provide this. Indeed if mother experiences severe post-natal depression, which in rare cases can lead to hospitalisation and thus seperation from baby, it is really important that the other parent, or another consistent person fills this gap.

Instinctively I feel that mother and baby are the ideal unit, especially given the researched benefits of breast feeding. However, if necessary, the other parent can offer the conditions vital for healthy emotional development. The key point is that the parent(s) are content in themselves because this seems to be communicated (absorbed) by the baby.

At the beginning of the pre-Christmas week, I thought it might be helpful to reflect on the difficulties some families experience at Christmas time, and suggest some coping strategies. The Morning Show, on BBC Radio Nottingham, with Frances Finn, was the forum for this.

In Western cultures, Christmas is often promoted as a special time for families, when everyone must enjoy time together and have fun. This peaks on Christmas Day itself, which can become a steaming pressure- cooker of expectations: the perfect turkey, complete with all the trimmings served at the right time, in a festive environment, with each individual’s preferences accounted for….. This is often against an alcohol fuelled, noisy background, with over-tired children (and exhausted adults) trying to get their own needs met!  Small wonder that this is also a peak time for episodes of domestic violence, when tensions can boil over into verbal conflict and finally erupt into physical expressions of anger and distress.

The Christmas expectations are only a part of the problem; sometimes the family members assembled together may be present from a sense of duty – perhaps with little in common with each other other than this relationship. Or perhaps there is unfinished business – emotional conflict which is unresolved from the past, with the initially suppressed sense of unfairness and frustration re-ignited by the disinhibiting effect of alcohol…..and alcohol can also upset careful attempts to ‘say the right thing’ and walk on eggshells around known sensitivities of particular individuals….or cause people to misinterpret well-meant remarks and make apologies clumsy at best and futile at worst. 

Another factor in all this is the concept of Self-fulfilling Prophecy. This describes the tendency to anticipate an outcome with such intensity that we actually influence it by our behaviour – even without conscious awareness of doing so. If, for example, we really dread this Christmas being a repeat of a bad experience last year, we may start to ‘awfulise’ and ‘catastrophise’ – and these negative thoughts are expressed non-verbally in our body language and picked up by the people around us, creating a ‘bad (uncomfortable)  atmosphere’ …..which degenerates into awkward silences and abrupt remarks ….and then possibly hurtful comments….and replies…and finally full-on rows, plate throwing and physical assaults.

Violence is usually the final resort of the person whose anger exceeds their capacity to fully verbalise it, and is sometimes a pattern copied from the behaviour of a parent. Typically the person who becomes violent feels threatened by something or someone (past or present), and the circumstances of Christmas, especially the element of alcohol (ironically ‘Chrismas cheer’), enflame this and it is deflected onto an available victim – someone less powerful; or it may be that this victim is a reminder in some way of the original threat, or holds a different kind of power over the abuser – perhaps the power to abandon him or her. 

COPING STRATEGIES

1. Awareness: recogising the potency of Self-fulfilling Prophecy and the effect of carrying a sense of ‘it’s going to be awful, a DISASTER!’ Aim to keep an open mind and treat the situation as a fresh start.

2. Set BOUNDARIES:

– Limit the time you spend with family members, in an enclosed space. Try to mix things up, spend some time outdoors if possible, make full use of space.

– Prepare ‘safe subjects’ for general discussion; avoid the 3 Taboos of Sex, Religion and Politics

– Focus on ‘now’ and not ‘the past’ . Leave Unfinished Business outside and don’t try to get to the bottom of issues/make amends/ repair broken bridges  -about things that have gone wrong in the past.

3. Avoid or limit alcohol; as a rough guide, the more strongly you think ‘I need a drink’ the less advisable it is to have one…..

4.Ground and soothe yourself: take Time Out. You absolutely can absent yourself for a few minutes to do some soothing rhythmic breathing. (Inhale fully for 3 seconds, inflating your abdomen with air (fresh air if possible) – the hold for 3 seconds – and breathe out with a long exhale, 3 seconds).  Repeat to yourself a calming phrase such as ‘It’s ok, it’s just one day, all over soon…’

5. And finally, remember, Christmas Day is just one day of 24 hours (and some of those you will be asleep) made up of 60 minutes in each hour. You can get through this ….and you may even enjoy it.!!    

Early September found me once again in the BBC Radio Nottingham studio, on the Morning Show with Fran. Our subject was the effect of the changing seasons on people who experience the August Bank Holiday as marking the end of the summer, a return to work and the beginning of the long, dark haul towards Christmas…..

Many people enjoy autumn, with its misty mornings, crisp sunshine and beautiful foliage. However, many more feel their hearts sink as they contemplate the prospect of chilly mornings and shorter daylight hours, with little or no time off from work until the Christmas break. The roads get busier as the autumn term starts; summer holidays become a fading memory, and there may seem to be little to look forward to.

This time of year brings fears for some people of the onset of Seasonal Affective Disorder (SAD), a form of depression experienced by approximately 2% of the population, with a further 10% who present with just some of the symptoms (eg lethargy, increased appetite and anxiety) and may feel they have the ‘Winter Blues’. One theory is that reduced sunlight impacts the processing of serotonin in the brain (serotonin is a neurotransmitter associated with wellbeing and efficient transmission of messages through the brain); it is also thought that light stimulates the hypothalamus in the brain, which is responsible for mood, sleep and appetite and is sensitive to melatonin levels (melatonin is a hormone produced by the pineal gland when it gets dark to help us sleep) – and people suffering with SAD may produce too much melatonin in the winter months. They consequently almost want to hibernate, feeling constantly tired, tearful, moody, stressed and forgetful, having difficulty concentrating, poor quality sleep, appetite changes and loss of pleasure in favourite activities.

People who are already feeling depressed, stressed or anxious may also notice an increase in symptoms at this time of year.

However, some people who would not normally consider themselves to be affected by the changing of the seasons, also experience particular feelings of dread as they contemplate returning to work after the (long) holidays.

There may be a number of reasons for this:

1. Performance Anxiety: often associated with people who have ‘full-on’ jobs or are high-flying/ambitious, but not exclusively so. Tendencies include a mad rush to get everything sorted before going on holiday – last minute phone calls from the airport to work to check on minutiae. Finally can’t contact the office any more…and RELAX ! (and then they may fall ill with flu-like symptoms – almost as if the ‘flu’ had been biding its time, waiting for the person to slow down/stop!). Intermittent worries whilst on holiday may include thoughts like ‘hope things are going to plan/ x has done what he should /they remember to do x  etc’ . When it is time to return to work the person with performance anxiety may feel sick, tummy churning, sleep poorly etc. Typical thoughts include: ‘I bet it has all gone wrong and they are blaming me/ what didn’t I remember to tell them?/ what if xxx happened?/ what will they be thinking of me?/ they will have discovered that x is so good at replacing me that they won’t need me any more…’ Lots of self-blame and self-criticism (insecurity)

2. Unresolved stressful work-place issues: typically, relationship difficulties with manager or close colleagues (= affecting self-worth/sense of unfairness); boredom or hate the job (= very stressful); too much to do/too little time to do the job properly (= sense of personal inadequacy, frustration, unfairness); communication problems at work (=frustration); redundancy worries (= helplessness). On holiday the person may be thinking/saying ‘I wish this could go on forever/ I could live here/ don’t want this holiday to end’ and may start to become sleep-disturbed, moody and become especially irritable on the morning of the flight home, for example. The juxtaposition or contrast with the holiday experience in which all the work issues were put on hold to the back of memory, can produce a sense of being overwhelmed ‘can’t go back/face this again’ and can sometimes result in the person putting off the return due to ‘sickness’ in which there are real physiological symptoms (as well as psychological unfinished business).

Working with the Dread

1. SAD and associated Winter Blues – light-boxes and/or anti-depressants to counter the chemical effects on the brain of melatonin surfeit and serotonin inefficiency; Cognitive-Behavioural therapy to explain the links between thoughts/behaviours/feelings and physiology in depression and structure a programme of activities and negative thought -challenging;self-help by seeking maximum natural daylight, exercise, balanced diet especially vitamins C and D, avoiding stress and seeking support from others!

2. Perfomance Anxiety – possibly incorporating self-help techniques auch as negative thought-challenging, but in addition developing a self-soothing capacity eg a gentler, warmer, wiser ‘other’ self, an imge which acknowledges the hidden key fears (rejection, exclusion, shaming) and gently and firmly challenges them, putting them in perspective as magnified, generalised and the product of fear, terror, even, and belonging in a past time, not relevant now, offering a more positive, realistic picture of what awaits at work. One to one therapy ( a Compassion-focused approach, or Humanistic/Person-centred approach) can help with this.

3. Unresolved Stressful work-place issues – most of these hinge on the person’s sense of powerlessness. The fear of change has created procrastination and avoidance of taking control of the situation. Books such as ‘Who Moved My Cheese?’ (Spencer Johnson 1998) shed more light on the strategies we can use to sabotage ourselves and keep ourselves stuck. Surrendering our power to others and tolerating the intolerable arise typically from impaired self-valuing, often itself the product of past deficits in key relationships, eg parenting/abusive partnerships. Developing the courage to change what we can – which is potentially lots – also requires the capacity to self-soothe and self-encourage. Again therapy can provide the environment we need to develop this capacity.

On BBC Radio Nottingham’s Morning Show with Frances Finn last week, our hot topic was Redundancy,  after the recent announcement by Notts County Council, that 3000 jobs are to go.

As this happened to me in 2001, after 25 years in senior management with C & A, I have both personal and professional experience of the many different individual responses to this situation.  For me, it was a relief after months of anxiety about ‘what if…?’  and after adjusting to the shock of it actually happening, I began to see it as a chance to do something more meaningful, and re-train.

Whilst this is one typical reaction, some of the people around me had different predominant emotions:

• Anger – how dare they do this to me/us after all I the years I/we have given this organisation……  
• Fear – What is going to happen to me? I’ll never get a job as good as this (at my age/with my skill-set/ working round my other commitments)  
• Bargaining – maybe if business picks up they will change their mind and then it will all be ok again
• Denial – well the end date is 6 months away, that’s ages yet…..
• Sadness – it feels like the end of an era, I am going to miss everyone/thing so much, it will be awful

These emotions, are of course, typically associated with loss and the grieving process. And there are many similarities; we suffer most in bereavement, for example, when we have a high emotional investment in the person who has died, (eg a child, or partner).  Some people value themselves by the job they do, and the professional or social status they perceive they have from it – eg a manager, a teacher, nurse etc.  This means that a partcularly significant part of the person’s identify is lost if redundancy strikes  (or other job loss, eg contract termination due to disciplinary action). Confidence and self-esteem can be thus be severely damaged.

Bereavement is also harder to bear at certain times in our lives, eg when we are vulnerable due to loneliness/isolation or past distress, especially loss.  Likewise, redundancy is tougher to face when an individual is singled out as ‘not needed’, which can feel like rejection, and may trigger recall of other such experiences; whereas when hundreds of others in the same company/organisation are made redundant at the same time, there is a sense of inclusion, a shared problem.

Generally, our reaction to the experience of redundancy mirrors our stance on change and our attitude to control. We are all on a continuum of internal versus external locus of control:  some people at one extreme end of this continuum are extremely prone to take responsibility for everything and anything and try to control their environment, whilst others at the opposite end take the view that ‘what will be, will be’ and abdicate all responsibility. Most of us are in the middle zone, with a controlling attitude to some aspects of our lives and a more relaxed attitude to others. It is a very human tendency to prefer order to chaos, and certainty to unpredictability.  Clearly, those need to control is not extreme are likely to feel  less threatened by change, and vice versa. And of course, those who have a ‘whatever’ attitude to control may well put the experience down to bad luck and just wait for things to improve somehow – not helpful either!

I find the book Who Moved My Cheese by Spencer Johnson (1998) really useful as an illustration of helpful versus self-sabotaging attitudes to change and uncertainty, in my work with clients and students.

The ‘cheese’ in this witty little parable represents something important to you in your life – your career, marriage, professional standing, etc. The point is that nothing stays the same forever – it is essential to keep working at it – as the French philosopher and writer, Voltaire said: ‘il faut cultiver notre jardin’  (we must keep working on our ‘gardens’ / lives)  because CHANGE IS UNAVOIDABLE AND NATURAL – so anticipating it, having a Plan B (eg with regard to job prospects) is really healthy, just as not taking the special people in our lives for granted – and looking for ways to keep the relationship strong – is essential.

When things change, as they must, being willing to let go and move on makes things easier for us. It may help to think about what really matters; for example, if you listed the 5 things that matter most in your life, and had to decide what to jettison first from your hot air balloon that needed to lose weight or crash – how quickly would you throw out work? On a typical scale of health, partner, family, friends etc…… work, important as it may be, could well turn out to be not that high up the list; it pays the bills, it makes life easier, but at healthy aim is to work to live, rather than to live to work? 

Focus the mind by imagining your headstone: ‘he/she was a …… who was ….. and will be …..’

Those missing words are unlikely to descibe your career, possessions and financial status, but rather the relationships of warmth that you had and the feelings of those you have left behind.

The sooner you face forwards, letting go of the past, the sooner you will be able to embrace the future and move on. Sometimes, the sense of failure can be so strong that it anchors us to the past and seems to transfix us; it can be helpful to envisage it as a THING/PROBLEM, place it on the ground and take a couple of big steps back from it, then slowly walk right round it, in a big circle, preferably with someone whose of objective opinion you know and trust. You will see that from each part of the circle you get a different perspective on this ‘failure thing/problem’.

As always, going with the flow rather than fighting the tide, makes the ‘swimming’ easier….so in the words of Spencer Johnson ‘MOVE WITH THE CHEESE’ and enjoy the ride, the challenge and opportunity! and get ready for new changes in the future….

When faced with redundancy, there are many practical steps that need to be taken, eg with regard to finances, job applications etc. It is not part of my role to advise on those; however, with acceptance and understanding of why you may feel the way you do, and a positive mind set to change, I believe the experience can be much easier.

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!