Grief during the coronavirus pandemic

Using an article ‘Grief, Lockdown and Coronavirus’  from the Financial Times dated 4 June 2020, we talked about changing attitudes to grief, and the necessary changes to funerals and the symbolism around death.

Our conversation was largely based on our many professional experiences of death and grief. In  police work, medical settings and in ministry, the use of precise –  even blunt –  language to convey news of a death was recognised as vital to avoid misunderstanding and false hope. In the face of shocking information, people can only process direct language. Nuance and euphemism leave far too much space for miscommunication.

In the time of a pandemic, the usual rituals that surround a death like saying goodbye in person, a vigil, a visit to view the body , holding a service,  shared anecdotes and memorabilia are either impossible or compromised.  We acknowledged the importance of symbols like these to initiate grief, but accepted that different symbols might serve the same purpose. Grief that is blocked will emerge in some form at some time in the future. We wondered if there is likely to be a backlog of grief after the pandemic, or if people will have found their own way through what is, after all, a natural process. Perhaps the looming mental health crisis forecast by the press is overblown.

There was some consensus that we are generally remote from death in modern Western life. We might even have an illusion of immortality. Even while half a million people worldwide have died, many of us remain at a distance from any personal impact. However, for workers on the so called NHS front line, they are seeing and dealing with far more death than normal. They are needing to be extraordinarily resilient and we question whether this is sustainable in the long term.

Grief during the coronavirus pandemic

Logotherapy

Fells and Dales meeting 15/05/20

 

We met to discuss a paper entitled “An overview of Victor Frankl’s Logotherapy” and an additional short list of exercises designed to illustrate the technique of   “cognitive defusion” as a way of dealing with anxiety.

 

Our discussions first focused on the impact of the current Covid 19 in terms of missing face to face counselling and instead using telephone or Zoom. We commented on the loss of immediacy and how the telephone in particular can be more intense and so facilitate client disclosure which can be positive but may also tend towards “too much too soon” and thus a need to encourage the client to slow down. Some clients may also feel less exposed if not face to face and so be less inhibited. A possible drawback can be that the client is less aware of the impact they are having on you as the counsellor and your responses risk being unsubtle and clumsy. Also eye contact can be difficult if using Zoom and this can be distracting for both counsellor and client.

A larger issue is whether the counsellor can trust their counter=transference with so much less “evidence” to go on?

We also wondered about the effect of the client seeing their image on the screen and that it could be useful to ask about this.

We then used the paper by Frankl as a kind of springboard for a more general discussion about working with meaning and with anxiety in particular. We thought of strategies to help clients re-frame or distract themselves from negative automatic thoughts and liked the ones in the second paper (5  ways to defuse anxious thoughts published by verywell mind). There was a reference to CBT techniques like keeping a thought diary and the notion of “wearing the energy out of a thought” through distancing and separating out experiencing and observing so the thought loses its sting. Also the notion of “parking” triggers can be releasing and so helpful.

Reference was made to a helpful website, Getselfhelp.co.uk and the 7 column thought record.

We also talked about “healthy” anxiety which may be present throughout life and whether the world is perceived as benign or antagonistic.  It was posited that there is a physiological and neuro-biological basis to anxiety which is part of our cell structure so can’t be escaped!

 

A link was made between the search for meaning and spirituality and a book was recommended entitled “ A history of everything, a short guide to Einstein”.

Our next meeting is scheduled for 26/06/20.

Rosemary Pitt

Logotherapy

Anxiety in the Corona virus pandemic

The Fells & Dales network of counsellors met on 17th April, of necessity using an online meeting platform.  We all agreed it was ‘second best’ to meeting in person, but we still managed to offer one another support and share our thoughts.  Even before the coronavirus pandemic it had been suggested that we might spend a session on the theme of anxiety, so we had no trouble finding a context for our discussion.  As a change from more academic papers, the pre-read comprised three recent press articles:  ‘Advice on how to cope with coronavirus anxiety’ by Bill Merrington (York Press 17/3/20), ‘The secret excitement that lurks beneath our distress’ by Matthew Parris (The Spectator 20/3/20), and ‘I was born anxious, so why am I not panicking about coronavirus’ by Adrian Chiles (The Guardian, 25/3/20).

We noted that anxiety and fear have spread as rapidly as the virus, and commented on clients’ differing responses, from feeling even more alone and isolated than usual, having their pre-existing underlying anxiety heightened, to feeling less ‘different’ because everyone else is anxious too.  We agreed on the importance of being containers of our clients’ (and supervisees’) anxiety, whilst also trying to cope with our own.  Whereas with most issues clients present, we may not share their experience but we are still able to empathise by imagining how they might be feeling, sometimes based on a commonality of experience.  However, with anxiety around the coronavirus, we all, without exception, have our own anxieties which we have to contain.  We are with our own ‘story’ at the same time as trying to attend fully to our clients’.

We identified some of the key principles of working with anxiety, including mindfulness/calming/breathing exercises, normalising and contextualising, managing rather than ‘solving’, and exploring the triggers.  The remarkable stoicism exhibited by many was observed, but we also wondered what would follow in the aftermath of the ‘lockdown’, and what the presenting issues might then be.

The differences between face-to-face and online working were discussed in some detail  –  practical, technical and relational.  We acknowledged the need to be grounded, prepared and confident, in order to be true to ourselves and own way of working, and to remember that we are interacting with a real person and not a computer screen.  As with in-person therapy, it is hopefully our intentionality that communicates our care and compassion.

Anxiety in the Corona virus pandemic

OVERVIEW of EMDR

6 March 2020
One of our members, a retired trauma therapist, was invited to give an overview of Eye Movement Desensitisation Reprocessing (EMDR). He was an accredited practitioner for over ten years.
The group was asked to respond to and ask questions about the following proposed and recent definition of EMDR:
The group was asked to respond to and ask questions about the following proposed and recent definition of EMDR:

Definition – EMDR is an evidence-based, clinician led, psychotherapy for Posttraumatic Stress Disorder (PTSD). In addition, successful outcomes are well-documented in the literature for EMDR treatment of other psychiatric disorders, mental health problems, and somatic symptoms. The model on which EMDR is based, Adaptive Information Processing (AIP), posits that much of psychopathology is due to the maladaptive encoding of and/or incomplete processing of traumatic or disturbing adverse life experiences. This impairs the client’s ability to integrate these experiences in an adaptive manner. The eight-phase, three-pronged process of EMDR facilitates the resumption of normal information processing and integration. This treatment approach, which targets past experience, current triggers, and future potential challenges, results in the alleviation of presenting symptoms, a decrease or elimination of distress from the disturbing memory, improved view of the self, relief from bodily disturbance, and resolution of present and future anticipated triggers. EMDR therapy is a therapeutic intervention that must be administered by an EMDR trained clinician or those who are currently participating in an EMDRIA Approved training.

Wisely the group noted the absence of ‘bi-lateral stimulation’ in this definition.

Reference was made to the insistence within theEMDR profession that the 8 stage protocol was adhered to rigorously. The fundamental reason was assumed to be to ensure that there was a consistent base upon which to base efficacy research. Evidently many many different adaptations of the basic protocol were available. The EMDR UK and Ireland has a jiscmail interaction and frequent requests are made for information about how to use the protocol for numerous different presentations.

A copy of the 8 stage protocol was shared with the members. As seasoned professional therapists this mapping of normal good therapeutic process was noted. The need to be thorough about history taking becomes clear when it is acknowledged that trauma builds on trauma. Often a current trauma effect does not get ‘cleared’ until earlier traumas have been dealt with. Just as likely is the scenario in which the client is unaware of earlier and unprocessed memories until processing begins. Processing refers to the use of bi-lateral stimulation when focused on the physical bodily awareness of a memory.

It is is of paramount importance to spend as much time as is necessary in the early phases of the protocol to ensure that a client is able to say where in the body the feeling that tells them there is an unprocessed memory upon which they may then focus using bi-lateral stimulation. And it is essential that as much time as is necessary is taken to ensure the client has learnt how to self-soothe. It would of course, be irresponsible to encourage the client to engage with a trauma memory without the practised confidence of being able to self-soothe.

A member of the group volunteered to experience bi-lateral stimulation being used whilst focused on a ‘safe place’ memory and the stored memories of each of the sensed about that memory. A client would be invited to practice accessing this now reinforced ‘safe place’ until they were confident that they could manage more anxiety than previously realised perhaps. This was acknowledged to be a real experience which made the safe place memory more vivid. The value of this for a client was noted.

Reference via a UTube video drew out the specific nature of PTSD as a particular form of trauma memory defined by DSM 5. The life long history of potential unhealthy experiences leading to trauma, beginning in the womb ‘where there are no words’ (with reference to the workshops led by Sandra Paulson), and moving on to the whole of the attachment process and the manner in which those experiences are recorded in the limbic system, was noted.

The group also had a transcript of an interview with Peter Levine whose book Waking the Tiger and In an Unspoken Voice were highly recommended reading. The interview can be accessed at: https://www.psychotherapynetworker.org/magazine/article/2347/an-interview-with-peter-levine

Reference was made in conclusion to the training available. in particular training  from EMDR Workshops and David Blore and that offered by Sandi Richman (the presenter’s trainers) was recommended.

Definition – EMDR is an evidence-based, clinician led, psychotherapy for Posttraumatic Stress Disorder (PTSD). In addition, successful outcomes are well-documented in the literature for EMDR treatment of other psychiatric disorders, mental health problems, and somatic symptoms. The model on which EMDR is based, Adaptive Information Processing (AIP), posits that much of psychopathology is due to the maladaptive encoding of and/or incomplete processing of traumatic or disturbing adverse life experiences. This impairs the client’s ability to integrate these experiences in an adaptive manner. The eight-phase, three-pronged process of EMDR facilitates the resumption of normal information processing and integration. This treatment approach, which targets past experience, current triggers, and future potential challenges, results in the alleviation of presenting symptoms, a decrease or elimination of distress from the disturbing memory, improved view of the self, relief from bodily disturbance, and resolution of present and future anticipated triggers. EMDR therapy is a therapeutic intervention that must be administered by an EMDR trained clinician or those who are currently participating in an EMDRIA Approved training.

Wisely the group noted the absence of ‘bi-lateral stimulation’ in this definition.

Reference was made to the insistence within theEMDR profession that the 8 stage protocol was adhered to rigorously. The fundamental reason was assumed to be to ensure that there was a consistent base upon which to base efficacy research. Evidently many many different adaptations of the basic protocol were available. The EMDR UK and Ireland has a jiscmail interaction and frequent requests are made for information about how to use the protocol for numerous different presentations.

A copy of the 8 stage protocol was shared with the members. As seasoned professional therapists this mapping of normal good therapeutic process was noted. The need to be thorough about history taking becomes clear when it is acknowledged that trauma builds on trauma. Often a current trauma effect does not get ‘cleared’ until earlier traumas have been dealt with. Just as likely is the scenario in which the client is unaware of earlier and unprocessed memories until processing begins. Processing refers to the use of bi-lateral stimulation when focused on the physical bodily awareness of a memory.

It is is of paramount importance to spend as much time as is necessary in the early phases of the protocol to ensure that a client is able to say where in the body the feeling that tells them there is an unprocessed memory upon which they may then focus using bi-lateral stimulation. And it is essential that as much time as is necessary is taken to ensure the client has learnt how to self-soothe. It would of course, be irresponsible to encourage the client to engage with a trauma memory without the practised confidence of being able to self-soothe.

A member of the group volunteered to experience bi-lateral stimulation being used whilst focused on a ‘safe place’ memory and the stored memories of each of the sensed about that memory. A client would be invited to practice accessing this now reinforced ‘safe place’ until they were confident that they could manage more anxiety than previously realised perhaps. This was acknowledged to be a real experience which made the safe place memory more vivid. The value of this for a client was noted.

Reference via a UTube video drew out the specific nature of PTSD as a particular form of trauma memory defined by DSM 5. The life long history of potential unhealthy experiences leading to trauma, beginning in the womb ‘where there are no words’ (with reference to the workshops led by Sandra Paulson), and moving on to the whole of the attachment process and the manner in which those experiences are recorded in the limbic system, was noted.

The group also had a transcript of an interview with Peter Levine whose book Waking the Tiger and In an Unspoken Voice were highly recommended reading. The interview can be accessed at: https://www.psychotherapynetworker.org/magazine/article/2347/an-interview-with-peter-levine

Reference was made in conclusion to the training available. in particular training  from EMDR Workshops and David Blore and that offered by Sandi Richman (the presenter’s trainers) was recommended.

OVERVIEW of EMDR

EMPATHY

 

On 24 Jan 2020 we looked at the subject of empathy and ethics with a review of Christian Keysers Book “The Empathic Brain” focussing on the chapter on empathic ethics and Psychopathy. The questions we looked with this chapter included :

What is the basis of empathy, Can empathy be learnt, Is empathy derived from the unconscious due of our mirror neurones or is it simply operant conditioning.

We started with a reminder of how the discovery of mirror neurones and has impacted on our understanding of neurobiology and sense of self by watching three short videos  from Dr Dan Siegal.

Dr Dan Siegal Mirror Neurones   :

https://www.youtube.com/watch?v=24fITRNWh1k

 

https://www.youtube.com/watch?v=Tq1-ZxV9Dc4

 

DR Dan Siegal The basis of empathy https://www.youtube.com/watch?v=CnvSRvmRlgA&list=PLqwFctTE_-O2t8er6kBsmjqYNMP4QsCD5

Dr Siegal describes how a sense of empathy comes from the unconscious interaction of our mirror neurones downwardly connecting with our Insula which is involved in perception and sense of self down through the brain to the body and back to give a sense of interoception.

We explored how our mirror neurones inform our  ethical decision making and the question of do emotions fog our ethical decision making.

We continued to look at Keysers observation that to change someone’s mind you have to make them see the problem from a perspective that is linked with other emotions to make them feel differently.

This led to a discussion on how to use grounding techniques to help those who feel suicidal and the importance was recognised of not just doing a cognitive process of remembering how things were in better times to really engage with an emotional element of when they felt well. We also looked at the risk of using grounding photos that may feel distressing and to use a bespoke assessment of client needs.

We agreed that an empathic approach to relating can be learnt but that our mirror neurones enable this also.

We looked at Keysers assessment that genuine empathic feelings and moral sentiments can co exist in a person along with brutal aggression and the “golden rule” of “do to others as you would have them do to you reframed from thinking about a  mirror neurone perspective of “I shall do to you what I wish would be done to me”.

We looked examples of clients who are challenging in their communicating and presentation and how our mirror neurones may give away a sense of how we are reacting.  Also the importance of relational depth in the moment and being careful not to be intoxicated by momentary deeply felt empathy but recognise it has to be strived for from moment to moment.

EMPATHY

Limits of Compassion

At today’s meeting we discussed the limits of our compassion for clients. Inevitably this varies between therapists and as much as anything it  reflects the least developed aspects of ourselves. For some of us, it is hard to find compassion for clients who are unable to tell the truth, for others the client’s behaviour is sufficiently distracting to block our view of the vulnerable person behind the behaviour. We looked at the unhelpfulness of allowing a testy relationship to escalate into a power struggle and the much more helpful attitude of allowing client autonomy, while the therapist stays calm and curious until the client’s world view becomes understandable. One theme was the impatience we can feel for clients who are not open to change, who are very rigid or cannot develop insight. We know that this is likely to be the client’s defense against pain but our lack of compassion here is presumably connected with our motivations for doing this work in the first place. Unsurprisingly, lack of compassion will result in incongruence in the therapist which will be picked up by the client and this inauthenticity will hinder or halt the therapy. We enjoyed thinking about compassion growing if the relationship can be sustained –  for example when clients who are originally inflexible later develop the capacity for change or insight. ‘It is a joy to be hidden, but a disaster not to be found’  (Winnicott)

Limits of Compassion

Compassion Focussed Therapy

Our discussion at our November meeting was centred around Compassion Focussed Therapy. We looked at a handout produced by positive psychology (available on their website, positivepsychology.com) entitled  “16 Compassion Focussed Therapy Training Exercises and Worksheets”. Compassion Therapy was developed by Dr Paul Gilbert, a psychologist who believed that compassion, both self and other-focussed, could be the key to relieving intrusive negative feelings of shame and self-criticism. He is also the author of “The Compassionate Mind”, Constable, 2009 where he outlines his theories at length.

We all found the exercises on the hand-out interesting and relevant and agreed that one particular exercise stood out. This was the idea of creating “your ideal caring, compassionate image” and then fleshing out in detail how this image would feel and look and how it would operate in the world- we saw this as of value to ourselves as therapists and potentially to use with clients, especially those with low self-worth.

We had varying views on the usefulness of other exercises such as having a “safe” colour to use as well as an imaginary safe space to retreat to in our minds  when anxious or threatened.

Some quotations to reflect on and states of mind to aspire to

‘’Ships don’t sink because of the water around them; ships sink because of the water that gets in them. Don’t let what’s happening around you get inside you and weigh you down”

“The things that have happened to you in your life are not your fault, but it is your responsibility to alleviate your suffering”

“Compassion is about choosing to be the best version of you that you can be”

 

(from suicide awareness/prevention)

Compassion Focussed Therapy

Imperfection

The Fells & Dales network of accredited counsellors met this morning to discuss the subject of ‘Imperfection’, prompted by extracts from Brené Brown’s book ‘The Gifts of Imperfection  –  let go of who you think you’re supposed to be and embrace who you are’ (Hazelden Pubishing, 2010).

 

Carl Rogers’ concept of the ‘fully functioning person’ was seen to be aspirational, compared with the ‘wounded healer’ or the flawed therapist, which seem much closer to home!  We acknowledged what a relief it is for us, and our clients, when we stop striving or pretending to be perfect, and embrace the whole of us as we are, warts and all.  And how unhelpful it might well be for our clients if they perceive us as being perfect, ‘sorted’, the expert, the one with all the answers.  Far better to model imperfection but also courage, tenacity, faithfulness and compassion.  We liked Brené Brown’s self-description as ‘a recovering perfectionist and an aspiring good-enoughist’!

 

We discussed the inevitability, and maybe necessity, of clients being disappointed in us, and letting them down, as they discover that we don’t have the power to ‘make it all better’, and yet that doesn’t mean we have nothing to offer.  We were reminded of the hope that we hold, and our faith in the process and in the power of relationship, within which clients can feel safe and held whilst we accompany them through what might feel like turbulent waters.  Such a committed, reparative relationship might be experienced like no other.

 

We readily called to mind some of the mistakes we have made in the past, and how hard it is to forgive ourselves, especially where there have been serious consequences.  When harm has inadvertently been caused, a most helpful and compassionate response was suggested, namely “That wasn’t my intention”.

 

I close with the words from Leonard Cohen’s ‘Anthem’: There’s a crack in everything, that’s how the light gets in.

 

and this image of the ‘Kintsugi’  –  the Japanese art of repairing broken pottery with gold.

kintsugi

Imperfection

Longing, Seeking, Yearning

Peter spoke to the material he had provided for the meeting. This was chapter two and three from Longing: Psychoanalytic Musings on Desire. Jean Petrucelli ed., published by Karnac in 2006.

 

Chapter 3: Secrets of analytic love and the transformation of desire; PollyYoung -Eisendrath

Chapter 2: “It never entered my mind”; some reflections on desire, dissociation and dislosure. Philip M. Blomberg

The focus was the former chapter 2.

 

The group found a way into the essence of what the author might have meant by ‘analytic love’. That essence emerged firstly out of our sharing our work with clients and our personal experience of disappointment because of our desire for them and for ourselves. We explored therefore the ways in which we seek to ‘move’ from our own inner disturbances to be with the client in theirs.

 

We ‘knew’ the author was on to something exquisitively real when we were able to name that disappointment and both parties then found themselves experiencing a deeply felt release, physically and emotionally and psychologically.

 

We understand, of course, that our ways of defending ourselves from shame, or anger, or disappointment or being a disappointment, were formed in our beings during early life attachment experience. We eventually found the image of parent and infant seeking and finding each other’s gaze put us in touch with what we need (desire) and the pain of loss when that ‘gaze’ and its correlates were not there. Hopefully that allows us to attune to the clients inner world a little better – to be ‘good enough parents’ for ameliorated psychotherapy to be effective. What we were in touch with here collectively was that we experienced ourselves the physical disturbance in our bodies that told us we were speaking of something true about human experience. No wonder then that we acknowledge the poverty of our capacity to do this in life outside of the consulting room.

 

The author used language of Einsteinian quantum theory to try to say something that was true and real about being human. Quantum theory we think, says that the object (subatomic particle) changes by being observed. Indeed it might also be exists only when it is observed. Could it be than that the human organism needs to be observed in order to grow, develop, be more fully human? If this is the case, then person centredness providing it was love not desire, is in itself healing for the other. Perhaps this is what the author was meaning when speaking of ‘analytic love’?

 

The members shared the disappointment felt when we know we are able to focus on the other when in a group or social situation, yet we share the experience and the pain that very selfdom does anyone seem to be able to do that for us. And that can be painful.

 

So, the book’s subject of ‘longing’ directed us to wonder about the hope that appears to be within us that as homo sapiens, our best development would come from paying attention to the other and attempting that empathic connection (even though it might not be reciprocated) and yet we ‘know’that such relationships would save our society and our world.(The academic questions here are about the choice between a belief that it is our neurobiological inheritance which, in order to survive, moved towards empathic connection. One wonders if the universal need in human beings to have a language for that which we call spiritual experience, might direct us to concept of creation and an creator for which homo sapiens uses the metaphor of ‘soul’ to describe)

 

Perhaps we can console ourselves with the realisation that we can express love, as analytic love, where we have the opportunity. With that awareness there is a hope of a changing world which must suffice as motivation for living, coupled with the belief that the loving gaze and attention of another is the way in which we grow and keep our emotional balance in the world.

 

In this we hope. And could continue to survive?

 

Longing, Seeking, Yearning

Brief Therapy With Couples

 

Brief Therapy with Couples – An integrative approach. Maria Gilbert and Diana Shmukler 2001

Today our group reviewed the chapters on Working through issues of compatibility  of value systems and Frames of reference (Ch6) and working through the issues relating to caring for the other (Ch 9) of Gilbert and Shmuklers book on couples therapy. We had an early observation that many of the issues of diversity we were to look at today could equally apply to the individual therapeutic relationship.

We opened with the quote “Frames of reference are influenced and contributed to by each persons personal and historical background which shapes an individual’s values”  and beliefs are usually implicit rather than explicitly stated. This is seen as to be viewed holistically as therapy continues and not necessarily a focus early on and the therapeutic dynamic is established.

We touched on how frames of reference can be learned by interpreting early exercises such as each client listing what is wrong in the relationship and what would they want the relationship to look like and these thoughts being shared only in session so that responses can be appropriately held.

We looked then at how to work with the early “life story” of the first partner and if the other partner  is invited to respond or present their “life story” and then negotiate what is within their frame of reference to work on.

We looked at the notion of clients often feeling “sent” to therapy by their partner and one usually being more enthusiastic for therapy than the other ensuring that the process is an inclusive autonomous process.

In reviewing the chapter on frames of reference we looked at individual examples of understanding and working with diversity in the relationship including , Gender, culture, class, religion, race, education, socio economic status of each and familial expectations of being involved in decision making for the couple. We also looked at gender role scripting and managing the differing expectations of some  same sex relationships.

We reviewed various skills exercises that sometimes arise within couples therapy such as using emotionally mature language like using I instead of U in exchanges and the importance of the therapist modelling the same.  Also encouraging the other to express the effects on them of their partners non verbal communication such as finger pointing and other body language.

We looked at the issue of intimacy and differing approaches of being directive contracting to avoid intimacy or negotiation about if abstinence would help or not and acknowledging difference in the room of approaches here.

A strong consensus was of the therapeutic space being an intuitive one with responding in the moment to what comes up and not worrying too much about having an instrumental approach. We also looked at managing the time, endings and top up sessions being requested by some clients.

In looking at the chapter on caring we considered the contribution of transactional analysis to conceptualising the parenting and nurturing concepts within relationships and finding balance of each partner adopting the role along with the risks on stagnation and stuckness within that dynamic.

We looked at how reviewing the subject of working with client differing frame of reference yet again encourages us to look at our own relationships in  renewed light.

Brief Therapy With Couples