Our latest research on emotional pain communication between patients at risk of suicide and their care team has been published in Crisis, the journal of the International Association for Suicide Prevention. You can read it here
Our latest research on emotional pain communication between patients at risk of suicide and their care team has been published in Crisis, the journal of the International Association for Suicide Prevention. You can read it here
At one time it seemed like exposure protocols were to be consigned for the few cases that therapists see each year of specific phobias – fear of spiders, or flying where the logic of a graded exposure program is self-evident. Curiously though, even in the treatment of OCD where exposure and response prevention (ERP) is the NICE recommended treatment, therapists (anecdotally) seem reluctant to go down that route. There is something that perhaps feels unkind or scary in taking people directly towards the thing they fear – particularly if you are a person driven to do a job by your desire to alleviate suffering, why ramp it up if there is another way to go? My friend and colleague Jennifer Sayrs co-director of the Evidence Based Treatment Centers of Seattle told me that sometimes clients who come from all over the USA to the clinic for treatment for OCD will never have been offered ERP despite seeing numerous therapists in the past.
Perhaps the one area in which an exposure protocol has continued to hold the foreground has been in the treatment of PTSD, with Employee assistance programs keen to ensure clients have access to suitably qualified practitioners to deliver this therapy. When I worked in Primary care counselling I was frequently asked to help people suffering from trauma associated with road-traffic accidents. And then of course with those who have suffered the trauma of rape and sexual abuse, which led me personally down a circuitous training route to eventually become a Dialectical Behaviour Therapist.
Marsha Linehan, the treatment developer of DBT has remarked that she believes exposure (talking through the details of the traumatic event) is the common ingredient in all therapies, and certainly avoidance of traumatic material was noted in the seminal work by Judith Lewis Herman, Trauma and Recovery, as the most common therapeutic error.
More recently there has been a resurgence of research and development in the trauma field. Martin Bohus of Germany is making great strides in in-patient exposure work with clients with Borderline Personality Disorder suffering from sexual abuse trauma, with some unusual techniques – having patients recall the trauma whilst standing on a balance board to prevent dissociation for example. Melanie Harned has developed a simultaneous DBT/exposure-based protocol, again for clients with borderline personality disorder that has had some life-changing results for patients unable to emotionally access the DBT therapy because the trauma symptoms were too intrusive. Melanie’s protocol was devised in consultation with Marsha Linehan and maybe the most prolific name in developing exposure treatments, Edna Foa who will be visiting the UK later this year to deliver her 4 day training to mental health professionals wishing to use her Exposure protocol*. I did this training a couple of years ago and despite being quite a fan of exposure therapies already, picked up nuances from Edna’s vast experience and training videos that took my own practice to a higher level. I think it is easy to overlook some of the subtle therapist interventions, but seeing actual tapes of sessions with patients and having Edna point out the pertinent strategies was definitely the best part of the course. Having delivered mostly long-term therapies myself I was amazed at how speedily Foa’s protocol gets results, in very severe trauma cases. A sobering thought.
Taken altogether the current interest in revisiting exposure can only be good for patients who have suffered for so long with trauma symptoms. Although it is difficult for both therapists and clients to hold to a protocol, the life-changing benefits can clearly be seen. I am looking forward to continued research in the field.
*Attendees at Edna’s 4-day training receive a certificate endorsed by the University of Pennsylvania. for details go to www.grayrock.co.uk
As a behaviourist I am a bit of a nerd when it comes to ‘controlling variables’, or in other words identifying what factors in any given moment made X do Y. It is really only possible to do this if we can define the problem in a behavioural way.
Firstly we have to be able to pinpoint the precise time and situation in which a behaviour occurred. That can be hard. We like to think in terms of categories of behaviour rather than specifics. This is particularly prevalent when thinking about relationships (a series of contacts that happen over a period of time). We like to say, “Claire is friendly” rather than, “On 32 occasions when I met with Claire she exhibited signs of prosocial behaviour, specifically: smiling at me, nodding, asking questions about me and telling me interesting facts about herself”. In fact the second sentence would be a very weird way to discuss someone, and is not recommended in casual conversation.
Lets take a very common example of unwanted behaviour and describe it factually. A common complaint in relationships is, “they don’t listen to me”. We rarely mean that they don’t listen at all, as in “there have been zero instances of voice-based communication between us.” Usually a more behaviourally specific assessment is that on a number of separate occasions in response to my verbal stimulus this person has displayed behaviour indicating non-responsiveness, namely: looking out of the window, checking their mobile phone, carrying on with their activity without raising their head, making no verbal response, not initiating my request, or doing the thing I just asked them not to do.”
In order to really work out what the controlling variables are for ‘not listening’. We have to be able to pinpoint one incident in time. This is because every time the behaviour happens it will be differentially motivated, although there may be patterns that crop up over multiple examples.
For example, a teenager not listening to his mum one Tuesday morning as he is just about to leave for school. She is in the kitchen and hearing him come down the stairs calls out “don’t forget your lunch box”. He simply ignores her and by-passes the kitchen, leaving without it.
This may have a number of possible controlling variables:
These are just a few of the possibilities, and there are another myriad of variables affecting Mum’s emotional response. If things are fine in other ways she might laugh off this one incident. If however it comes after a long line of similar ‘ignoring’ situations this low-key event could act as a straw that broke the camel’s back. If she has other distractions she might not even notice. Whereas if other adverse factors are stacking up in her life this could become a battle-ground. If she spent ages making his lunch she might be annoyed, if she has noticed he’s generally off his food, she could be worried. If she thinks, shouldn’t let a good lunch go to waste, I shall eat that myself, she might experience no adverse consequences at all. People, situations, responses, they are all complicated.
Being able to pinpoint a behaviour and look at it in more detail is an example of being mindful. Mindfulness is characterised by one-thing-in-the-moment, and helps us understand that even if we can identify an important factor on one day, the same behaviour even one day later might have come about for a different reason.
So why might we want to do this in-depth assessment at all? Well, knowing some of the possible drivers and obstacles points us in the direction of solutions. We can hypothesise and then try out those solutions, to see if the behaviour goes up or down. Should mum stop taking his lunch to school and see if that makes him more responsive to her prompts? Should she tackle him about his weight? Should she stand between him and the door and hold out the box? Should she absent herself entirely from his morning routine?
A behavioural assessment can also help us to avoid interpreting the behaviour. Often our interpretations are based on the effect the behaviour has on us. So instead of looking for other drivers we assume that the consequence we experienced was the intended consequence – e.g. “I was really annoyed when he ignored me, therefore he must have done that expressly to cause me annoyance.” Whilst it is possible to be correct in our interpretations, a lot of the time they just muddy the waters.
The example above is a very simple one explaining the concept of being behaviourally specific, and then brainstorming controlling variables. This same procedure is applied to more complex behaviour in a clinical context. All behaviours are understandable at some level, we just have to be prepared to view them as a puzzle, and not stop at our first assumption. Moreover we need to look for what we might have missed out, are there other factors that could be contributing to this behaviour?
Lastly we need to understand that even when something is motivating our behaviour, we might not be aware of that. This teenager might not want to be interrogated by his mum about his after-school plans, but that thought might not have formulated clearly in his mind. Instead he might just experience this as a vague notion of not wanting to visit the kitchen at that moment. Just in the same way that you sometimes feel uneasy in a certain situation and only later realise it reminded you of a past unpleasant experience.
Next time you find yourself labelling categories of behaviour see if you can tie it down to one instance, and work out as many of the potential controlling variables as you can. The process can be remarkably illuminating.
At times we all struggle with self-control, whether with our spending, our eating, our drinking, our screen-time or some other habit. It might seem like a simple equation to work out how hard this will be, surely it is just about how much we want this thing versus how much we want the alternative -being thin, being rich, being healthier or whatever?When we fail to stick to our goals we might conclude, I just don’t have enough willpower.
But what if you found out that it wasn’t just about resistance? That actually you were being sabotaged. Whenever you thought about not having that glass of wine, or that cream cake, or that new jacket you got a painful electric shock. What if you discovered that you experience real physical discomfort whenever you are in a state of anticipated deprivation?
This is what it feels like to have Deprivation Sensitivity, and it is nothing to do with how much you like cream cakes. It is a neurological ‘alarm’ that goes off when you perceive yourself to be (or about to be) under-resourced. Some people never experience this. For them it’s I’d like to buy that Jacket, but I’d just as easy have the money in my pocket, and when they walk away it’s cost-neutral, they are no worse off. But if you have Deprivation Sensitivity when you walk away from that jacket in the shop you are one jacket down, even though you never had it in the first place. Not only is it hard to deny yourself, but it can be painful to see other people getting what appears to be a treat of some sort. One deprivation-sensitive person told me, “I felt envious when my friend got a kitten, even though I can’t stand cats. Just knowing that she’d got what she wanted made me feel bad. I must be a really horrible person.”
That’s absolutely not the case. Deprivation Sensitivity is a curious phenomenon. For each individual it probably has its origins in long periods of being genuinely deprived; wanting something badly that was never delivered such as care from a parent or approval from a significant other. It can be set off by periods of poverty, unrequited love or being thwarted in pursuit of an important goal. This original episode needed to have been painful enough to lurk at the back of the mind as a discomfort-memory, waiting to be triggered by a multitude of smaller, less significant deprivations. Each thing you are denied takes on an additional value; it represents compensation for those earlier much-wanted resources. Now you don’t just want that glass of wine, you feel as though you need it.
At this point your brain hijacks you. It is capable of conjuring up anticipation of the horrible feeling you will get when you are bereft, suffering the loss of the desired item. Past deprivations and current ones merge, so that it is impossible to recognise that these are associations. Eventually this predicted deprivation becomes so uncomfortable that you give in.
Ask yourself, how am I generally with minor deprivations? If on the whole you are not bothered by saying no, except for one Achilles heel (shoes, for example!) then this doesn’t really apply to you. But if you regularly suffer from FOMO (fear of missing out) then suspect Deprivation Sensitivity; it simply is not as easy for you to go without something as it is for others. Stop being hard on yourself, your body is conspiring against you.
Another clue to having Deprivation Sensitivity is how easily your feelings are hurt by others. If you find yourself ruminating on minor slights long after other people would have forgotten or gotten over them, you may have this additional handicap. Having our needs met enables us to develop resilience, allowing us to shrug off self-esteem injuries. People who suffer from Deprivation Sensitivity often begin a friendship feeling like they are already in the one-down position, so the odd harsh remark can be particularly painful. They may be accused of over-reacting, but the emotional pain is more acute for them- it’s not a level playing field.
There are some things you can do to reduce Deprivation-Sensitivity. It is important to restore some perspective and this is where mindfulness comes in useful. When you notice those pangs of discomfort stop and ask yourself, what is the loss I will suffer in this moment if I deny myself this thing? What will it mean to my life? And how much sadness do I think is appropriate to that loss? Then see if the amount of pain you are having exceeds what you think would be normal. It’s always hard to judge, but initially just see if you can identify where there is a huge discrepancy between your internal distress and the real value of the item.
Next, formulate a sentence that describes the situation. This engages the cortex area of the brain, which has a dampening effect on the amygdala from where those painful feelings emanate. So for example you might say, “I have seen a new jacket that looks really nice on me, although the price is higher than I want to pay.” Avoid using the words, “I can’t” or “I mustn’t” or “I shouldn’t”. This won’t come naturally; you have to practice. After all, you are breaking associations with past deprivations.
Now we need to look at the manner in which you say this to yourself. You want to use the same tone of voice in your head as you would use if you found a missing sock under the bed; basically that this is No Big Deal. So definitely not “I’ve found a jacket that looks really fantastic on me! oh. It’s soo good but…” Keep your eyebrows in a rested position, not raised, and not furrowed. Again, this might be very different to the natural tone of your thoughts. Get a degree of firmnes (but not rigidity) head and jaw; hold your body upright. Speak (whether out loud or in your mind) in a matter-of-fact voice, not too fast or slow. This change in postural and voice tone creates a very different experience because of the bio-feedback between your brain and your body. You will never know how powerful it is until you try it.
On a final note, there is another, even more destructive consequence of Deprivation Sensitivity, where instead of compensating yourself by giving yourself things you want, you go to the opposite extreme, continuing the deprivation-cycle by telling yourself “I don’t deserve this”. At some level this is psychologically satisfying, in that it fits perfectly with a very negative self-view. If this is you, then DON’T WAIT until you think you deserve something, work out if it is something you can afford and is not harmful and then treat yourself with kindness. You may have to do this even in the presence of the thought, I don’t deserve it.
Remember – don’t be hard on yourself, this will only exacerbate any pain you are already feeling, and set you up to need MORE compensation, or to feel MORE undeserving. Over time you will get much better at understanding which losses are in the here and now, and which are to do with prior deprivations. Even if you are able to say to yourself, “My Deprivation Sensitivity is making this out to be more important than it really is,” you have taken a vital step forward.
I often get asked how to handle dissociation when it occurs in therapy. As a behaviourist it is good to ask, “What is the behaviour that I am labelling as dissociation?” as there are a number of different forms. The general theme is that the person has detached their attention from the room and usually has turned it inwards. Occasionally the client can enter a ‘fugue state’ where they simply lose conscious awareness whilst retaining some functioning e.g. enough to travel by bus or train. However this is rare.
It is helpful to see dissociation as being on a continuum from a momentary lapse of attention at one end, to – at the other end -the client getting completely caught up in some internal thought or memory and seemingly oblivious to normal ‘call-back’ cues such as the sound of their name or a wave of a hand. Another factor to consider is how involuntary this seems to be. At one end is the attentional hi-jacking caused by an unwanted traumatic memory, whilst semi-voluntary daydreaming during a boring lecture is towards the other end.
It is useful to start by describing what the client does that you can actually see, and noting what he or she reports about the internal experience. Are there vulnerability factors that make this more likely? Are there any specific cues that always seems to set it off? Pay attention also to the contingencies that follow dissociation, are there any potentially reinforcing consequences? Remember, just because the consequences are reinforcing it does not mean the patient intended to get them. Behaviours can be reinforced outside of our awareness.
For example, I had a client who was a witness to a crime and was desperate to have the perpetrator apprehended. However, when she tried to give a statement to the police she would dissociate and the interview would be stopped. Trying to make the interview less stressful through a variety of methods did not reduce the dissociation. When the police decided to continue with their line of questioning, repeating the question of necessary and just waiting for her to re-attend, the phenomenon stopped. The client had wanted to make the statement, but perhaps her subconscious mind had found a way to relieve her of the trauma of doing so without her active consent. Once this involuntary action no longer worked (i.e. did not get her out of the situation) the dissociation went away. The dissociation in no way indicated conscious reluctance to take part. Clients need to understand that attending to possible reinforcers of the behaviour does not imply it is currently under their conscious control.
Once you have got some data about the phenomenon you can look at the range of options open to you as interventions. These are also on a spectrum from a minimal response to maximum intervention; e.g. ignoring it, or just mentioning it, instructing them to do something different or adding a contingency, analysing what just happened, and coping ahead for times when this might happen in the future. Occasionally if someone does something very dangerous whilst in a dissociated state they might need to be detained (again this is rare).
Audial cues can reorient attention, such as saying the person’s name and describing exactly where you would like them to put their attention, e.g. “Emma, you are staring into space, tap your feet on the floor and turn your attention to my voice.” Tapping the table or clicking your fingers are socially accepted cues for getting someone’s attention. Talking in a firm voice is more likely to produce a response, only because we are more attuned to firm voice-tones at times of stress. If there is a bull and a rabbit in a field, we are programmed to focus on the bull. Coaching in grounding techniques encouraging the client to use the sensation of touch for example, can also help, as can mindfulness.
Ask questions to identifying starting and stopping points of the dissociation episode. For example, asking, “Can you repeat what I just said?” If the client says, “sorry I can’t remember”, then you know that they at least heard the question.” If they say, “Sorry? What?” then at least they were associated enough to know that you were speaking. Ask, what is the last thing they remember hearing or seeing?
Dissociation can be a problem if the client is working through traumatic material. Professor Edna Foa, developer of the prolonged exposure protocol for PTSD, describes how some clients can be ‘over-involved’ in the traumatic memories as they recount them during treatment. To mitigate the effects she introduces strategies that help the client to get more protective distance from the material. For example, keeping their eyes open instead of closing them, imagining that they are viewing images through glass, and if necessary raising their hands as though they are touching a sheet of glass in front of them. In some circumstances she has allowed the client to write down their narrative rather than speak it out. These strategies have to be balanced against making sure the client is able to access the emotion associated with the trauma, as without experiencing emotion the trauma cannot be processed.
Physical strategies can help. Martin Bohus researching trauma treatments in Germany does trauma work with the patient standing on a wobble-board. If dissociation becomes problematic in therapy you can ask the patient to sit on a yoga ball, which requires ‘present focus’ to stay balanced. Even putting a book under the back legs of the client’s chair can tilt the seat just enough that they have to stay more focussed than usual to prevent sliding forwards. You can explain this to the client by saying, “this dissociation seems to be a problem so we need to do some things to try and keep your focus in the here and now, here are some ideas I have – we can try them one at a time”. Over time, by experimenting, you should be able to identify some controlling variables.
It is important that you don’t change your normal intervention in the face of dissociation. If clients in DBT for example have difficulty with chain analysis because they can’t remember what happened, ask them to choose their best guess, “so where were you when you harmed yourself?” “I don’t remember.” “Ok, do you think you were inside or outside?” “Inside, probably” “Upstairs or down?” “I don’t know” “Just choose the most likely” “probably upstairs” etc. Clients are responsible for their behaviour whether they are dissociated or not, so it is vital for them to rehearse strategies for any potential problems. And even if you have not got the chain absolutely, as long as you are working on roughly what happened and doing solution rehearsal it is fine. They might end up saying, “I don’t think it was like that…” at which point you can alter the solutions to fit the scenario they think was more likely. Similarly if clients get panicky because there is a gap in their memory – “I’m really scared because I have no idea how I ended up at Claire’s house” Ask them to fill in what they think is the most believable scenario, and we’ll go with that. If they say, “But what if something awful happened?” Then you can reply, “let’s assume the best until we have firm evidence that this was not the case.” If they cite their own worry as evidence, ask them to try and put it to one side and see what other evidence turns up.
Finally, there are some useful behavioural rehearsal exercises for dissociators. One is a practice where you tap the table and they have to give an internal observation, then you tap again and they have to give an external one: E.g TAP “I notice the thought – this is weird” (internal) TAP “I notice the carpet is blue” (external) TAP “I notice a sensation of tightness in my tummy”(internal) TAP “I notice the glass of water on the table is sparkly”(external) TAP “I notice a mental image of the sea” (internal)TAP “I notice the shadow of the bookshelf on the wall” (external). Developing recognition of the difference between internal and external foci of attention is a vital skill. High emotion has a way of demanding our internal attention so this exercise needs to be practiced during gradually more intense emotional experiences.
Therapists are programmed to listen, and helping clients to feel heard is at the heart of what we do. There are times, however, when something seems to go wrong with this process, and although the therapist has applied the most careful attentiveness, validation and change suggestions the client wants to recount the same information over and over again. Therapists report that too much going over the same ground feels wrong, they can sense it is not helping and they feel stuck in a loop. As a behaviourist I am going to ask, “What is reinforcing this client behaviour?”
There could be any number of controlling variables. The first possibility is that something pleasant happens inside the client when they tell their story. The most common internal reinforcer is hopefulness. So at the point that the client retells their story they experience a surge in hope that on this occasion a desired outcome will occur – perhaps they will feel relief or the therapist will come up with a different solution. This is the same mechanism that gets people buying lottery tickets even when they never win. To the client, recounting the story means, “I have not given up, I am still in with a chance of a different resolution to this issue.”
Another internal positive reinforcer is a sense of congruence. The active ingredient here is not the therapist hearing the story, but the client connecting with their own accurate description. Their inner validation; “That’s right! That is EXACTLY how it is!” can be very rewarding. Watch to see if the client is scanning your face for clues to your response, or if they appear to be watching a film unfold in their mind’s eye, quite separate from you. If it is the second they are probably after an internal sensation rather than anything you can say or do.
Retelling is more likely if the story is emotionally evocative and the client has few other experiences in which to employ their full emotional range. When you think that the entire multi-billion pound entertainment industry is built on dragging us poor punters through every available emotion; terror, horror, despair, relief, joy, excitement then you can see just how important it is to experience those emotions in everyday life. If the client’s only emotional outlet is in the therapy room, then “Houston, we have a problem…” If you are the client’s sixth therapist, suspect that this variable might be in the driving seat.
Self-justification can be very powerful. If someone has hurt me and here I am contacting that pain then it proves I was hurt. If I am the victim of an injustice and here I am in connection with that grievance it is clear evidence that the injustice took place. It is reassuring to any of us when our experience fits the facts. For some, to let go of retelling can feel like letting the person who hurt them off the hook. This is the saddest of them all, where potential years of happiness are sacrificed on the altar of bearing witness to injustice, and yet for many the crime against them is indeed so great that it takes a superhuman effort to reclaim their rightful pleasure from life.
The response from the therapist can also reinforce the behaviour. An understanding look, a reassuring nod, the giving of time to listen. If the very first time the client told their story they experienced a huge surge in positive emotion from these things why would they not want more? It can be like being let out of prison after a long term, and the client seeks to replicate that feeling. This is the same mechanism that maintains substance misuse, where the person ingests more of the substance hoping to replicate the initial high – but takes it beyond that point, to where only lows are waiting.
Negative reinforcers are the removal of unpleasant consequences. So if the client can get the therapist onto a familiar and well-worn track they may be keeping them away from other more painful topics. In some way the client is taking control of the session.
Equally if the client has underlying misgivings about their own behaviour during the critical incident they may wish to ‘anchor in’ their version of it, to steer themselves (or the therapist) away from the part that causes them most doubt. For example it may be that they are defending against a feeling of guilt. Although that guilt could be justified or entirely inappropriate, it is the lurking presence of unacknowledged doubt that condemns them to a perpetual cycle of restatement.
Finally there is the fear of forgetting. The protective injunction to avoid traumatic events is so strong that the client is afraid of unhooking from the incident. They worry that such carelessness might leave them victim to the same thing happening again. Alternatively if the incidents they recall evoke pleasant memories then they fear that these will become inaccessible if not regularly shared.
So what can a therapist do having assessed the drivers for the behaviour? My top tip is to start by honouring the story told. In 80% of cases one simple strategy will result in change – the therapist starts a session by saying – before the client has even begun to speak – “I have been thinking about you, and about the incident we have been discussing, and remembering that you….”(here the therapist tells their story back to them in their own words.) Don’t paraphrase, use exactly the words they use. Timing is crucial here – it simply does not work if you wait until the client has begun the recounting. You must get in before the incident is mentioned or referred to, because it is your unprompted remembering that is so effective in reassuring the person that they have been heard.
If this doesn’t stop the behaviour then a second line strategy is to type out the story in a letter to the client and hand it over in session, “I believe that this is a very significant event and it is important we keep the details, and add to them if we feel we are missing something.” Then keep a copy of the document with you so if the client begins retelling you can get it out and see if anything needs adding in. Seeing the therapist do this can act as a reminder that the story is not lost, but also offers a chance for the client to expand on any missing links.
If neither of these strategies reduce the behaviour I would suspect it is to do with a dearth of other emotionally evocative events outside of your sessions. I have used a diary-card for this problem, asking clients to tot up daily the minutes of thinking-time devoted to their repeatedly described incident or situation, and then in a different column to track ‘new life thinking.’ This is any time devoted to planning or engaging in activity to build or refresh their daily emotional experiences. I am quite demanding that one figure should be reducing while the other needs increasing.
If this doesn’t work then track their urge to tell the story to you. As soon as the re-telling begins, say, “I wonder what was going on for you right then when you had the urge to tell me this?” Try to pinpoint the thought or emotion that acted as a trigger. Then you might be able to work out out how the recounting of these familiar details either reduces or enhances the thought or emotion.
If absolutely all else fails then hand the problem over to the client in a radically genuine way; “I know that telling me about this again seems to be important, but I am worried that if we keep our focus here we are not going to move forward in therapy. Can you help me to make sure that we don’t just go over old ground?”
Knowing the function of a behaviour always leads to more insight into what the therapist could do to help alleviate it.
The emotion of shame is one of the social emotions designed to keep us as part of a social group, as during evolution the protection of others was a big factor in our survival. Shame occurs when you have committed an act that you predict would be against the norms or values of your group, to such an extent that if the group knew about it there is a risk that you would be ejected from the tribe. Unlike guilt which prompts us to try to repair the damage, the emotion of shame has an action urge of hiding or concealing one’s crime.
This is an excellent protective instinct. If you have done something hideous and you don’t think you will escape the wrath of your peers, the behaviour of keeping a low profile could allow any tribal heat around your transgression to die down. Hopefully everyone will forget about the incident and you will be assimilated back into the social structure when you eventually surface.
It makes sense that an emotion that served such an important life-or-death function would have an accompanying sensation that feels pretty horrid. Shame is particularly painful and so it should be – so that there was no risk of you wandering out nonchalantly into a crowd that is baying for your blood.
The components of the emotion are body heat (burning with shame) an urge to hide from view which leads to head hanging and shrinking back, a subservience to others and self-accusatory thoughts. Unlike sadness where muscles are flaccid, in shame it is possible to note a certain amount of flight-tension, i.e. the muscles retain a readiness to run or push others away. Think of trying to comfort someone who is very ashamed, they may push you off in a way that sad people are less inclined to do.
So we can distinguish shame from related emotions like guilt or sadness. Occasionally shame can elicit defiance as an internal defence, so it can mimic anger, but the tell-tale signs are in the direction of motion – the angry person is more likely to approach others, the defiant person will stand still.
Professor Paul Salkovskis has suggested to ask clients, “What kind of people feel shame?” They have often failed to register that it is an emotion felt by people who have a conscience. Psychopaths and hardened criminals rarely exhibit shame, although there is also an argument that they have just become more practiced at defending against it.
The compassionate mind theory of Professor Paul Gilbert suggests that many clients have not developed the part of their brain that can show compassion to themselves, and need to be helped to do so. People with this problem may believe that the pain of their shame is well-deserved.
In taking a behavioural approach to reducing shame we first want to be mindful. In the presence of a shame-inducing trigger clients can be only too quick to lump together anything and everything that they have ever felt ashamed of. So when treating a current episode of shame it is vital to ascertain what exactly set it off. Questions like, “what is the latest thing that made you feel ashamed?” are helpful. You simply cannot treat shame in a global way, you have to teach the client to work incident by incident.
Try to establish if their current episode of shame is one of the following
Clients need to learn these types of shame, as stepping back from the incident in question to classify it will usually take a little of the heat out of it.
Some therapists hold that shame is never warranted, but I disagree, having consulted to teams that deal with patients who have committed very serious crimes such as murder. If such clients are ever released and hear taunts or threats in public the urge to hide could save their life. This is especially true if they have been rehabilitated with a fresh identity, being in danger of revenge attacks. It is also realistic for clients who have past self-harm or drug habits to assume that some groups might reject them and it is wise for them to be discerning if the social stakes are high.
When treating shame the therapist MUST ascertain the nugget of truth in the patient’s position. Saying to clients, “you have absolutely no reason to feel ashamed,” is often invalidating – because for some reason they do feel it. So the therapist is looking to find one sentence, just one, that sums up succinctly the reason that the client feels shame, but – and here is the art – it is tempered with more reasonable language. So the client who has had her child taken into care because of her self-harming might be taught to say, “I would prefer that I had not self-harmed because of the consequence of having my child removed, it does not fit my values to live separately from my child” the therapist will know that the sentence is correct because the client says, “yes, that is exactly the reason I feel ashamed,” but they can also hear within that message the conscientiousness that Salkovskis is referring to. The client is encouraged to say this reasonable statement in a non-shamed posture. So head up – firm voice, look the therapist right in the eye and say it. If it doesn’t feel quite right to the client change the wording and add bits on until it hits the exact spot.
Here is my top tip, if the statement starts to sound defiant or aggressive coach some muscle relaxation, then get them to stand up straight and say it again. There is a fine line in the muscle tone between making a non-self-shaming summary and being defiant, but defiance is a safety behaviour so it will prolong shame. Defiance is not needed if shame is already waning. You are aiming to get them to make a simple declaration of their position in a calm but convincing way. Not cowering or cringing, not damning themselves or others. Just a straight-down-the-line statement of fact. Sounds simple, but is amazingly powerful.
This mechanism of change here is one that Professor Marsha Linehan would call ‘opposite action’, a bio-neurological strategy based on the assumption that if you take action incompatible with an emotion the mixed messages back to the brain will reduce the intensity of it. In this case, an upright (but not totally rigid) posture, a direct gaze, a calm declaration made with complete conviction in a strong (but not aggressive) voice-tone are all actions incompatible with shame. It might also be necessary to cool the person’s body temperature, take off a cardigan or jacket, and suggest they have a cold drink. All these factors taken together will inhibit the brain’s shame-induction system in that moment.
For clients who are shameful about some past incidents my advice is to deal with the after-effects first, before doing any exposure treatment. Having some confidence that they can reduce a ‘shame attack’ can help them to withstand recounting the actual incident at some stage in the future. So usually in these cases the client gets shameful when he or she encounters a trigger that sets of the memory. In the example we have already used the client sees people in the supermarket with their children coming up to Christmas and regrets not being with her child, Stick with what she can say to herself in the supermarket, as above, (though she doesn’t have to say it out loud, she can still make the declaration in her thoughts). Only when she can confidently manage this type of trigger is she ready to go back in therapy to the incidents around the time when the child was taken into care.
Shame by association when the client is totally innocent is hard to shift but it is helpful to acknowledge that the discomfort felt in the body does not signify guilt, but rather demonstrates a complete rejection of the act itself. Sometimes the client has been encouraged to feel shame. The statement for this client will be something like, “I feel discomfort when reminded of this event because the action itself was so completely against my own values. This feeling is not a sign of guilt, but comes from my firmly held belief in what is right and wrong.” Head up, confident pose, firm but calm tone of voice, say it with conviction, no flinching. Change the wording until it feels correct to the client.
The client may say, “But I feel shame all the time”, and this is where mindfulness is key. Teach the client that each moment unfolds differently, and if you take care of the moments the hours will take care of themselves. It is wise to keep some shame if the shame is justified, as a warning not to repeat the same behaviour again. Remember that shame is a skill in the repertoire of conscientious people, but in excess is extremely damaging to our self-esteem.
Paul Gilbert will be doing a one-day workshop for us on compassion-focussed therapy in London on Jan 8th 2016. Please go to our Guest Speaker page to see details.
Many clients would not dream of saying ‘I can’t cope’ until their emotional resources are completely spent. They struggle on, trying to manage without calling for help. For some it is a matter of pride, others have been punished for showing what is perceived as ‘weakness’, some have asked for help in the past to no avail and have simply given up. Admitting they can’t cope can have unpleasant consequences – will it mean a hospital admission? Medication? Losing face? Or even losing employment. There are lots of reasons why people hold out as long as they can without revealing their difficulty.
In other situations saying or thinking “I can’t cope” can become a pervasive problem. One of my clients said; “My sense of self-worth and confidence is so low, that even the smallest thing is a challenge. I can’t find change for the parking meter, and I stand in the street just thinking, ‘I can’t cope’. I don’t even have to say it to anyone, it’s like I’m saying it to myself throughout the day.” To this person, “I can’t cope” has become an acknowledgement to themselves of their own sense of inadequacy.
When a client says “I can’t cope” the listener knows immediately that
something is wrong, and that it’s no minor thing. So it is a very effective way of communicating distress very quickly. The problem for mental health professionals is the sheer amount of exposure they have had to this particular phrase. It is probably heard on a daily basis in community mental health teams, and beyond a cry of pain doesn’t immediately indicate what help is needed.
So unfortunately instead of galvanising the listener into offering help, the phrase ‘I can’t cope’ can result in both parties feeling hopeless. A counsellor told me, “When my client says, ‘I can’t cope’ I feel like I have failed.”
Mental health professionals can ask for some pointers from the client on what ‘I can’t cope’ indicates, as for each person it will be different. I keep a list of some possibilities that we can look at together, and whilst not an exhaustive list it is a good start;
Even if the client says, “all of these apply to me”, getting them to pick their top one can get the therapy moving again. Sometimes I get the client to generate their own list of possible meanings, and to turn to it whenever the phrase pops into their mind. If they choose a statement from this list to say to their family, friends or mental health professional they are more likely to get the help they need.
One of the mental health nurses who mans the crisis line told me there is always a peak in calls as ‘Eastenders’ finishes. Why? because watching a favourite soap opera staves off the painful loneliness that clients feel, which then comes crashing back as the titles roll. I am often asked in supervision how to go about actively treating loneliness.
That pain of being lonely is actually one of nature’s best-ever inventions. Without it, as soon as the agony of our first relationship break-up kicked in we would vow NEVER to do that again and the human species would die out. Fortunately nature made being lonely more painful than the worst break-up to secure for us all the advantages of social bonding. So the first step in treating loneliness is to stop your client defining the pain of loneliness as, ‘this is a sign that I am a sad loser’. Instead encourage mindful describing; ‘this pain means I am a basically sociable person but my relationships have fallen below my desired level, either in number or in quality’. That’s what loneliness really is –an alarm that goes off in sociable people to warn that their relationships need attending to.
There are 4 components in the treatment of loneliness: Friend-recruiting, Connection-making, Connection–keeping (when apart) and Tolerating aloneness.
In this phase we want the client to do 3 things; Seek out other people, speak with them and engage in joint activities. The client is often stuck between a rock and a hard place, the pain of being lonely versus the terror of friend-recruitment. Therapy at this level involves identifying internal obstacles. The thought ‘they might not like me’ (or sometimes, ‘I might not like them’) and the emotion of fear are perfectly normal. Remember to use mindfulness to turn attention away from unhelpful thoughts.
Flooding is my top tip here, ask the client to get out their old address book and contact every person in coffee-drinking distance, and ALSO join 3 local groups and one volunteering project. Rehearse how to say, “Hi my name is xxxx and I am new to this group/project…”
If the client is single ask whether they would like to find a partner. There is nothing more insulting than your therapist assuming you wouldn’t want a close personal relationships without asking you. It implies the person is not date-worthy. So always ask, and – my tip- if a lonely client says no they don’t want a partner, then it is more therapeutic to gently enquire ‘why not?’ than to inwardly heave a sigh of relief, nod and accept that they don’t.
If they do want a partner encourage dating. Say the actual words, ‘We need to get you dating’. Prepare for the storm that follows (your suggestion is preposterous) but do not be deflected. Remember dating is normal behaviour for people who want partners. Even clients young enough to NEVER use the word ‘dating’ will get your drift. It’s natural for clients to hold back because they doubt themselves, but you can help them with the doubt, just activate the behaviour and solve the obstacles as they crop up. Occasionally clients tell me, “There is no one out there who would want me”. For this I set them the homework of sitting outside the local registry office on a Saturday for the whole day to see the newly-weds come out. All manner of couplings are there. I tell them, “your soul mate can’t find you if you just stay home.”
I’m not talking here about shared interests, rather that feeling of being close to someone, social intimacy. For this clients need to learn the skill of mindful relating. This means in this moment staying ‘with’ the person to whom they are speaking. Probably the main obstacle here in the chronically lonely person is too much self-to-self thinking. By this I mean the tendency to engage in a higher than average number of reflections inside their head. I might explain; “You know how you can be really engrossed in watching a film, completely absorbed in the action? What happens if you start to think; ‘Hmm, I love this actor, but he was better in his last film, and I hope the dog doesn’t get injured cos I hate films where that happens, and I really don’t like what that girl is wearing’. Most people can acknowledge that they have left off watching the film to have a conversation with themselves about it.
We all have this capacity to make comments to ourselves, and we do it a lot of the time, but I have noticed that people who complain of poor connections with others do this more. If they are communicating with themselves in this way, there really is no opportunity for their companion to connect with them. You can help clients to break this cycle by noticing when attending to their private thoughts starts to exclude the person they are with.
Use mindfulness to help the client be alert to their self-to-self thinking, which in company might look like this; “I don’t agree with what you said, but I’ll just nod”, “I would never have said what you just said”, “I wonder how I’m coming across right now?” “I think I made a fool out of myself then,” or “You just don’t get me at all” Judgements, queries, doubts, disagreements, all this is mind-traffic that blocks the client from a) properly hearing or seeing the other person and b) truly being heard or seen by the other person. So the connection suffers.
In longstanding relationships that have gone bad, often one or both parties have resorted to almost total self-to-self thinking, to the exclusion of any proper connection. These clients report feeling lonely despite being in a relationship. Sometimes they defend their internal retreat by saying, “I shouldn’t have to verbalise my thoughts and feelings, they should know,” or “I don’t want to rock the boat”. Sadly this still results in loneliness. More verbalising mindfully and some boat-rocking is required for intimacy.
Of course some people go too far the other way and blurt out too much of their inner material – which leaves little room for the other person to be known, but that is often easier for therapists to pick up on and diffuse.
This is about how clients keep connected with friends when they are NOT present. When I go away on my travels my family and friends don’t cease to exist for me, I somehow keep a sense of being connected to them. But many lonely clients feel a really painful sense of loss when they are physically alone and do not have any sense of absent friends still being there for them. Normal cues such as photos and keepsakes can help. However, the usual way that we keep loved ones ‘current’ is to mentally reference them as we go about our business. So when we lock ourselves out of the car and have to phone the RAC we think – “oh, I will tell Frank about this when I see him”, or “Kelly will really laugh about this when I tell her.” Lonely clients don’t have much confidence in future meetings, or they are fraught with fear about them, so it doesn’t occur to them to do these routine affirmations of the relationship. But when we do this we are telling our subconscious – we will see our friend again and they are part of our everyday life.
This mental referencing others is an antidote to our old enemy ‘self-to-self’ thinking. With this technique the client has to learn to represent the friend in their mind and mentally conjure up their unique reaction to things. It is very similar (but not identical) to how we keep people alive for us after they have died, we see something and think, “Grandad would have loved this”. In treating loneliness we want the client to predict not only the reaction but the face-to-face contact in which they will experience it. Of course it does rely on the client having meetings lined up, so they still have to work on friend-recruiting.
This should only be done when friend-recruiting is on a roll, because some clients will think that if they get good at tolerating aloneness they won’t need any friends. But they do, so focus on that first. However, no matter how popular we are there will be times when we do not have company, so we all have to be able to manage that.
When loneliness hits, the client should ask themselves what time of day is it and what are people normally doing right now? Block any ‘Disney’ fantasies about people in couples or families. Households are not always sitting round sharing their problems with each other and receiving support. In fact around a third of people in the UK live alone. What are those people doing? Some of my clients wake up in the night feeling lonely – but actually most people in the middle of the night are sleeping, not even aware that anyone else is there! Visualising the rest of the 30% of the living-alone population going about their daily activities can be quite reassuring. Ask the client – if you could see though walls how far do you think you would have to walk before you pass another person who is alone in the house in this moment?
Next, whatever the client chooses to do in their alone time, they need to do it mindfully. This involves turning their mind to information coming in through their five senses, instead of paying attention to the thoughts like, “other people have someone to care for them” and “no one is here for me”. When they notice those thoughts they can mindfully label them as unhelpful thoughts, and turn their mind back to their (hopefully purposeful) actions.
Some clients get freaked out by being in an empty house, but interestingly only at certain times of day, so it is not the emptiness per se that is a problem, more their interpretation of it. Being able to say “I am alone in this room” at times when it doesn’t bother them (in the bathroom is a good example) can help them to notice it is being alone plus some other thing that makes it scary. The thoughts might be ‘I’ve no one to watch this TV program with’ or “It’s awful to be on your own”. Blocking those interpretations helps, so the client can learn to state mindfully, “I would like more company, and I am working to increase it.”
One caveat is to avoid telling people, “distract yourself, do a jigsaw or watch a DVD.” In my experience trying to distract from loneliness increases the pain of it ten-fold, because it implies that it is somehow an awful plight. The client then engages in MORE self-to-self reflections on their unwanted situation. Instead we are trying to get people to see that loneliness is normal and just a prompt to improve contacts and connections, and that aloneness is an ordinary and sometimes desirable state. Being alone can be sad, but need not be tragically sad unless there is no plan in place to improve things.
What is Emotional Pain?
I spent 7 years researching the communication of emotional pain from suicidal patients to mental health professionals. I became interested in emotional pain many years ago when analysing an incident of self-harm behaviour with a client. He described his feelings during an argument as ‘painful’, and at first I accepted this as a colloquial term, as in, ‘relationships can be painful’. But I was intrigued; This pain in my client’s body was a key factor in his urge to harm himself. So was he actually experiencing pain? Or was he speaking metaphorically? Was he describing a component of a bigger experience such as grief? Was he somehow scrunching his internal organs to produce actual tissue damage? What exactly was going on?
I searched the literature and found a range of related phenomena but with slightly different names; social pain, psychological pain, emotional pain, mental pain, psyche-ache and psychic pain. Furthermore it seems that high levels of this experience are thought to play a role in completed suicide. Back in the 1970s eminent suicidologist Edwin Shneidman analysed suicide notes for recurring themes and identified that the most common one was a desire to escape from emotional pain.
More recently neuroscientist Naomi Eisenberger and her colleagues at UCLA studied the brain scans of subjects during a computer-game which was deliberately manipulated to have some players experience being left out by the others. The brain areas that became active in the rejected players were those also activated during physical pain. One such area is the anterior cingulate cortex. Decades ago brain surgeons did experimental surgery on this brain-site while attempting to treat intractable physical pain, because ablation of the anterior cingulate cortex removed the unpleasantness of the pain experience. Sadly these poor patients ended up with such horrendous physical injuries from NOT feeling pain (such as when touching a hot surface) that this surgery was discontinued.
This sharing of the same neural networks in physical and social pain has been called ‘Pain overlap theory’. So if the same neural architecture is involved in physical and emotional pain, how do they differ? Research suggest that physical pain has an additional component; information from the somatosensory cortices, i.e. a location marker from your skin or vital organs, pointing to a specific place in your body where injury or illness has occurred. But why would the same neural alarm sound in a social situation where no wounding to the body has been sustained? Eisenberger suggests that pain acts not so much as a damage indicator, but as a discrepancy monitor, signalling where something is deviant from its desired (or usual) state. Pain focusses your attention on what is wrong, enabling you to attempt to heal your body, repair your relationships or mitigate your losses.
This theory makes sense on so many levels. Firstly it accounts for the shared language across physical and emotional pain, for example we talk about bereavement or unrequited love as aching or agony. Secondly it provides a good rationale for self-harming behaviour. If you have intense but free-floating pain you are relieved once you can identify one area of the body for that pain, not only does it give ‘reality’ to the experience, but also allows you to predict its ending. As your flesh heals you might reasonably assume that so will this inner torture. It also explains how any emotion can hurt if it is discrepant from what is desired or anticipated – we can even experience painful joy if its intensity takes us by surprise.
Some patients say it hurts when they self-harm, others that they don’t feel it. Could this depend on the difference in intensity between the physical injury and emotional pain in that moment? Like hearing a shout in a noisy factory – if the background noise is louder, it won’t be heard. If the emotional pain is more intense, pain from the injury site will go unnoticed. In these circumstances it is only seeing the injury that will have that reassuring ‘realising’ effect, and we know that some clients report it is the visual appearance of their wound that brings relief.
Because emotional and physical pain are so closely related analgesics work for both – alcohol, drugs and over the counter painkillers will numb emotional pain as they do physical pain. When people become suicidal they are often trying to destroy the seat of their pain where it resides – in the body. Intuitively we all know this already. The wonderful Paul Gilbert notes that when gangsters go to war they threaten to harm the children of their enemies rather than the enemies themselves. This is because the thought of emotional pain is the worst.
However, culturally we do not yet treat emotional pain as equivalent to physical pain. A colleague who read my research remembered a relative who had killed himself without warning. “Although there were no suicide threats before his death, there was a lot of emotional pain communication”. Physical injury motivates us to move with urgency towards the injured party, to see what we can do to help. We In contrast subjects in my research reported that even being able to articulate their emotional pain somehow communicated the message, “if you can talk, it can’t be that bad.”
I believe the current campaign for parity between mental health and physical health is an opportunity to call attention to these similarities. Let’s begin to ask our clients and patients routinely about their emotional pain. Just as when assessing physical damage a doctor usually asks, “How much pain is this causing you?” We can ask clients to monitor their emotional pain levels. We can assure them that this pain isn’t random, it’s not a sign of weakness, there is a proper physiological reason for it, and that we can help them problem-solve the issue that set it off. Emotional pain is the smoke to the fire of suicide and self-harm. We need to respond as if it is an actual fire, and as soon as we smell burning. Let’s not leave it until the flames have taken hold.