“I can’t cope”

DSC_0440Many 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;

  • I have pain or discomfort in my body that doesn’t go away and I need relief from it
  • I am in an intolerable situation to do with; a relationship, employment, finance, accommodation, physical or mental health (say which one)
  • I have an image in my mind that I can’t get rid of that is causing me distress
  • I am unsure how to proceed to solve a practical problem, I need help to generate solutions
  • Something is coming up and although I know what to do I need help to face it
  • An event has occurred that I can’t get out of my mind
  • I feel overwhelmed by an emotion – either sadness, shame, anger, guilt, disgust or fear (say which one)
  • When I look into the future I can’t see anything that looks appealing
  • I am really exhausted, I need help to generate some energy
  • I have constant negative or self-critical thoughts and need to be able to think of some other things
  • I want to be relieved from a sense of responsibility, it feels like it is all on my shoulders
  • I don’t want to have to think about my problems any more, I need a break from them

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.

Advertisements

“It Hurts So Much”

What is Emotional Pain?

ireland stepsI 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.

“I just woke up that way”

WIN_20151024_171201

If your client or patient reports that suicidality occurs immediately on waking, it can be helpful to do an analysis of those initial moments in which the urge occurs.

First – was that the very first thought that went through the person’s mind? Like; Wham! – I’m awake, now I want to kill myself. Usually it doesn’t happen that way. Sometimes the client wakes and gets a physical sensation – perhaps pain due to illness or injury. Is there some physically draining health condition that just wears this person down? So much so that becoming conscious of it immediately prompts the desire to escape. Can this be problem-solved or can the physical pain be mitigated in some way? How long is it since they had a pain review?

Although early morning low mood is a symptom of depression, don’t assume that’s all there is to it.  On waking is the person predicting an unwanted event. In my experience this often consists of social circumstances in which the person feels trapped; The abusive partner, financial problems, childcare issues, work stress. Can the therapist and client make a plan to change this thing or if not, add in some other factors to make it more bearable? Is there something the client says they cannot face that is likely to happen in that particular day? There is nothing worse than predicting an unpleasant event and then having to actually deal with it. The golden rule – help the person both deal with the problem when they get to it, and also cherish the moments in which it is not happening.

Sometimes it is not a feared event, but anticipation of non-events. The client can see nothing that has meaning for them in the day to come. Even if they can identify such a thing, they can’t work out how to get it. The hardest part here for the therapist is that it always (always) takes time to build those positives, and it is hard to get ones feet on the path when the destination feels impossibly far away. This problem sometimes presents as a kind of regret-paralysis, wishing to turn back the clock and make different decisions. When this happens it is energy-sapping, and so the client has no reserves to put into creating the new future. Mindfulness can really help here. Sometimes the patient can see a better future but feels blocked from it, “I want to leave my partner but it would cause too much heartache”. But hey, ALL not-dying options trump the others, right? Even the world-rocking ones.

For some the fear is in the past – manifesting as traumatic memories. If this is a symptom of PTSD then the client should be encouraged to seek proper prolonged exposure therapy. This can be a daunting prospect so is it possible for them to speak to someone who has had the same treatment and recovered?

Finally some clients deal with relentless pressure on a daily basis without being suicidal, and then exhaustion just crashes through their resilience. This is the equivalent of running 20 miles of a marathon and then crumbling under the weight of one’s backpack with 6 miles still to go. Suicide masquerades as a comfy resting place. Is there something that has overtaxed the client’s resources on this particular day? Can the therapist help them to get some respite without quitting the race? Has a protective factor been lost? Can it be replaced?

From my experience clients really appreciate the feeling that whatever problem they face, they and the therapist or care worker are in it together – getting their two detective heads on the issue and working on solving it. To really feel this co-bearing effect the therapist needs to add in non-routine contacts, an extra call, a card, a text. Genuine human connection with the client, honouring their problem. Just to say, “I’m thinking of you, I’m sending good vibes, I think we can work this out together, stay in this, we can do it.” in this way the therapist is lending their own energy and resources to the client to effect problem-solving until the suicidal crisis passes. “Let’s break this thing down into what we can do today to move closer to a better future, and what we can do after that, one step at a time.” Suicidality is transient. It WILL pass.

When working with upon-waking suicidality I have always suggested the client make an environmental change immediately to remind them we’re now problem-solving; Turn their bed 90 degrees, or put their head at the foot end, pull the mattress onto the floor if necessary. Wake up in a different physical space to begin the journey to a different mental space. Mostly clients’ predictions and fears have a lot of validity, but that does not mean they are unsolvable. It’s a journey, and one that is better shared.