“I can’t cope”

Posted on by Christine Dunkley

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.

“I dread being alone”

Posted on by Christine Dunkley

DSC_0086One 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.

Friend-recruiting.

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.”

 

Connection-making

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.

Connection-keeping

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.

Tolerating Aloneness

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.

“It Hurts So Much”

Posted on by Christine Dunkley

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 Don’t Deserve It”

Posted on by Christine Dunkley

We all need positives in our life, whether it is an occasional treat or a regular pleasurable event. Behavioural activation, or encouraging people to build new positive experiences is a recognised treatment for depression. But what do we do when the client is aware of that, and although rewarding activities are available they are inhibited from accessing them by the belief, “I don’t deserve it”?

This obstacle comes up a lot when the client has high shame, perhaps they feel bad because of their mental health problems, or because of previous behaviour. When I consult to prison Mental Health teams they often report clients saying; “How can I deserve anything good when I’ve committed a crime?” Sometimes, though, there is no logical reason at all. Clients with low self-worth maintain that it’s as if everything has to be earned, and they are all out of ‘deserving’ points.

There was a time when I would engage in providing contradictory evidence to the client, reasons to justify that they did indeed deserve whatever was on offer. As you might guess, half the clients experienced this as invalidating. The other half found it pseudo-reassuring; “My therapist thinks I deserve it” works briefly, until the next time, when further encouragement is required. We sometimes help people to side-step this dilemma by asking “what would you say to a friend?” but then the client may maintain a covert rebuttal, visibly agreeing, whilst all the time thinking yes, but it’s not the same for me…blog2b

As a behaviourist I now enquire much more about the nature of this phenomenon. How does this undeservedness manifest? Can the client describe it mindfully?  A familiar pattern is that a physiological sensation in the gut happens first, almost like that sign outside a supermarket – ‘Trollies will stop suddenly as they are wheeled past this point.’ It is an uncomfortable sensation accompanied by the thought, “I don’t deserve it” and an irresistible urge to cease or recoil from the activity.

For a number of clients in addition to the sensations and thoughts there will be an association. One of my clients could momentarily ‘hear’ in her mind her mother saying, “You’ve caused us so much misery”. For another there was an image of her stepfather glowering at her. A third would picture her children as they were taken into care. These were very powerful inhibitors, allowing me to validate; “If that happened to me every time I was going to do something nice for myself, I would also think twice.”

Sometimes there are additional controlling variables within the environment. One client told me her partner asked “why didn’t you buy that scarf if you liked it?” when she said “I don’t deserve it” he become irritated and said she was not doing enough to help herself. Sadly his annoyance was entirely consistent with her own view of herself, inadvertently confirming her ‘undeserving’ status.

There is one more inhibitor to recognise; clients have past experience of enjoyment being paired with guilt. This sets up conditions where anticipatory guilt produces the involuntary stomach-clenching which then sets off the thoughts and images, plus the urge to avoid. And so the cycle persists.

It can be really helpful to summarise these very valid reasons for not doing pleasant activities; “You get some anticipatory guilt, a horrid sensation in your stomach, a thought about being undeserving, and associations with unpleasant memories. These factors strip away any pleasure while even considering the activity. Then, if you decide not to do it, all those aversive things vanish. No wonder you feel reluctant.”

So we encourage the client to accept that for them, at least at first, this is going to be unpleasant. The key phrase is, “You are going to have to learn how to do these things even in the presence of the urge to avoid doing them”. This strategy has two helpful components, firstly it is congruent with the person’s subjective experience, and secondly it relieves them of the notion that they are doing something inherently enjoyable, so they don’t have to worry about being ‘deserving’.

Next we can advise clients to simply observe the thought, “I don’t deserve it” whenever it crops up, and return their focus to doing the activity mindfully. This means if either a body sensation, another thought, an association or an emotion shows up they reorient their attention away from it and onto the required task. Breaking it down into these components allows them to label, “That’s a thought” or “that’s a sensation” as an aid to unhooking from it.

So why would they do this at all? Well, we encourage them to use their mindfulness skills to capture even one moment of reward before any guilt kicks in. That’s all, one moment.  We will foster curiosity about it; invite them to just notice any pleasure as it arrives, and also to accept whatever follows. The person learns that whilst ignoring the obstacle of “I don’t deserve it” they can still experience joy. Over time the vicious cycle is broken and the client’s capacity to be open to the whole range of emotion increases.

For further insights into helping clients to have more compassion for themselves see Paul Gilbert on Compassion-Focused therapy  http://bit.ly/1l9BpYo

“I just woke up that way”

Posted on by Christine Dunkley

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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.