How do you know if you need therapy, and whether or not it will help?
Recently, I was interviewed for a ‘Meet the therapist’ series which included questions about myself as a practitioner - how, why and where I work. And one question stood out;
What do you wish clients knew about therapy?
There’s so many things a client might like to know, as I recollect having lots of questions about therapy. Psychotherapy is a commitment, yet it may only be a commitment of a single-session. (Something you don’t often hear within therapeutic culture) and I know that clients often feel apprehensive about seeking support. Moshe Talmon suggests ensuring clients are under no illusion of ‘hocus pocus’ or any other kind of magical fix by clearly defining the role of the therapist and the therapeutic encounter. In his book, “Single Session Solutions. A Guide to Practical, Effective and Affordable Therapy” (1993), Talmon writes ‘a therapist’s introductory letter to a potential client’ (Pg.195). I believe this letter encapsulates a lot of the areas I wish clients knew about therapy;
“To My Clients:
It may be helpful to tell you how I see the job of a therapist. My job is to facilitate your psychological well-being, by helping you to solve the problem or dilemma that may have made you feel stuck and demoralized.
The first thing you need to know is that the goal of the therapist is to help you help yourself. The therapist’s greatest pleasure and reward should be to see you go back to the business of life more confident of your ability to take care of your problems, trusting your judgment and intuition. Therapy should be helpful and efficient, and thus, as brief and un-intrusive as possible to your normal life. Our main allies in achieving this goal are not the latest technologies or scientific findings. They are your mental and physical abilities. The therapist is not the healer. You are! The therapist’s job is to help activate and facilitate your own healing mechanism and your inner wisdom.
The therapist should never doubt that your pains and problems are real. The act of seeking the help of a psychotherapist may make you feel as if you are crazy or a hypochondriac. You are not! The therapist will learn about you by listening very carefully to everything you say and asking questions to find out what got you stuck. Why are your warning signals flashing? Most important, the therapist will search with you for ways to get you unstuck and facilitate the necessary shift or change.
The combination of your available psychological knowledge and the wisdom of your body-mind is a powerful team and knows what to do. Muster your resources – spiritual, emotional, intellectual, physical, and social. You are not alone. Many sources of help are available to you. Do not panic or give up. Your most powerful tool is your will to live. Your coming to see a therapist is an expression of your will to live and your willingness to do whatever you need to do to recover and regain your self-mastery. Don’t ask yourself to do anything unless you know that you are capable of it and that it will facilitate the necessary changes. At all times you will be in charge of the change and of the healing process. The therapist should not trick you or make you do things that may humiliate or harm you or allow you to lose control.
Although the therapist will be available and by your side whenever and as long as necessary, your job is the make the therapist obsolete as soon as possible. End therapy as soon as you feel that the problem is solved or – more likely and more precisely – that you can manage it on your own.
You are here because you want to stop the pain and regain hope. This will be the time to put into the fullest use whatever capacity is left in you to enjoy and laugh. Talk with your therapist about your joys as much as sorrows, about solutions as much as problems. Therapy is not a place only to complain and blame. You many have come to therapy because you feel helpless and like a victim; do not make therapy a place to do more of the same things that made you feel badly. Therapy is a place to change, take charge, regain hope, and solve problems.
No doubt you have some negative feelings right now and you should express them openly. But watch out! Negative feelings can ignite your entire mind like a fire in a windy, dry summer. When negative thoughts occupy the mind, they can block out other perceptions, prospects and pleasures.
Forgiveness is a gift you need to give not only to others but to yourself. Everyone makes plenty of mistakes and everyone needs to be forgiven in order to move on. Nothing clutters the soul more than remorse, resentment, recrimination. Guilt and blame are the best bet for not changing. The easiest way to deepen grievance is to cling to it. The surest way to intensify a problem is to blame yourself. Change and action come more easily out of a non-judgmental understanding and self-love than out of criticizing and undermining yourself.
Therapy should generate and encourage your confidence in yourself and in your capacity to solve the problem. Form a partnership of hope. Your hope, which you’ve displayed by coming to therapy, is the therapist’s secret weapon. It is the most potent ingredient in any prescription, in any task you decide to take upon yourself.”
- Moshe Talmon -
If you need support, are considering therapy or are therapy-curious, then please contact me to arrange an initial phone consultation.
The letter is taken from Moshe Talmon’s book “Single Session Solutions. A Guide to Practical, Effective and Affordable Therapy” (1993) published by Addison-Wesley publishing company.
Psychological ‘treatments’ for trauma are predominantly cognitive based and due to the high drop-out rate for these treatments, researchers are considering “non-traditional” treatments for trauma (Frewen, Rogers et al. 2015.Pg.1323). Frewen, Rogers et. al (2015) ‘proof of concept’ study showed that mindfulness was “considered potentially helpful… in the context of treatment for trauma… as well as more broadly for persons seeking to improve their self-regulation” (Pg.1331).
When an event occurs that is beyond our normal realm of experiencing, it can have a damaging effect on our self-structure as a response (Turner, 2012.Pg.31). Trauma is a threat (or perceived threat) to the survival of the Self, and the effects of such an event are that the assimilation of the information from the traumatic experience isn’t initially integrated with the existing self-concept - “it is frighteningly outside normal experience” (Turner, 2012.Pg.33). Trauma throws into question everything a person understands, or believes they understand, about themselves and themselves in the world (Turner, 2012.Pg.31).
In our brain, we have an area called the amygdala which is key in the detection of threat. Once threat is detected (either real or perceived), the sympathetic nervous system (SNS) is activated and our body responds by ensuring we’ve sufficient resources for “fight-or-flight” (Joseph, 2013. Pg.52) to ensure our survival. When a person is presented with sounds or images relating to their original trauma, adrenaline surges occur that initiate the physiological response to the trauma memory, “increase blood pressure, heart rate and oxygen intake” (Van Der Kolk, 2014.Pg.42) and mirrors the same responses that would have happened at the point of the original trauma (Van Der Kolk, 2014. Pg.45). Conversely, when ‘fight-or-flight’ responses aren’t available, the body enters “tonic immobility”(Joseph, 2013.Pg.56) due to an initiation of the parasympathetic nervous system (PNS), where “heart rate and respiration decrease, blood pressure lowers” ”(Joseph, 2013.Pg.53).
The hippocampus, in conjunction with the amygdala, form the limbic system with the hippocampus responsible for creation and storing of memory. When the amygdala is activated, the hippocampus area is deactivated, which means that initially it’s unlikely a person has a coherent narrative surrounding their trauma. Through neural imaging, Van Der Kolk (2014) discovered there’s a reduction in the Broca’s region of a traumatised brain - an area of the brain responsible for speech, “without a functioning Broca’s area, you cannot put your thoughts and feelings into words” (Pg.43). This highlights why talking therapies are necessary in the ‘treatment’ of trauma.
A consequence of trauma is the impact on affect regulation which means a person may not be able to regulate their emotions or responses. However, “enhancing affect regulation competences can be considered as a core therapeutic goal with client’s with complex trauma histories” (Ford, 2013. Pg.58) and “to rediscover the personal goals, choices, and abilities”, ”validate strengths” and “engage clients in a constructive self-directed examination” (Ford & Russo, 2006.Pg.343). In order for a person with a trauma history to undertake a therapeutic endeavour, “learning to observe and tolerate your physical reactions is a prerequisite for safely revisiting the past” (Van Der Kolk, 2014.Pg.209) and adults with a trauma history “may respond best to therapy if affect regulation problems are directly addressed” (Ford, 2013. Pg.62). That’s where mindfulness steps in…
Mindfulness & Self-regulation
“Emotion regulation is vital to creating a sense of safety” (Kalmanowitz & Ho, 2016.Pg.60)
Understanding that affect regulation is impacted by trauma, I want to explore how I can facilitate a client’s self-regulation. Mindfulness is based on Buddhist introspective principles that have been adapted for Western culture (Jooste, Kruger et al., 2015.Pg.555) and defined as ‘”paying attention in a particular way: on purpose, in the present, and nonjudgmentally” (Kabat-Zinn, 1994. Pg.4 as cited in Jooste, Kruger et al., 2015.Pg.555). Mindfulness is a particular type of meditation and is sometimes described as breathwork and can involve visualisation and guided ‘body scans’.
Van Der Kolk (2014) proposes that through focussing on sensations within the body, and becoming curious of the effects that breathwork has on a particular sensation, a person may find that there’s a memory attached to that sensation.(Pg.209). Within the therapeutic setting, the practitioner is there to ensure that a persons’ threat detector (amygdala) isn’t instigated.
In Shapiro et. Al (2006) they propose that the ‘mechanism of mindfulness’, is composed of three axioms, “Intention, attitude & attention” (Pg.374). Shapiro et. al (2006) discuss the importance of intention, “why one is practicing” (pg.376), as not only is it missing from previous mindfulness teachings but also because their findings support that “outcomes correlated with intentions” (Pg.376). Within the therapeutic setting, if the client and therapist openly discuss the intention behind introducing mindfulness (attaining a more balanced affect regulation), I’d anticipate the client experiencing growth.
“mindfulness increases the ability of the individual to handle the emotions they have, as opposed to trying to escape them” (Kalmanowitz & Ho, 2016.Pg.58)
With the second axiom, attention, Shapiro et. al (2006) describe the phenomenological view of experiencing the experience (pg.376) and through this attentiveness there’s an attainment of presence. The third axiom in Shapiro et.al (2006) paper, attitude, refers to the “qualities one brings to attention” (Pg.376) in a balance of heart and mind, nonjudgment and acceptance (Shapiro et.al, 2006. Pg.377).
Shapiro et. al (2006) remarks that “self-regulation is based on feedback loops” (pg.380):
“intention - attention - connection - regulation - order - health” Fig. 2. (Shapiro et. al, 2006. Pg.380)
The same principle could apply to the therapeutic work of a person with a trauma history; restoring the feedback loops, creating regulation and order by assimilation into their adapted self-structure.
The effect of mindfulness on the brain is incredible, Kabat-Zinn states when “resting in awareness—they exhibit an oscillation in the brain that we call y oscillations… These y oscillations are high frequency oscillations of about 40 cycles per second that have been implicated in basic mechanisms of synaptic plasticity” (Paulson et.al, 2013.Pg.92). Purely stated, mindfulness changes the brains plasticity and causes new neural pathways to be forged. And potentially, the same principle could be applied to the mechanisms of anxiety. With the effects of trauma, such as a heightened state of arousal, rewiring the brain through mindfulness allows a new arousal baseline to be set. With that new baseline, a person can begin to self-regulate more effectively, and/or understand their triggers, which frees them to focus on other aspects of their therapeutic endeavour.
Ford, J.D., (2013) Enhancing emotional regulation with complex trauma survivors. In: Murphy, D. & Joseph, S. (Ed.)(2013) Trauma and the therapeutic relationship: approaches to process and practice. Basingstoke: Palgrave MacMillan. Ch.5.
Ford, J.D. & Russo, E. (2006) Trauma-Focused, Present-Centered, Emotional Self-Regulation Approach to Integrated Treatment for Posttraumatic Stress and Addiction: Trauma Adaptive Recovery Group Education and Therapy (TARGET). American Journal of Psychotherapy. Vol.60(4). pp.335-355.
Frewen, P., Rogers, N., Flodrowski, L. & Lanius, R. (2015) Mindfulness and Metta-based Trauma Therapy (MMTT): Initial Development and Proof-of-Concept of an Internet Resource. Mindfulness Vol 6. Pp.1322-1334.
Jooste, J., Kruger, A., Steyn. B.J.M., & Edwards, D.J. (2015) Mindfulness: A foothold for Roger’s humanistic person-centred approach. Journal of Psychology in Africa. Vol 25(6). pp554-559.
Joseph, S. (2013) What doesn’t kill us. A guide to overcoming adversity and moving forward. Piatkus: London.
Kalmanowitz, D. & Ho, R.T.H. (2016) Out of our mind. Art therapy and mindfulness with refugees, political violence and trauma. The Arts in Psychotherapy. Vol.49. pp.57-65.
Paulson, S., Davidson, R., Jha, A. & Kabat-Zinn, J. (2013) Becoming conscious: the science of mindfulness. Annals of the New York Academy of Sciences. Vol 1303. pp.87-104.
Shapiro, S. L., Carlson, L.E., Astin, J. A., & Freedman, B. (2006) Mechanisms of Mindfulness. Journal of Clinical Psychology. Vol. 62(3). pp.373-386.
Turner, A. (2012). Person-Centred approaches to trauma, critical incidents and post-traumatic stress disorder in: Tolan, J. & Wilkins, P.(Ed.) Person Issues in Counselling & Psychotherapy. Sage: London. Pp.30-46.
Van Der Kolk, B. (2014) The body keeps score. Mind, brain and Body in the Transformation of Trauma. Penguin: UK