depression

Wake up

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A good friend of me writes poems, and I liked one of them so much that I asked him if I could publish it. To my joy, he said yes. The poem was written to a friend of him who has struggled. It speaks of dreams, and everything that is important in life.

You wanna wake up,

To hear your loved ones,

To see them when you can,

To make them happy,

To see the cuteness of your niece,

To be teased by your siblings,

To be loved by your parents,

To be cared by your friends,

Share joyous time with them.

You wanna wake up,

To live your dreams,

To travel the world,

To wear that red dress and many more,

To feel beautiful,

To spread the happiness hidden deep within,

To dance like no one’s watching.

You wanna wake up,

To feel the magic in the world,

To see the bright flowers that make you glow,

To hear chirping birds that give you peace,

To breathe the fresh air deep into your lungs,

To admire the beauty of Bergen time and again.

You wanna wake up,

To sip chai latte by Bryggen,

To eat your fav food ;),

To stroll on the mountains,

To take a dip in the cold sea,

To sun bathe and feel some color,

To be pampered with food n massage.

You wanna wake up,

For the house you want to be in,

To make it cozy as you wish within,

To spend your evenings in your own made bliss,

To get your cute dog and stroll around with,

To become happy go lucky as you really are.

You wanna wake up,

To make that cunning cutie pie face of yours,

For those late night candy shopping strolls,

Watch new girl and laugh heartily,

Watch modern family and feel the emotion.

You wanna wake up,

Trust me on that,

I know you do,

I see those eyes have little dreams,

They wanna live it to the fullest

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What does clients find most helpful about therapy?

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This is a reblog from Damon Ashworth Psychology! A brilliant post that I hope will be helpful and interesting.

Therapist-and-Patient

When clients first begin their therapy journey, they often ask to be taught specific skills that are going to help them achieve their specific goals.

They believe that if they can be taught these skills, they will be able to overcome their difficulties, or the problems that led to them entering therapy, and they will have no subsequent difficulties or need for additional therapy going forward.

Cognitive Behavioural Therapy (CBT) is a short-term treatment that clients can easily understand. It is based on the premise that all difficulties arise from unhelpful cognitions (beliefs, expectations, assumptions, rules and thoughts) and unhelpful behaviours. CBT aims to help clients see that their cognitions and behaviours are unhelpful, and tries to teach them skills that can help them to replace these unhelpful cognitions and behaviours with more helpful ones. If this is achieved, the assumption is that clients will change and therefore improve.

I do believe that if a client is able to have more helpful cognitions and behaviours then they will have significantly improved psychological health and overall well-being. I’m just not sure if I agree that the process that is required to get to this outcome is the same as what many CBT clinicians would believe. In fact, focus on distorted cognitions has actually been shown to have a negative correlation with overall outcomes in cognitive therapy for depression studies (Castonguay, Goldfield, Wiser, Raue, & Hayes, 1996).

What actually leads to improvements across treatment?

My previous article “What Leads to Optimal Outcomes in Therapy?” answers this question in detail and shows that the outcome is dependent upon (Hubble & Miller, 2004):

  • The life circumstances of the client, their personal resources and readiness to change (40% of overall outcome variance)
  • The therapeutic relationship (30% of overall outcome variance)
  • The expectations about the treatment and therapy (15% of overall outcome variance)
  • The specific model of treatment (15% of overall outcome variance)

For cognitive therapy for depression, both therapeutic alliance and the emotional involvement of the patient predicted the reductions in symptom severity across the treatment (Castonguay et al., 1996). Many therapists are now aware of these findings, but clients are generally not.

What do clients view to be the most valuable elements of therapy once they have improved?

By the end of treatment, especially if it is a successful outcome, clients tend to have a much different outlook on what they think are the most valuable aspects of therapy when compared to what they were looking for at the beginning of their treatment.

In Irvin Yalom’s excellent and informative book ‘The Theory and Practice of Group Psychotherapy’, he goes into detail about a study that he conducted with his colleagues that examined the most helpful therapeutic factors, as identified by 20 successful long-term group therapy clients. They gave each client 60 cards, which consisted of five items across each of the 12 categories of therapeutic factors, and asked them to sort them in terms of how helpful these items were across their treatment.

The 12 categories, from least helpful to most helpful were:

12. Identification: trying to be like others

11. Guidance: being given advice or suggestions about what to do

10. Family reenactment: developing a greater understanding of earlier family experiences

9. Altruism: seeing the benefits of helping others

8. Installation of hope: knowing that others with similar problems have improved

7. Universality: realising that others have similar experiences and problems

6. Existential factors: recognizing that pain, isolation, injustice and death are part of life

5. Interpersonal output: learning about how to relate to and get along with others

4. Self-understanding: learning more about thoughts, feelings, the self, and their origins

3. Cohesiveness: being understood, accepted and connected with a sense of belonging

2. Catharsis: expressing feelings and getting things out in the open

1. Interpersonal input: learning more about our impression and impact on others

The clients were unaware of the different categories, and simply rated each of the 60 individual items in relation to how helpful it had been to them.

What becomes apparent when looking at these categories is that giving advice or suggestions about what to do is often not found to be a very helpful element of the therapy process, even though this is exactly what most of the clients are initially looking for. What is far more important is the client developing a deeper knowledge of themselves, their internal world, and how they relate to and are perceived by others in interpersonal situations.

 

The top 10 items that the clients rated as most helpful were (Yalom & Leszcz, 2005):

10. Feeling more trustful of groups and of other people.

 

9. Seeing that others could reveal embarrassing things and take other risks and benefit from it helped me to do the same.

 

8. Learning how I come across to others.

 

7. Learning that I must take ultimate responsibility for the way I live my life no matter how much guidance and support I get from others.

 

6. Expressing negative and/or positive feelings toward another member.

 

5. The group’s teaching me about the type of impression I make on others.

 

4. Learning how to express my feelings.

 

3. Other members honestly telling me what they think of me.

 

2. Being able to say what is bothering me instead of holding it in.

 

1. Discovering and accepting previously unknown or unacceptable parts of myself.

Each of the 20 clients that made up these survey results had been in therapy for an average of 16 months, and were either about to finish their treatment or had recently done so. Obviously these items were in relation to group therapy, so the most important factors for change across treatment in individual therapy may be different. However, even with individual therapy, Yalom believes that in the end, it is the relationship that heals.

For more information, feel free to check out Chapter 4 in ‘The Theory and Practice of Group Psychotherapy’ by Irvin Yalom and Molyn Leszcz (2005), or any of the other studies out there that look into the outcomes or therapeutic factors involved in change across psychological treatment.

If you have ever wanted to discover and learn more about yourself, accept yourself more, express yourself better, take greater responsibility for your life, challenge yourself and develop more trust in others, a longer-term psychological therapy may be just what you need!

 

Dr Damon Ashworth

Clinical Psychologist

20 Signs of Unresolved Trauma

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20 Signs of Unresolved Trauma

Many people enter the therapy process with minimal awareness of their trauma history.  When the trauma survivors are dissociative, they have the ability to block out an awareness of their trauma.  They may know that their family had problems, or that their family was dysfunctional, etc, but they may believe they were never abused.

child abuse
child abuse (Photo credit: Southworth Sailor)

However, blocking out conscious awareness of trauma does not mean that the survivors have no effects of that trauma.  Using denial and dissociative skills does not mean that the abuse did not happen.  Denial means that the person simply is refusing to acknowledge or accept the fact that they were traumatized.  They are pretending they were not hurt, when they were actually hurt very badly.

Even if the memories of abuse are hidden from the survivor’s awareness, blocked trauma / unresolved trauma creates very noticeable and obvious symptoms that can be easily seen in their every day lives.

People will enter therapy aware of some of the following symptoms, but they may not realize these complications are suggestive of unresolved trauma issues:

.1.  Addictive behaviors – excessively turning to drugs, alcohol, sex, shopping, gambling as a way to push difficult emotions and upsetting trauma content further away.

2. An inability to tolerate conflicts with others – having a fear of conflict, running from conflict, avoiding conflict, maintaining skewed perceptions of conflict

3. An inability to tolerate intense feelings, preferring to avoid feeling by any number of ways

This powerful photo of emotional pain and inner turmoil was taken by ShaylinJanelle photography. http://shaylinjanelle.tumblr.com
This powerful photo of emotional pain and inner turmoil was taken by ShaylinJanelle photography.
http://shaylinjanelle.tumblr.com

4. An innate belief that they are bad, worthless, without value or importance

5. Black and white thinking, all or nothing thinking, even if this approach ends up harming themselves

6. Chronic and repeated suicidal thoughts and feelings

7. Disorganized attachment patterns – having a variety of short but intense relationships, refusing to have any relationships, dysfunctional relationships, frequent love/hate relationships

8. Dissociation, spacing out, losing time, missing time, feeling like you are two completely different people (or more than two)

9.  Eating disorders – anorexia, bulimia, obesity, etc

10. Excessive sense of self-blame – taking on inappropriate responsibility as if everything is their fault, making excessive apologies

11. Inappropriate attachments to mother figures or father figures, even with dysfunctional or unhealthy people

12.   Intense anxiety and repeated panic attacks

13. Intrusive thoughts, upsetting visual images, flashbacks, body memories / unexplained body pain, or distressing nightmares

14.   Ongoing, chronic depression

15.   Repeatedly acting from a victim role in current day relationships

16.   Repeatedly taking on the rescuer role, even when inappropriate to do so

17.   Self-harm, self-mutilation, self-injury, self-destruction

18. Suicidal actions and behaviors, failed attempts to suicide

19. Taking the perpetrator role / angry aggressor in relationships

20. Unexplained but intense fears of people, places, things

.

Stop ignoring child abuse
Stop ignoring child abuse (Photo credit: quinn.anya)

These same symptoms can be applied for survivors already working in therapy.  Attending regular therapy does not mean the clients have resolved their trauma issues or that they are even working in that general direction.  Many therapy clients will continue to deny, dissociate, and refuse to look at their trauma even if they are aware of their daily struggles.

If you are experiencing a number of the symptoms listed above, ask yourself if you are truly ready to address your trauma issues, or if you find it more comfortable to continue living with these struggles.

Is it harder to face how you were abused and who abused you?  Or is it harder to live a life full of depression, anxiety, thoughts of suicide, troubled relationships, extreme fears, physical pain, and addictions?

Running from your trauma history will not help you feel better.  In the short-run, you might not have to face the issues, but the cost in the long-run of unresolved trauma weighs more heavily than you might suspect. Unresolved Trauma

Your life can be better than it is.

Be brave – face your trauma issues!

__________

Copyright © 2008-2016 Kathy Broady MSW and Discussing Dissociation

His back 

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You could just see his back. His face was hidden from view, but you still tried to read him. But you failed. You did not know what he felt, what his history was or where he was going. And in that moment, he didn’t either.

  

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The wall between me and you

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He sat waiting for the doctor. The door goes up, and a man in a white coat and thick glasses peer out: “Henry Wall” he calls. His handshake is firm before he points to the chair where Henry can sit. Henry sits down nervously, looking around in the room, feeling his heart beat hard in his chest. The doctor sits in front of the screen, his eyes searching intently for something. 

“So, what can I do for you?” He barely looks over at Henry, but reach for a cup of coffee next to the computer. 

 “Well, I haven`t felt so good recently..”. 

 “Yes, I see that you have a history with several cases of the flu. It`s that time of year!”. 

 Henry looks down, its more of a mental flu, but how can he explain? The doctor writes something that must be “flu”.

 “So, how long have you been sick” 

“Well, it all started…” 

“Give me days!” The doctor interrupts, the lack of patience obvious even if he tries to suppress it.

Henry looks at him, swallowing the lump in his throath. 

“Well, I`m not exactly sure..”

The doctor looks irritated, waits for more information.

 “Maybe.. A week?”. Suddenly this has become a contest. Like if he has the right answer, he will get one of those small presents children get when they have been brave at the dentist’s office.

The doctor nods. He continues to ask about the symptoms, and also listens to his heart and looks down his throat. He takes his blood pressure, and says it`s slightly elevated.

Henry answers as fast as he can on every question. When the doctors asks about low energy levels or fever, he starts to say “Well, I`m not sure exactly..”, and the doctor takes this as a confirmation on the reality of the symptoms, even if he didn`t say that he had them.

Before he went in, he had thought about if he could manage another day feeling like he does. He had been thinking about how easy it would be to not live anymore. He had wondered If anybody would care if he died, and even if somebody would find him in his house. Should he drive a car into the water? Could he make it look like an accident? In huge letters it professed that one in four suffers from depression, and it could help to see a doctor to get an appointment where you could talk with somebody. Maybe even medication. But now he just felt stupid.

He left the office with a sick-leave in his hand. He didn`t need it. He would never go to work again.

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Best of me

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The sound of lifting heavy baggage

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baggReblogged from a psychologist who writes about Borderline Personality Disorder in a non-judgmental way. This is so important, and I thank the author for this nuanced view of the psychological challenges people with BDP face.
 
 
 
Friday, 20 September 2013

Borderline personality disorder: Abandon the label, find the Person

 
Steven Coles
 
In 1980 the mental health industry invented a new diagnostic label, one of many, for the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III). The American Psychiatric Association (APA) presented DSM III to the world as a scientific revolBorderline Personality Disorder Awarenessution in psychiatric understanding. If people suffering emotional distress had accepted the APA’s statements about the new manual, they would have rejoiced that such a wealthy and powerful organisation had put its energies into making sense of psychological suffering. The vast majority of people receiving one of these new labels had experienced great trauma – sexual abuse, extreme life events and repeated abuses of power. Quite a progressive move by the APA then: understanding the effects of power on people. Psychiatrists could show care, understanding, and perhaps even provide a sense of solidarity to people who were marginalised. Unfortunately, in 1980 the APA willed Borderline Personality Disorder into being. The APA’s idea of empathy and understanding led to vast numbers of survivors of abuse being labelled as disordered individuals.
 
In many ways the diagnosis of BPD is an easy target for criticism and satire. The diagnosis of BPD is defined by a series of social and moral judgements, applied to people who have been traumatised and dressed up as a medical problem. If we had a friend who revealed to us after years of secrecy and shame that they had been repeatedly sexually abused as a child, our first response is unlikely to be “your personality must be really disordered – no wonder I’ve felt like rejecting you”. Instead we would show care, be amazed at their survival and probably feel anger at the perpetrators of abuse – basic common sense and decency. Sadly when it comes to psychiatric diagnosis good sense does not prevail. The survival of psychiatric diagnoses is in many ways an astonishing feat of magic; its supporters have woven a spell that repels good sense, compassion, logic and evidence.

There are multiple problems with a diagnosis such as BPD. Here I want to highlight just one: it locates the problem within t08d0ab8d1b1a5435a32a3e5134150cd2he individual. ‘BPD’ hides disordered environments, misuse of power and perpetrators of abuse. The following quote from Suzi, someone who received the label, makes the point better than I can:

 
‘I cannot understand how the vast majority of perpetrators of sexual violence walk free in society; whilst people who struggle to survive its after effects are told they have disordered personalities’ (Shaw & Proctor, 2004, p.12).
 
Think about the implications of that for a second. It’s accusing us of failing to recognise the abuse of power in society, of colluding in suffering. People are traumatised and hurt in many ways. For some there are obvious damaging events involved, for other people the circumstances are more complex and subtle. The flow of power is usually crucial in each. Unfortunately, the way in which we offer mental health services can lead us to ignore life circumstances and power. An understandable reaction to a horrifying life experience is converted into an illness, which a person is held responsible and rejected for having.
 
If that doesn’t paint a pretty picture of mental health services what are the alternatives? Perhaps a little good sense might help here. We need to support people to make sense of their distress in relation to their life experiences and circumstances – survival strategies in the face of disordered environments. People need to be offered practical support and guidance, as well as compassion and care. It seems unnecessary to grab at the concepts of illness, treatment and disorder, when we can talk with people using ordinary language. Our conversations need to honour people’s survival and strengths against the odds, as well as their difficulties and needs. When supporting people who have experienced high levels of abuse and are struggling in life, workers need space, supervision and time to reflect on and cope with their own feelings, and to consider the most useful ways to help. People should not have to accept a label and the attached baggage to receive support.
 

There are multiple problems with a diagnosis such as BPD. Here I want to highlight just one: it locates the problem within the individual. ‘BPD’ hides disordered environments, misuse of power and perpetrators of abuse. The following quote from Suzi, someone who received the label, makes the point better than I can:

 
‘I cannot understand how the vast majority of perpetrators of sexual violence walk free in society; whilst people who struggle to survive its after effects are told they have disordered personalities’ (Shaw & Proctor, 2004, p.12).
 
Think about the implications of that for a second. It’s accusing us of failing to recognise the abuse of power in society, of colluding in suffering. People are traumatised and hurt in many ways. For some there are obvious damaging events involved, for other people the circumstances are more complex and subtle. The flow of power is usually crucial in each. Unfortunately, the way in which we offer mental health services can lead us to ignore life circumstances and power. An understandable reaction to a horrifying life experience is converted into an illness, which a person is held responsible and rejected for having.
 
If that doesn’t paint a pretty picture of mental health services what are the alternatives? Perhaps a little good sense might help here. We need to support people to make sense of their distress in relation to their life experiences and circumstances – survival strategies in the face of disordered environments. People need to be offered practical support and guidance, as well as compassion and care. It seems unnecessary to grab at the concepts of illness, treatment and disorder, when we can talk with people using ordinary language. Our conversations need to honour people’s survival and strengths against the odds, as well as their difficulties and needs. When supporting people who have experienced high levels of abuse and are struggling in life, workers need space, supervision and time to reflect on and cope with their own feelings, and to consider the most useful ways to help. People should not have to accept a label and the attached baggage to receive support.
 
Abuse and misuse of power are social and political issues. We seem to resist asking the questions that flow from this though. Such as why is sexual violence so prevalent in society? How do we prevent people doing horrendous things to each other in the first place? What economic policies decrease oppression and misuse of power in society? Going back to the 20th century, at one point the APA decided people who identified 616557b8644a5f124a2ad7e3964173fathemselves as gay were suffering from an illness. Some of those who were labelled accepted and internalised the label. However due to lobbying and activism this idea was eventually abandoned. It is now time to speak up and say that people in emotional pain, who have suffered and attempted to survive, should no longer be labelled disordered. It is time to abandon the concept of borderline personality disorder and instead find and honour the person.
 
Shaw, C. & Proctor, G. (2004). Suzi’s Story. Asylum (Special Edition: Women at the Margins), 14 (3), 11 – 13. Also reproduced here.
 
Steven Coles is a Clinical Psychologist  and co-editor of Madness Contested: Power and Practice (PCCS Books, 2013). Follow him on Twitter @Steven_Coles_.

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