What kind of career-related issues do we encounter?
Work can be a place and process of true personal realisation. Our work is an expression of our vitality and values and helps us contribute to the welfare of our families and to society.
It is precisely because work is so important in our lives that the problems that relate to it can be so debilitating. And in the same way that rewarding work helps create the conditions for a better private life, problems at work always “spill over” into the time we reserve for our leisure, our friends and families.
The most common example of such an overspill is the degradation of work-life balance because of overwork.
The most frequent problems that can appear at work are:
loss of motivation
loss of self-confidence
significant lowering of performance
blocked progression or career
work relationship problems such as bullying or harassment
How can counselling and therapy help with work-related issues?
These problems reveal themselves because one notices (or is told of) a change in one’s behaviour, or in other people’s. Sometimes it is clear that they are the consequence of events in the workplace, which are beyond one’s control, such as disciplinary procedures, redundancy, company-wide restructuring or performance problems. Sometimes the link is less obvious: a problem appears at work but it is harder to see what is causing it.
Wherever the causes of the problem, its resolution requires skills, knowledge and support that are not available at work.
My business background and qualifications, as well as my experience of one-to-one coaching for professionals including senior business leaders have given me in-depth knowledge of the problems affecting professionals on the workplace and the approaches that are most successful to support those who are affected by them.
I suggest an initial contact for you to:
describe your current circumstances and concerns
receive immediate, emotional and practical support
find out about how I can provide further help
After this initial contact, you may want to opt for further counselling consultations. These consultations are a safe, containing and supportive environment in which to develop deeper insight into patterns of behaviour, and get support to try out concrete changes.
In my experience, focused work such as this can be very powerful. I have also found that, sometimes, my clients choose to engage in longer-term work when they feel that they need more time and support to get to the bottom of the issues that they are facing.
Depression is the most prevalent of mental health problems. Studies have shown that it occurs in 1 in 10 adults or 10 per cent of the population in Britain at any one time, (Healy, 1998, Hale, 1997). It is quite common to experience a depressive episode as a reaction to an event. It also happens that depression sets in “out of the blue”, and does not seem to go away by itself.
This experience can be deeply painful; poet John Keats wrote to a close friend: “I am in a temper that if I were under water, I would scarcely kick to come to the top”.
This experience can be deeply painful; poet John Keats wrote to a close friend: “I am in a temper that if I were under water, I would scarcely kick to come to the top”.
It is part of life’s requirements that we should be able to tolerate periods of low mood, and it is to be expected that sometimes we find ourselves challenging the value of things and of life itself. Psychotherapist D.W. Winnicott (1958) wrote of John Keats that:
“[he] was someone who took the risk of feeling things deeply and of taking responsibility. […] If we look at depression this way, we can see that it is the really valuable people in the world who get depressed.”
If however we have an entrenched feeling of futility and find ourselves disempowered and persistently disengaged from life, this is probably something worth attending to.
How can therapy and counselling help with depression?
In my experience it is possible to understand and successfully to address depression through the process of psychotherapy and counseling. The aim of this process is to allow insight to emerge and to use the therapeutic space as a “springboard” to reconnect with oneself, with others and with the world.
Anxiety is one way to respond to an external event that we see as a threat. In a state of anxiety, some of our physical and mental functions are heightened so that we are able effectively to confront what is threatening us, or to escape it. This is referred to as the “fight-or-flight response”. As such, it has been essential to our survival as a species, and continues to serve us in situations of severe danger.
However we find that we often experience it in situations that don’t really call for it.
What is anxiety for?
In itself, anxiety does not teach us anything about its causes. It does not tell us anything about the best way to resolve a problem. It does not tell us how to be less anxious. It just prepares us for a very simple response – fight or flight. We may even find that, in a state of anxiety, we are less able to act, as a situation really requires – in these cases, anxiety clearly “gets in the way”!
So, paradoxically, anxiety can end up decreasing our quality of life, sometimes to the extent that it becomes intolerable. It is estimated that about one in six adults experience levels of anxiety that they feel are excessive and debilitating, with 1.5 to 3.6% of these being diagnosed with General Anxiety Disorder (Carter RM, Wittchen HU, Pfister H, et al, 2001).
How does counselling and therapy for anxiety help?
People who have come to see me for psychotherapy and counselling at my London practices have wanted help with finding out why they were excessively anxious, and what they could do to change this. It is therefore my aim to help my clients:
better contain and express their anxiety
understand the cause(s) of their anxiety
develop ways of responding more appropriately to their environment
make decisions concerning the causes of their anxiety
It is through our understanding of the root causes of our anxiety that we can see clearly how we could change certain aspects of our lives. It is my aim to support my clients in developing this clarity and making essential life changes.
Most online and offline publications will define social anxiety as the excessive fear of social situations. People who have come to see me for help with this problem have also often described that they may feel discomfort in any social interaction, even if this is with “just the one person”. Because of this, I prefer to define social anxiety as the discomfort that relates to the experience of any relationship.
«In every contact, we communicate a bit of ourselves to the other, and the other is there to receive it, for better or for worse. In that respect, every social situation is significant, because it says something about us.»
Why does it happen?
We form our person and our character in the context relationships – to the family we were born in, to the community around us, to school, to our chosen communities of friends, spouses and children, to our communities at work. These relationships are not just a backdrop to our lives: by interacting within them, we evolve through them, and them through us.
It is perfectly healthy to feel a measure of trepidation in all forms of contact with other people, whether it is a brief exchange with a waiter, a discussion with a headmaster, or a presentation in front of the board of a company. After all, every personal contact, no matter how brief or apparently shallow, is an experience that engages our person, consciously and unconsciously. In every contact, we communicate a bit of ourselves to the other, and the other is there to receive our communication, for better or for worse. In that regard, every social situation is significant because it says something about us.
«Psychotherapy, to be effective, must include two aspects at least: reflection on oneself and action on one’s environment.»
When does it become a problem?
However, for many, this creates a level of discomfort that can feel difficult to bear, which may lead some to assuming that all social contact will be painful, and therefore to avoiding certain social situations, and sometimes, most, if not all, social situations. This can be extremely distressing and debilitating.
Addressing the issue
It is my experience that psychotherapy, to be effective, must include two aspects at least: reflection on oneself and action on one’s environment. This is especially true when the concern that needs addressing is social anxiety. Action alone, which can be, for example, challenging one’s assumptions about other people’s thoughts about us and changing the way we interact with them, is not enough to create a deep-seated sense of safety in a social setting. Similarly, reflection alone will not help the person to “land” the insights acquired and create new and more helpful behaviours.
Therefore, I encourage my patients to:
take a historical perspective on their experience of social interactions
examine the feelings, thoughts and sensations that they associate with them
get a deeper sense of who they are as a person, and what sort of social existence they are really meant to live
observe in detail what they go through as they apply their insights and progressively approach life with others in different ways
The quote by St Francis of Assisi sums quite well my approach to helping people address their social anxiety, as it reflects its progressive nature and the surprises that can arise out of the process:
«Start by doing what’s necessary. Then do what’s possible; and suddenly you are doing the impossible»
Abstract: People considering psychotherapy and researching the topic and looking online for practitioners are not readily presented with material that will give them a concrete idea of what goes in a session. This is partly a result of the fact that each course of therapy is unique to the individual, and it may even help the therapeutic process. It is however possible and beneficial to publish facts about psychotherapy, that inform while leave enough to the imagination.
The first article in this series is about the initial consultation. I make the point that even though this key session looks more structured and concrete than the sessions that may follow, it is still unique to each individual. Some data is necessary for the therapist to assess a patient's presenting problems and suitability for psychotherapy, but this data can be transmitted and acquired in various - and sometimes surprisingly roundabout ways.
People who come to see me for their first consultation of psychotherapy often say right at the beginning: “I’ve never done this before, what happens now?”. This is not very surprising. We hear more about people’s experiences with their doctors, lawyers or even their plumbers than we hear about their experiences with their therapists. I have even become quite convinced that psychotherapists willingly cultivate an air of mystery around their practice.
«Working with a person’s expectations of a relationship is a key aspect of psychotherapy, and it starts “working” before the protagonists (patient and therapist) have even met.»
If you have indeed been looking for a therapist online and have visited their websites and blogs, you may have noticed that little appears to be said about what exactly goes on in therapy. Therapists write, as do I, about their principles, ethics and theoretical frameworks. They write about how, in general, psychotherapy can help people with certain common ailments such as anxiety and depression, but more rarely about what it is that really forms the interaction of patient and therapist in the fifty minutes of a session.
While researching this, you may have come across Irvin Yalom’s lively and thoughtful accounts of existential psychotherapy practice, or perhaps watched three of the old masters, Fritz Perls, Carl Rogers and Albert Ellis, respectively demonstrating in the film “Gloria”, gestalt psychotherapy, person-centred psychotherapy and rational emotive behaviour psychotherapy. A lot has been – and is being – written, and professional journals will abound with what is dryly called “clinical material”, but, unless this material makes its way to paperback or interactive media, there is little chance that someone willing to undertake psychotherapy will be readily presented with it by professionals.
Undeniably, there are three upsides to this. First, when therapists stay vague about what happens in a consultation, they give a greater opportunity to the person considering psychotherapy to imagine what it could be like, and then to confront what they have imagined, with what is happening in reality. Working with a person’s expectations of a relationship is a key aspect of psychotherapy, and it starts “working” before the protagonists (patient and therapist) have even met.
«Is it possible to write something that informs, and perhaps inspires, while respecting the frame of mind of the person looking for help, and acknowledging the unique character of each session?»
Second, it is genuinely difficult, and some would argue, unhelpful, to be precise about the course of a session. Sessions are conversations between two people, where one has the function of attending to the other’s needs. And whatever patterns may emerge in a conversation between two people rarely applies neatly as a template for another conversation.
Third, allowing some degree of mystery about psychotherapy is consistent with, and respectful of, the fact that the forces that the individual feel are at play in their psyche may feel like a personal mystery. Psychotherapy aims to help a person develop an interest in this mystery, so that its workings becomes known, so that they can grow beyond the experience of helplessness that often characterises their life before therapy.
The scarcity of material relating to what happens during a session seems to be both unavoidable and beneficial to the unfolding of a person’s psychotherapy. So, is it possible to write something that informs, and perhaps inspires, while respecting the frame of mind of the person looking for help, and acknowledging the unique character of each session?
This series of short articles will attempt to do this. I first aim to address the need presented by many patients in their first session, by giving some bearings about what happens during the initial consultation.
This initial consultation is the easiest to describe, as it often appears to follow more of a formula, as there are things that I will be interested with every new person. It is a first contact between patient and psychotherapist, and the aim is for both the therapist to find out if they can help the patient, and for the patient to form an opinion, or at least get a sense if the therapist can help them. At the end of this session, I am in a position to make a recommendation to the person in respect of psychotherapy, and to establish together what the frequency of the sessions should be, and perhaps the term of the treatment, if this is important for the person at the time.
In this consultation, it is important for me to get an understanding of what is troubling the person who has come to me for help, and to know more about their current circumstances and the history of these troubles and how they fit (or not) in the person’s life story.
«I don’t need to know everything about a person in the first fifty minutes – In fact, it has happened quite a few times that a patient tells me something quite important about themselves much later in their therapy – sometimes, several years after the initial consultation.»
I will be interested in hearing the person’s perception of their life so far, and to see if anything stands out for them in some of the key relationships that contribute to forming one’s personhood, such as parents, siblings, significant relationships at school, college, the workplace, and any other significant setting.
In my experience, this can take many different shapes. Some people choose to tell me stories about themselves and do it with ease, (and sometimes gusto), some like talking about themselves in a less structured way, some have very accurate memories and others quite vague ones. Some people don’t like talking about themselves at all and find it difficult to put into words what it is that they struggle with and what makes them seek help. This is all fine.
Indeed, while it is important that I know some basic facts about a person’s personal history and current circumstances, so that I can establish if psychotherapy is a suitable form of treatment or if the person should be referred to another professional, I don’t need to know everything about a person in the first fifty minutes. In fact, it has happened quite a few times that a patient tells me something quite important about themselves much later in their therapy – sometimes, several years after the initial consultation.
I recall a first contact with a young man who seemed to be struggling to answer my questions. Generally, I ask open questions, so that the person has the space and time to give whatever shape they wish to their discourse. It also informs me greatly about their state of being to see how they use the space that I provide for them. I have found that asking too many precise questions right away tends to give impression that psychotherapy is a data collection exercise, where there are right and wrong answers.
This young man would answer my questions in a very vague, perfunctory manner. His childhood was fine, his parents supportive, his partner was nice, he sort of liked his job… it was just that he needed to turn his life around by making a bold decision about where to live and work, and he found himself unable to make this decision, without knowing why. This was all said quite briskly in the first few minutes of the session, and once I was done asking him questions, he looked at me expectantly.
I told him that, on account of how fast he’d run through the story of his life, I had the impression that he didn’t seem to find it worth saying too much about it. He didn’t reply directly, and told me that he just wanted to stop feeling rudderless and indecisive all of the time. I asked him more questions about his experience of indecision. Again, his answers were quite perfunctory. I smiled and made the observation that it seemed that I was more interested in him than he was. He seemed quite puzzled by this, and reiterated that, really, he’d come to see me to sort this particular problem out, and didn’t feel that talking about himself would be helpful at all. As for his childhood, he didn’t remember much before the age of 10 anyway. But he did have some facts about it, which he shared with me.
«This young man’s apparent inability to talk to me about himself during the initial consultation was a live, “here-and-now” illustration of how he had been shaped by his earlier life.»
He explained that he was the youngest of three siblings, who had been born quite close together. His parents argued a lot throughout his childhood, and began separating when he was eleven. They divorced when he was eighteen after a protracted custody battle that involved both children needing to “take sides”. He also told me that, after offering his mother constant emotional support throughout his late childhood and early teens, he had chosen to stop doing so for his own sake.
It became apparent to him that his inability to make big decisions in the present was consistent with his earlier experience of his parents involving him in their own. On the one hand, he was to act like an adult by supporting his mother and then choosing which parent he would live with. On the other hand, he felt he was being treated as a child because those decisions were being imposed upon him. If his parents had taken an interest in him, they would have understood that all that he wanted was for them to make up ask him how he was.
So, this young man’s apparent inability to talk to me about himself during the initial consultation was a live, “here-and-now” illustration of how he had been shaped by his earlier life. It showed clearly that it was new for him that anyone should take an interest in his person. His reluctance to take the lead in the session also illustrated that, for him, there wasn’t a positive experience of taking the lead in his life, and he wondered whether he would one day be able to do so.
On the day of his last session, five months later, as I was waiting for him to ring the doorbell, I received a call from him. He was at the airport, about to board a plane for New Zealand. He had wanted to have his last session over the phone, saying with humour that it was “so that we are both certain that I’m going to get on that plane!” He was able to muster the resolve that had eluded him for so long, and moved there to live and work.
As a conclusion to this short article about the initial consultation, I would like to stress that there is no set, perfect way to go about it, neither for the patient, nor for the therapist. My aim is to offer my patient a space, where they can tell me about themselves and start to see themselves with a greater degree of clarity. This initial consultation shouldn’t be something for patient or therapist to “pass with flying colours”. It is about being curious about the other, in a way that leaves them the space to say what matters to them, or if words are not available to them at the time, to show me with their actions what is holding them back in their life.
Article review – Peter Fonagy on psychotherapy in the NHS
I am reading Martin Pollecoff”s interview of Peter Fonagy in the Psychotherapist, the magazine of the United Kingdom Council for Psychotherapy, of which I am a member, and find myself resonating with Pollecoff’s concern that “in IAPT (increasing access to psychological Therapies) you have people who have been through a year’s training with no therapy of their own. I am concern about the political shift between the therapist and the client. It’s a model in which the expert, who is OK, is treating the poor client.There is something wrong there for me”.In my view, Peter Fonagy is absolutely right to point out that the medical model has failed in the provision of adequate mental health services to a broad public, and that the IAPT initiative is a way to Address this failure. But I don’t feel that in this interview he answers the interviewers’s questions with total clarity. Fonagy says that the psychoanalytical model is the best way to understand how the mind works and how a person can heal. He also describes three essential elements in psychotherapy (the working alliance, mentalisation and compassion). In my experience of practising psychotherapy in London, all three elements are totally contingent upon the relationship between the patient and therapist, and I feel it can only be beneficial to the patient if the practitioner has experienced these elements in a relationship with a confirmed practitioner for a significant amount of time.
Fonagy says “you have to be robust”, and in my view this comes as a result of the practitioner having tested out the solidity and healing potential of a working alliance, not as a result of a short one year training. Generally, it is my experience that the patients who come to see me at my London practices will only ever go as far as I have been myself. If there is something that I cannot negotiate within myself, then it follows that I cannot help my patient negotiate this corner for themselves. Fonagy has gone through intensive analysis himself, and I am surprised to see that he remains quite vague when discussing the essential aspect of practitioner therapy with Pollecoff.
Integrative psychotherapy and coaching – how do the two mix?
As published in the Autumn edition of the Newsletter for the Association of Integrative Coach-Therapist Professionals (AICTP) Coaching interventions in psychotherapy: challenges to the transferential relationship
As I was looking for inspiration to write this short piece about how we can draw upon our coaching skills as psychotherapists, I noticed a thought-provoking comment on the AICTP discussion thread “How do you manage movement between disciplines when using an integrative coach-therapy approach?” A participant described how he had decided to challenge his client, who was “reluctant to make external decisions and changes” so that she would get out of the comfort zone of her inner exploration, and suggested moving from counselling to coaching.
It is quite a common assumption (which I have seen expressed even by the most senior practitioners of counselling and psychotherapy in London) that coaching is future-oriented and psychotherapy about the past, and that coaching is about the outer world, and psychotherapy about one’s inner world. If we choose to accept the assumptions as the truth, then it follows quite naturally that there is a line in psychotherapy that the therapist and his or her client need to cross together when the focus of the work shifts away from the inner life and the processing of unmet childhood needs, and towards achieving life goals within a partnership of equals. The participant’s comment on the AICTP thread describes a situation when it is the therapist who takes the initiative of introducing the coaching perspective in order to shift the focus of the work.
I have also frequently observed in my practice that it can be the client who requests that the therapist intervene as a coach. This can be the case when clients feel particularly stuck in their therapy, or are particularly anxious for their lives to change in a way that they can control. I noticed that people who suffer from addictions and who experience repeated relapses will from time to time ask for a directive, solution-focused approach.
What is then supposed to change when we make coaching interventions in psychotherapy or move the relationship on and away from therapy, towards coaching? If coaching is about the future-external and therapy the past-internal, are the corresponding ways of working respectively dictated by concrete goals, and by the inner process unfolding in the person? And if so, what is the effectiveness and appropriateness of doing so, and what are the pitfalls?
What are the appropriateness and possible pitfalls of switching between therapy and coaching?
One of my patients, a woman in her late thirties who has been in twice-weekly therapy with me for the past three years, has been constantly frustrated by her inability to build lasting relationships. She was also unsure whether she should seek a same-sex or heterosexual relationship, and her inability to decide has caused her great frustration. During the early stages of her therapy she was able to discover, accept and act on a sexual appetite, which she had perceived as non-existent since her early teens. As a result of this, she had several same-sex encounters, sometimes resulting into brief and casual sexual relationships. She also formed an ambivalent attachment to a man of her age, who already had children from a previous marriage.
But she continued to berate her inability to “get started in earnest” and remained deeply dissatisfied at the “sterile” nature of her encounters and longs for a steady partner, with whom he would be able to settle down and have a family.
A few months ago I took the initiative of introducing goal-oriented work in one of her sessions with me. Rather than reflecting back her helplessness, her frustration and her anxiety, I decided to help her articulate and clarify her hitherto vague thinking about what needed to be done concretely to start looking for suitable partners and making herself available to be found.
As I expected, the first part of the conversation resembled a game of “why-don’t-you-yes-but” game (Berne, 1971), but instead of reaching the conclusion of mutual defeat described by Berne (the therapist runs out of suggestions and the client demonstrates that there is nothing that she can do to change), she trailed off and eventually said to me: “it feels quite weird, you coaching me like this. I know why you’re doing it but I don’t think my problem is about that”. I ventured “it feels weird to be coached when you don’t actually know what you want”. She agreed completely with my statement. This allowed us to explore how ambivalent she was towards her sexuality, arriving at the conclusion that in her mind, having a sexually satisfying relationship and a relationship in which she could thrive and find meaning in seemed mutually exclusive.
This proved to be a watershed moment, as she fully realised that her ambivalent position towards creating relationships exactly mirrored her mother’s own ambivalence towards her family, manifested by a series of affairs that were never spoken of in the family. My client had known that this mirroring existed in the way she conducted herself in her life. But until it only ‘landed’ when it was made real and tangible as a manifestation in her therapy. She was able to relate emotionally and intellectually to an past-internal item on the basis of a failure to progress on a future-external one.
What is at the heart of Coaching?
My decision to change my stance and become more inquisitive, active and even risking suggestions by asking such questions as “…and have you thought of doing x?” momentarily changed the dynamic of the relationship. As I fostered her taking ownership of the problem, she became aware that her problem was not so much in her inability to take appropriate action, but to know for sure what it was that she needed to do in the first place.
In my view, the heart of coaching lies more in the process where two parties reach a clear contract about the boundaries, means, general purpose and outcomes of the coaching session, than in the set of actions that the coach agrees to hold the coachee accountable for. With the above example I hope to have shown that by making interventions that challenge the client by bringing up her outer world and goal-directed activity in a space that is in principle dedicated to the exploration of her inner world, we can draw from essential aspects of the contracting process in coaching in order to create awareness.
However, before seriously considering experimenting with a coaching intervention I had to identify and reflect on all the aspects on my own countertransference of helplessness and frustration, lest my intervention be an acting out.
This is what has I am in the process of exploring with another patient, a young man who has come to me because he currently lacks the vision and confidence to plan and execute a change of careers. He was referred to me by his GP, after suffering a series of panic attacks.
This young man is expressly asking me to coach him, but wants a coach who has the “sensitivity of a psychotherapist”. He explained in the initial consultation that his parents would react very strongly if they knew that he is seeing a therapist, and that they have very strong prejudices against psychotherapy. This is why he chose to speak to a coach. He told me that he knew that it was likely he needed to work on himself, but that his priority would be to create concrete actions. It seems that he is asking me to focus on concrete actions and remain “sensitive” to the way that he feels in himself. All the material that he brought to the session was linked to his family and his relationship with his partner.
At the end of the consultation I recommended that he consider psychotherapy above coaching, and bring to the therapeutic space any concrete problem that he wished to explore, and that he could set a short-term review deadline to make an informed decision about what he felt would suit him best. I told him that by agreeing to coach him I would enter into a contract that perpetuated his childhood experience, where his inner life would be in full view but not the focus of my attention. I also felt – but did not tell him – that he was setting up a transferential situation where I would get and experience close to his childhood’s, which was to feel a frustration at not being able to engage with him as he genuinely needed.
The healing process in therapy and coaching
With both clinical examples I hope to have shown that it is possible, to some effect, to change one’s stance towards a client to either help raise awareness. However, in my experience, this change of stance should be clearly “called” (by the client or the therapist) and it should function within, and not instead of, the transferential relationship. With this in mind, it would seem that the assumption that seemed to underpin the comment on the thread is incorrect because it posits that therapy and coaching work only in succession, not in unison.
The essentially ambivalent position of the therapist (as a separate person and a recipient of various projections and transferences) is, I feel, brought in sharper contrast when the therapist is also a coach. I would like to suggest that in person of the coach-therapist, the client is seeking the clear line that may exist between the past and the present, the outer and the inner. If we do not give due consideration to the transferential factors that arise out of this situation, we run the risk of facilitating an inner split when we act as if that line were really there. As integrative coach-therapists, we need to ensure that we facilitate integration in the person, not splitting. It is my view that the client always knows what is good for them, but that the vagueness of the cues they give us (their requests for different modes of intervention, and our countertransferential feelings) is commensurate to the vagueness of this self knowledge. It us up to us to tolerate this vagueness and help the client connect meaningfully with their own healing process.
In this article, David Zigmond, who is a GP, Psychiatrist and psychotherapist, gives us four fundamental questions to ponder when we see patients for psychotherapy. Zigmond is concerned that the medical model, prevalent in the NHS, does not equip us with the mindset that is necessary for an authentic encounter.
He proposes four fundamental questions for therapists, which “escape subsumption to prepackaged, designatory psychologies”, and are, in his experience, “primal to any likely successful engagement”.
1. What is it like to be this person, to have lived their life?
2. What is the meaning and experience, for them, of this kind of distress?
3. What is the meaning and experience, for them, of me, now?
4. What do I need to understand of their needs that theyvpossibly cannot yet express, or even think about?
Zigmond describes these questions as “naive”, in that they assume very little. Indeed, by asking ourselves these questions as practitioners we are necessarily led to discard accepted theories and conventional perceptions so that we can form an understanding of the person’s presenting needs based on our experience of them, of ourselves as we are in relationship with them, with empathy, curiosity and openness.
The term “naive” is quite important here and I find myself drawn to it. As a psychotherapist and counsellor in London I have, like my colleagues, undergone years of therapy, supervison and training, and I know still that my learning has only begun. Psychotherapist D.W. Winnicott prefaced his book “playing and reality” with the following words: “to my patients, who have paid to teach me”.
It is tempting for many to adopt a top-down approach to psychotherapy for depression, relationship problems or problems such as anxiety. By this, I mean that the practitioner concerns themselves with acquiring an understanding of the symptoms that each condition presents and developing an approach whereby they can track progress in treatment according to criteria of functioning that may have nothing to do with the person, but that are instead taken from a group-level view.
While the latter approach is necessary in driving some areas of research and monitoring outcomes in institutional settings, the former needs adopting in every encounter. By doing this, the practitioner has the better chance of not only fulfilling their role in an institution, but also to meet the person who is suffering as an equal and give them a chance to be understood more fully and more immediately.
This recent article by the Guardian, “Why do identical twins end up leading such different lives?” adds yet more weight to the argument that even though our genes may predispose us to certain traits, and therefore give us strengths and vulnerabilities, our epigenetic makeup, i.e., the pattern by which certain genes are expressed or not through of our interactions with the world, will make a huge contribution to the building of our personality.
Very often, psychotherapists in London and elsewhere will mention under the same breath that they help people with “anxiety and depression”, almost as if it were one and the same thing. This is probably because, according to the ONS, there are almost three times more people who suffer from both depression and anxiety that people who suffer from depression alone. Indeed, depression with anxiety is experienced by 9.2% of people in Britain, while depression without anxiety by 2.8%.
What is the relationship between anxiety and depression?
It is hard to say if unmanageable anxiety triggers depression, or if a state of depression generates anxiety. It depends highly on individual cases and even then It often feels like a circular situation and in my experience it is not helpful to try and find out what came first. The essential is to help the client address these feelings as a whole in their therapy, and to consider anxiety and depression as intricately linked as opposed to separate phenomena requiring different approaches.
An apparent paradox
It sometimes seems paradoxical that depression, whose symptoms are said to be mostly negative (i.e., describing the absence of something), can co-exist with anxiety, whose symptoms are mostly positive (i.e., describing the presence of something). For example, in depression, sufferers experience lowered mood, loss of motivation, loss of meaning and loss of concentration, while in anxiety it is the positive symptoms that seem to prevail, for example, increased heart rate, presence of recurrent unpleasant thoughts and restlessness.
How to approach individual treatment of mixed anxiety and depression
As an experienced counsellor having helped many people deal with issues of mixed anxiety and depression in London, I have noticed that people suffering from this problem fall in three very broad categories:
those who feel that they will benefit more from guidance and education, and expect from the therapist clear instructions and coping strategies,
those who prefer a non-directive approach and want to explore their experience in an open, unstructured manner,
and those who feel that it is most helpful for them to experience both in their therapy.
As an integrative psychotherapist, I believe that it is best to offer my clients what is going to be helpful to them and not just what a specific approach says I should do. This is why I mostly offer my clients a space to be with themselves and also a forum where they can clarify, understand and plan concrete life changes.