Dr Carolyn John BSc; PhD; MSc; C.Psychol; AFBPsS
CONSULTANT CLINICAL PYCHOLOGIST
Worry is a natural extension of thoughts and doubts about what might happen in the future, when we feel overwhelmed by the challenges we face. People may feel tense, nervous or panicky and can have intense physical feelings such as palpitations, ‘butterflies’, muscle tension and headaches. There is a feeling of restlessness and difficulty concentrating and the sense that our thoughts are out of control. Generalised Anxiety Disorder (GAD) is a heightened sense of threat that can relate to a large number of situations and is characterised by the intolerance of uncertainty, and Panic Disorder describes acute attacks of fear that may seem to ‘come out of the blue’. Specific Phobias are the fear of an object or situation that does not normally trouble others and which is debilitating. As with panic disorder, phobias are disabling and may discourage us from facing certain situations, and so interfere with our daily lives. There are tried and tested therapeutic methods to address all of these difficulties, involving compassion-focused and cognitive-behavioural approaches.
Depression refers to feeling low in mood, helpless to change and troubled by negative thoughts. This may be reactive to specific recent stressors or related to longer term difficulties that have affected our self-esteem. It can affect our judgement of ourselves and others, cause irritability, tiredness, appetite changes, bodily discomfort, reduced ability to concentrate and make decisions, be associated with thoughts of or actual self-harm and make us feel reluctant to go out or spend time with others. Therapy involves working out together the causes and the things that are maintaining these difficulties, processing the emotional pain and with this improved insight, employing tried and tested methods to regain control and develop a robust set of coping skills to promote lifelong recovery.
Trauma responses - PTSD and Adjustment Disorder
Trauma refers to an overwhelming threatening experience, be it a single event such as an assault, disaster or accident, or of a more prolonged nature such as being neglected, abused or bullied on a repeated basis. Both of these types of trauma lead us to thoughts that we are unsafe and influence the brain’s threat system which primes us to be on ‘red alert’ for readiness to face the next challenge. Post-Traumatic Stress Disorder (PTSD) is the name given to the way this affects our thoughts and feelings (flashbacks, nightmares, anxiety) our need for safety (avoidance and feeling distant) and physical arousal system (irritability, increased startle response, sleep disturbance). Complex PTSD arises from chronic trauma and deeply affects our ability to regulate our emotions and to trust and relate easily to others.
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Therapy involves helping the person to understand that these symptoms are normal responses to extreme trauma and to enable them to process the enormity of the experience they have suffered. It may involve the use of Emotional Memory Desensitisation and Reprocessing (EMDR) which is a highly effective way of helping to dislodge the intensity of the emotional feelings from the memory of the event.
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Adjustment disorder refers to a period of adaptation to a significant life change or a stressful life event causing the person to feel vulnerable and unable to cope or plan ahead. Examples are an unwelcome change in role at work or a relationship breakdown. The person may feel depressed or experience a disturbance of other emotions and the therapy will assist the person to obtain relief and adaptation.
Bereavement, separation and loss
Grief is a normal response to bereavement of a loved one or the loss of something one holds dear such as a specific role that gives life meaning. It is extremely painful partly because as humans we form strong attachments and our life is given meaning through our roles and relationships. When this changes abruptly we feel shocked, lost and rudderless and we need to go through a painful period which may involve distress and anger, moving towards acceptance and adaptation to our changed life. Sometimes this grieving process becomes stuck due to the complexities of our attachment relationships and therapy can enable the person to understand these processes, to begin to grieve naturally and to reach a more bearable position.
Chronic Pain management
Chronic pain, whether caused by injury, disease or the result of emotional stress, can make it difficult to get on with daily activities and can prevent a person from doing the things they want to do. This can cause cognitive and memory impairment and feelings of low mood, frustration, anger and anxiety. Without strategies to manage the pain this can lead to a feeling of helplessness. Therapy focuses on identifying the pattern of pain symptoms and learning psychological coping strategies to help manage the chronic condition.
Sleep disorders
As we all know, refreshing sleep is crucial to feeling well. Insomnia is often caused by stressful events and worry, or can be due to difficult shift patterns or disturbance in the environment. It is a normal response to life and is usually temporary. First ruling out any physical causes such as narcolepsy, restless legs and sleep apnoea (which require referral to a neurologist), our work involves a detailed interview to elicit the causes of delayed onset or disrupted sleep patterns, to work with emotional material that may be affecting restful sleep, to learn helpful habits and to help re-set the sleeping pattern to promote healthy and refreshing sleep. Having used and supervised numerous NHS staff in the use of Cognitive Behavioural Therapy for Insomnia (CBTi) I find that this can provide some helpful methods to get sleep back on track, and skills to keep it that way.
Addictive behaviours
Psychological dependence upon certain substances or activities can arise because they were first enjoyed as a source of pleasure, comfort or recreation, to solve a problem such as to overcome low self-confidence or distract from difficult circumstances, to take the edge off physical pain, or to be included in friendship groups. Over time they may gradually take on a more important role in our lives, strengthened by becoming part of routines and developing into a habit. Neurochemical reactions may then lead to a physical dependence as the body craves a continued supply. Substance addictions include alcohol, drugs, food and smoking, or they can be behaviours such as gambling, spending, gaming and the internet. If the intensity of craving exceeds the person’s ability to resist, they may feel trapped and the effects of this cause disarray in their life. Therapy would first focus on developing an understanding of the development of the addiction and its function. We would work on processing the emotional difficulties and building resilience and alternative coping strategies. We would develop strategies to tackle the addictive behaviour and to protect against relapse, and address problems caused to other areas of life including relationships and work.
Relationship difficulties
We have multiple relationships with others, for example with members of our family, friends, partner or work colleagues. As we perceive the world from different perspectives this can sometimes give rise to misunderstandings or disagreements that if left unaddressed can escalate into disputes and distress. Therapy aims to identify shared and different values, to help the parties to understand differences of perspective and repeating patterns and to manage these through cooperation and agreement.
Eating disorders
Some causes of changes in eating patterns are associated with physical illnesses. In psychological terms, eating is also an essential part of our lives which is often highly social but at the same time a very personal act as one determines what substances enter our body. It is a prime area therefore in which issues of communication, control and autonomy can be experienced. Specific disorders range from Anorexia Nervosa in which the person deliberately attempts to lose weight, Bulimia Nervosa which involves bingeing and purging, Orthorexia Nervosa, which involves an unhealthy obsession with healthy eating, and over-eating or loss of appetite in response to stress. Therapy focuses on understanding the particular features of the eating behaviour and seeking to understand the meaning to the person of eating. This forms the basis upon which to plan a piece of work. Where appropriate, it enables us to find alternative methods of healing emotional distress.
Obsessive Compulsive Disorder - OCD
Obsessions are frequent and unwanted intrusive and distressing thoughts or images that pop uninvited into our heads. Depending on the content they can involve self-doubt, can induce fear (e.g. 38% experience contamination fears) or guilt (16% are about being a perpetrator or blasphemous) and 5% experience an urge to hoard useless objects. OCD is not about what you have done or are likely to do, it is a response to your fears of what you might have done or may do. Compulsions are acts repeated over and over in an attempt to satisfy (and stop) the obsessive thoughts. For example, it has been found that 40% involve safety checking and repetition and 11% are ritual behaviours. Their onset may be characterised by a feeling of holding a high level of responsibility with an insufficient level of control to meet the challenge, and they are maintained by an ongoing feeling of being unsafe. This fuels the person’s level of anxiety which in turn escalates the symptoms into a vicious cycle. In therapy we aim to create a solid understanding of the processes involved and to learn self-compassion and alternative methods of addressing these feelings and we employ cognitive and behavioural strategies to interrupt the process to enable the person to regain control.
Stress and burnout
Stress is a feeling emotional strain and pressure experienced when faced with a challenge or threat. Small amounts of stress can be helpful in motivating us to rise to a challenge, but chronic amounts and excessive levels of stress, causing us to feel overwhelmed and helpless, may lead to physical harm. It can increase the risk of ulcers, strokes, heart attacks and cause mental difficulties such as reduced concentration and memory capacity, disrupted sleep and disorders including depression and anxiety. External stressors can be single traumatic events, or chronic, ambient or organisational stressors in the environment such as the school or workplace. Our perception of our capacity to cope with the challenges posed determines how aversive they feel and our capacity to feel in control. Burnout refers to a state when the person has reached their capacity for coping with their environmental stressors and feels unable to function normally. They may develop symptoms of anxiety, anger and mood disorder. Therapy involves developing a sound understanding of the nature and impact of the stressors, making strategic choices about what changes can be made, and developing psychological coping skills to reinforce them.
Persistent Physical Symptoms
Formerly known as ‘medically unexplained physical symptoms’ or somatic disorder, this refers to symptoms for which doctors have found no medical cause, or whose cause remains contested. Studies suggest that the most common medically unexplained symptoms are musculoskeletal pain, headaches, abdominal pain and gastrointestinal symptoms, fatigue, and dizziness. They may have attracted the diagnosis of chronic fatigue syndrome or fybromyalgia. Whilst the cause is unidentified, these distressing symptoms are often accompanied by depression and anxiety. Psychological therapy has been shown to be helpful in learning to understand and manage the pattern of physical symptoms and to treat the mood disorder.
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