This article explains the use of Gestalt Therapy for crisis intervention with patients who are suicidal. The article by Young & Lester (2001) , provides for good information on the topic. I shall list the following points presented by the authors.
Gestalt therapy is an ideal method for dealing with crisis situations. This is because of the methods focus on the here-and-now and being present for the patient. Working with suicidal patients in crisis, being empathic and listening is everything. Accounts from patients in dire situations are filled with expressions of loneliness and helplessness. Hence being with someone who is actively listening without judgement is precious.
This is an article for persons who need to work with and help suicidal individuals.
I am putting together notes from seminars attended and literature read on the topic of working with people who are imminently suicidal. I hope that the information is useful.
Unless one is familiar, or has come to terms with one’s own thoughts of suicide, one cannot really put him/herself in the shoes of a person in the situation of wanting to kill him/herself. The below video of a talk by Kevin Briggs is a good introduction of how to talk to suicidal people.
How to spot a person who is in danger of suicide
Often when a person is determined to take his/her own life, he/she is alone. Being able to spot a person (family member, acquaintance, friends or other loved ones) in a pre-suicidal situation is life saving.
Ringel (1953) writes that pre-suicidal syndrome is characterized by:
Narrowing of the ability to act
Narrowing of the emotions
Narrowing of the perception
Narrowing of the relationship capacity
Narrowing of the seeing value (or positivity) in the world
Increase of the self-directed aggression
Increase of the imposing suicidal fantasies
Other signs of Suicidality
Feelings of helplessness and hopelessness
Feelings of being offended / hurt
Unbearable mental pain
Desire to impress or punish others by suicide
Long-lasting sleep disorders
Affective and aggression congestion
Lack of resources
Poor impulse control
Some Observable Signs that a Person is Seriously Contemplating Suicide :
there is persistent suicidal thoughts.
there is no distancing from the suicide ideas.
the person has a suicidal plan — take appropriate action when weapons or medicines are easily accessible or if the plan involves the patient going to a place no one can find them.
the person sends out recognizable farewell signals such as letters, giving away objects, cleaning up unfinished businesses, creating orderliness.
Send the Person to the Hospital if…
Call the ambulance when, the person in danger:
clearly announces suicide
is not believable
is not conversant
denies intention to commit suicide, however, the external circumstances clearly indicate intent to commit suicide (severe previous attempted suicide in case of continuing stress situation, depression with hopelessness, concrete suicide preparation, details of relatives).
How to Act in the Presence of a Person in Danger of Suicide
Stay calm, breathe.
Try not to be hastily comforting. Comforting is generally not effective.
Emphatically empathize instead of admonishing.
Concretize rather than generalize. Ask the person specific things, and not talk about hypothetical things.
Take the problem mentioned seriously. Do not downplay the problem. Avoid negating the person by using the words “no” and/or “but”. If unsure, say “yes”, “uh huh”.
Listen quietly with understanding, instead of judging and commenting.
Carefully gather information from the person instead of investigating, questioning, analyzing.
Holding a Conversation with a Suicidal Person in Crisis
Be understanding to the person in his / her specific situation, especially in the situation that led to suicidal behavior. Ask, “How was that exactly, can you tell me more about it?”
Relate to this event. Ask, “That’s a situation where you thought of suicide?”
Speak openly when addressing suicidality. “You thinking of ending it all?”, “Can you tell me more about it?”, “I am interested to hear about it.”
Talk about the relationship and interaction in the here-and-now between you and him/her. Ask, “How are you feeling with me now, during our conversation?”
If you feel touched, or have warm feelings, share this with the person.
Handling Crisis Intervention by Telephone
When someone on the other line of the telephone is in danger of taking their own lives consider the following:
Stay calm, breathe.
Talk directly about the problem. Encourage him/her to describe the reason for the call. Talk about what concrete help is needed.
Discuss what can be done, what realizable help is possible.
Invite the person to a face-to-face conversation.
Hearing the person out, let him/her talk. Be accepting of what you hear. Respond empathically to sounds of distress. Withhold any judgement, negation (saying “no”, or “but”), blame or preaching.
Discuss clearly the next steps about what can be done, if applicable.
Please remember this…
You are in a position to be there for someone in his/her darkest moment. It is a privilege to be there. Be patient and listen with an open heart. Accept what you hear as the other person’s truth. Be present. Focus on your own breathing. If you feel touched, sad or thankful for the contact that you are having, tell it to that person.
Wait for the appropriate time to bring this up…
Even at moments closest to committing the act of suicide, the person is still ambivalent about his/her death-wish. Verbally acknowledge to this person, that something in him/her still wants to live.
“Being with you right now, I’m hearing (or feeling, or sensing), that a part of you really wants to live. “
More Notes on Conversation with Suicidal Persons in Crisis
Take every suicide note on the phone seriously A person tired of life is still talking. He/she is still wants to live, otherwise he/she would not be talking to you.
Suicidal behavior is often an attempt of that person to communicate with somebody. It matters not who you are, you are an important listener.
Suicidal remarks must trigger active listening.
People in distress often see black and white. They respond better when you communicate with them clearly, in short, simple language.
The dangerous moments of a suicidal crisis last only a few hours. Do not fear that it would be too much for you to withstand.
If you are someone who is in touch with your own suicidal thoughts and desires, you are more likely to cope with the suicidal aspirations of the other.
Show concern, but do not be afraid of the words and intentions of the other.
Avoid anxious-well-meaning paraphrases. Instead of saying “suicide”, say, “You want to take your life”.
Suicidal callers ambivalently waver between life and death. Talk about this ambivalence and reinforce it. This will help the person to remember that part of him/her still wants to live.
Call the person by the name, in order to develop a personal relationship.
The suicidal person before you has the right to make personal demands and say absurd thing, even though it might get on your nerves.
Talk to the person in the way he/she wants to talk to you. Mirror the person’s kind of talk.
Do not let yourself be drawn into his/her feelings or thoughts of hopelessness. Ask instead about these feelings, and the memories, etc. behind them.
Avoid asking “why” – type of questions. Similarly avoid asking for reasons. These questions are interrogatory.
Encourage mini-actions. “would you like to meet up (if in phone conversation) or “should we have a cigarette?”
Ask about other people who are still important in the person’s life. If there really is nobody, offer yourself as such a person.
Encourage the person to develop fantasies about his/her future, but
do not do it for him/her.
Do not allow his/her conclusions to convince you like “why I have to kill myself “. Turn it around to, “there is still time to do such and such”.
Tell the other how glad you are to talk to him.
Try to reach an agreement that the other before he hurts himself to call you again.
Do not forget, that despite your best efforts, some still would want to exercise their right to take their own lives. Keep this in mind.
Presenting a psychotherapy case study about how psychotherapy treatment heals.
The full potential of psychotherapy is healing. The healing work enabled through psychotherapy is holistic. This means that psychotherapeutic healing involves the biological, psychological and social aspect of the patient.
Psychotherapy is a complement to medical treatment
Unlike medical professionals who traditionally focus solely on the body while ignoring the social and mental state of the patient — that is now changing in, thankfully– psychotherapists pay attention to the entire person. Particularly true for chronic diseases like cardio-vascular heart disease, medicine and medical procedures only try to remove the symptoms. Psychotherapy helps the patient to work through stress that resulted in the symptoms in the first place, manage behavior to help maintain lifestyle changes, and work through coping with the depression and trauma of having been diagnosed.
Psychotherapy is a more intensive form of counseling or psychiatry
Psychotherapy is a profession that is often confused with others, like counseling, psychology and even psychiatry. To really briefly describe the essential focus on each field of mental health I would say that counseling works on problems of daily existence, daily functioning at work and play, or problems created from behaviors that do not support daily function. Psychology is a broad field of work that researches human behavior and responses to situations. Psychiatry considers that which is emotional and behavioral to be biological, and deals with these issues with medicine or medical procedures.
The way to explain the gestalt therapy attitude towards healing is with this Chinese idiom:
“When cutting grass, the roots are not pulled out, when spring arrives, the grass grows back.”
We can see this in ourselves and in others. Our emotional problems, issues with relationships, problems with work, health problems tend to show repeating patterns. Sometimes we even see these patterns in our parents or in our children. Oftentimes we try to fix the problems. Often another problem of a similar nature surfaces. This is the metaphorical grass mentioned in the above idiom.
If you do go for psychotherapy, your attitude as a patient is to work towards identifying and removing the roots. It is not always painless, but a therapist who is well versed in the work can walk you through it.
The tool of Psychotherapy is dialogue
The term “talking cure” was coined by a patient of Breuer, Anna O, the first recognized patient of psychotherapy. Talking is not the right word. Rather I would used the word, dialogue. Gestalt psychotherapists like myself work with verbal and non-verbal communication. We can work with persons who do not talk or are not able to.
Psychotherapy works through affects and unconscious activity through dialogue and expression of these thoughts and emotions. The goal is to relief stress from painful emotions, by working through traumatic memories, painful thoughts, and difficult emotional experiences. Through working with the unconscious, awareness is formed and stress is relieved.
Relief of stress from psychotherapeutic treatment and health consequences
The relief of stress creates a change in the neuro-chemical balance in the brain. In turn, the hormonal system is readjusted. This changes and strengthens the immune system and cardio-vascular system. Balance in the immune system reduces risk of cancer and even aids in healing cancer, while reduced stress to the cardio-vascular system reduces blood pressure and heart attack & stroke risk.
Psychotherapy heals the body by causing a readjustment of the neuro-chemicals and hormones in the organs. Patients can feel this effect after an effective session of psychotherapy.
What one gets from Psychotherapy is a holistic benefit: empowerment to build relationships, energy for work, study and play, and inner peace.
What is the consequence of this relief of stress? Let this interview of Bruce Lipton explain to you how relief of stress as a result of dealing with the unconscious leads to physical healing and prevention of serious diseases. Lipton explains how medical problems are influenced by epigenetics rather than genetics. Unlike genetics, which we cannot change, epigenetics describe the expression of genes. Expression of genes is determined by environmental and situational factors that we face in our daily lives.
Lipton explains that belief can determine outcome of treatment of illnesses, and how this translates to the concept that our consciousness affect if we get ill or get cured.
Healing in the psychotherapeutic session
I focus on the emotions and the connected thoughts that arise. The opposite is also important: memories and even fantasies are investigated to examine the underlying emotions. The integration of the person with his/her emotions and thoughts through dialogue and behavioral experimentation in the psychotherapeutic session leads to chemical change in the neurological system of the patient.
This is a case study of a patient who came to therapy because of experiencing stress at his workplace. He was often on sick leave for chronic migraine, hemorrhoids and even un-explainable occasional hearing loss. Close to losing his job, he attends therapy. Only after weeks of treatment, did he realize how he, as a young child, was affected by traumatic situations at kindergarten and later elementary school. His home country was governed by a communist regime during the time of his childhood in the 80s. He had survived his childhood years by forgetting how frightening and lonely the situation was, while secretly hoping that he would be sick so that he could skip school.
This client’s psychotherapy treatment was about working through the trauma. With time, we worked together integrating his memories with awareness of which emotions belonged to the past, and what is no longer needed in the present. One of these was the realization that he no longer needed to “get sick” to skip work. He took breaks, sometimes weeks of non-paid vacation. He learned to regulate his spending, so that he could breathe easy when he took those breaks. Talking about and expressing painful emotions allowed him to release energy that he had bottled up and forgotten all his young life. He became more aware of tension in his body, and started doing yoga. Soon after, he stopped taking medication for migraine. The patient realizes that his path to healing is life-long. Along the way, he was able to find love as well.
The Lasting Effect of Psychotherapy
Unlike taking a pill to regulate emotions, neurological changes brought about by psychotherapy are subtle and lasts the lifetime. With regular sessions, these changes snowball into observable physical improvement. Unlike medication, treatment with psychotherapy does not leave behind negative physical side-effects, as can be seen with antidepressants.
For reasons that Psychotherapy is chemical-free, it is a treatment much needed for children, teens, young adults, and people hoping to be parents.
Through working with the psyche, psychotherapy enables the patient to better function in work, play, sex and relationships. As the patient becomes more self aware, he/she also becomes more aware of his/her relationships. He/she ultimately functions better in life. The effect of psychotherapy achieves what one looks for in counseling, with the added benefit somatic healing.
Just as there exists many schools of psychotherapists, there are, of course, different opinions on this subject of healing. The article written reflects my own work.
Obsessive Compulsive Personality Disorder explained and treated with Gestalt Therapy method.
The DSM V describes obsessive-compulsive personality disorder (OCPD) as a pervasive pattern of preoccupation with
mental and interpersonal control.
Individuals who present phenomenon of OCPD give up their flexibility of behavior and thought. They become “closed up”, showing lack of openness to the environment around them.
The consequence is that of being in-efficient in doing daily tasks, since the preoccupation is on distracting details, rules and schedules, that leaves the main task undone. The quest for having tasks done perfect also leaves task unfinished. While everything takes longer to complete, there is obsession with work and productivity, leaving little energy left for leisure activities and relationships. Relationships suffer because there is a tendency to be overconscientious, and inflexible about matters of ethics. Many individuals with OCPD tend to have religious or ideological stance, that they hold on to. They may also have a fixed idea of how things should be done, and would not delegate their work to others, unless the others follow his/her way of executing the tasks. Some persons show tendency to hold on to unnecessary objects. Similarly there is a tendency to being miserly. A certain feature of this personality style is the display of rigidity and stubbornness.
OCPD is differentiated from Obsessive Compulsive Disorder (OCD) by the by the presence of true obsessions and compulsions in OCD.
Obsessive Compulsive Personality Disorder Explained with Gestalt Therapy
Looking at this condition through gestalt therapy lens, we can appreciate the complexity of the treatment process. In seeing the process at each stage and the resistances of the individual towards change, we can follow the clients’s path with more understanding and patience.
At the sensory stimulation phase (the initial phase): one’s own needs are ignored. Habitual behavior and thoughts take the place of present needs. Feelings that arise in the foreground become interrupted by background noise of routine activity. The patient may find difficulty articulating needs or accessing emotions. Difficult emotions are avoided. In place of this is the need to continue habitual behavior.
At this phase of treatment, focus on arising emotions is the work. Often the patient is able to recount difficult life situations, but the narration lacks emotional content. The therapist’s job at this point is to support the patient in embodying the denied emotions, instead of blocking them out with compulsive thought.
At the Orientation phase: There is seeking of external rules. The self has to be perfect, and be right. “I must do it right”. “I must check this…”
There is a sense that being not perfect may lead to loss of love, rejection and helplessness. Control against these feelings are directed towards the external environment.
Experiment with words, making statements and dealing with projections (e.g. other people will judge me if ….) plus dealing with emotions is the work at this stage.
At the Action phase: This is the phase that occurs when the individual is guided to act on behalf of his/her needs rather than acting on his/her impulses. This can bring about anxiety. OCPD actions are acts out of fear of helplessness, and behaves so as to avoid the possibility of situations that leads to helplessness. This means controlling and perfecting the environment, and external self. Ultimately nothing suffices.
Therapy at this phase brings to light the anxiety that arises. There is also projections (attributing thoughts of the self on other people) and retroflections (holding the self back, or blaming the self) that need to be worked through.
At the Assimilation phase: At this phase, the individual would have tried to change his/her behavior. This is possible through practicing will-power, or having behavioral-style therapy. However, attempts to change behavior get quickly sabotaged by introjected messages (like “this is wrong”, “it will not work”) that lead to the individual rationalizing the attempt, denying the point of attempting change, feeling contempt for the effort or try playing down the problem. This is the reason why in gestalt therapy, we are aware that behavior modification attempts alone does not resolve the issues of OCPD.
At this stage, it would be better to check with the patient about his/her introjects, and feelings of guilt or shame that may arise from taking appropriate action.
At the release phase: Let’s say that the patient has managed to overcome the first four phases, the next tendency would be to hold on to the identification of the self with OCPD. There need would be to not let go of the habitual thoughts and action, to see them as the “right thing to do”. This is a protection mechanism against the grief that can arise from feelings of loss and feelings of loneliness.
At this phase, the patient may seem very sad or look depressed, angry. He/she shows strong emotions. The therapist supports the patient by being present and acknowledging the client’s difficult emotions, and helping him/her work through the mourning process.
The treatment process in Gestalt therapy for OCPD, when done in it thoroughness, with the above phases worked through requires a good amount of patience within the psychotherapeutic alliance. At each phase, difficult emotions need to be acknowledged and processed.
Treatment of symptoms arising from personality disorders take time. Patience is essential for both therapist and patient. Where dealing with loss is concerned, the mourning process is an important, positive step to healing.
Physical appearance is usually thin, haggard, not enjoying, gray, tensed.
The emotions include fear, anxiety, loneliness, helplessness, defiance, vulnerability. Initial emotionality may look flat, and restrained.
Psychosomatic reactions may include stomach and gastro pain and symptoms, constipation, circulatory system problems (e.g. myocardial infarction).
Polarities to work through are :
Powerfulness – Helplessness
Fear – Aggression, Anger, Bitterness
Control – Chaos
Obedience – Defiance, unruliness
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
Anger, H. (2018) Gestalt Diagnostics. Private Lecture at the Sigmund Freud University, Vienna.
My work in psychotherapy is about healing. It is in my foreground every minute I work with a patient. Oftentimes patients do not realize that in our therapeutic conversation, there is an underlying therapeutic process. This is because the therapeutic dialogue is, a conversation with another person, but different. The phenomenon of a relational gestalt therapy (my school of study) dialogue is mostly felt, tasted and sensed, before it gets intellectually understood.
Subtle is the therapeutic process not
When we go for therapy, we may experience no big change for weeks or months. We may talk about the same things in circles before something happens: an insight, an understanding, a gush of emotions, a relief from tension. When and how we get to this point in the therapy is usually not foreseeable.
Case Study of healing process in psychotherapy
I recount a case study of a journalist named Mary (not her real name), who came to therapy because of stress due to conflict with her colleagues. Her goal of therapy was to reduce the stress and panic feelings when she is at work. She feared that she may become too emotionally unstable to go to work because of this. For months, Mary talked about her work environment, the colleagues and tried to understand the incidents that triggered in her deep emotions. She also talked about her work, which she calls “her passion”; to remind women of their rights through feminist writings and stories. More weeks went by, and I began to wonder myself if her process was heading anywhere. I stuck to the process of her work, which with time, saw Mary more comfortable with expressing more difficult emotions, especially feelings of vulnerability. Baby steps. One day, she revealed that she had been sexually assaulted by a group of college mates and that she had kept this incident a secret for 20 years. She was able, after 14 months of therapy, to talk about it in session. Along with this revelation came a flood of feelings: resentment, shame, guilt, vulnerability, frustration, anger, grief, and also thankfulness. At one point, she was even angry at me for having initiated her emotional unravelling. For a couple of weeks, she said that she could not work. She, however, recovered from this.
Mary transformed. She had been afraid of coming to terms with a painful past. In so doing, she re-lived her inner feelings of resentment, frustration and anger towards others and herself in her workplace and even in her writings. While these feelings helped her to write powerful articles, it also caused her to build walls between herself and the society in which she is in contact with. The conflicts left her stressed out and panicky at work. She was helpless against the emotional turmoil. Working through of her traumatic experience, she unleashed the source of these painful feelings. Through this process, Mary was awarded choice. She could tap on these feelings as motivation to write and guide others. She is, however, not bounded to these feelings anymore. She finds inner-calm — which she said “had always been there”, but she did not realize it– in her social context. With time, she was able to build more allies. Panic feelings were soon past.
So what is healing to me in the psychotherapeutic sense?
Mary’s healing was a journey towards self-awareness and growth. The time, energy (and, not to forget, money) she had spent in therapy rewarded her with freedom from unconsciously re-living a traumatic past.
Healing in psychotherapy takes place when the patient, like Mary, is able to grow and transform through insight and experiencing (and sharing) of feelings. This healing provides the individual with choice. This concept of healing is unlike that of conventional thought of “healing diseases”, which strive to remove the disease. In psychotherapy, mental and emotional issues are not to be judged as bad and removed; but understood. Depression, anxiety, PTSD and personality disorders aren’t “diseases to be cured”. These are opportunities for personal growth.
The healing –in a way described in this article– achieved in psychotherapy, is permanent. What Mary has gained will be with her for life, and she will continue to grow with it.
Studying and learning can take you so far in life yet it can feel so hard to get down to it. Whether it’s college study or you need to be studying to advance your career; studying can be one of the most important things you’ll have to do.
Difficulty staying focussedon the assignments is the major complaint among students.
You can have all these distraction/displacement activities – stuff you do instead of getting down to studying or finishing your writing assignments.
“The moment I sit down to start on my essay, I feel like to doing something else… like feeding the cat or calling a friend,” says Maggie, 23.
Self-control is hard…
Practicing discipline and self-control is a logical step in getting anything done to completion. This is, however, much easier said than done.
Oftentimes, pushing oneself with self-discipline is painful and futile. The experience can feel like swimming in a river against strong current. A the effort builds up, we feel overwhelmed and “drowned” in the work.
Getting to know the currents you’re swimming against makes you more productive
A swimmer who takes time to study the current before he/she gets in the water saves him/herself the stress of the fight against opposing forces.
Similarly, if you’re finding yourself fighting with getting important things done, it is well worth the effort to consider this: What are the opposing currents that keep you from the tasks?
To find the answer, is to work towards awareness of the self.
If you’re working alone, do some meditation before embarking on the task. Feel deeply in your body for points of tension and stress. Breath into these parts, and try to relax. If memories or flashbacks pop into your head, allow them to happen without judgement. Observe yourself with understanding.
Getting support from a counsellor or psychotherapist is an effective way of overcoming issues related to hinderances in getting important tasks done.
What My Study Motivation Coaching Sessions offer:
Individual Personality Assessment using the Enneagram Method.
Identifying emotions / thoughts and bodily sensations that precede distractive thoughts.
Identifying emotions / thoughts and bodily sensations that cause lack of motivation or feelings of insecurity in getting the assignment done.
Assignment-by-assignment emotional guidance.
Raising academic performance through time and space planning.
Number of sessions needed and intensity of sessions depend on individual needs.
Contact for Information and/or appointment:
Price per 45 minute session (in English and German): EUR 68.
Sessions are also available over Skype.
This article is a reflection on the lecture series on the topic of addiction. The focus here is that of nicotine addiction.
Nicotine addiction seems less serious to law enforcers than addiction to other “hard substances” like opioids, for example. However, for the many persons who need to quit the cigarette for health reasons, addiction is an important issue. This short paper addresses some of the different aspects of nicotine addiction that warrant attention. Through this overview, we can appreciate how one “habit” transcends over many fields of science, and how psychotherapy, within these fields that can support cessation.
The Social Norms of Smoking Initiation
The habit of cigarette smoking is observed to be most often developed during adolescence. Qualitative studies were thus conducted by Peters, et al. (2005) involving high school students who are smokers, regarding the latter’s beliefs in smoking initiation and nicotine addiction.
Questions posed to the subjects were like, “who was with you the first time you smoked?”, to which the answers were largely peers and family members of the same age-group like cousins. Smokers from both genders regard “curiosity” and “peer pressure” as motivation for starting the habit, while for boys, the added motivation is for “cool / image”.
Other means of modelling and encouragement given to teenagers as motivation for initiation of smoking are:
Self medication and coping: “My parents were arguing so I went in her car and saw her cigarettes there, I wanted it to calm me down” and “Because I was having problems at my house and my friend told me if you want to feel better you should start doing it.”
Peer Pressure: “Because someone asked me if I have ever done it”, “because he (boyfriend) kept telling me try it, try it” and “because everybody was smoking one at the bus stop.”
Curiosity: “We were just curious”, “something to try” or “I was curious to see if it was an effect.”
Other Modeling Recurrence: “Because I saw my friends doing it”, and “Because everybody else was doing it, so I wanted one.”
The majority of the subjects revealed that the next time they smoked after the initiation is within 48 hours of the first smoke. This recurrence of smoking crystallizes the behavior into an addiction:
Craving/Withdrawal: “I was craving it and I wanted to be with my friends”, “I had to have another cigarette”, “When they are shaking.”
When asked “how long does someone have to smoke before they are hooked?” The first 3 times emerged as the most frequent response from the subjects. Most subjects also say that one pack or less is all it took for them to get hooked on the smoking habit. This is also the topic of question for Birge, et al. (2017), “What proportion of people who try one cigarette become daily smokers?”.
At the mention of “being hooked on the habit” or eventually “becoming daily smokers”, it is interesting to also note that it may not necessarily mean that the subjects were actually spontaneous addicted to the substance, nicotine, per se. This would have only been clearer had the subjects who were just initiated, were induced to try to “quit” after the 2nd, 3rd (and so on) smoke after initiation.
Smoking Regularity and Nicotine Addiction in Adolescence
Selya et al. (2013) worked on the little-known time-varying effects of smoking quantity and nicotine dependence on the regularity of adolescent smoking behavior. The findings indicated that, in adults, smoking quantity and extent of nicotine dependence is significantly related to regularity of smoking during adolescence. Nicotine dependence is found to increase over time as the effects from regularity of smoking decreased with time. This indicates implicitly also that the initial phases of smoking have more significance in causing nicotine addiction.
A Brief Neurobiology of Nicotine Addiction
From the above studies alone, one gets the impression that, for adolescents at least, smoking is an addictive habit from the beginning. What is not so clear is to what extent, and which time frame does the biological effects of nicotine take over the psychological need to light up a cigarette. The students cite mainly psychological factors (e.g. image and peer pressure), rather than physical factors (e.g. pain management) in getting initiated to smoking.
Nicotine molecules target neuronal nicotinic acetylcholine receptor (AChRs) of cells, in particular neurons. Activation of these receptors is involved in a chain reaction that regulates the system related to dopamine (the dopaminergic system). Consuming of Nicotine regularly causes an “up-regulation” of these receptors. This means that the cells are genetically stimulated to produce more or more effective AChRs receptors. This change in biological structure in neuronal cells changes the normal homeostasis of the intercellular environment of the brain. This process of up-regulation is known to be responsible for the initiation of nicotine dependence (Ortells & Arias, 2010).
The motivation for smoking, like other drugs and addictive behaviors, relies on neurons in the brain’s reward system, based in a brain region called the ventral tegmental area (VTA). Obtaining a reward leads to excitation of these neurons and the release of a neurotransmitter, dopamine. Dopamine transmission from the VTA is critical for controlling both rewarding and aversive behaviors. The degree to which the reward system can be activated is normally tightly controlled by a neurotransmitter called GABA which inhibits excitatory signaling in neurons and keeps the system in balance. Figure one pictorially represents how the main neurotransmitters are held in homeostasis in living cells (in particularly the brain). When a substance like nicotine affects the effects of a neurotransmitter— in this case, Acetycholine— the system would adjust itself to regain balance. Chronic exposure to nicotine leads to the cells adjusting permanently to the imbalances. Such changes are adaptations that occur at a genetic level (since it involves receptors, which are proteins). When the addictive substance is no longer in the system, the imbalance caused by the adaptation would be felt.
Figure 1: (Tretter, 2018)
Researchers have also discovered enzymes that disinhibits dopamine neuron action with chronic nicotine exposure (Buczynski, et al., 2016). Pointing further to the biochemical action of nicotine that leads to the addictive phenomenon.
Nicotine Effect on Metabolism
The negative side-effect of smoking caused by tar and “smoke pollution” (figure 2) that causes lung damage is well known and quite easily grasped. However, the effects of nicotine in itself on the biological system – especially on the metabolic system— is relatively not well understood by the general public. This has likely given rise to the misconception that chewing nicotine or smoking nicotine vapors are the answer to countering the negative health effects of smoking. In fact consuming nicotine only adds to the metabolic issues in the body.
Figure 2 (Ambrose & Barua, 2004)
The effects of cigarette smoking on metabolism is illustrated through a recent Japanese study by Kang, et al. (2009). Fasting blood insulin, glucose and lipid levels were measured in 2 groups of women. One group consisted of regular smokers and the other non-smokers. Fasting levels of these substances are indicative of the efficiency of the metabolic system. During fasting, insulin levels and glucose levels in the blood should ideally be low. Since there is no food entering the body during fasting, one would expect that glucose that had entered the blood from the previous meal to is already removed from the blood stream. The hormone, Insulin, is produced by the Islets of Langerhan cells of the pancreas immediately during food consumption to signal to the other cells in the body that glucose released into the blood from digested food needs to be quickly removed from the blood. High levels of glucose concentration in the blood is toxic to the body, and this process of insulin release is a form of homeostasis. During insulin release, fat cells convert glucose to fat, muscle cells convert glucose to glycogen, and cells stop releasing glucose (gluconeogenesis) into the blood stream. After a period of time, the blood glucose level is supposed to be lowered, and Insulin levels in the blood will drop to safe levels (Eckel, Grundy, & Zimmet, 2005).
As with the above study by Kang et al., when comparing the blood profiles of the group of cigarette smokers with the group of non-smokers, the results showed significantly higher mean Insulin and blood glucose levels while lower mean high-density lipoprotein (fats molecules) in smokers as compared with non-smokers. This indicates that nicotine affects the functionality of Insulin by making this hormone inefficient in reducing the glucose levels in the blood. With nicotine, fat cells do not respond as effectively to insulin by storing fat, muscle cells do not respond as effectively to storing glycogen, and cells do not respond to Insulin as effectively to inhibit gluconeogenesis. So blood glucose after meals take longer time to return to safe levels, causing more Insulin to be pumped into the blood. This conditions mimics that of type 2 diabetes or metabolic disorder.
There are many papers that have highlighted the link between smoking and cardiovascular-related illnesses. The above study is an example that explains to us that nicotine affects blood glucose regulation and the function of insulin. Impaired blood- glucose regulation is related to a pre-diabetic condition also known as insulin resistance.
Weight Gain and Smoking Cessation
A better-known cause of insulin resistance is not smoking, but high carbohydrates and/or alcohol in the diet coupled with sedentary lifestyle. However, cessation of smoking leads to a “similar” phenomenon of gaining weight. This phenomenon is unpleasant, and it is a signal that nicotine consumption messes up the function of insulin in glucose metabolism.
Figure 3 is an illustration from a paper by Nogueiras et al. (2015) that examines the biochemical link between insulin resistance and nicotine use. If more attention is paid to educating the general public (and doctors) on metabolism, the medical field can perhaps help people with smoking cessation.
During cessation, nicotine is suddenly “deprived” in the system, fat cells no longer become insulin resistant (which is a good thing). Fat cells start to “hear” the insulin signals, and mop up the glucose from the blood (also a good thing). Since there is excess insulin in the blood, blood sugar levels become very low and fat cells begin to hold on to the fat (which causes one to put on weight).
It could be, that one possible way out of this situation is to maintain a very controlled diet that does not cause more insulin to be released in blood. Since Insulin is mainly triggered when sugars enter the blood stream, it might just be that a very low intake of carbohydrates may be the answer. With time, the body would cope by producing less insulin. Less insulin means that the fat cells do not absorb more sugars but actually start to burn off the fat. This is how the biochemical aspect of metabolism becomes paradoxical and really interesting, but this is a big subject in itself.
Figure 3 (Nogueiras, Diéguez, & López, 2015)
Smoking addiction begins with the initiation at mainly adolescence, which opens up a whole potential field of education, and psycho-social influences. There is also biochemistry. Biochemistry is many-factorial and complex. There is the harmful effects of tar and other chemicals other than nicotine.
Nicotine, being known as the addictive substance is significant to the field of neurochemistry and pharmacology. What is interesting and important is nicotine on metabolism. This could be relevant in psychotherapy, since it involves lifestyle and effects of hyperinsulinemia or a diabetic-like situation. Hyperinsulinemia is incidentally linked to as well to depression (Löwe, Hochlehnert, & Nikendei, 2006) (Vogelzangs & Penninx, 2007).
For psychotherapists, this is a common addiction of functioning (and also paying) clients. Knowledge of the different aspects of this addiction lends itself to a multifaceted way of providing therapeutic support.
Ambrose, J. A., & Barua, R. S. (2004). The pathophysiology of cigarette smoking and cardiovascular disease: an update. . Journal of the American college of cardiology., 43(10), 1731-1737.
Birge, M., Duffy, S., Miler, J. A., & Hajek, P. (2017). What Proportion of People Who Try One Cigarette Become Daily Smokers? A Meta-Analysis of Representative Surveys, . Nicotine & Tobacco Research.
Buczynski, M. W., Herman, M. A., Hsu, K. L., Natividad, L. A., Irimia, C., Polis, I. Y., & Roberto, M. (2016). Diacylglycerol lipase disinhibits VTA dopamine neurons during chronic nicotine exposure. Proceedings of the National Academy of Sciences, 113, pp. 1086-1091.
Eckel, R. H., Grundy, S. M., & Zimmet, P. Z. (2005). The metabolic syndrome. . The lancet, 365, (9468), pp. 1415-1428.
Kang, Y., Imamura, H., Masuda, R., & Noda, Y. (2009). Cigarette Smoking and Blood Insulin, Glucose, and Lipids in Young Japanese Women. . Journal of health science, 55(2), 294-299.
Löwe, B., Hochlehnert, A., & Nikendei, C. (2006). Metabolic syndrome and depression. . Therapeutische Umschau. Revue therapeutique, 63(8), pp. 521-527.
Nogueiras, R., Diéguez, C., & López, M. (2015). Come to where insulin resistance is, come to AMPK country. . Cell metabolism, 21(5), 663-665.
Ortells, M. O., & Arias, H. R. (2010). Molecular mechanisms of nicotine dependence. Journal of Pediatric Biochemistry, 1(2), 75-89.
Peters, R. J., Kelder, S. H., Prokhorov, A. V., Meshack, A., Agurcia, C., Yacoubian, G., & Griffith, J. (2005). Beliefs and social norms about smoking onset and addictions among urban adolescent cigarette smokers. . Journal of psychoactive drugs, 37(4), 449-453.
Selya, A. S., Dierker, L. C., Rose, J. S., Hedeker, D., Tan, X., Li, R., & Mermelstein, R. (2013). Time-varying effects of smoking quantity and nicotine dependence on adolescent smoking regularity. Drug and Alcohol Dependence, 128(3).
Tretter, F. (2018, Feburary). Neuroscience and Genetics. Private lecture at the Sigmund Freud University. Vienna, Austria.
Vogelzangs, N., & Penninx, B. W. (2007). Cortisol and insulin in depression and metabolic syndrome. Psychoneuroendocrinology, 32(7), p. 856.
What can you expect from your couples therapy or marriage counseling session? In this article I shall endeavor to give you an overview on psychotherapy with couples in my practice.
I am influenced by the principles introduced by Bob and Rita Resnick, who together with their faculty of GATLA have been my mentors for many years. I have personally experienced their work by being a model couple at a workshop in Slovenia, 2015.
“Two becomes one, and then there is none.” Bob Resnick
This quote explains how almost all relationships begin with blissful passion only to evolve with time into something less — often much less.
Falling in love involves meeting a person different from ourselves
Falling in love is about meeting someone, and realizing a “chemistry” with that person. In love, all you want to do is to be with the person to feel his or her presence. There exists interest, curiosity and need. This is a time of exploration and fun. Sometimes it is also a time of anxiety of being with someone new. These emotions make us feel fresh and somewhat alive.
Two becomes One
Passions fade with newness. How come?
As the relationship progresses, two very different people become more and more alike. This seems to be a “natural” process in most intimate relationships. “Successfully” married (especially elderly) couples, often look and act like each other, oftentimes even being able to read each other’s minds and/or finish each other’s sentences. For that reason perhaps, we’d think that “two becoming one” is the path to take in relationships.It , after all recited in most marriage vows.
…then there is none
Resnick argues, however, that when two become one, there’d be none. The passion arising from the meeting and the curious exploration of two different people is doesn’t exist anymore, when these two different people become the “same person”.
It would then seem like an ideal if both persons in a romantic relationship can stay together as unique individuals, different from each other.
Changing the Other or Changing for the Other
With attachment comes reliance. There is mutual responsibility attached to serious relationships. We need this kind of mutual responsibility. Caring mutual responsibility is healthy.
What unfortunately gets mixed up with caring responsibility, is the idea that we have to give up our needs altogether, or that the other person is expected to give up his/her needs likewise.
With personal needs unmet, both parties begin to make silent demands on the other. This circle of needs and demands go unnoticed in the undercurrent of the relationship. There is dissatisfaction as one tries to change him/herself to fit into a relationship role, and there is conflict when one tries to change the other person in to his/her role.
Maintaining a Mutually Nourishing Relationship
To be ourselves and to be with the other. To be for ourselves and to be for the other. To be taken care of by the other and to be take care of the other. Movement between being for ourselves and being with the other is the premise of a mutually nourishing relationship.
Oftentimes, though, we are not moving, we are really stuck.
We can only “be ourselves” if we are aware of who we are. We can only be well taken care off, when we are fully aware of our own needs. We can be for the other only if we are able to listen to what the other person is saying. Without awareness, both parties can only rely on guesses, expectations, silent resentment, and conflict.
Couples Therapy Approach
When couples come to the practice, the “client” is the relationship. Relationship functions through communication. Couples therapy will then be centered around communication between two persons in the relationship.
Questions to ask are: How do we perceive our needs? How do we express what we want? How do we hear the other? How do we react to the other person’s needs? How do we compromise? What do we want the other person to know? How important is the relationship to us? Who are we? …
During therapy, an assortment of themes arise. The focus is on how the couple deals with these themes. How do they communicate with each other in situations. The focus is on dialogue.
Each person gets his/her space and voice. The background of each person in the relationship is considered, validated and heard. What has he/she been through? What is he/she going through now? What do both persons want for the future?
Contact me if you have questions regarding Couples Therapy
This page features a collection of video lectures on the subject of self harm orNon-Suicidal Self-Injury (NSSI) and it’s connection to emotional pain. These resources, I hope, will provide some personal and professional answers in dealing with, or appreciating the phenomenon of self harm.
The aim of this learning is to bring awareness of what is possible and what is needed to assist others with the same issues. Self harm is a behavior to be respected, because it serves the person. It is also a behavior to be taken seriously, and with compassion.
Willis, J. on “Bullicide”
Willis tells us about the impact of bullying on people who self harm. He also explains with neuroscience that both physical and emotional pain activates the same area of the brain.
Lewis, J. on his personal experience with self harm
Lewis’ sharing of his experiences of self harming may resonate with many people. As in the above video, bullying is known to be a trigger for self harm. Lewis tells us of the value of loving people who are suffering from emotional pain.
Working with Self Harm in Psychotherapy
Self harm is a clear indication of the need to cope with un-bearable emotional pain. The most important aspect of treating clients who have learnt this coping strategy is to authentically respect the person, what he/she does and feels.
The therapy sessions will then deal with the emotional turmoil that underlies the need to self harm. Therapist and client work together to understand the origins of difficult feelings. Reminiscing past experiences in a secure therapeutic environment bring up emotions attached to these experiences.
As Lewis explains, it is the cutting that silences the emotions. Therapy brings the voice back to these emotions. This voice is also heard by the therapist who respects the process.