Ask yourself these questions to decide if you need psychotherapy.
This article is for the people have landed on this site looking for psychotherapy, and are wondering if psychotherapy is what they need right now.
Here are some questions (in no particular order) to ask yourselves. If one or more of your answers is a “yes”, it is probably a good idea for you to speak to a psychotherapist.
Your doctor / psychiatrist / teacher or other professional advises you to get therapy.
Your loved ones encourage you to seek therapy.
You are looking for answers about your inner experience.
You are experiencing a difficult milestone in your life: leaving home, getting married or divorced, having a child, being diagnosed with illness, migration, etc.
You find yourself in a difficult or abusive relationship at home or at work.
You experience physical reactions that you cannot understand: like panic attacks, crying attacks, rage.
You are having thoughts that are churning in your mind.
You suffer anxiety: social anxiety, phobias, paranoias.
You’re not sleeping well: not able to get to sleep, waking up in the middle of the night and not getting back to sleep, not able to wake up, sleeping all day, having nightmares.
You have an overwhelming feeling helplessness.
You have an overwhelming feeling of guilt. You blame yourself for many things.
You harm yourself physically.
You have suicidal thoughts and/or plans.
You are addicted to substance.
You are addicted to a behavior: working, shopping, internet use, porn, sex.
You are on antidepressants, anxiolytics or antipsychotic medication, and are thinking of reducing these.
You obsess over certain activities. These activities preoccupy your life, affecting your work, and family life– like work, sports, collecting certain things, hoarding things.
You have problems eating: obsessive thoughts about eating or not eating, bingeing, throwing up after eating, thoughts of starving yourself, feeling anxious around food, not able to enjoy food or the eating process.
You have issues having sex.
You suffer pain and aches that your doctors cannot find physical cause of.
You are having problems working or studying, and feel like you’re about to burnout.
You are socially isolated and / or feel very lonely.
You have lost a parent / family member or two for over a year and have not got over the loss.
You had had difficult childhood experience of abuse, neglect or abandonment.
You have been sexually abused in your life, and have not worked through this experience with anyone.
You have difficulty remembering parts of you childhood, and you suspect trauma.
You’ve encountered a traumatic event that was threatening to your life or the life of someone else.
You cannot feel or identify your emotions.
You see, hear of feel things that are not there.
You or a loved one suffer chronic physical ailments or disability.
You or a loved one have been diagnosed with terminal ailment.
Your children are suffering from poor grades, ADHD, stress or are suicidal.
This is not a comprehensive list, although it does cover issues that I deal with in the psychotherapy practice.
This lecture is presented in this site because it is a good argument for going to psychotherapy sessions that involve working through emotions and childhood traumatic experiences.
Gabor Maté’s message is an important one. As I write this reflection article, I am myself experiencing being in a situation which is teaching me an important lesson: I am forced to take a 5-day unexpected break from a hectic schedule which I had created for myself. I had an accident. I fell from a deep flight of stairs, and escaped with injuries that could have been much worse. Sitting at home nursing a swollen brow and black-eye, I am reflecting on how, for the last couple of months, I had wanted this time off but did not have courage to put appointments aside. I did not want to disappoint other people.
This accident was no accident, but a warning. A therapist myself, I knew what was going on in me, but I really thought that the rest could wait. Wrong I was.
It is so easy to fall into the trap of self denial, because we are programmed to be so. Maté’s lecture, “When the body says no — caring for ourselves while caring for others”, hits the nail in the head.
On premature aging due to stress of taking care of others
2:30 DNA studies show aging in people who live under stress.
Preoccupation for the needs of others, while neglecting the self as a risk factor for chronic illness.
4:20 A story of the personality of a woman who has breast cancer. How she worries about her husband’s emotional state rather than dealing with her own illness.
5:31 He reads obituaries of people who died too soon, to illustrate the self-sacrificial and self-denying behavior of people who have died from chronic illnesses.
Dealing with Anger
7:50 The dangers of suppression and repression of healthy anger leads to autoimmune disease and cancer, while going into rages, which is the polar extreme leads to heart disease.
The healthy way to deal with anger is to notice it, accept the feeling and talk to someone who is willing to listen about your anger feelings. Healthy way to deal with anger is crucial to health.
9:55 Mate describes a study from Australia of married women. Those that were unhappy in their marriages and could articulate them were better off physically than those who suppressed their unhappiness. The issue was not about happiness of the marriage but the ability to express the anger underlying.
Hanging on to roles society imposes on you, trying to please everybody, while forgetting to take care of your health can cause deterioration of health and death.
We cannot separate mind from the body.
14:05 Mate explains to us about chronic illness and the current medical attitude towards these illnesses.
We cannot separate the individual from the environment
16:11 We are shaped by the environment. Environment is not only physical, but also the psycho-social environment. This means that the environment includes the people we live amongst.
To illustrate this, he cites studies where children whose parents are stressed are more likely to get asthma in polluted environment and other illnesses. This is known to be directly as a result of stress since asthma drugs are stress hormones themselves.
We cannot separate ourselves from the mental states of others in our society.
Talking about anger to someone is important reliever of stress
19:10 Studies of breast cancer patients in Australia found that having a stressor in life AND being socially isolated made the subjects 9x more likely to have cancer. Mate explains that connection with another person, talking to others about feelings of anger is instrumental to maintaining healthy life.
Stress from anger is not only mental, stress is also felt in the body. In short term, stress hormones help to escape, long term stress causes chronic ailments.
ALS is a neurological motor neuron disease, which strikes usually healthy people, and is fatal. Mate found these patients to have a personality tendency of denying their negative feelings, denying the experience of the self, while having the overwhelming need to always be there for others-
27:03 He talks about the story and personality of Lou Gehrig. Gehrig’s name is the name for ALS. His personality of selfless ambition and helpfulness is typical of what Mate considers a personality that is typical of patients wit ALS. Lou Gehrig had childhood trauma from growing up a child of an alcoholic.
These are caused by unconscious patterns. Not the fault of the patient’s themselves.
Unconscious self-denying behavior is learnt from infanthood.
19:30 Mate tells us his own story of how unconscious factors affect how he too has a tendency of self denial while trying to protect his mother.
Infants pick up on the stress of the mother and other caregivers. Infants learn to suppress their own pain in order to maintain a relationship with its care-giver. This infantile suppression becomes a memory that is recorded by and stored in the body. It is called trauma.
Making oneself lovable is done by suppressing feelings and denying own needs.
Mind and body are inseparable.
Personality patterns are learnt from infanthood. These patterns translate into physical illness.
36:00 Newborn need to establish these patterns to maintain attachment to adults.
Emotional centers of the brain are attached to the hormone system, and nervous system are connected to the immune system. These systems are connected.
38:40 Mate explains the phenomenon of “gut feeling.
How and why we give up our authentic selves as children
Children read and respond to gut feelings intuitively. Children are born with ability to intuit body language of adults accurately. As we get older, we begin to suppress this gut feelings, and rely on intellect.
41:40 There are 2 great needs of children. One is attachment to the care-giving adults. The other need is to be authentic. This is a need in order to function as an individual human being. In situations where we, as children have to sacrifice our authentic self, because this authentic self endangers the attachment to our parents, leads us to a pattern of having lost touch with our needs and feelings.
Our problem as adults is that we still stick to this need for attachment.
42:48 The Heart-brain Connection predictive activity.
Hence our emotional states is connected to our physical health.
Healthy anger is about knowing your boundaries and expressing it
44:45 Mate demonstrates what boundaries are and how boundaries can be breeched. He explains that healthy anger is necessary for us to communicate to the other that our boundaries have been crossed and to back off.
Immune system is linked to our emotions
The role of our emotions is boundary integrity. To keep out what is unhealthy, and let in what us enriching. The job of the immune system has similar roles.
Autoimmune disease is a way of the body attacking itself.
To prevent illness or overcome illness, we need to exert who we are and to say, “no”.
Saying “no” may trigger fears about attachment, but we have to remember that we are adults.
If you are caring for others, you must demand support also for yourself. Ask yourself and reflect on this question: in what situations in your life is it difficult for you to say, “no”.
Psychotherapeutic change is observable. Noticing the progress of the client is an important aspect of therapy.
An important aspect in the work of the therapist, is to track patient progress. In my practice, even if I do not mention to the patient, I look for signs at every session.
The healing process in psychotherapy is often a subtle one. Meeting the patient every week, it is possible for the therapist to overlook these changes. Therefore, I give special attention to looking out for the signs.
Importance of looking out for the patient’s progress and change during therapy sessions
It is important for the therapist to be alert to change. Patients are normally oblivious to the subtle changes in their own personality. Left on their own, individuals may start doubting their new sense of being (due to persistent introjects / resistances).
Noticing the client’s change and progress is helpful to him/her. The therapist, in bringing attention to the development of the patient, helps the patient to integrate fully with this new attitude or behavior, through:
acknowledgement of the perceived change,
appreciation of how the change is impacting the life of the client,
understanding of how the change is developing and meaning making,
assimilation of the experience, i.e. how it feels to exist with this change.
Some signs of change observable in the patient during the course of therapy.
There are many signs of change. Here is a brief description.
Change in how the patient makes eye contact, makes facial expressions.
Change in posture, dressing, hairstyle — not the usual change of styling, but when the client comes in, and his/her aura feels different.
Change in topics brought up in session — most individuals bring up a kind of focus topic (like work or kids…). I’d notice a change when the topic is suddenly no longer interesting to talk about, or when another becomes figural. Generally, when the topic becomes more about the experiences of the self, it is progress.
Change in the client’s emotional vocabulary.
Client’s own account of perceiving new feelings or losing anxiety . Especially after holidays, the client reports that certain old feelings of anxiety around the festive season is no longer felt.
Client making new decisions. This applies to clients who have difficulty doing so.
Client reducing medication (esp, meds that have been long time prescribed), or reports having alleviated physical symptoms.
Client reports that children / spouse, etc are “doing better” (usually relationshipwise).
Note that these changes may not mean that the goal of therapy is reached. Change indicates that the therapy is in progress, and the patient can look forward to more enrichment from the sessions.
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.
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.
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