How a therapist can tell the progress of the patient

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.

Psychotherapy is Healing through the Psyche

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.

Studies have been surfacing about the link between stress and chronic diseases. Read this article featuring a lecture by Gabor Maté : Denial of own emotional needs and its connection to chronic illness.

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:

斬草不除根,春風吹又生

“When cutting grass, the roots are not pulled out, when spring arrives, the grass grows back.”

Chinese idiom

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.

Read also: The Neuroscience of Language Explains How and Why Psychotherapy Cures 

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.

Case study:

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.

What does “healing” mean in Psychotherapy?

My work in psychotherapy is about healing through the integration of psyche and body. It is in my foreground every minute I work with a patient. Oftentimes it is not obvious that in our therapeutic conversation, there is an underlying therapeutic process.  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 change from the beginning, or 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. The process can be described as to be like titration. We make small steps. There is no explosion, but natural, holistic change.

Case Studies of healing process in psychotherapy

Case 1, Mary: 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 then emerged 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 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 of the past. Mary’s healing came about in little steps.

Case 2, Sunil: Sunil (not his real name), was a foreign student from India. He has chronic pain and problems with his digestive system, which doctors have diagnosed as Irritable Bowel Syndrome. He knows that his physical symptoms are related to “stress”(actually compulsive intrusive thoughts and actions) and sleeplessness. Sunil grew up experiencing family violence. With therapy, Sunil learned to notice his emotions and how past memories of childhood affects him today. He learned to observe the triggers in his everyday environment. He learned how to notice and accept his triggered self. Sunil learned to engage the support of his loved ones by explaining to them what was going on in him, and what he needed. With time and help from others, Sunil’s episodes reduced in duration and intensity. Sunil learned in therapy to be conscious of changes in his body when he got triggered. He was guided to find out what his body needed to calm down from its hyper-aroused state. Sunil’s healing process involved dealing with somatic reactions to triggers, and working through past hurts. Within months, Sunil’s digestive system stabilized. He also slept better. Sunil’s healing process was a holistic one.

So what is healing to me in the psychotherapeutic sense?

Mary and Sunil’s healing was a journey towards self-awareness and growth. The time, energy (and, not to forget, money)  spent in therapy rewarded them with freedom from unconsciously re-living traumatic pasts.

Healing in psychotherapy takes place when the patient 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.

Anorexia & Eating Disorders in Children: What Parents and Family can do

When a child in the family develops symptoms of eating disorder (like anorexia nervosa, anorexia bulimia or binge eating disorders), other members in his/her family, in particular the parents may feel overwhelmed by the situation and even helpless.

The ways in which different families deal with the illness vary individually.

As parents or guardians the most immediate thing to do is to get for themselves support from a professional in treating eating disorders, be they doctors /psychiatrists  and/or psychotherapists.

What parents can do

The actual diagnosis and treatment of the physical and psychological aspects of the eating disorder is conducted by doctors. Usually these are done by specialists.

Parents can help the professionals by offering information on the family situation when these questions are posed to them by the diagnostician.  If there is such an interview given, it is best to provide the information as openly and honestly as possible.  This would facilitate un-hindered support for the children.

Once in the care of professionals, it is best for parents to allow the process to take place. 

It is a common reaction for worried parents to want to “take things into their own hands” when they perceive that help is not achieved adequately or quickly enough. Reacting to the child’s treatment in any way, so as to affect the relationship between the child and the professionals treating him/her, or to affect the child’s emotional state can be counter-productive.

If you are a parent of a child who is being treated for eating disorder, and feel uncertain or unpleasantness about the progress of the child’s treatment, do seek a conversation with the professionals in charge, before taking other action to change the treatment process.

Eating disorders arise and develop out of different situations. Sometimes the causes are linked to family dynamics, and other times it is not the case. Regardless of this, there is a tendency for parents and other family members to hold feelings of sadness, anger and guilt, as the result of realizing that a child is suffering from the disorder.

Difficult emotions being felt by parents, when ignored, can make problems worse, rather than better. This is because, when the emotions are pushed aside, they become stress factors that result in actions or behaviors that cause more stress in the family environment. In turn this may snowball into more problems for the child, and his/her other siblings.

It is hence recommended that parents themselves seek some kind of counseling from a psychotherapist, or a self-help group (if such is available).

Having counseling for parents, does not mean that the parents are in any way at fault, or have problems themselves. When parents go for counseling they are supporting the child by helping to provide a stable environment at home for him/her to get better.  

This short article is written with the wish that parents of children suffering from eating disorders take to heart that in order to support the healing of their children, they can do well by taking care of their own emotional state. Having a child diagnosed with eating disorder is, after all, stressful and riddled with questions and judgements of and from the self and others.

It is good to consider this metaphor taken from the aircraft emergency procedures:

“In the event of emergency, put your oxygen mask on first.”

The consequence of not following this aircraft safety advise is the loss of emotional bearings due to hypoxia (lack of oxygen in blood), rendering the person unable to help others, and worse…

In the case of supporting the child with eating disorder, counseling  for the self is the oxygen mask. It helps provide emotional stability in times of stress in the family.

Other Readings

Cottee‐Lane, D., Pistrang, N., & Bryant‐Waugh, R. (2004). Childhood onset anorexia nervosa: The experience of parents. European eating disorders review12(3), 169-177.

Bundesministerium für Arbeit, Soziales, Gesundheit und Konsumentenschutz (2018). Essstörungen: Was Angehörige tun können. Web source from URL:https://www.gesundheit.gv.at/krankheiten/psyche/essstoerungen/was-angehoerige-tun-koennen. Retrieved on 06.2018.

Honey, A., Boughtwood, D., Clarke, S., Halse, C., Kohn, M., & Madden, S. (2007). Support for parents of children with anorexia: what parents want. Eating disorders16(1), 40-51.

Lask, B., & Bryant-Waugh, R. (Eds.). (2000). Anorexia nervosa and related eating disorders in childhood and adolescence. Taylor & Francis.

Crisp, A. H., Harding, B., & McGuinness, B. (1974). Anorexia nervosa. Psychoneurotic characteristics of parents: Relationship to prognosis: A quantitative study. Journal of Psychosomatic Research18(3), 167-173.

Dreams and Dreamwork in Psychotherapy     

The publication On Dreams was written by Freud (1900) after having written his (what was labeled) “book of the century”, Interpretation of Dreams. With these writings,  Freud tries to make his innovative ideas of dream analysis accessible to the wider audience. His was the aim of reaching the “educated and curious minded reader” (Quinodoz, 2013).

Freud prides himself in taking the mystique out of dreams. He says dreams are composed of latent and manifest content. The manifest content, Freud explains, is material that appears in a dream. The latent content is the material that underlie the dream that is hidden within the unconscious. Using his own dreams he analyzed himself on paper. With that Freud brings us on a journey towards his own dream work.

Freud and Adler’s Differences


Alfred Adler’s work on dreams is an elaboration of Freud’s.  While here is fundamental agreement of both theories, the main difference is that Adler is very much focused on the individual’s awareness of one’s position in society, and expression of one’s “style of life”, viewing dreams as having a forward-looking, problem solving function. Adler also realizes that the conscious and unconscious are not contradictions to each other, but a unity (Ansbacher & Ansbacher, 1956).

Adler made a point about dream analysis that transcended Freud’s: by acknowledging that even made-up dreams are significant to analysis (p. 359). It implies that the act of talking about dreams alone is fundamentally relevant to the therapy—no matter from where the dream arises. The use of dreams in psychotherapy functions in a manner to facilitate therapeutic process, help patients gain insight and self-awareness, provide clinically relevant and valuable information to therapists and provide a measure of therapeutic change (Eudell-Simmons & Hilsenroth, 2005).

Gestalt Therapy Attitude towards Dream Work in Therapy

How the analysand describes his/her dream is rich in not only the latent content of the dream, but also the latent content of the moment of analysis. Gestalt therapists work on dreams by acknowledging the phenomenon within the client at the moment of analysis.

Enright (1980) recounts a dream work done by Fritz Perls in Los Angeles 1963 (found in the section Memory Gems). After the client recounts his dream, Perls would ask the client to identify himself with elements of that dream, by talking about it in the first person. In an example, an elderly, subdued man had a dream of seeing some friends off on a train. The man worked at first by identifying himself as himself, then as his friends with no effect. As the man identified himself with the train, he felt a bit more energy. Perls then asked the man to “become the station itself”. Enright writes, “At first it seemed as unproductive as the rest. Then, as he said, ‘I’m old-fashioned and a little out of date—I’m not very well cared-for; they’re letting dust and litter accumulate—and people just come and go, use me for what they want, but don’t really notice me,’ he began to cry, and for the next few minutes the current and recent past thrust of his entire life became obvious—what was happening, what he was doing that wasn’t working, and even some possible new things to do.”

Perls, in this example, demonstrates a way of working in the moment. While working with a dream, client and therapist remain in dialogical contact. Nobody gets lost in analysis. The therapist deals with the process of the dream work rather than the content of the dream. Working with process allows a lot of creative freedom; the dream is treated like a work of art, “fruit of the extraordinary creative powers of childhood” from which the patient must be able to experience freely, free of theoretical considerations; so that the person can communicate with and re-create his/herself  (Sichera, 2003. p. 95).

Conclusion

Dreams are useful material for use in understanding the self. If the client brings a dream to the session, and if the dream has significant emotionality attached to it, it is worth spending time on. Recurring dreams are especially interesting, according to Fritz Perls.

The time and setting is also considered before such work is done. There are moments when working on particular dreams lead somewhere important. There are moments when dream work is not appropriate, or when the dream topic is a distraction from current material that is more important for the client.

Working with dreams are tools, but are not ends to itself. The focus lies always on the here-and-now.

Read also:

Dream Analysis

Fritz Perls: Working with Dreams in Gestalt Therapy

Bibliography

Ansbacher, H. L., & Ansbacher, R. R. (1956). The individual psychology of Alfred Adler.

Enright, J. B. (1980). Enlightening gestalt: Waking up from the nightmare. Pro Telos.

Eudell-Simmons, E.M. & Hilsenroth, M. J. (2005). A review of empirical research supporting four conceptual uses of dreams in psychotherapy. Clinical psychology and psychotherapy. 12, 255-269. John Wiley & Sons.

Freud, S. (1900). On dreams, Standard Edition of the Complete Psychological Works of Sigmund Freud. Vol.5. pp. 633-686.

Quinodoz, J. M. (2013). Reading Freud: a chronological exploration of Freud’s writings. Routledge.

Sichera, A. (2003). Therapy as an aesthetic issue: creativity, dreams, and art in Gestalt Therapy. In M. Spagnuolo Lobb & N. Armendt-Lyon (Eds.). Creative License: The art of Gestalt Therapy. NY: Springer.

 

Different Facets of Countertransference

Different feelings brought about by countertransference during a therapy session. Here is a rundown of how countertransference within a therapeutic relationship can manifest itself.

 

Transferences from therapist’s own childhood unfinished business is put onto the client. For example, the client reminds the therapist of his controlling mother.

Reactive feelings arising from therapist’s own narcissism.  Like defiance, being offended, wanting to take revenge, envy, lust, feeling insecure, feeling  inferior or superior, etc.

Complementary countertransference: when the therapist encounters the transference of the client, out of which incites the therapist to behave towards / feel towards the client the way the client’s  caregiver or significant other  would feel.

Identification with client’s significant other (parent, child, spouse, children, boss): in such a way that the therapist cannot empathize with the client.

Projective IdentificationFeelings of the patient’s childhood experiences which have been split/dissociated, and projected onto the therapist and simultaneously the therapist feels and acts in a way (e.g. sadistic, critical, judgmental… like his father) that leaves the therapist bewildered.

The consequences unrealized countertransference feelings is that the client is robbed of the empathy he/she needs from the therapeutic sessions, which ultimately renders the therapy unprogressive.

The challenging job of the psychotherapist is to be constantly aware of these feelings and the sources of these transference. Self awareness through self therapy, and workshops and supervision are the only and best way to work through these transferences.

 

 

Hoarding Disorder

Definition of hoarding disorder:  the extensive collection of objects followed by difficulty discarding them for aesthetic reasons, or because of an object’s emotional value or consideration of its possible usefulness in the future.

The consequence of hoarding objects is accumulation of objects in living spaces, leading to limited space, poor hygiene and feelings of embarrassment.

Items that people hoard can also be those of abstract nature, like hoarding of digital items. Hoarding becomes a “disorder” when it starts to interfere with relationships and functions of daily life.

Many people with hoarding disorders have tremendous difficulties with relationships. Partners and family members suffer from problems associated with the syndrome like cluttering of the living space. As a result of the behavior, hoarders live lonely lives, and are often suffer depression.

Hoarding is a chronic syndrome, and individuals live with this lifelong. With age, the situation can get worse. Support from others and professional psychological aid, where available, help individuals get on well with their lives despite difficulties.

Check out my Hoarding test here.

Questionnaires to evaluate hoarding disorder

The Saving Inventory-Revised (SI-R) by Frost et.al (2003).

Compulsive Acquisition Scale (CAS) by Frost et.al (2002).

A major contributing factor in hoarding disorder is the need for control over possessions.

Bibliography

Frost, R. O., Steketee, G., & Kyrios, M. (2003). Saving Inventory–Revised (SI-R).

Frost, R. O., Steketee, G., & Williams, L. (2002). Compulsive buying, compulsive hoarding, and obsessive-compulsive disorder. Behavior therapy33(2), 201-214.

Frost RO, Steketee G, Williams L. Compulsive buying, compulsive hoarding, and obsessive-compulsive disorder.

van Bennekom, M. J., Blom, R. M., Vulink, N., & Denys, D. (2015). A case of digital hoarding. BMJ case reports.

Experiences of Grief after a Loss of a Loved Person

What does a person go through when he/she loses a very dear person? This person could be a parent, spouse, child, friend or even pet.  Every person’s experience is unique, because every relationship is unique. In order to understand what people may go through after the death of someone special, here is a questionnaire that I found.

How is the experience of grief described?

This is a set of questions that one can reflect upon when accessing the grief experience.

Since the death of your loved one, how often did you:

      1. Think that you should go see a doctor?
      2. Experience feeling sick?
      3. Experience trembling, shaking, or twitching?
      4. Experience light-headedness, dizziness, or fainting?
      5. Experience nervousness?
      6. Think that people were uncomfortable offering their condolences to you?
      7. Avoid talking about the negative or unpleasant parts of your relationship?
      8. Feel like you just could not make it through another day?
      9. Feel like you would never be able to get over the death?
      10. Feel anger or resentment toward your loved one after the death?
      11. Question why your loved one had to die?
      12. Find you couldn’t stop thinking about how the death occurred?
      13. Think that your loved one’s time to die had not yet come?
      14. Find yourself not accepting the fact that the death happened?
      15. Try to find a good reason for the death?
      16. Feel avoided by friends?
      17. Think that others didn’t want you to talk about the death?
      18. Feel like no one cared to listen to you?
      19. Feel that neighbors and in-laws did not offer enough concern?
      20. Feel like a social outcast?
      21. Think people were gossiping about you or your loved one?
      22. Feel like people were probably wondering about what kind of personal problems you and your loved one had experienced?
      23. Feel like others may have blamed you for the death?
      24. Feel like the death somehow reflected negatively on you or your family?
      25. Feel somehow stigmatized by the death?
      26. Think of times before the death when you could have made your loved one’s life more pleasant?
      27. Wished that you hadn’t said or done certain things during your relationship?
      28. Feel like there was something very important you wanted to make up to your loved one?
      29. Feel like maybe you didn’t care enough about your loved one?
      30. Feel somehow guilty after the death of your loved one?
      31. Feel like your loved one had some kind of complaint against you at the time of the death?
      32. Feel that, had you somehow been a different person, your loved one would not have died?
      33. Feel like you had made your loved one unhappy long before the death?
      34. Feel like you missed an early sign which may have indicated to you that your loved one was not going to be alive much longer?
      35. Feel like problems you and your loved one had together contributed to an untimely death?
      36. Avoid talking about the death of your loved one?
      37. Feel uncomfortable revealing the cause of the death?
      38. Feel embarrassed about the death?
      39. Feel uncomfortable about meeting someone who knew you and your loved one?
      40. Not mention the death to people you met casually?
      41. Feel like your loved one chose to leave you?
      42. Feel deserted by your loved one?
      43. Feel that the death was somehow a deliberate abandonment of you?
      44. Feel that your loved one never considered what the death might do to you?
      45. Sense some feeling that your loved one had rejected you by dying?
      46. Feel like you just didn’t care enough to take better care of yourself?
      47. Find yourself totally preoccupied while you were driving?
      48. Worry that you might harm yourself?
      49. Think of ending your own life?
      50. Intentionally try to hurt yourself?
      51. Wonder about your loved one’s motivation for not living longer?
      52. Feel like your loved one was somehow getting even with you by dying?
      53. Feel that you should have somehow prevented the death?
      54. Tell someone that the cause of death was something different than what it really was?
      55. Feel that the death was a senseless and wasteful loss of life?

Finding the Answers

The questions, answered in the affirmative within the first 2 years of loss of a loved one, reflects the natural response of grief. After a longer period of time, the feelings should subside. If feelings of grief develop into depression, seeking counseling can be a life saver.

Seeking a balance in allowing oneself to grief, and then to slowly move on with living a life without the loved one is an act of taking responsibility for one’s own survival. That is a matter of individual choice, and freedom. Finding resources to survive loss is part of the act of responsibility. A good resource one  can achieve for oneself is to find someone who would listen. This person may be in the form of another family member, friend, counselor, priest or psychotherapist.

Bibliography

Barrett, T. W., & Scott, T. B. (1989). Development of the grief experience questionnaire. Suicide and Life-Threatening Behavior19(2), 201-215.

Psychotherapy for Cardiac Patients?

This article explores the mutual, interactive influence between cardiovascular disease and mental health. The psychological issues present among patients of cardiac health issues are mainly that of anxiety and mood disorders. Often termed “psychocardiology”, this field integrates both medical aspects of cardiology and psychotherapy.

The interactions between the mind and body are pronounced and evident. When we feel anxious, our heart pumps faster and we feel breathless. The interaction between psycho and soma is also complex and multifaceted.

Cardiological and psychiatric disorders are closely interrelated and have a bi-directional relationship. This is what we understand as a psycho-somatic interaction.

Mind and Body Connection in Cardiology

Cardiovascular disease is among the leading cause of morbidity and mortality in the industrialized world.  While psychiatric disorders have a prevalence rate close to 20% of the population, depressive illness  is one of the leading cause of disability worldwide (Murray & Lopez, 1997). 

Put together,  depression and anxiety related to depressoin is identified as a significant risk factor for mortality in patients with coronary heart disease (Barth et. al. 2004).

cardiovascular disease and depression

The article cites a meta-analysis of research papers and have found that depression and anxiety contributes to the mortality of patients of coronary heart disease. Cardiac patients who suffer depression are 2x more likely to die than cardiac patients who do not suffer depression in the 2 years of initial assessment of the disease.

Halaris (2013) highlights links underlying recognized cardiovascular disease and mood disorders. Genetic and epigenetic factors affect how an individual reacts to mental and biological stress. Psychosocial and environmental stressors together with lifestyle choices also determines susceptibility to level of disease states.

Among patients with Congenital Heart Disease, for example, it is found that illness perception of the patient is a significant predictor of  patients’ quality of life, cardiac anxiety and depression one year after the heart intervention (O’Donovan et.al. 2016). It indicates that how the patient see his/her illness and the self in this situation affects his/her health development and quality of life.

Psychological effect of Diagnosis of Heart Defects on Patients

Being diagnosed with heart complications, whether it is congenital heart disorder or coronary heart disease leads to years of continuous physical, psychological and/or social burdens for the patient and family.

Patients with early-recognized congenital heart defect live with the condition throughout life. This is especially so in the case of babies / children diagnosed with congenital heart defect.  The psychological state of these patients is deep rooted becomes embedded in identity.

Encased in the anxiety of other types of patients whose heart disease emerge later in life is the shock/abruptness of the heart failure due to a previously unknown / undetected defect. This further stir associations regarding health in general (loss of former self-identity, increase of insecurities etc.).

Psychotherapy needs of Cardiac Patients in Cardiology

Medical professionals in countries like Austria realize the need for an integrated-method of treatment of cardiac patients. Medical treatment is more focused upon when the symptoms are acute, and with chronic ailments the psychological work take precedence. Many fields of mental sciences work together with the doctors for after-care of the patients.

Psychotherapists, as per the studies cited in this article have un-covered the major psychological issues patients face: Clinical anxiety coupled with depression. These have also been shown to have adverse affect on the health development of the patients.

Anxiety is an increase in the awareness of psychic or physical sensations to a degree that makes it impossible for the real or imagined danger to be avoided; there is a constant danger signal together with the incapacity for active coping (Waelder, 1960). Relaxation in the tensions of anxiety seeks the experience not of satisfaction but of security (Sullivan, 1953). 

Patients come to psychotherapy with existential anxiety because of their life-death situation.  Illness perception is linked to these feelings. Along with it comes the perception of oneself in relation to a defect. Patients talk about the feeling of being vulnerable, ‘damaged’, ‘weak’.  For adult patients (especially those who are independent in life), these experiences are often concealed from relevant others.  

In therapy, these themes are worked through in the confidentiality and security of the session. The psychotherapist for such patients has to possess the resources to contain the very strong emotions of the clients, approaching the sessions with empathy and patience. Patience is normally understated, but important. Many patients take time to trust the therapeutic process, and may discourage the therapists from helping them. Feelings of hopelessness /helplessness do become projective identification.

“.. the therapist should function as a container of the patients’ anxieties. The fundamental therapeutic task at this stage is the analyst’s containment and interpretation of the patient’s anxiety. To the extent that this process is carried out, if the patient deposits—or rather evacuates — his anxiety and the analyst is able to bear it, a type of relationship is established in which the patient feels the analyst is an object who’s function is to contain him … As this process repeats itself, the patient develops a growing confidence in the relationship and gradually introjects ‘it’. It can be said theoretically, that from the moment there has been sufficient introjection, the patient has (achieves) within him an object where he (from now on) can deposit his anxieties … “

(Etchegoyen, 2005, p. 620).

The therapists who is able to see through the difficulties of the therapeutic sessions eventually builds the sound alliance. He/she is then able to support the client through the worst of feelings (especially that of loss), thus alleviating existential loneliness and isolation that is part of the depression.

Psychotherapy for Parents and Siblings of Children with Congenital Heart Defect

Psychotherapy cannot ignore that alongside a patient is his/her social system. Parents and siblings of child patients bear a big burden. Work with the family on a long term basis helps alleviate chronic stress faced by parents and supports the family. We can take heart from the research mentioned by Re et.al. (2013).

 

 

 

Bibliography

Barth, J., Schumacher, M., & Herrmann-Lingen, C. (2004). Depression as a risk factor for mortality in patients with coronary heart disease: a meta-analysis. Psychosomatic medicine66(6), 802-813.

Etchegoyen, R. H. (2005). The fundamentals of psychoanalytic technique. Karnac Books.

Halaris, A. (2013). Inflammation, heart disease, and depression. Current psychiatry reports15(10), 400.

Murray, C. J., & Lopez, A. D. (1997). Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. The lancet349(9063), 1436-1442.

O’Donovan, C. E., Painter, L., Lowe, B., Robinson, H., & Broadbent, E. (2016). The impact of illness perceptions and disease severity on quality of life in congenital heart disease. Cardiology in the Young26(1), 100-109.

Re, J., Dean, S., & Menahem, S. (2013). Infant cardiac surgery: mothers tell their story: a therapeutic experience. World Journal for Pediatric and Congenital Heart Surgery4(3), 278-285.

Humiliation, Shame and Violence

This is a presentation I gave some years ago on the connection on antisocial violent behavior in some men, and how researchers (in this article I feature the work of J. Gilligan) have learnt how these violent behaviors are linked to culturally-adapted values. Such values function as introjects in individuals. The resultant of which is violent and aggressive emotions as consequence of displaced feelings of humiliation and avoidance of shame.

Mass shooting incidents do happen and the perpetrators leave behind chilling messages that point to a root cause, which Gilligan has pointed out.

 

Here are the list of extreme cases of violence in young males. The motives for their actions were later revealed to have mysogynic undertones. Many express their hatred for women.

Working with Shame

  • Empathic understanding of the patient’s experience with shame
  • Assist the client to understand fully this experience.
  • Showing warm understanding, acceptance and respect.
  • To heal shame, the therapist must understand shame. Therapist must understand this in context of the patient.
  • Therapist must be committed to dialogue.

(Yontef, 1996)

  • Hold the client in unconditional positive regard.

Working with Humiliation

Why Humiliation?

Shame is related to humiliation, but they are not the same emotions.

The Phenomenological difference between Shame and Humiliation

  • Humiliation relates to distinct “self and other” interactions, and to distinct levels of self-definition.
  • Humiliation is done by one person to another purely for own selfish purpose.
  • Humiliation implies an activity occuring between oneself and another person.
  • “Humiliated” is a feeling of position of oneself in relation to another or others. It is also an interpersonal interaction.
  • Humiliation is the feeling of an act of being put into a powerless, debased position by another who at a point in time posesses greater power than oneself.
  • Humiliation can involve anger over one’s lowered status.  (Gilbert & Andrews, 1998)

References

Anderson, E. (1994) The Code of the Streets. The Atlantic Monthly 5 81-94

Cohen, Vandello, Rantilla (1998) The sacred and the social . Cultures of honor and violence. In P Gilbert, B Andrews (Eds.) Shame: Interpersonal Behavior, Psychopathology, and Culture pp.261.

Gilbert, P. E., & Andrews, B. E. (1998). Shame: Interpersonal behavior, psychopathology, and culture. Oxford University Press.

Gilligan, J. (2001) Preventing Violence. London: Thames & Hudson.

GILLIGAN, J.. (2003). Shame, Guilt, and Violence. Social Research, 70(4), 1149–1180. Retrieved from http://www.jstor.org/stable/40971965

Herbert, B. & Gilligan, J. (2014) Bob Herbert’s Op-Ed. TV: Dr James Gilligan on our Culture of Violence. Youtube Video. https://www.youtube.com/watch?v=IozZsuCfiZo

Retzinger, S. M., 1995 Identifying shame and anger in discourse. American Behavioural scientist 38(8) 1104-1113.

Yontef, G. (1996) Shame and guilt in Gestalt Therapy. In R. Lee & G. Wheeler (Eds) The Voice of Shame. San Francisco: 390. pp. 370-371.