Elaine Noble Psychotherapy
Shoreditch

Could this be your New Year's Resolution?

March 17
Telling a story
Are you sitting comfortably? Then I'll begin. So began Listen with Mother but I was reminded of it when I began to think about the importance of telling stories and how important it is for us to be able to tell our story, of making sense of ourselves, our lives, of the world and in particular of making sense of trauma in our lives and the important part therapy can play in this. From Shekhar Kapur's TED talk We are the Stories we Tell to Tracy Chapman's album Telling Stories or Tim Burgess's (the Charletans) biography of the same name or the personal narrative part of the 12 steps programme, it seems I am not the first person to have realised that telling stories is a pretty pervasive human activity. We have been telling stories for as long as we have been able communicate. Perhaps animals also tell stories, pretty simple ones about where the food or danger is, but stories nevertheless. Children love to listen to stories, made up or read by carers and reading and film watching are some of our most popular pastimes. Apparently 60% of what we talk to each other about is personal stories, otherwise known as gossip.

Stories we tell each other contain raw data but an emotional narrative is woven around the data by the storyteller and this is what makes it interesting. The better the storyteller the more immersive the story and good storytellers have generally been highly regarded in society.

So it is the emotional part of story telling that makes it so gripping. And so perhaps here is the clue about the importance of our emotional story. We want the emotional part of the story, that's what hooks us in and perhaps in therapy the data part of people's stories becomes even less important and the emotional narrative is what it is all about. Not so much to entertain, as with a storyteller but to try to make sense. Being listened to while telling the story, being asked about gaps in the story, being asked about the feelings surrounding the events in the story, this is the bread and butter of therapy and it is unusual in this fast and furious world for people have the space and the time for this essential human activity of telling and being listened to while telling your emotional story. The story can get confused or forgotten or you begin to believe that no one will be interested in the story and this is when problems arise and as Maya Angelou said "There is no greater agony than bearing an untold story inside you."

There are also times in our lives when we need to be able to tell ourselves a story in a specific situation, when we have suffered a trauma, disappointment, bereavement, accident, illness and we need to try to understand it and make sense of it. So a story needs to be composed in a more limited sense, not as broad as how to make sense of out lives nor as narrow as where the food is but a story about which helps us to make sense of what has happened to us and how we can live on with this trauma.

So I wanted to encourage us all to think about our own story in order to make more sense of ourselves and the world around us and also to get help when you can't tell the story or you have forgotten it and find someone to help you tell the story inside you and to have your story listened to and attended to.






Dec 2016
Interesting article by Manu Bazzano entitled Healing and resilience in Therapy Today (BACP publication) which includes interesting comment and critique on neoliberalism
"Our very humanity is denied by neoliberal ideology. Low moods, fragility, sadness, vulnerability are disdained because they slow a person down... To pause and reflect on one's experience is seen as idleness. To quietly rejoice in the pleasure of living is to be unpractical."
Let's try to pause and reflect on our experience over the festive break and quietly rejoice in the pleasure of living for the rest of the year and hopefully on into the New Year as well.

Sept 16
Can you tell boys that they are crying like a girl? The article in the Independent suggests maybe best not.


Feb 15
Neuroplasticity. Could this be one of the ways that therapy works?

By the experience in the room with the therapist new neural pathways are created which enables changed in thinking, behaviour and feelings to happen?

The old pathways begin to be used less and so they degenerate and new ones are created which become more entrenched the more they are used. Three or four times weekly therapy is relatively unusual now and not favoured by the NHS but perhaps this is what is needed in order to establish new neural pathways and change established ways of thinking and being, to give neuroplasticity a chance to happen?

Dr Norman Doidge, scientist, psychiatrist and psychotherapist, and who has written The Brain that Changes Itself and The Brain's Way of Healing certainly believes that the brain is infinitely more adaptable and able to heal itself than was previously believed.

I'm sure that as research continues in this area it will show what many therapists already know, that change is possible and that even into older age we can learn new ways of being.

Good interview/article in the Guardian at the weekend


Dec 14
Just saw article in the Guardian about how it's easy to see in the family dramas which often take place at this time of year how human relationships might be a matter of long-suppressed wounds, unconscious resentments and similar forces beyond reason's grasp. I think it was something very similar to what I was trying to say here exactly a year ago so at least someone is thinking like I do even if he is more lucid and erudite!

So if you have one, enjoy Christmas with your family and at least you might be able to understand the tensions a bit better if you think about the "games" everyone is playing. If you don't have family to spend Christmas with then either you're having a less emotionally charged Christmas with friends, in which case lucky you.

Or perhaps, for the reasons suggested in the article, you are estranged from them, or maybe they are not around any more in which case that might be a cause of sadness, loss and regret. However I'm not sure that their absence or yours will stop the "games" even being played even if they now have to be played in yours and their minds.

Games, Burkeman said are a tolerable way to pass the time so, as he says, "I don't suggest you pick a petty fight with a sibling just for something to do. But I'll understand if you do. I probably will."



Nov 14 - parity of esteem
I have been hearing a lot lately about "parity of esteem" - treating mental health equally to physical health.

NHS England found that among people under 65 nearly half of all ill health is mental illness and that 6 million people in this country suffer from depression. Those are perhaps shocking statistics that are a sad reflection of the state of the mental health of our younger people.

But I began to wonder what equal treatment was and whether it was possible. Treating a broken leg or cancer is a relatively straightforward matter in some ways. The problem is diagnosed and treated if possible and the patient recovers, or treatment is not possible and the patient does not recover. Mental health is not so straightforward, the same drugs or treatments can have very different outcomes, the same treatment administered by different people can have very different outcomes especially if the treatment is a talking cure of some sort. Both diagnosis and treatment are difficult and unpredictable.

So I wondered if treating them the same was a helpful way to think about treating mental health conditions. Surely depression, anxiety and gloom are essentially human emotions which almost everybody experiences during their lives as a response to sad, difficult or traumatic experiences. However it is when those feelings are not just a temporary response to a specific situation but is a permanent state of mind, that people's ability to work, form or maintain relationships and to function begins to suffer. But this makes them essentially distinct from physical health problems which have organic and external causes and are not necessarily common human responses to experiences.

I also wonder about the effect on a patient's mental health of physical health problems and treatment. When someone realises that all is not well either physically or mentally or is diagnosed with an illness or undergoes surgery or other invasive treatments such as chemotherapy, suffers from infertility or a long term chronic conditions such as diabetes or multiple sclerosis, this has a huge effect on mental wellbeing. This impact does not seem to have been addressed in the report and there does not seem to be adequate provision for the often devastating effects on mental health both of the patient and their families of the impact of illness and suffering and the debilitating legacy it sometimes leaves.

It seems to me that physical and mental health are inextricably linked and that therefore when a patient is treated for whatever he is suffering from, both mental and physical health should be taken into account, talked about and managed. The rigid separation of mental and physical health does not seem to reflect people's experience of unwellness.

I'm not sure there are answers exactly, only perhaps more challenges in our thinking about illness and suffering.



Sept 14 - absence

It has been some time since I wrote anything here and so it got me thinking about absence.

Absence is a big subject. We are sociable creatures and we all need to be with other people. Of course we also need time on our own and peace and quiet is essential to our well being. Absence suggests an unwanted lack of the presence of someone else rather than a choice to be on one's own and absence often has a significant impact on others whether at home, school or work.

In the very early stages of our lives we are dependant on the presence of others to care for us, to feed us and keep us warm and in the absence of these needs being met we cannot survive. This lasts for an unusually long time in our species and this leaves a lasting psychological legacy on us. Although we do not remember those feelings of fear and abandonment we experienced in the very early days of our lives when our carers were not instantly there when we wanted something and it felt as if they would never be there again, somewhere in us those feelings leave a memory which can be activated in later life when people who we need and care about are absent.

Freud wrote about how children try to master the painful experience of absence. He noticed his grandson played a game which Freud called fort da with a cotton reel, making it disappear over the side of his cot and then pulling it back again in order to better able to manage the absence of his mother.

Hopefully we grow and mature so that we are not dependant on others to provide these basic needs for us but there are often times in our lives, whether through sickness, financial difficulty or pregnancy when we again depend on the help of others to provide for our needs. This can arouse mixed feelings in us. It draws us closer to people to have them provide for us and know that there are people who are able and willing to help us and that we can rely on them. This is what we hope for in our most intimate relationships. However when we have to rely on others it also forces us to confront the reality that we are not self-sufficient and omnipotent and that we sometimes other people's help and this can feel humiliating and difficult to ask for. The helplessness when we cannot meet our own needs and have to rely on someone else can be infuriating and frustrating.

Some people go to great lengths to ensure they are self-sufficient and need to rely on others as little as possible, whether by earning huge amounts of money or growing all their own food or producing all their own energy needs.

So absence, "the state of being away" as the Oxford dictionary defines it, arouses a mixture of feelings in us and can be a relief but can also make us aware of our own dependency and reliance on others which makes us realise that we are not self-sufficient and that isn't always comfortable. Perhaps that's the real reason absence makes the heart grow fonder, we realise that being on our own does not bring the freedom and liberty we thought it would.



Feb 14 - anxiety

I've been hearing a lot about anxiety recently and this week there were new NICE guidelines issued in relation to quality standards aimed at improving care for people experiencing anxiety disorders and so I thought it might be useful to muse about anxiety. The new quality standard does go some way to acknowledging the need for improvement in the recognition and care of people suffering from anxiety disorders which is a positive step for many suffers and hopefully means that treatment on the NHS will be improved. There are also many helpful websites (for instance the mental health charity mind) about anxiety which provide clear information about anxiety, its symptoms and some of its causes.

Studies suggest that 1 in 6 people suffer from anxiety or depression but that only 15% of those suffering are receiving treatment for it.

Anxiety can be extremely debilitating and people often feel a great deal of shame in admitting suffering from anxiety disorders. It seems as if people would prefer to have a physical cause of their symptoms and a diagnosis rather than accept that their symptoms are caused by a problem which 'is in their mind'.

It seems sufferers often try to minimise or dismiss the serious physical impact anxiety can cause and try to ignore the multitude of symptoms which can be caused by anxiety and the lifestyle changes they have to make to accommodate these symptoms.

Life events involving change often causes anxiety, exams, a presentation, moving house or a new job but these are usually short term and once the event has happened the person feels as they did previously. Or people can be anxious about the state of the world, global warming, the war in Syria, the fact that thousands of people in this country now rely on food banks to have enough to eat, but these anxieties do not usually cause long lasting physical symptoms. Anxiety disorders are different from these type of anxieties and involve worrying about everything, expecting the worst to happen and constantly anticipating disaster. Often people believe they have a serious illness or that they are about to lose their job because they are not good enough and all manner of worries which come to control their lives even though in some way the person 'knows' the worry is not rational or justified but nevertheless feels extremely real.

The shame of admitting to suffering from this kind of anxiety seems to be deep in both our psyches and our culture and studies suggest that over half of the people who suffer from anxiety do not go to the doctor. We do not want to believe that things which are not objectively real or cannot be proved scientifically are real. Is a feeling real? Is a fear that we will be rejected real? How can we prove that we are unhappy? The existence of these emotions which we know are real to us cannot be proved scientifically and this conflicts with our desire for rationality, clear explanations, evidence based beliefs and our demand for reasons for everything which we do and happens to us. We are, as people and as a culture, very averse to acknowledging and accepting the importance of subjective truths.

There are many ways of managing these types of anxieties one of which is mindfulness which has become very popular recently and many people find it helpful both in managing anxiety and also depression. Recently there was a beginners guide to mindfulness in the guardian and Oxford Mindfulness Centre is one of the organisations at the forefront of training and research on mindfulness.

Therapy too can be a very helpful place to think about these sorts feelings and fears with someone else. It may uncover previously unknown causes of such anxieties and how such anxieties have built up and multiplied over time. Often talking about such feelings confidentially to someone who has experience of and knowledge about anxiety and will not dismiss the feelings as unreal and imagined and be able to give you time and space to think about yourself and gain insight and understanding about yourself can be a huge relief and be an important start in managing this debilitating condition.


Jan 14 - New Year

It's a new year and so of course it's time for new year's resolutions. What were yours? Which? reported that the most popular priority was to lose weight but perhaps it was to join or go to the gym. However 77% of consumers admitted to Crunch.co.uk that they did not stick to their new years resolutions and Which? reports that 'Brits' waste £37m a year on unused gym membership. Whatever it was will you be able to stick to it, achieve what you want? Why do we find it so difficult to get what we want and be who we want? There seem to be unseen forces of which we are unaware or dimly aware which stop us from achieving our goals and making the changes we say we so desperately want.
That is probably because there are unseen forces at work preventing us doing what we say we want and think we can do and psychotherapists call it the unconscious. There is an amazing reluctance by people to accept the existence of the unconscious and yet only a moments thought will strongly suggest that it exists and is more powerful that we would like to believe. It is a huge subject about which reams has been written by awesome people but I like to think of it as dark matter.
The existence of dark matter has been inferred by scientists to explain the discrepancy between mass determined by gravitational effects on large astronomical objects compared to the mass of what they contain, stars, dust and gas etc. So the unconscious is inferred by psychotherapists to explain the discrepancy between what we say or think we want to do or be and what we actually do and say. This may seem simplistic but it is one way of thinking about the unconscious. Although it feels uncomfortable to think that we are not wholly in control of what we think and do I wonder how many of us truly thought we were when we look at our lives and the way we behave and perhaps some of our public figures behave too!
Change is always challenging as it involves leaving familiarity and control behind and stepping into unknown territory which is one of our greatest fears.
Therapy was designed so that these unconscious desires, fears, conflicts, wishes and ideas could be explored and discovered and we could then understand why we behave in certain ways and what it is that is controlling our actions in such a powerful way. It can be surprising and sometimes disappointing to find what is lurking there in the unconscious but it is always fascinating and each person has a truly unique unconscious, like their fingerprints. When we begin to discover and become familiar with that part of ourselves which has previously been hidden, after we get over the surprise and outrage, we get a sense of being more of ourselves, feeling more at home with ourselves, understanding oursleves which is enriching and comforting.

Dec 13 - Xmas

It's nearly here and Xmas means so many different things to different people that it seems worth thinking about it.
People often have strong childhood memories of Xmas and it can be a special and magical time for children when presents arrive that they have wanted, hoped and waited for, family and friends are around, time seems to float and it seems exactly what children dream of. However for others the stark reality of poverty, neglect, family breakdown and damaged relationships are exposed and magnified, arguments and resentments festering and boiling over in between turkey, mince pies and disagreements over the TV.
As we grow older earlier experiences of Xmas loom large in our minds and the pull to either repeat what we have experienced or do exactly the opposite feels hard to resist. It often takes a significant external event such as marriage, divorce, birth or death to change patterns which have become habits at this time of year. At Xmas we come face to face with family politics and personal realities which can raise awkward and difficult questions. Who will I spend Xmas with, why am I still on my own, who will pay for it and why do I have to cook again? All we want to do is have a good time and enjoy some good company and tasty food. But all too often the reality is very different. We end up spending Xmas regretting what we don't have or weren't given, wishing people were easier to get along with or silently begging our partner, parent, in-law, just to "relax", desperate to get back to work, the break from which only days before we were eagerly anticipating. Why is that?
Perhaps those earlier experiences of Xmas and indeed during the rest of the year, cannot be so easily put aside for the day, we carry them with us as resentments, anger or hurt. Feelings of not being attended to, understood, getting what we needed or wanted or not being cared about enough are powerful and fundamental emotions which cannot simply be forgotten for the day. They have caused a scar which we cannot ignore and pain which has become woven into us. They lurk close by us and although we wish we could forget them and move on, they are too painful to be ignored and must be acknowledged and attended to.
Perhaps they are the psychic equivalent of skeletons in the cupboard which come back to haunt us if we do not face them. Xmas seems to be one of the times that these uncomfortable feelings can rise to the surface and overshadow the festivities as we spend time with the very people who were responsible for us all those years ago and go to places where those experiences happened or even sleep again in the room where they were wept over.
Therapy helps to acknowledge those feelings and talk about them with another person who can listen and help unravel them so they are no longer foreign feelings we wish we didn't have, don't really think are "us" or attribute to everyone else. We can learn to understand ourselves and all our feelings whether they are peaceful pleasant feelings of generosity and caring or less festive feelings of resentment and irritation. Therapy enables us to think about our feelings honestly and work through them so that they do not return in unwanted and unexpected ways or at moments when all we want to do is to have a Merry Xmas.



Nov 13 - Anti-depressants

There is a special report on anti-depressants in the the guardian today. The report suggests that anti-depressants are an important treatment for depression but are most effective to treat serious clinical depression caused by chemical imbalances in the brain. However GP's tend to also prescribe them for more mild cases of depression for which there is less evidence of effectiveness, hence the headline "Unhappiness being medicalised, warn time-poor doctors". The report also suggests that depression is being diagnosed more widely than it used to be and it cites China as an example of somewhere depression is beginning to be recognised and the prescription of anti-depressants has increased hugely. Patients seem to think that although medication is an important part of their treatment, talking therapy is also a vital part of their long term recovery.
The report mentions a number of times that access to talking therapies is poor or patchy. It is true that despite NICE guidelines indicating talking therapy is the preferred treatment for certain types of depression and GP's having more control over spending their budgets, few GP's refer patients with mild depression for talking therapy on the NHS. It seems occasionally, as the guidelines suggest, some patients are given written materials or details of web based self help programmes based on CBT principles which is supposed to be supported by a trained practitioner but rarely seems to happen and more often just the materials are provided without the trained practitioner. This clearly is not talking therapy for the obvious reason that there is no one for the patient to talk to, only a recording to listen to and instructions to follow when what the patient needs is to be listened to not to listen.
One problem is that talking therapy is a blatant challenge to the medical model which is built on the premise that there is a biological cause of all illness which needs to be diagnosed then treated. Doctors are thoroughly trained and immersed in this model but it doesn't always work very well for mental health problems because the symptoms can be misleading and there often does not appear to be a biological cause. Is sadness when a relationship ends for example, biological? It may cause biological changes in the brain and the body but the cause is not biological it is psychological and emotional. The medical model tends to ignore these aspects of pain, illness, suffering and also of treatment.
Sadness, loneliness, loss and unhappiness are not medical conditions they are part of being human and the human response to it surely is to talk to and share the feelings with another human being who will listen, is understanding and not judgemental and is empathetic and if necessary challenging?
There are many therapists who have undergone extensive and rigorous training in order to fulfil this role and there are many people who have personal experience of the positive effects and change that talking therapy can have. Therapy is widely available.

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