COPYRIGHT CITY SANCTUARY THERAPY

No part of this website, including the blog content may be copied, duplicated, or reproduced in any manner without the author’s permission. Any information, materials, and opinions on this blog do not constitute therapy or professional advice. If you need professional help, please contact a qualified mental health practitioner.

Adverse Childhood Experiences/Childhood Traumas

What are ACEs/Childhood Traumas

Adverse childhood experiences (ACEs), also known as childhood traumas encompass the big stressors ” big T traumas”, and any other events which undermines the child’s sense of safety & emotional well being -“small t traumas”.  We often overlook the significance of these events unless if we examine  their impact on the child (0-17), who has no emotional capacity to process them. These traumas are not only actual events, but non-events, and deficits, that have a negative impact on the emotional wellbeing of the child. Our experiences in early life shapes our physiology, and brain structure which is primary to the developing personality. Contemporary studies in Adverse Childhood Experiences (ACEs) suggest that individuals  suffer “disrupted neurodevelopment” and “social emotional and cognitive impairment” following exposure to adverse and traumatizing environments during their development, which is associated with later costs to both mental health and physical health (Peckham, 2023).

The medical model has historically neglected the impact of the environment in “psychopathology”, until recent years where there is an acknowledgment of the intersection between early life traumas, and the development of emotional and psychological problems in adulthood.  In contrast, psychotherapy, particularly the analytic approaches, have always  put greater emphasis on the early life  experiences in the formation of one’s personality, and the development of “psychopathology” in adult life.  I am quoting psychopathology as it implies scientific knowledge, and conceptualisation, which goes against the non scientific  model of trauma which l am subjectively in favour of. It is true that most people who seek mental health treatment, or psychological interventions have a history of complex trauma, or some form of early trauma/s.  This means, without acknowledging the significance of ACEs,  these individuals would have their suffering pathologized, and diagnosed as having some mental disorders, and subsequently medicated- they simply become commodities in a system that seeks to label and medicate.  The psychotherapy world is experiencing a paradigm shift,  to a trauma informed  approach– which is ecological rather than pathological framing. This approach privileges the impact of life experiences, over underlying “pathology“. The trauma informed approach gives weight to the early life experiences, in shaping ones adult way of functioning; it also seeks to de-stigmatize, and de-pathologize one’s suffering.

My work as a therapist, and mental health practitioner, as well as my own lived experiences has given me the full appreciation of the impact of our life experiences in the formative years, in shaping ones subjectivity, personality, ways of viewing the world, and relating to others. I fully endorse and subscribe to the trauma informed model- philosophically and as an approach to therapy. I strongly advocate for an ecological approach, rather than medical approach, which often gives people fixed labels, without a consideration of the contextual factors behind ones emotional and psychological suffering.  Emotional and psychological suffering should not be viewed as some form of pathology, that should require a fixed diagnosis.  I fundamentally believe that as therapists, by focusing on psychiatric diagnoses and labels, we are unintentionally shaming our clients, and objectifying them as simply a “psychiatric diagnosis”. This has the effect of invalidating their unique lived experiences and the traumas that is behind one’s psychological distress.  That said, l am not anti-psychiatry; l fundamentally believe that the medical model and the trauma informed approach can inform each other, and work collaboratively, resulting in a more holistic way of working. Having alternatives also mean clients are empowered; they have options to choose between the medical or trauma informed approaches to address their difficulties.

Many research studies have  demonstrated the negative impact of adverse childhood experiences on an individual. Neuroscience Research (Amann, 2022) has proven that having a combination of ACEs increases the likelihood of developing mental health and emotional difficulties in adult life; three times higher  than the average person. This study examined 93000 cases, and concluded that those who experienced childhood traumas are 15 times likely to be diagnosed with borderline personality disorder. BPD is a personality disorder where the sufferer experiences difficulties with regulating emotions and experiences the world in extreme (black and white) terms. This leads to intense highs and lows, as well as other self-destructive behaviours. People with BPD often have great difficulties building and maintaining healthy relationships, as well as emotional regulation.  The formative years are crucial to personality development and some people’s emotional challenges in adulthood are directly related to a combination of environmental and psychological factors in their upbringing. Other studies on ACEs have been carried out by Kaiser Permanente and the Center for Disease Control in the USA involving 17,337 adults and correlated the number of categories of adverse childhood experiences (ACEs) with physical and mental health outcomes.

Allan Schore’s (2000) research and  pioneering work highlights the likelihood of people who have experienced childhood trauma- which corresponds with brain development- experiencing mental health challenges in adult life. Like Fonagy, he puts emphasis on the developing child’s capacity to emotionally mature, enabled by their environment-the attachment  with mother and relationship with mother who is able to help the child to regulate affect.  Schore coins the term ‘relational trauma’ bound in the traumatogenic experiences happening within the ordinary transactions between parent and baby in the course of looking after the baby. Through the research work there is evidence that early trauma impacts the child’s brain development, attachment styles, capacity to mentalise, which are the hallmarks of emotional and mental health difficulties in later life. Martin Teicher  researches on child abuse and maltreatment argues that “Brain development is directed by genes but sculpted by experiences” (p652). These approaches are viewed by many as medical, as they conceptualise that trauma leads to physiological changes in the brain development and functioning, leading to psychopathology. The focus is on the link between physiology and pathology.

Among other vital research, Young Minds (2018) and Bellis et al, (2014) concluded that having a situational or cumulative ACEs led to poor mental health in adult life. ACEs affect the child’s emotional development, which translates to problems with relationship with themselves, others and the world as adults. Apart from experiencing mental health difficulties in later life, people who had a combination of ACE are likely to have drug and alcohol problems, have early or unplanned pregnancies, are likely to be involved in crime, and likely to end up in the criminal justice system. Aman (2022) concluded that ACEs were related to mood disorders, depression, PTSD, anxiety disorders, eating disorders, schizophrenia, and substance abuse. For every reported type of abuse experienced in childhood, a participant’s risk for PTSD increased 47%. Each cumulative trauma also increased one’s risk for making a suicide attempt by 33%.

Examples of ACEs are:

• Physical Abuse
• Verbal abuse
• Sexual abuse
• Emotional neglect
• Parental divorce/separation
• Parental sickness or ill health
• Having a parent who experienced mental illness
• Having a parent  who went to prison
• Living with a parent who abused drugs or alcohol
• Living with a sibling who has a disability or mental health challenges
• Exposure to parental conflict-family dysfunction
• Loss through death-parent/sibling or family member
• Loss of home-boarding school, foster care
• Loss of home- foster care/adoption, house moves
• Loss of home through emigrating and or house moves
• Childhood sickness & illness eg asthma, cancer, eczema etc
• Development issues eg stutter, dyslexia, bedwetting
• Bullying
• Relational Trauma in how the child is cared for by the parent
• Accidents-car/fires/etc
• Wars/conflict
• Parental Responsibilities

The Child and the Adult

It’s easy to overlook the significance of childhood ACEs unless if we unpack and understand their long-lasting impact on one’s way of relating to the self, others, and the world, as well as one’s overall personality. Many people come to therapy unaware of the fact that some of their experiences in childhood were adverse. At times it’s a defence (Klein, 1946) against the pain of acknowledging it, while others simply genuinely lack the understanding, or the language to express it. Having an awareness of how an experience that was adverse or traumatic is impacting on one’s current life is significant. Not only is it validating, but helps that person integrate the trauma, and work through it. Knowing something about ourselves, helps us develop a more intimate relationship with ourselves, and relate to ourselves in a more sophisticated way. It makes that problematic issue less scary and we can also approach it with compassion.

Trauma and Privilege

Having a privileged life does not mean one is immune to ACEs. Parents who can provide economically but  emotionally cold, cause significant psychological harm to the child. A child who has been send to boarding school (rupture from their care givers & emotional support) is no different to a child who is placed into foster care. The emotional impact is the same.  The only difference is one has an economically privileged life, while the other comes from poverty. In her book on Boarding School Syndrome Joy Schaverien writes, evocatively, about the trauma of the privileged child who is removed from home, and send away to an artificial environment (boarding school) away from the primary care givers (Schaverien, 2015). Bullying is rife in boarding schools, and the children are deprived of love, physical affection, and emotional warmth, something that they fundamentally need in these formative years. Drawing on real life stories from ex-boarders, she is able to demonstrate how people who went to boarding school earlier on in their lives tend to experience significant difficulties with intimacy, sustaining emotional connections, have an impoverished sense of self, and lack confidence in adult life. This creates secondary issues in relationships -both romantic and interpersonal. Many ex-boarders have been negatively impacted by the separation from their care givers at a young age, tend to feel a lot of guilt and shame, and that they have no right to complain about their parents for creating such a solid foundation for them. These contradictory feelings invalidates their trauma and leaves them feeling even more isolated in their pain.   It is always important to reflect on the experience from a child’s perspective, not an adult; the adult is able to make sense of a lot of things that the child was incapable of.

Immigration and Loss of Home

 Many people do not recognise the significance of rupture from one’s home, and the impact of not having consistency in childhood. Whenever there is a move, we experience loss of home- the environment- as well as the relationship we create with that home (environment) and other people in our lives. When children are moving from one place to the other, whether it’s a one off or repeated moves, there is an internal sense of loss they experience. There is a breakdown of attachments (emotional bonds) (Bowlby, 1969) they create with the home itself, their friendship groups, teachers etc. This leaves emotional scars where in adulthood, attaching to others is avoided as there was never a sense of permanence in their world; attaching also means experiencing loss, so their relationships remain very superficial albeit unfulfilling. In adult life it’s not unusual for these people to have difficulties building and sustaining long term relationships, and having deep emotional connections with others. Some may also have identity issues, and feel rootless at an emotional level, and untethered in life.

Parental Divorce/ Separation

Most of the ACEs listed above happen in the children’s home environments, where there is either one or both parents present. It’s obvious that any form of abuse negatively impacts on the child; parental divorce and separation also does. While it may be the best outcome for parents and the children,  children inevitably experience loss of a parental unit, a family unit, and a disruption of their lives. The parental situation is not something that they can inform, nor make a decision on- as a result children of divorcing parents tend to blame themselves for the divorce, or feel that they are a liability. The adults involved often overlook the meaning of parental divorce and separation on the children  as the focus is on themselves. Ongoing parental discord does compound this trauma, while healthy co-parenting mitigates some of the trauma.

Parentification

Another ACE to keep in mind is when the child is being given parental responsibilities, also referred to as parentification. It is not unusual for parents to give their children adult or parental responsibilities and to be put in that role. This is typically the oldest child who is made to look after their younger siblings, or becomes an emotional confidant for one or both parents. It can also be a child who is made to manage other household chores, budgeting, etc. this takes away the child’s innocence and right to be a child who does not have adult responsibilities. Often, we hear people say “she/he is very mature for his age” implying that its a good thing. What we do not recognise is that we are burdening a child with adult responsibilities, and the perceived maturity is the only way that child had to cope with the situation. People who were parentified often turn out to be adults who are not very good at prioritizing their needs and advocating for themselves. They also easily become people pleasers, and may struggle with recognising when they are being exploited.  This is because as children, they never learnt to fully take care of themselves, as the attention was on others. They also lack the sense of justice  and injustice- boundaries-as their own boundaries were infringed at a very young age.

Abuse

It is no surprise that children who experience any form of abuse-physical, emotional, sexual and neglect will develop some psychological and/or  mental health challenges in adult life. Healthy development of a child is highly dependent on an environment where there is emotional safety,  where the mother  or care giver is able to make both environmental and emotional provisions for the child. The care giver has to be emotionally available and attuned to the child (Winnicott, 1960). Any adverse experiences will interrupt the normal and natural psychological development of the child. Children do not simply mature physically, but emotionally-they have certain milestones that they need to successfully reach and succeed. Without his holding environment and the presence of ACEs mean that the development can be arrested at any time. This means a lack of psychological maturity which translates to mental health problems in adult life. Neuroscience confirms that the child’s brain develops differently where there is abuse.

Discord in Parental Relationships

Children who grow up exposed to parents’ fights are indeed being harmed by those experiences. It is adverse and damaging for the child to witness directly to have an indirect awareness of parental discord. Children need to grow up in an environment where there is emotional warmth and safety. Even if the fights are concealed from them, children are very sensitive and emotionally perceptive. Children do very easily blame themselves and adapt according to what they think is best for the parents, not for them. This means that the children end up looking out for the parents, and putting their own needs down. They mould their world around their parents’ not according to their own growth trajectory.  Many parents stay in dysfunctional homes “for the sake of the children”. What they do not realise is that, raising children in an emotionally volatile environment is more harmful, and damaging to them than having two happy and warm homes, they can spend time in. Some cultures promote the idea of staying in toxic relationships for the sake of the kids which is damaging for them. For any parents, recognising the different ACES, minimising the exposure to them, and cultivating a healthy environment where the child is nurtured emotionally, supported, and their wellbeing prioritised is key.

Therapy and Healing Trauma

Neuroplasticity

Neuroplasticity refers to the capacity of neural systems to adapt and change. Neuroscience suggests that neurons in many parts of the brain continue to undergo structural change not just through childhood and adolescence, but throughout life. This means that any new experiences, at whatever age, can cause the brain to physically alter its synapses and change. In other words, we are stable enough in our environment because our genetic inheritance has been sculpted by natural selection over many lifetimes, but we are “plastic” enough to adapt to our environment within our lifetime. Peckham (2023) argues that “For so many mechanisms of neuroplasticity to have evolved indicates that the capacity to learn from and adapt to past experiences and to better anticipate the threats and opportunities we may have in the future enhances inclusive fitness, survival, and reproduction in our environment. p.5.

Trauma informed approach therapy validates one’s lived experiences and acknowledges the link between presenting symptoms and early trauma-ACE/s.  Since our brains are capable of changing, we can recalibrate them, and re-adapt to new experiences. The new “new experiences” can be used to heal or mitigate the impact of previous experiences; psychotherapy being an obvious candidate for “new experience”. The intersubjective relational work done in therapy enable people to work through the ACE trauma. The trauma informed approach is anti-shaming- it is very easy to shame our clients in therapy and retraumatise them, which also re-confirms their trauma. If the “new experiences” contradict the old experiences, clients are able to develop new ways of relating and being. This is what defines healing. Repeated shaming experiences generate an anticipation of shame and the experiences that trigger it. This anticipation may be referred to as toxic or chronic shame where the shame experience organizes a person’s identity and life around avoiding the anticipated and feared shame experience. Shame-driven distress and suffering is common across experiences of trauma and adversity.  “Recovery can take place only within the context of relationships; It cannot occur in isolation. In her renewed connections with other people, the survivor recreates the psychological faculties that were damaged or deformed by the traumatic experience. These faculties include the basic capacities for trust, autonomy, initiative, competence, identity, and intimacy. Just as these capabilities are originally formed in relationships with other people they must be reformed in such relationships” (Herman, 2001, p101).  Herman’s words highlights  why therapy is a fundamental aspect of healing childhood trauma. Van Der Kolk one of the pioneers in the trauma gives emphasis to the neuroplastic nature of the brain and the ability for trauma to be worked through in therapy. He postulates that traumatized people experience incomprehensible anxiety and numbing and intolerable rage, and how trauma affects their capacity to concentrate, to remember, to form trusting relationships, and even to feel at home in their own bodies. This work can only be done in a therapy where there can be repair to the damage caused by trauma. For more on the trauma- The Body Keeps the Score by Bessell Van Der Kolk and The Myth of Normal by Gabor Mate are excellent copies on trauma and healing.

Attachment Styles- Secure Attachment

Bowlby’s work on attachments-internal working models – relationship templates we create in childhood suggests that they can be repaired throughout the course of life. ACEs  lead to people having unhealthy attachment styles-avoidant, anxious, disorganised.  This create difficulties in interpersonal relationships as the attachment style informed behaviours and distress responses get reactivated in adult relationships. However through therapy, we can heal  and redefine these ways of relating to more secure relational patterns. The relationship with the therapist is a strong conduit for these attachment working models to change, as we can learn to trust others as reliable consistent, nurturing, and trustworthy beings.  The therapist can be experienced as a reliable care giver, and the therapy space becomes  a secure base. Donald Winnicott would have viewed this as  providing “corrective emotional experience”.

Understanding the significance of ACEs helps us make sense of why some people experience emotional challenges and psychological distress in adult life. No one is damaged, we have the capacity to heal and heal others through our own healing.

References

Amann, B.,  (2022) Trauma During Childhood Triples the Risk of Suffering a Serious Mental Disorder in Adulthood, European Archives of Psychiatry and Clinical Neuroscience.

Bellis, M.A., Hughes, K., Leckenby, N. et al. National household survey of adverse childhood experiences and their relationship with resilience to health-harming behaviours in England. BMC Med 12, 72 (2014). https://doi.org/10.1186/1741-7015-12-72

Bowlby, J. (1969). Attachment and Loss, Vol. 1: Attachment. Attachment and Loss. New York: Basic Books.

Fonagy, P. and Target, M. (2000) Mentalisation and personality disorder in children: a current
perspective from Anna Freud Centre. In Lubbe, T. (ed.), The Borderline Psychotic Child, 69–89. London: Routledge.

Herman J.L. (2001). Trauma and Recovery: From Domestic Abuse to Political Terror. Pandora ed. New York, NY: Basic Books

Klein, M. (1946). Notes on Some Schizoid Mechanisms. International Journal of Psychoanalysis, 27, 99-110.

Peckham, H. (2023). Introducing the Neuroplastic Narrative: a non-pathologizing biological foundation for trauma-informed and adverse childhood experience aware approaches.  Journal of Frontiers Psychiatry,  Psychopathology Volume.

Schaverien, J. (2015). Boarding School Syndrome: The Psychological Trauma of the privileged child: Routledge, London.

Schore, A.N. (2000) Early relational trauma and the development of right brain. Unpublished invited presentation. London: Anna Freud Centre

Winnicott, D. W. (1960). The theory of the parent–infant relationship. In: The Maturational Processes and the Facilitating Environment (pp. 37–55). New York: International University Press, 1965.

Image Credit- Chen Mizrach Unsplash

COPYRIGHT – CITY SANCTUARY THERAPY

No part of this website, including the blog content may be copied, duplicated, or reproduced in any manner without the author’s permission. Any information, materials, and opinions on this blog do not constitute therapy or professional advice. If you need professional help, please contact a qualified mental health practitioner.

Why are some people emotionally sensitive than others, & why do some people experience emotional difficulties more than others? There are a range of personality tests, for example- the Myers Briggs, SAPA Project Personality Test, Helen Fisher Personality Test, and Ennegram Personality Tests. Each one of them reveals that we are all unique,  and we have varied traits and personality types. Even identical twins who grew up in the same environment, and had similar experiences throughout life will never have identical  personalities. Within these personality domains, we all have our strengths and weaknesses.  Having high intellectual abilities does not correlate with high emotional intelligence. Paradoxically, it is  often the case that people who are highly  intelligent struggle with understanding and making sense of their emotions. This may be because while they have developed their intellectual capabilities, their emotional abilities are not as developed. Personality is not something we acquire; it’s something we develop throughout our lives. The formative years are crucial to personality development and some people’s emotional challenges in adulthood are directly related to a combination of environmental and psychological factors in their upbringing.

Despite growing up in the same environment, siblings do not always turn out the same. Some turn out to be more emotionally buoyant and robust than others, who may be more sensitive or have difficulties managing emotions. We may have siblings who developed some mental health challenges-anxiety, depression, Emotionally Unstable Personality Disorders/Borderline Personality Disorder, or just struggle with regulating emotions. Or we are that person. It can be distressing to have a sibling who experiences  emotional difficulties, or to be that person who  suffers from mental health problems and or emotional difficulties. In some cases, it often leads to parents and siblings blaming themselves, or each other for causing these difficulties. Some parents tend to view their children developing emotional difficulties as a sign of failure in their parenting. This is a key reason why some people who may have been raised in homes where they had everything they needed environmentally and economically, struggle with seeking help. There is often a sense of guilt attached to their struggle, and they feel that they do not have the right to struggle. To them it also means they have failed or translates to their parents having failed. It’s as if they have no right to complain, struggle or suffer. Yet they are only human.  Children need more than just economic provision. Emotional warmth, nurturance, co-regulation with adults, emotional safety, and adults who are emotionally attuned to the developing infant are all key to how we develop our ability to emotionally regulate as adults.

How do we develop emotional difficulties in adulthood

1- Biology

Biology (genetics) plays a big part of our makeup. Epigenetics is the study of how changes in the external or internal environment impact gene expression.  Fonagy views our capacity to seek attachments as part of our biology and genetic inheritance. He considers that there is a gene- environment interplay which shapes how we develop biologically. The environment is the attachment relationship.   Neuroscience research proves that sensitive people have certain gene variations which create activity in certain brain regions. Martin Teicher  researches on child abuse and maltreatment argues that “Brain development is directed by genes but sculpted by experiences” (p652). This means that our genetic make up is shaped by our environmental experiences.

2-Psychological

Childhood trauma-abuse, neglect, prolonged stress in early life, childhood illness, early loss through death or separation. Research suggests that people who experienced adverse childhood experience are likely to struggle with their emotions and develop severe mental health difficulties in adult life (Young Minds, 2018; Bellis et al, 2014).   1 in 3 people with mental health problems had adverse childhood experiences. Read my blog post on Adverse Childhood Experiences where there is more information about ACEs. Though his pioneering work Allan Schore evidences that the brain development of people who are brought up in environments where there is trauma and maltreatment is significantly different to those who were raised in more nurturing environments. He considers the emotional relationship between child and caregiver as the environment for brain development and that brain development is an adaptation to that environment. Allan Schore’s (2000) research highlights the likelihood of people who have experienced childhood trauma experiencing mental health challenges in adult life. He terms this ‘relational trauma’ bound in the traumatogenic experiences happening within the ordinary transactions between parent and baby in the course of looking after the baby.

2- Environment

The environment we grow up in plays a huge part in how we manage emotions as adults.

Environments where children grow up with adults who are emotionally dysregulated themselves only lead to adults who are unable to regulate emotions emotionally. “You cannot speak a language you never learnt”.

Environments were adults invalidate the children’s feelings & the child is made to hide their true feelings (sadness/shame, anger etc) lead to adults who never learnt to bear difficult feelings.

Environments where the child has to constantly tune into the parents’ own emotions, ie disregarding their own emotions.

Environments where the parent is absent from the child’s emotional landscape -emotional neglect.

An environment where healthy emotional expression and emotional regulation was modelled is key to healthy emotional development and expression in adult life.  Psychological trauma also predisposes some people to having difficulties with their emotions. Psychoanalytic theories put greater emphasis on the ability of the parent to offer a form of emotional containment (Klein, 1946;  Bion, 1962). They  give value to a care giver who is emotionally attuned (good enough mother) and creates an environment (Winnicott, 1960) where the child can feel emotionally held by the parent. Without this, the child never develops the capacity to manage difficult emotions, which should be moderated by the parents, and handed back in a palatable and less toxic form- Bion calls this “containment”. Winnicott (1960) also uses the concept of mirroring where the baby develops reflective abilities through the mirroring of mother’s affective states and learn to emotionally regulate  as a result- omnipotence- and integrate the mother as a good object . The mother has to be attentive and attuned to the baby’s emotional states; in some cases the mother fails to facilitate the mirroring process which has negative consequences on the baby’s developing psyche.

Attachment and Affect Regulation

Through his scientific research work, Peter Fonagy proposes that we have an inbuilt biological evolutionarily advantageous potential for an interpersonal interpretive capacity: the capacity to ‘read’ and understand the mental states of others and our own (Fonagy, 2000). He terms this mentalisation. However this capacity can been diminished as a result of prolonged exposure and adaptation to an ongoing stressful caregiving relationship in childhood. This interruption often creates difficulties in understanding and attuning to other people’s affective states in adulthood- inability to mentalise, and difficulties with emotional regulating. This is indeed a form of relational trauma which stems from a mother not responding to the baby’s affective states, and therefore not developing the capacity to regulate affect.  Fonagy developed a therapy approach called mentalization which is essentially learning to develop  the capacity to reflect on one’s affective state and that of others. Fonagy’s  mentalization approach is commonly used in the treatment of BPD and it has demonstrated positive result. Most people’s struggle with emotions is due to their inability to emotionally regulate, and to reflect on their affective states, and that of others- mentalise.  This has a huge impact on interpersonal relationships, and managing one’s own emotional reactions. The capacity to mentalise is rooted in the child’s attachment relationship with their  care giver, and it is something that can change throughout one’s lifespan.

Neuroscience

Allan Schore’s work on brain development and emotional growth, highlights the significance of  affect regulation, which is developed in childhood. He views  the capacity to manage emotional states  as a neuropsychobiological developmental achievement, arising out of the early mother-infant relationship. In normal development, the child learns to regulate their own emotions, initially through a process of co-regulation with the (maternal) care giver . Schore considers the capacity to experience, communicate, and regulate emotions as key milestones in the development of the human infant, which is heavily dependent on the quality of the relationship with the care giver. Pathology develops when the child is left in heightened emotional states, leading them to develop maladaptive ways of coping with emotions, something that continues in adulthood. The interaction between brain development and the environment which is seen as key.  Schore links the infant’s right brain maturation- ability for affect regulation- giving significance to the early interpersonal affective experiences with care givers.  This development has an impact on other parts of the brain-limbic system- which deals with processing the processing of physiological and cognitive components of emotion. Schore centres human emotional development to the ability for the brain to self organise, and the infant to interactively regulate.

Alexithymia and Autism

Some people do not experience emotions at all, a condition called Alexithymia.  Some, but not all people who are on the autistic spectrum experience difficulties with experiencing certain emotions, such as empathy. Alexithymia and Autism are two distinct conditions; however some people who are Autistic can also be Alexithymic. Like Autism, Alethythimia has a spectrum. Some people may have the trait (primary) or secondary Alethithymia where it is situational- for example where there is trauma, PTDS symptoms may lead to the subject experiencing  difficulties identifying their emotions. Anyone who is Alexithymic  lives in a world where there are no emotions, and they rely on their cognition to make sense of the world.  They may be able to say “l love you”, ” l am sorry”, etc but they are not able to emote, or relate any of their life experiences to an emotion. Their bodies do not respond to any emotional states- for example anger means heart racing, anxiety means restlessness, sadness means tears etc.  This must make their world both obtuse and abstract. The lack of emotion creates a lot of challenges in interpersonal, and romantic relationships. Resultantly, people with Alexithymia are very vulnerable to having relationship problems, and depression.   Alethythimia is associated with trauma, and extreme emotional neglect in childhood. One may hypothesise that the emotional blankness may be a result of a defence the person created as a child, in an environment where there was emotional neglect or trauma (Klein, 1946). This defence then becomes part of ones personality, and remains present in adulthood.

Emotional sensitivity or having difficulties managing emotions is not a sign of weakness. Having relationships where our feelings are validated & checking in with oneself is crucial. Knowing one’s vulnerabilities- what’s likely to bring out the sensitivity can also help in mitigating it.

                                                  Logic of Emotions -Triune Brain Theory

Dr Paul McLean proposed the evolutionary brain theory back in the 1960s- see image below. Today, this theory is widely accepted in the field of psychology.  He viewed the brain as having three main layers, superimposed on each other, which developed at different stages in our evolution. Viewing the brain as an entity that is composed of these 3 layers, helps us understand why sometimes we do things that are contradictory to how we feel, and that defies our usual way of doing things. This is so because our behaviour is at times controlled by our reptilian brain (behaviour-reflex), or our creature brain (emotional response). Recent studies have concluded that neurons in many parts of the brain continue to undergo structural change not just through childhood and adolescence, but throughout life- any new experiences, at whatever age, can cause the brain to physically alter its synapses-a characteristic known as neuro-plasticity.

The Truine brain model also helps us understand why some people struggle with managing emotions, which means they have not nurtured, and not fully developed their emotional (middle) part of the brain. This can be done, and therapy helps. Today’s society values reason over emotion, people who experience difficulties regulating emotions are often left feeling alienated and misunderstood. Emotions have their own logic, quite distinct to the logic of intellect. Its vital that we comprehend the logic of emotions.

Triune Brain Illustration (Image credit to Dimitri Roman)

Reptilian/ Mammalian

This is primitive and innermost part of the brain which deals with instinct, survival, safety, territory and repetition. It’s the part that is reflexive and triggers the fight, flight, freeze, reactions when there is perceived or actual danger.  We inherit this brain from all the animals in the animal kingdom, which we are a part of. For example, if there is a loud bang, the mammalian brain triggers a response for us to either run (flight), freeze (hide) or find out where the bang is coming from (fight). This part of the brain is what creates most difficulties in interpersonal relationships, where people are reactive, not reflective.

Limbic Brain- Creature Brain

This covers the mammalian brain and is more sophisticated. Also called the creature brain, it is the part that emotes, and helps us make emotional connections to experiences. It helps us make sense of our senses-pleasure pain and enables us to nurture, experience humour, grief, playfulness and other social experiences.  It also handles our behaviours and motivations and helps us make connections between experiences and emotions. We experience a range of emotions through this part of our brain. It’s the part that is also able to make sense of the need to keep away from things that brings us displeasure and draws us to things that brings us pleasure. Using the example given above of hearing a loud bang-this part of the brain helps us recognise the feeling it evokes-fear, anxiety etc

Neo Cortex

This part of the brain is the recently evolved part, and it’s the part that deals with anything intellectual, logic and reasoning. It deals with facts- why, how and make sense of the world in a logical manner. This part is highly developed for many people as it can be developed through learning and exercising our intellectual abilities. Drawing on the example of the loud bang,  its the part that seeks to investigate what caused the bang, why, where and make sense of it.

Discussion- Therapy and Emotional Maturity

Using the Triune theory, people who struggle with emotions have not fully developed the emotional part of their brain and this could be for several reasons. The environment is primary to how we learn to relate to emotions, so is our biological  make up, although (l believe) this is secondary. In many cases, it also means that the intellectual part of their brain is very well developed, while the emotional part has not been sufficiently developed. The primitive part of the brain is something we cannot change. However, we can learn to tame it if we use the emotional, and intellectual part of our brain and make sense of situations that are perceived as threatening. This philosophy informs Cognitive Behavioural Therapy (Aaron Beck), as well as Mindfulness.

Peter Fonagy’s Mentalisation Based Therapy (MBT) approach which is based on developing the capacity to reflect on the affective mental states could also be seen as a way of expanding emotional repertoire, therefore developing an understanding of one’s emotional states in relation to others. Mentalisation Based Therapy (MBT) is a free standing therapy approach used to treat people with Borderline Personality Disorder (BPD)- where people experience huge difficulties regulating emotions and inability to reflect on their mental state and that pf others- mentalise. I believe that therapy per-se,  has some mentalisation aspects, where there is  fostering of the capacity to reflect on one’s emotional states and triangulation of experiences.

Regardless of modality, my view is that therapy as a reflexive process, helps people develop emotional maturity. It helps people nurture  and develop their emotional vocabulary & expand it. Therapy also helps with developing the capacity to mentalise- reflect on one’s mind, the mind of others, as well as regulate emotions. Therapy enables us to re-establish broken attachment patterns and restore healthy ways of relating (form a secure attachment), in a secure and safe way-this is why the relationship with the therapist is central. Neuroplasticity– the capacity for our brain to adapt and change over time throughout our life span mean that we can learn healthier ways of relating, and rebuild new pathways to emotionally responding to situations.  Therapy enables us to develop an intimate relationship with our emotions & own how we response to them. There is a difference between responding & reactivity- the former is healthier, while the later is a more primitive way of  handling emotions. If we learn that we have other options, and not simply repeat, but reflect on our feelings, we are indeed nurturing that emotional part of ourselves.

I always view therapy as a process where some people who feel strongly need help to understand their feelings and emotions, while others who understand need help to feel. Emotions enriches our lives-they make it colourful and beautiful.  Without emotions, our lives are grey and gloom- we wont feel joy, excitement, sadness, anger, anxiety, which makes us feel alive and shapes life. However they become problematic when they diminish the quality of our lives due to either overwhelm, lack of,  or inability to regulate them.

Interestingly, mildly stressful experiences of novelty, and complex enriched environments in childhood, can enhance our ability to cope with more complex emotions in adulthood,  -adaptive advantage- and help us build emotional resilience.

This paragraph is from Thomas Ogden’s Book Chapter- On Potential Space- in Spelman et al book referenced below. It highlights the mother-infant, and environment context and the functions of the mother in helping the infant regulate emotions.

“Within the context of the mother–infant unit, the person who an observer would see as the mother, is invisible to the infant and exists only in the fulfilment of his need that he does not yet recognise as need. The mother–infant unity can be disrupted by the mother’s substitution of something of herself for the infant’s spontaneous gesture. Winnicott (1952) refers to this as “impingement”. Some degree of failure of empathy is inevitable and in fact essential for the infant to come to recognise his needs as wishes. However, there does reach a point where repeated impingement comes to constitute “cumulative trauma” (Khan, 1963; see also Ogden, 1978). Cumulative trauma is at one pole of a wide spectrum of causes of premature disruption of the mother–infant unity. Other causes include constitutional hypersensitivity (of many types) on the part of the infant, trauma resulting from physical illness of the infant, illness or death of a parent or sibling, etc. When premature disruption of the mother–infant unity occurs for any reason, several distinct forms of failure to create or adequately maintain the psychological dialectical process may result: (1) The dialectic of reality and fantasy collapses in the direction of fantasy (i.e., reality is subsumed by fantasy) so that fantasy becomes a thing in itself as tangible, as powerful, as dangerous, and as gratifying as external reality from which it cannot be differentiated. (2) The dialectic of reality and fantasy may become limited or collapse in the direction of reality when reality is used predominantly as a defence against fantasy. Under such circumstances, reality robs fantasy of its vitality. Imagination is foreclosed. (3) The dialectic of reality and fantasy becomes restricted when reality and fantasy are dissociated in such a way as to avoid a specific set of meanings, for example, the “splitting of the ego” in fetishism. (4) When the mother and infant encounter serious and sustained difficulty in being a mother–infant, the infant’s premature and traumatic awareness of his separateness makes experience so unbearable that extreme defensive measures are instituted that take the form of a cessation of the attribution of meaning to perception. The dialectic of reality and fantasy becomes restricted when reality and fantasy are dissociated in such a way as to avoid a specific set of meanings, for example, the “splitting of the ego” in fetishism. (4) When the mother and infant encounter serious and sustained difficulty in being a mother–infant, the infant’s premature and traumatic awareness of his separateness makes experience so unbearable that extreme defensive measures are instituted that take the form of a cessation of the attribution of meaning to perception. Experience is foreclosed. It is not so much that fantasy or reality is denied; rather, neither is created. (These four categories are meant only as examples of types of limitation of the dialectical process. In no sense is this list meant to be exhaustive.) Pages 124-125

References

Bion, W. R. (1962). Learning from experience. London: Heine-mann. Reprinted by Karnac 1984, ‘’The K-link,” pp. 89–94. By permission, Karnac Books.

Klein, M. (1946). Notes on Some Schizoid Mechanisms. International Journal of Psychoanalysis, 27, 99-110.

Bellis, M.A., Hughes, K., Leckenby, N. (2014). National household survey of adverse childhood experiences and their relationship with resilience to health-harming behaviors in England. BMC Med 12, 72 (2014). https://doi.org/10.1186/1741-7015-12-72

Fonagy, P. and Target, M. (2000) Mentalisation and personality disorder in children: a current
perspective from Anna Freud Centre. In Lubbe, T. (ed.), The Borderline Psychotic Child, 69–89.
London: Routledge.

Ogden T. (2014)On Potential Space: in Spelman, M. B., & Thomson-Salo, F. (Eds.)The Winnicott tradition : Lines of development-evolution of theory and practice over the decades. Taylor & Francis Group.

Young Minds (2018). Addressing Adversity; Prioritising adversity and trauma-informed care for children and young people in England. Mental Health Review Journal.

Schore, A.N. (2000) Early relational trauma and the development of right brain. Unpublished invited presentation. London: Anna Freud Centre

Winnicott, D. W. (1960). The theory of the parent–infant relationship. In: The Maturational Processes and the Facilitating Environment (pp. 37–55). New York: International University Press, 1965.

Image Credit- Nathan Dimlao-Unsplash

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No part of this website, including the blog content may be copied, duplicated, or reproduced in any manner without the author’s permission. Any information, materials, and opinions on this blog do not constitute therapy or professional advice. If you need professional help, please contact a qualified mental health practitioner.

In my role as a therapist, l have met many people who have friends, family members, or work colleagues who have experienced a mental health crisis, or a mental breakdown. At times this means one getting signed off work, and in extreme but not usual cases, admission into a psychiatric hospital. I have also met people who have lost loved ones who died by suicide, unexpectedly, and this was due to their poor mental health. Stories of this nature  dominate the media; there are many others that we do not hear about. For the family, friends, and colleagues of the person who has had a mental health breakdown, or died by suicide, there is often shock, despair and a lot of guilt attached to not having helped them, and  profound feelings of having let them down.

I have also worked with people who have experienced actual mental health breakdowns and crises, varying in nature, degree, and severity. Some may have had to take time off work, on their GPs orders, while others had to be admitted into psychiatric facilities due to risk to self, or for intensive treatment.  These are typically people who are very busy in their lives and make no time to rest, reset, pause, or make time for self care. The reason for this happening lies  in the delay in recognising that one’s mental health is deteriorating, and seeking help in a timely manner-early intervention.

I always remind my clients that “If you have a breakdown due to work stress, and burn out, they will hire a replacement tomorrow, and you only have yourself to fix, and you cant replace yourself either”.

This is a reality which we often forget, more so now, where the world we live in is centred around success, wealth, and status- capitalism. There is no room for emotions. Nature has cunning ways of bringing us back to basics.  Work stress and burn out are key factors in poor mental health, which can lead to attempted suicides, or completed suicides.  Most people who are struggling do not say it out loud even if they recognise it; that’s why suicide rates are high.

While mental illness is an internal experience, people who are struggling with their mental health often display certain signs and behaviours externally. If we are able to tune into what’s going on with people around us, we can detect any signs of mental ill health, and intervene early. Early intervention- diagnosis and treatment (therapy/medical) – lead to better outcomes. Again, l remind my clients that the best Doctors in life are: “Dr Rest, Dr Sleep, Dr Exercise, Dr Heathy diet, and Dr Hydration/Water”

People who are experiencing mental health difficulties may not recognise it subjectively. The onset can be mild, and the deterioration very surreptitious.  It may take others around them to pick up the signs, and changes that may be indicative of poor mental health, or a deterioration on one’s mental state.  If we become more conscious of the behaviours that are likely to manifest outwardly, we can do a lot to help, and support people may be struggling with their mental health. That also means we may safeguard some people who may end up suicidal, or even dying by suicide, something of concern in present day society.

“Early intervention translates to better outcomes”.

If you notice some of the signs of poor mental health  on your loved one, or colleague, do try and engage with them and/or notify other people around who may be able to intervene. Silence and ignoring that person is not an option. Rather give them flowers when they are alive, than take them to the hospital, or to their funeral.

Here are some of the signs of poor mental health:

1- Social Withdrawal & Self Isolation

Social withdrawal  & self-isolation from the world are some of the key  signs that someone may be experiencing some mental health challenges. This maybe due to lack of energy, loss of interest, not wanting to engage or simply giving up on life. The withdrawal and isolation may  be due to shame and a way of avoiding having to answer any questions that may reveal the person’s vulnerability.

2-Poor Hygiene & Poor Self Care

Poor hygiene is one of the noticeable signs of someone who may be having some mental health challenges, especially in depression. Poor self-care may be a sign of giving up on life, lack of energy, and lack of  motivation to look after oneself. A dishevelled look is always a give away.

3- Anger & Irritability

Anger and irritability (mood changes) can be related to underlying mental health challenges. It’s not unusual for people who are struggling to feel angry and irritable & at times easily snap or lash out. This often comes up in how they interact with others. Paradoxically, this is likely to negatively impact on relationships, leading to one becoming even more isolated, yet what they really need is company & support.

4-Hostile Behaviour

People who are struggling may behave in a hostile manner. This may be subconsciously a way of seeking attention, or expressing their feelings, however in an unhealthy way. Beneath that hostility is a lot of vulnerability. Hostility may be  unconsciously a way of keeping people away, yet consciously they need them the most.

5-Behaving out of Character

People who are struggling me start behaving in unusual manner. This may be behaviours that are not consistent with their usual selves. For example one may become very erratic & unusually chaotic. They may be even unaware of these behavioural changes. If they are, they may make excuses for these behaviours when asked.

6-Sleeping More or Nocturnally

People who are struggling may begin to sleep more, or have a reverse sleep pattern. This is a sign of not coping with life or lacking energy, apathy, or just social withdrawal. This may compound the poor self care and impact on productivity.

7- Poor Sleep

Most people who are struggling tend to have difficulties with sleep. If you notice that your loved one is unable to sleep, it may be a sign of them struggling with their mental health. Poor sleep leads to fatigue and feeds into the deterioration.

8-Eating More

Food plays a big part in emotional regulation, and people who are struggling tend to eat more as a way of regulating how they are feeling. This may lead to noticeable weight gain. In the long term this impacts on one’s confidence and self-esteem.

9-Eating Less

People who are struggling tend to eat less. This may be due to a loss of appetite, self-punishment and at times they have simply given up. This often leads to noticeable weight loss.

10- Mood Changes -Emotional Lability

Apart from showing signs of sadness, people who are struggling with their mental health may show some rapid mood changes where they may become tearful or emotionally hypersensitive. They can become easily triggered and can switch from being elated to tearfulness. These mood changes can happen throughout the day and at times diurnal.

11- Emotional Detachment

People who are struggling may become emotionally detached. They may seem stoic & unaffected by things. However deep down they are struggling & the stoicism/detachment is a defence. This is very common in suicidal people.

12- Overfamiliarity & Trauma Dumping

Despite sounding rather paradoxical, when struggling, some people may attempt to reach out to others in ways that are unusual to them & deemed imposing on others. However this may be their way of seeking some connection and making some form of emotional contact. If you notice someone who has suddenly started making more contact with you or talks about their difficult experiences each time you chat, do not dismiss or ignore them. Listen and tune in. Remember to signpost them to therapy is you feel burdened by them.

13- Personality Changes

People who are struggling may show signs of personality changes. For example someone who used to be gregarious and outgoing may suddenly become very distant and disinterested or highly anxious. This can happen over a period of time, not just daily. Do not be quick to judge. Check in if you can.

14- Excessive Drinking (alcohol) or Drug Misuse.

Excessive or regular alcohol consumption is one of the most common thing people who are struggling tend to do. This can be in social situations for example night out with friends or colleagues, or at home.  The drinking behaviour is a way of numbing feelings or escaping from an emotionally painful place.

15- Adopting a negative outlook to life, pessimism & dispondence.

When one is struggling with their mental health, they may give hints of their words view and how they view life. This is often in  negative & pessimistic terms, regardless of any good things that may be going on in their life. These good things may be meaningless to that person, hence why they describe their world in these negative terms. Listen and don’t judge.

16- Overspending & Compulsive Buying

People  who are struggling may find themselves compulsively shopping or overspending. This is even more problematic due to access to the Internet and online shopping. The compulsive buying is a way of trying to fill an emotional  void, and derive  happiness and pleasure  from material things.

17 – Hypersexual & Sexualised Behaviours

It is not unusual for people who are struggling with their mental health to start becoming hypersexual and having loads of casual sex. Sex is used as a soothing tool with no emotion attached  to it. This is the reason why so many people who struggle with their mental health are regular people who go on nights out  with their friends and colleagues & seem to be functioning normally. We often here about suicides or breakdown which seem unprecedented.

Image Credit to Mark Wielinga- Unsplash

Published on  Counselling Directory on the 20th April, 2023

COPYRIGHT CITY SANCTUARY THERAPY

No part of this website, including the blog content may be copied, duplicated, or reproduced in any manner without the author’s permission.  Any information, materials, and opinions on this blog do not constitute therapy or professional advice. If you need professional help, please contact a qualified mental health practitioner.

Trauma in women’s gynaecological health problems and self-care

By Dr Joyline Gozho, Adult Psychotherapist (Individual & Couples) FPC, UKCP, NCS

Published on  Counselling Directory on the 20th April, 2023

COPYRIGHT CITY SANCTUARY THERAPY

No part of this website, including the blog content may be copied, duplicated, or reproduced in any manner without the author’s permission. Any information, materials, and opinions on this blog do not constitute therapy or professional advice. If you need professional help, please contact a qualified mental health practitioner.

BAATN Conference: Celebration of Diversity in the Profession

The main picture on this blog post was taken on the 16^th April 2023, at a conference to mark the 20^th Anniversary of the Black and Asian Therapy Network (BAATN). BAATN is an organisation which brings together therapists from Black and Minority Ethnic (BAME) backgrounds, offering support and opportunities to network, connect, reflect, and process our experience of being therapists in the UK. It seeks to amplify the voices of therapists and trainees and create a safe space for all its members. BAATN has many resources, including a directory of BAME therapists, newsletters, CPD workshops, mentoring programmes, bursary opportunities, jobs, and facilitates other educational pursuits. The 2-day conference was in Milton Keynes, and it was attended by up to 160 therapists from all over the UK.  I was only able to attend one day (Saturday); l regret not committing to attending the 2 days. Some may wonder why this conference was such a big deal. I hope by reading this post, you will get an idea of why it matters so much. The silent struggle of therapists from minoritized background needs to be heard.

Stepping out of my comfort zone

I do my very best to remain professional, and avoid  sharing my political views  or leanings in my work life. That’s my boundary.  But race as a concept is political indeed, and not talking about matters that relates to our lived experiences as black therapists would be me doing myself a disservice. I did not intend to write about my experience, prior to attending the conference. However, upon reflection and processing all day, l realise I needed to. For my own benefit, in order to put my thoughts and feelings into words.  My experience of the conference was very meaningful and enriching to me and everyone else in that shared space. I feel invigorated & replenished as a practitioner, having spent what was a very special time with people who knows what’s it like to be me. It felt like l was “home”, I didn’t have to sensor myself or edit what I say, how I say it & how l will be perceived. I felt seen & heard and we honoured each other. It reminded me of the significance of community.

Why does BAATN matter?

Black and Asian people have endured many centuries of suffering and subjugation- slavery, colonisation, Windrush etc.  The psychological impact and trauma of the dehumanising injustice and the festering wound of centuries-long racism cannot be overstated. Racism remains rife in our societies today. Therapy is about alleviating human suffering and distress. As BAME therapists we have continued in our work to support others in emotional and mental distress while carrying our own pain from our own lived experience of racism and discrimination. When the whole world went on a standstill, following George Floyds murder, we were part of it. We saw it on TV, just as you all did.  There was an influx of people coming to therapy to talk about their own experiences of discrimination and racism. It’s their trauma. It was ours too.  We had to and continue to bear others’ pain, while going through it ourselves. It’s not an easy place to be, and one which requires a lot of emotional stamina and psychological strength. How do we look after ourselves & each other? Our struggle needs to be acknowledged.

It is not an easy path to become a psychotherapist. Being a therapist of colour means working ten times harder than everyone else. It doesn’t get easier after qualifying as the role itself is very challenging, practicing in a white world. Therapists from minoritised backgrounds face bigger hurdles in the profession. Unless we get together to explore and identify what these hurdles are as we did at the conference, and in BAATN, we remain disconnected, divided and conquered.

Decolonising Theories and Diversifying Training

Psychotherapy is a western concept, and the theories which underpins the philosophies and practice are Eurocentric.  Many trainees from the BAME background really do struggle with grasping these theories; it feels like they are learning a new language altogether. And it’s not their fault. What’s sad is that many of them fail and leave the course, hurt and disappointed.  Is there room to decolonise the curriculum; if so how can we go about that? As a lecturer, and someone who is seen as “having a seat on the table” l am often perceived as the token, the puppet, because l am not helping them.  Many do not realise just how painful it is being in the space in between-interface between students & the university, such a powerful organisation. Watching others, while being observed at the same time.  As a tutor, it’s difficult not to feel complicit in these students suffering and feeling guilty. Many a time its as if l have become the perpetrator myself, and a traitor. But l am only doing my job. The fact that there are not many black academics in my field, leaves a void where I cannot share some of my experiences in a nuanced manner. I must deal with this myself, and process.  BAATN gives me the opportunity to share my experience with other academics who are in the same path as l am and hear their stories. There is validation and processing in being able to share and connect over painful experiences.

In relation to psychotherapy training, of great interest is a mixed method study carried out by Ciclitira and Foster (2012) where they interviewed trainee psychoanalytic psychotherapists of BAME backgrounds eliciting their experiences in psychoanalytic training. One of the key themes that came up was that trainees felt that the clinical programs failed to adequately address issues of race, culture and ethnicity and there was a lack of multicultural competence. A key theme that came out of this research was that students of BAME backgrounds felt silenced, and unable to fully articulate issues of diversity including race. Another study was from Gordon (1993) who surveyed thirty-three psychotherapy training institutes and found that most of them did not address the low ratio of Black trainees despite them supposedly committing to equal opportunity policies. Lowe (2006) writes about psychoanalytic training institute’s avoidance of issues of race and becoming colour blind, which again mutes the conversations on race and other differences. Morgan (2007) argues about the harmfulness of racial “colour blindness” in training and supervision which arises where issues of racial skin-color difference is seen as external and irrelevant to the work. While these issues stem from training organising, they become even more pronounced in the profession where the concepts of diversity and inclusion, and equal opportunities are simply tick box exercises.

Psychotherapy is a White Middle-class profession and the disparities in the ratio between white and non-white therapists is high. This is a known fact confirmed by Ciclitira and Foster (2012), Gordon (1993), Morgan (2008), and Tummala- Narra (2004). The nuances of one’s identity in relation to the intersections of race, class, gender become very much heightened when you are a therapist. Why? Because the caricature of a therapist is a middle age-old aged bearded white male, or a middle-aged cardigan wearing white middle class woman. All black therapists including myself neither embody nor represent what society views as the conventional version of a therapist.  A psychotherapist colleague of mine- who is also a well respected author and lecturer, Dr Dwight Turner, started a viral hashtag #thisiswhattherapistlookslike after being racially profiled. He was in a pub and he was asked if he was a pub bouncer, only because he is a tall black man. I have received similar treatment on many occasions.  In the past, l have had clients allocated to me, terminate therapy when they learnt that l was black.  Sadly, some black clients have done the same too. There is an assumption that white is good and black is bad. Dalal (2006, p. 152) make very potent claims highlighting the semantic use of the words Black and White as racial categories arguing that Black has historically, from mediaeval times, been associated with darkness, death, evil, dirt, misfortune and badness, while White is seen as clean and pure. Dalal (2006) argue that these ideas are translated on how Black and White people are viewed and treated in society. While this view is helpful in highlighting the associations made due to skin colour variations between the so called Black and White races, its main significance is in how we internalise meaning of good and bad based on the language we use and how black is a symbol of lack/bad/evil/grotesque/dark. No matter how highly qualified and competent you are, you are seen as not good enough, by virtue of being black or other.

Safety and Risk

Therapists are regulated by regulatory bodies- BACP, UKCP, HCPC, NCS.  Therapy is risky business, it is unsafe. It is a highly litigious profession and there is an occupational hazard of having vexatious complaints made against you. It is confirmed that therapists from minoritized backgrounds face a much higher risk of having complaints made against them (Cox, 2023). They are easy targets for pathological acting out the fantasies of punishing and causing harm. The motives behind complaints which may be racial are never questioned. The regulatory bodies take the complainant’s side, l understand to protect the public. Surely that can be done without turning against your registrants. If you are a therapist from minoritized background, you face greater risks of the process being doubled down and it being incredibly adversarial.  Ellis (2021) refers to this as “dialling down of empathy towards people of colour” (p. 77). I have been a victim of this experience myself following a crafted complaint by a white male client, leading to a lengthy and heinous treatment by a regularity body. I am very aware of how unsafe and dangerous Black Excellence is.   I consider myself to be a highly qualified and highly experienced and exceedingly competent therapist. Ellis (2021) made this clear by arguing that “People of colour understand that if they put their foot on the accelerator of their lives, they can only get so far before they run the risk of losing their reputation…” (emphasis added: Ellis, 2021, p. 206). I take pride in my profession and hold it to the highest standard. If this detestable experience happened to me, what more the newly qualified therapists who are not as confident and seasoned in the profession?

There is abundant literature which evidence that therapists of colour are at greater risk of facing investigations for lesser perceived practice infractions than their white colleagues, and endure harsher penalties (Cox, 2019: Naqvi, 2019). I was subjected to a 2-and-a-half-year (9 hearing days) investigation procedure for saving a suicidal man quoted above, by referring him to the Crisis Team following an assessment. No other therapists have ever been brought to a hearing for safeguarding a vulnerable client. No surprise the case was dismissed as there was no evidence of malpractice. In fact, the panel commended my practice for its rigor and robustness. In my past l worked in a Crisis Resolution Team with highly complex and high risk clients. Carrying out risk assessments is something l do in an evidence based and in skilful manner. I teach risk assessing skills. Hearing similar stories through the BAATN confirms just how unsafe being a therapist of colour in the UK is. The professional bodies do not protect us, and we are effectively up against a powerful persecutory force. Racism is embedded in the systems, and enabled.

As therapists of colour, what have we tried to do about it? Eddo-Lodge (2017) asserts that, “entering into conversations with defiant white people is frankly a dangerous task for me. As the hackles rise and defiance grow, I have to tread incredibly carefully, because if I express frustration at their refusal to understand, they will tap into their prescribed tropes about angry black people who are a threat to them and their safety (p. xi).” I have been called the angry black woman in white spaces when l have asserted myself and tried to put boundaries in place. It is exhausting.

Dr Robin DiAngelo (2018) describes the concept of ‘white fragility’  as: “In the dominant position, whites are almost always racially comfortable and that have developed unchallenged expectations to remain so. We have not had to build tolerance for racial discomfort and thus when racial discomfort arises, whites typically respond as though something is ‘wrong’, and blame the person or event that triggered the discomfort (usually a person of colour). This blame results in a socially sanctioned array of responses towards the perceived source of the discomfort, including: penalization; retaliation; isolation and refusal to continue engagement” (online).

I have nothing further to add to these succinct assertions from Eddo- Loghe and DiAngelo.

Happy 20 year birthday  BAATN

We shall prevail….

References

Cox, P. (2023a). Uses, misuses and abuses of complaint processes. In A. Sachs and V. Sinason. (Eds.). The psychotherapist and the professional complaint: The shadow side of psychotherapy. (Chp. 11, 153-176). London: Karnac

Ciclitira, K. and Foster, N. (2012). Attention to Culture and Diversity in Psychoanalytic Trainings. British Journal of Psychotherapy, 28(3):353-373.

Dalal, F. (2006). Racism: Process of detachment, Dehumanization and Hatred. Psychoanalytic quarterly, 75: 131-161.

Eddo-Lodge, R. (2017). Why I’m no longer talking to white people about race. London: Bloomsbury Press.

Ellis, E. (2021). The race conversation: An essential guide to creating life-changing dialogue. London: Confer Books.

Gordon, P. (1993) Keeping Therapy White? Psychotherapy Training and Equal Opportunities. British Journal of Psychotherapy. 10 (1) 44-9.

Morgan, H. (2008). Issues of „Race‟ in Psychoanalytic Psychotherapy: Whose Problem is it Anyway? British Journal of Psychotherapy: 24, 1.

Tummala-Narra, P. (2004) Dynamics of race and culture in the supervisory encounter. Psychoanalytic Psychology 21(2): 300-11.

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No part of this website, including the blog content may be copied or reproduced in any manner without the author’s permission.

My recent interview with Gosolo- Subkit

Interested in starting your own entrepreneurial journey in mental wellness but unsure what to expect? Then read up on our interview with Dr. Joyline Gozho, Founder of City Sanctuary Therapy, located in Milton Keynes, Buckinghamshire, UK.

What’s your business, and who are your customers?

I’m a Psychotherapist for individual clients and couples, as well as a University Lecturer.

Tell us about yourself

My training to become a psychotherapist was borne out of my acute awareness of how much trauma and suffering there is in the world and how much of it is medicalised. Through my work in the NHS, l encountered many people who were prescribed medication and given medical diagnoses (labels) for what l consider to be a normal human reaction to trauma. For example, for people with anxiety and depression, instead of understanding why one is experiencing anxiety and depression, they would prescribe medication. The issues provoking these symptoms are never interrogated, and this is harmful.

I am a firm believer in the healing nature of talking and connecting on a deeper level. If our pain can be given time, space, and a voice, we can heal and grow as humans. Our ancestors lived and thrived in communities, which is what innately holds us as humans. We have an innate drive to connect and feel safe. My desire to do couples training and work was stimulated by me seeing that a lot of issues people bring to therapy in adulthood are very much a product of growing up in dysfunctional homes and families. If we can create healthy relationships for the parents (couples), we can also raise healthy children. Furthermore, relationships are the core of our being, and our whole existence as a human is relational. Healthy relationships translate to a healthy mind and overall sense of well-being.

What’s your biggest accomplishment as a business owner?

I have managed to establish a thriving private practice where l see individual clients and couples. I also run relationship enrichment workshops for couples at all stages of their relationships. I am also able to pursue my passion for education and sharing knowledge by teaching a Psychotherapy Course at the University of London. I come from a large family of teachers, and growing up, l swore that l never wanted to be a teacher – but here l am and enjoying it!

What’s one of the hardest things that comes with being a business owner?

I don’t have an assistant or a team, so l do a lot of admin on my own, which l prefer. Coordinating my schedule between clients, teaching -lesson planning, marking, etc., and family can be a challenge. I need to have strict boundaries; otherwise, it’s very easy to have my nonwork life completely shrunk.

What are the top tips you’d give to anyone looking to start, run and grow a business today?

1. For Psychotherapy, the first thing is to do the training if you think you are cut out for it. It’s not for everyone, and it is not easy.
2. Be clear about what you want to do and where your passion is – niche your work if you can.
3. Do something that helps you stand out – a higher qualification if you can, or specialist training.

Where can people find you and your business?

Website: https://citysanctuarytherapy.com/
Instagram: https://www.instagram.com/drjoyline.therapist/
Twitter: https://twitter.com/AlfredoGozho
LinkedIn: https://www.linkedin.com/in/dr-joyline-gozho-schwitters-57024233/

If you like what you’ve read here and have your own story as a solo or small business entrepreneur that you’d like to share, then please answer these interview questions. We’d love to feature your journey on these pages.

COPYRIGHT CITY SANCTUARY THERAPY

No part of this website, including the blog content may be copied, duplicated, or reproduced in any manner without the author’s permission. Any information, materials, and opinions on this blog do not constitute therapy or professional advice. If you need professional help, please contact a qualified mental health practitioner.

Covid Trauma

Each time l travel to central London, l have to remind myself that we are still in the middle of a pandemic. The streets, shops, and restaurants are forever buzzing with life.  But aren’t we suppose to be taking some safety precautions, to minimise the risk of contamination, and spreading the virus? We are! Not that long ago, the trains were halted.  l couldn’t travel to central London as freely as I do now. People were locked in their homes, and we were only allowed a short window to leave our homes to exercise-stretching.  These days, people no longer wear masks; the mention of social distancing is responded to as if you are speaking a foreign language. But that was our reality then; keeping a minimum of 2-meter distance, and disinfect, disinfect, disinfect. No one seem to care anymore, yet we were still in the middle of a pandemic. It’s as if we have suddenly forgotten just how tragic the last few years have been. Is this our defence against confronting the reality?  Our way of dealing with the trauma; some sort of amnesia or splitting (Klein, 1946)- pretend it never happened and it no longer matters. When it really does.

Covid is still here, and it’s here to stay. People are still dying due to some Covid related illnesses. The Gov.UK website reports that there have been 531 Covid related deaths in the UK in the last 7 days.  What made the past few years hugely significant in our history is the tragedy and trauma secondary to the mass deaths we had due to Covid. Some people lost their loved ones, while every other person knows someone who lost their loved one to Covid. Trauma is vicarious. An experience can still be traumatic, even if it did not happen to you directly. Some people had Covid and suffered immensely, both physically, and psychologically. It left them completely debilitated; at times with long Covid. Even if one never had Covid, or had a mild version of it, living with the threat of impending death is indeed traumatic.  As with any trauma response, we go into survival mode-fight, flight or freeze (De-Kolk, 2010). Which we are still in-individually and collectively. It is important that we continue exploring what the pandemic means to us as a society, and heal from this trauma, not just individually but collectively. Discussing Covid related loss and grief is a necessary part of our processing and working though this trauma.

Death, Loss, and Grief and Traumatic Grief

Our life cycle begins with birth, and ends with death. Each stage of life from baby-latency- adolescent- adult- old age- involves loss of the older version of who we were, and grieving for that loss. Death, loss, and grief are natural parts of life, both physical and psychic death. However, when death arrives suddenly and unexpectedly, the overlap of the traumatic experience, and the grief of the loss can be overwhelming psychologically.  This may result is some people getting “stuck” in the trauma and avoiding the feelings of grief and loss. Grief is a natural reaction to loss. We grieve because we love; if we did not love the person we lost, we won’t grieve at all. That is why grief is a painful process we need to lean into, that involves a range of feelings before we can come to a place of acceptance, relinquish the loss, and bargaining whatever we can take away from that lost relationship. We need closure.

Elisabeth Kübler-Ross (1969) was the first person to develop an epistemic theory of grief identifying the different stages of grief. Her ideas were informed by her work with dying patients and relatives, observing how they responded to loss, and grieved for the loss of their loved ones. Kubler-Ross (1969) hypothesised that people who grieve go through different stages of grieving which are denial, anger, bargaining, depression, and acceptance. These stages are not linear, and people will oscillate between them at different stages of their grieving process. Some people will go through the grieving process much easier and swifter than others; we do not grieve in the same fashion. When death is sudden and unexpected, shock is a preceding stage, which we experience as part of our grieving process. The shock itself is a response to what feels like an emotional violence.

The relationship we had with the lost person has a big part to play in how we grieve, along with how we have coped with other losses in life. The way we grieve for the loss of a loved one through death, and the loss of a relationship (break up) is no different in any way as it involves going through all the different stages identified. There is a lot of emotional labour involved.  We always talk about the first heart break, when you broke up with your first love-perhaps in your teens. It is one of the most painful experiences in life, and a defining one. Why? Because it involves a lot of emotional labour. It also becomes a process that sets a template of how we deal with other losses in life.

Covid Losses

Many people lost their loved ones to Covid. Most of these losses were very sudden and dramatic in how everything unfolded. You hear stories of someone who woke up fully fit, developed a cough, took a Covid positive test, placed in intensive care unit, intubated, and dead by the end of the day. As dramatic as it sounds, these are consistent themes and stories we have all heard, repeatedly. Many people who lost their loved ones in such a sudden and abrupt manner have experienced traumatic grief. Others continue to experience traumatic grief. The fact that in many cases death was sudden, and there was a restricted way of mourning the death of loved ones-not being able to bid farewell and not able to attend funerals, makes the grieving process complex. This goes against how we deal with loss and grief as humans and complicates grief. Its an emotional blow.

Sudden death by suicide, accidents and other unexpected deaths, can also lead to traumatic grief. We will concentrate on Covid losses this time.

Traumatic Grief

Not every sudden or catastrophic loss results in traumatic grief. Grief is personal, and we all experience it differently. According to Phillips (2021), some people experience uncomplicated bereavement, while others may show signs of both trauma and grief. They might avoid talking about the person they lost altogether, or they might become fixated on the way their loved one died.  Because of the trauma embedded within the grief, it can be challenging to differentiate between posttraumatic stress disorder (PTSD), grief and traumatic grief. “PTSD is about fear, and grief is about loss. Freud would have termed this melancholia- Freud, (1917). What makes a loss traumatic is not only the way the person died but also the meaning attached to the death. Freud (1917) differentiated normal mourning from pathological mourning, which he called melancholia. What’s different about melancholia is that there is no trauma embedded in the loss, it’s simply a process where the grieving process gets stuck and there is a narcissistic fixation with the lost object (person). The loss itself in the end becomes all about the person who is grieving, not necessarily the lost person. With traumatic grief, there is trauma, and one gets stuck in the trauma before they are able to grieve.

Social and cultural factors (such as personality, spirituality and race/ethnicity) affect how we all approach loss and mourning. In some cultures, there are certain rituals in the grieving process, and these are often done collectively. Grief is a process we cannot go through alone, we need others to bear witness, share the feelings, and talk about the loss-what it means to us.  Being able to share the experience is very important as it enables us to process and heal. In most western cultures, grief is a very personal experience where people tend to go though it in isolation.  This is often in the background of depression (unprocessed grief) and anger issues- (unprocessed grief). Normal grief involves a working through all the different stages to a place where we can get closure. Without this closure, we get stuck in the grief and we are unable move past it, no matter the length of time.

People who are experiencing traumatic grief experience these symptoms:

• Nightmares related to the lost loved one/s or about dying
• Anxiety about the possibility of losing other loved ones
• Guilt and self-blame “I” statements frequently “I should have done more to help them”
• Physical pains, have trouble sleeping
• Distressing thoughts or dreams
• Hyperarousal or anhedonia/numbness
• Loss of appetite
• Trouble sleeping (which can resemble signs of depression)
• Difficulty focusing (which can look like a sign of attention-deficit disorder)
• Preoccupation with the deceased at times in an obsessive manner
• Experiencing localised pain in the same area as the deceased
• Extreme longing for the person
• Hearing the voice of the person who died or “seeing” the person
• Being drawn to places and things associated with the deceased
• Experiencing disbelief or anger about the death
• Thinking it is unfair to live when this person died (suicidality)
• Having difficulty caring about or trusting others

How can we heal from traumatic grief?

Many people came to therapy with complex grief symptoms, and traumatic grief. If grief is not worked through, and remains unresolved, it can have a long-lasting impact on one’s mental health and relationships.

People experiencing traumatic grief are operating in survival mode. Like with any trauma treatment, its important that we create safety, so they can start to feel grounded, and engage with their grief feelings.

Therapy helps people with traumatic grief to emotionally regulate.

Therapy helps create new meanings-“its not my fault and l accept this happened”

Therapy helps processing the feelings- sit with the anguish with the therapist being fully present with the client

If conflict existed in the relationship with the person who died, people may need to work through challenges that they had or feelings of guilt or shame that can be present following the loss

Therapy enables us to develop a narrative around the loss which is a significant part of healing

Therapy enables us to consolidate the contradictory feelings we may hold towards the person we lost. Its not easy to grieve for someone we may have held a grudge against or someone who may have hurt us.

Apart from individual therapy, support groups can give you the holding space to process. Grief is not an experience we go through in isolation. Healing comes from sharing your story and allowing someone to hold you through the vulnerable experience.

References

Der Kolk, B.A.(2014), The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma. Viking

Freud, S. (1917). Mourning and melancholia, London.

Klein, M. (1946). Notes on Some Schizoid Mechanisms. International Journal of Psychoanalysis, 27, 99-110.

Kübler-Ross, E. (1969). On Death and Dying. New York, The Macmillan Company.

Phillips, L. (2021) Untangling trauma and grief after loss. APA: Counselling Association.

COPYRIGHT CITY SANCTUARY THERAPY

No part of this website, including the blog content may be copied, duplicated, or reproduced in any manner without the author’s permission. Any information, materials, and opinions on this blog do not constitute therapy or professional advice. If you need professional help, please contact a qualified mental health practitioner.

I wrote this publishable  paper as part of my professional Doctorate which was a taught Doctorate,  consisting  of 8 assignments and a 50 000 word thesis. Unusual, considering that most PHDs and Doctorates, (with the exception of Clinical Psychology and a few others), only comprise of research modules, and the main thesis. 

The publishable paper was wrote for publication in the Journal of Psychoanalytic Psychotherapy. While it passed, and met the publication requirements, l never got round to publishing it.  Time being one of the major constraints, and to be frank, the antipathy to peer reviews.

I had to add this paper to my blog as the matters discussed in it are very close to my heart as a perpetual student myself, lecturer, and psychotherapist. 

Modality should not be the guiding factor in any therapy. It should be the client’s needs that guides the therapist. CBT and psychoanalytic oriented therapies are often pitted against each other,  yet in reality they inform each other. 

Delivering Psychological Therapies to University Student Client Groups: Does Modality Really Matter? An Attachment Perspective

Abstract

Leaving home to begin University studies can be a very challenging experience for some students, due to the external, physical separation and the internal loss, resulting from the disruption of vulnerable attachment patterns. Some students seek psychological interventions through the University Student Psychology Services because of the sudden emotional distress they experience. Since the National Institute of Clinical Excellence (NICE, 2009) guidelines identify Cognitive Behavioural Therapy (CBT) as the first line of treatment for common mental health problems, this is the therapy which is regularly prescribed, even for those students who may be struggling with attachment and loss issues. Whilst recognising the valuable contribution of CBT in mental health provision, I would argue that cases like those identified above are better understood and reframed from an attachment perspective (Bowlby, 1969) and therefore best approached using a psychoanalytic, clinical framework, which addresses loss and mourning (Freud, 1917) and includes interpersonal relationships, unconscious processes and affective qualities (Lemma, Target, & Fonagy, 2010; Shedler, 2010). A single vignette will be presented, as an example of the typical student client group psychopathology, illustrating the therapeutic process.   The name of the university and the client’s identity are not disclosed.

Key words: Loss, Attachment, Cognitive Behavioural Therapy (CBT), Adolescence, Psychoanalysis

Difficulties some students experience when leaving home to start University

The external reality of moving away from the family home to attend university is often consciously experienced as being very liberating. It signifies the beginning of a new life in a new environment, forming new friendships, developing independence, perhaps developing sexual relationships and creating an adult identity. However, the internal reality is that the experience can be very traumatic for those students who have not relinquished their infantile object relationships and who are insecurely attached. This is because leaving home not only involves physical separation, but the loss of the familiar environment, emotional displacement, challenges to established attachment patterns and loss of the family as a secure base (Bowlby, 1969). Bowlby (1973), postulates that attachment patterns are ‘internal working models,’ which he believes “represent an accurate reflection of the experiences of individuals” (p. 235).

In recent years, we have seen increased awareness of mental ill health problems in UK universities and even the suggestion of a ‘suicide epidemic’ among first year undergraduates.  The British Broadcasting Corporation (BBC) News http://www.bbc.co.uk/news/education-36378573reported an increase in self-harm incidents and suicides in first and second year UK undergraduates.  The findings of this BBC report and others seem to suggest that these cases were the result of the stress related to leaving home and a potential breakdown of attachments. It is unlikely that academic difficulties were a major factor, as all undergraduates have met rigorous criteria to achieve university admission.  We cannot totally discount the ‘small fish in a big pond’ aspect, which may negatively impact on someone who has been outstanding in their former school and is now surrounded by other high achievers. I suggest that the internal loss and challenges in attachments which the students experience because of leaving home makes them extremely vulnerable. If these issues are not understood and dealt with adequately through appropriate therapy, they can escalate, resulting in severe mental illness and, in extreme cases, suicidal actions. Such cases illustrate the potential gravity of the impact that leaving home can have on some students.

Recognition of the increasing incidence of mental ill health problems within the student population has led universities in the UK to invest in psychological therapy services, which mirror Improving Access to Psychological Therapy (IAPT). Traditionally, the model of choice was psychoanalytic, but today there is gravitation towards CBT, because of the NICE guidelines. This means that most students who are seen in student counselling services are prescribed CBT.  The majority of therapists in the service now have to be trained to deliver the minimal, low intensity CBT in order to meet this need. The apparent mental health crisis in the undergraduate population suggests an urgent need for practitioners to engage with the root cause of the problem, which I believe is the internal impact of breakdown of attachments and that focusing on symptom management, whilst producing some undeniable benefits, offers only a partial solution to the problem.

Most of the students seen for therapy in universities are in late adolescence or early adult stage of development. Lamb, Hall, Kelvin, and Van Beinum, (2008) declare that in the UK we need to recognise the importance of providing psychotherapeutic services to the adolescent and young adult population during their transition into adulthood because the complexities of this developmental stage render the age group particularly vulnerable. This highlights the need to provide a space for the individual to understand their loss, to explore attachment patterns and to reflect on their interpersonal relationships. The therapeutic relationship can also be used as a basis for the student to learn how to build healthy relationships, as well as relinquishing broken attachments. I would argue that a psychoanalytic approach, which allows an exploration of interpersonal relationships, loss, mourning the experience of leaving home and reflecting on the breakdown of attachments, offers the only best way to resolve the internal problems.

CBT approach and NICE Guidelines

Following the Layard report (Layard, 2006), short term, manualised therapies, such as CBT, that are considered to be evidence based are now widely adopted.  NICE has recommended CBT as the gold standard treatment model for most common mental health problems (DOH, 2009). Psychoanalytic oriented therapies appear to have fallen out of favour. Most of the CBT evidence base has been gained using Randomised Controlled Trials (RCTs), which many psychoanalytic clinicians view as unsuitable in assessing the process and outcome of psychoanalytic oriented therapies (Taylor, 2010; Shedler, 2010; Hinshelwood, 2010; McLeod, 2011; Cooper, 2011). NICE recommendations have therefore inadvertently hindered the dissemination and delivery of psychoanalytic oriented therapies in the UK.

Somewhat ironically, CBT was developed by Beck, a psychoanalyst, and has its origins in psychoanalysis, despite it being out of step with psychoanalytic informed therapies (Beck, 1995; Knox, 2013).  CBT, a behavioural model, assumes that the way we think (cognition) affects the way we feel (affect) and behave. The hypothesis is that by altering one’s maladaptive thinking and developing flexibility, one can reverse the cycle and change the way we feel (cognitive change). CBT focuses on acute symptoms and the external world. It does not seek to understand the cause or origins of the symptoms. The use of cognitive change methods, self-management skills and the adoption of behavioural strategies to counter maladaptive behaviour are considered key in the CBT model.  Clients are actively required to use a range of tools in and out of sessions, with considerable emphasis on recording their thoughts and reflecting on them (Greenberger and Padesky, 1996). Most importantly, clients must be able to consciously access their thoughts and feelings.

The CBT model is manualised; it requires careful planning, and clearly identified desired outcomes. Experiments are a common tenet of the CBT model.  Clients are encouraged to have graded exposure to their phobias and aversions, to systemically desensitise them (Leahy, 2003). Significantly, there is a teaching element in CBT delivery; the therapist must teach the client the model and how to use the techniques and tools.  The psychotherapist’s role is therefore helping the individual to identify their negative cognitions or distorted belief systems and to be able to evaluate their own behaviour (Beck, 1995). CBT requires the use of monitoring tools – (Spitzer, Kroenke, Williams, and Löwe, 2006) Generalised Anxiety Disorder (GAD-7), (Kroenke, Spitzer, and Williams, 2001) Physical Health Questionnaire (PHQ-9), session by session.

Psychoanalytic approach and why it is most appropriate for the student client group

The significant decline in the delivery of psychoanalytic oriented psychotherapies has mainly been due to the NICE guidelines assertion that CBT is more empirically evidence based than other approaches (NICE, 2009). Shedler (2010) states that the poor evidence base of psychoanalytic oriented therapy is not because of its ineffectiveness, but stems from the “poor dissemination of research and the arrogance and elitist attitude shown by traditional psychoanalysts who shunned research and inter- disciplinary working” (p. 98). Psychoanalytic oriented psychotherapies, however, still have an important role to play clinically. Unlike CBT, they allow an exploration of the client’s interpersonal difficulties and of their internal world, which are key elements when working with the student client group.  Norcross (2005) argues that psychoanalytic oriented psychotherapies have positive outcomes which go beyond symptom prevention, which is the goal of CBT.

Psychoanalytic theories have their origins in the work of Freud, who initiated the theory of the unconscious (Freud, 1915). Despite the apparent differences in contemporary Freudian schools of thought, what underpins them all is the belief in the unconscious world, the importance of early life experiences and the psychopathology that can occur because of disturbances in the parent-infant relationship. Psychoanalytic oriented psychotherapies are fundamentally centred in working with the transference in the analytic space. This analytic space between the therapist and client is used to explore unconscious processes, with the transference relationship acting as a catalyst to generate an understanding of the interpersonal effects. Through the experience of psychoanalytic oriented therapy, clients learn to build inner resources (Shedler, 2010).

The building of a therapeutic alliance between the client and therapist is vital. It enables clients (students) to build trust and gain confidence in others, an important aspect of interpersonal relationships. The therapeutic alliance is considered most crucial in psychoanalytic oriented therapies and central to its success (Orlinsky and Howard, 1986; Shedler, 2010; Safran, Muran, and Eubanks- Carter, 2011). Most of the students’ client group present with issues related to complexities of navigating from their infantile object relationships to adult and romantic relationships. In the psychoanalytic context, the transference relationship between the therapist and student can be used to trace the source of the disturbed infantile object relations, which might be the underlying cause of difficulties in current relationships.

Interpretations also play a major part in psychoanalytic oriented psychotherapies; they enable the mutative links between the past and the present. Malan’s triangle of conflict, which focuses on past relationships, current interpersonal relationships and the ‘here and now’ (Malan, 1995), allows psychotherapists to formulate approaches which enable them to assist clients in comprehending the nature of their internal difficulties. These approaches render psychoanalytic psychotherapy more relevant and effective than CBT, when working with the student client group.

Psychoanalytic psychotherapies readily offer the invaluable space in which to explore loss and mourn the loss of attachments (Bowlby, 1969), which CBT does not. The notion of gaining insight into unconscious drives is what makes psychoanalytic oriented therapies more effective than other treatments (Norcross, 2005; Shedler, 2010). Fonagy (2015) argues that psychoanalytic treatments provide a unique window on human behaviour and the theories are rich and imaginative in developmental, clinical, and applied accounts.

CBT focuses on symptomology, while a psychoanalytic framework creates a space where difficult experiences can be safely explored and complex feelings expressed. Psychoanalytic oriented therapies also help the client to conceptualise their problem and situate it, thereby helping them build internal resources and reach beyond symptom remission. Shedler (2010) argues that the reason many therapies are successful is because they use techniques which are centred in psychoanalysis. This raises questions about the NICE recommendation of CBT as a panacea for common mental health problems.  Psychoanalytic psychotherapies that seek to address the client’s internal world allow mentalization and in-depth exploration of the nature of the client’s difficulties, elements which are not covered when using the CBT model, suggesting that psychoanalytic therapies are appropriate when working with the identified student client group.

Loss through leaving home and the disruption of attachments

Attachment patterns are established at an early stage and are centred in the relationship between the infant and its primary care giver (Bowlby, 1969; Ainsworth, 1973).  Leaving home, separating from siblings, other family members and friends seems to result in a psychological de-compensation and a breakdown in defences for some students (Klein, 1926). Bowlby (1969) argues that our early attachment patterns can be reactivated in times of psychological distress and in social or relationship crises and that the disruption of these patterns in later life can bring forth a breakdown of defences and the onset of depressive feelings.  Bowlby (1979) postulates that secure attachment to the mother stems from the mother’s consistent and sensitive provision of security and love, thereby creating a healthy emotional bond, which includes a tolerance of separation.  Bowlby’s (1979) view suggests that the ability to separate without experiencing distress seems to be what some students have difficulties with when they leave home to start University.

Bowlby hypothesises that mothers who are not attuned to the infant’s needs tend to lack warmth; they respond to the infant erratically and this leads to insecure attachments, which can be categorised as disorganised, ambivalent and avoidant (Bowlby, 1969; Main, Kaplan, & Cassidy, 1985). The result is that these insecurely attached individuals are the ones who, in later life, are more likely to experience difficulties in interpersonal transactions when building and maintaining relationships, which can lead to psychological problems. Research has demonstrated that certain types of attachments are associated with particular psychopathologies, ranging from self-esteem issues to depression, together with deep seated feelings of worthlessness (Zuroff & Fitzpatrick, 1995).

Stressing how attachments are re-activated in times of stress, Bowbly (1988) argues that

A feature of attachment behaviour of great clinical importance and which is present, irrespective of the age of the individual concerned, is the intensity of the emotion that accompanies it. The nature of the emotion aroused appears to depend on how the relationship between the individual attached and the attachment figure is faring. If it is threatened, there is jealousy, anxiety, and anger. If broken, there is grief and depression (p.4).

Bowlby’s assertion explains how a disruption or breakdown in attachments can be traumatic, leading to a complex set of painful feelings. Bowlby (1980) declares that “intimate attachments to other human beings are the hub around which a person’s life revolves, not only as a toddler but throughout adolescence and the years of maturity into adulthood and old age” (p. 442).  This would explain why disruption of attachment patterns in the late adolescent stage can be so challenging for some individuals.

Can psychoanalytic theories and attachment theories inform each other?

Psychoanalytic paradigms, particularly object relations and attachment theories paradigms, are not natural bedfellows.  This seems to stem from the history of the evolution of both disciplines. It is known that Bowlby deviated from the mainstream object relations theories, with his greater emphasis on external behaviours, parent-infant emotional bonds, the infant’s reaction to separation and loss and interpersonal relationship (Bowlby, 1969; Bowlby, 1973). Psychoanalysis, on the other hand, places greater emphasis on the internal world, including fantasies and internal dynamics, with less emphasis on observable external experiences.

The strength of Bowlby’s attachment theories lies in his embracing of empirical research in his work with mothers and babies, which was continued by Ainsworth (1973; 1974) and Main et al. (1985). Attachment theories have retained a solid presence in various disciplines and are widely embraced in developmental psychology, neuroscience, and in social psychology, where they have been useful in determining the quality of romantic relatedness in partners (Hazan and Shave, 1994). Longitudinal studies in attachment behaviours, for example, Grossman and Grossman, (1991) and Waters, Merrick, Albersheim, and Treboux, (1995) identified their appeal in psychoanalysis as a means of conceptualising psychopathology.

In recent times, there has been a gradual push for an interdisciplinary dialogue between psychoanalytic theories and attachment theories to inform research and clinical practice. Levy and Blatt (1999) argue that despite the fundamental differences, the psychoanalytic concept of ‘mental representations’ and attachment theories of ‘internal working models’ are analogous, as they are both developmental theories based on the early maternal-infant relationship, which shapes personality development and adult psychopathology. Psychoanalysis can therefore contribute to the study of attachment theories through the identification of developmental levels of representations, the degree of differentiation and internalization.  Levy and Blatt (1999) view the application of psychoanalytic object relations theories to attachment theories as “providing an elucidation of interpersonal functioning within the insecure attachment types, thereby giving attachment theory a broader application, clinically and non-clinically” (p. 558).

A contemporary theorist, who is robustly engaged in integrating psychoanalytic and attachment theories clinically and through research, is Fonagy, who argues that the two theories are compatible, as they are both fundamentally based on the importance of parent-infant early relationship (Fonagy, 2001). Fonagy and Target (1996) coined the concept of mentalization, which embraces both attachment and psychoanalytic theories.  Fonagy, Gerglely, Jurist, and Target (2002) define mentalization as the ability to reflect on others’ thoughts, beliefs, desires, and feelings, while also subjectively reflecting on one’s own mental state and how it may influence others. Mantalization capacity, developed in infancy, enables the infant to experience emotional regulation and inter-subjectivity.  Failure to develop these abilities causes psychopathology in later life.

Fonagy et al. (2002) suggest that mentalization, usually attained at around 4-6 years old, indicates a secure attachment between the infant and its carer, while a lack of resolution signifies disturbed attachments. The differentiation of ego, the ability to recognise others as separate and mature object relations, are all ego capacities which are key to mentalization and are deeply embedded in the psychoanalytic discourse.  Fonagy argues that the inability to experience inter-subjectivity or to affect regulation difficulties are the result of insecure attachment, which leads to psychopathology in later life (Fonagy, 2001). Psychoanalysis places greater emphasis on the mother’s emotional availability and her ability to tolerate the infant’s distress without feeling overwhelmed, to modify it and hand it back in a tolerable form, a process called containment (Bion, 1962).

Another major development in drawing psychoanalysis and attachment theories together is in the development of Dynamic Interpersonal Therapy (DIT). DIT was developed by Lemma et al. (2010) through an amalgamation of attachment theories, object relations theories and mentalization theories (Fonagy, 1996). DIT views depression as a disturbance in interpersonal relational (attachments) and it also emphasises the importance of the interpersonal relationship (object relation) between the therapist and client, while working in the transference. DIT has recently been included in the NICE guidelines (NICE, 2011). This demonstrates how psychoanalytic theories and attachment theories can work together, enriching both disciplines clinically.

Case example 1.

‘Brian’ is a 19-year-old man, who has moved from a small city to study for an undergraduate degree. He is experiencing severe problems sleeping and is constantly worrying that his girlfriend, who he has left behind, is going to abandon him. He obsessively ruminates about her cheating on him, which upsets him, makes him feel guilty and triggers bouts of anxiety. His feelings, behaviour and thoughts are destroying his relationship with his girlfriend, who he claims to love deeply.  Brian’s parents divorced when he was four after their relationship had become acrimonious. His father is estranged, but Brian is very close to his mother, who he calls daily.  He was referred for the standard six CBT sessions for anxiety.

In session 1, Brian presented as an intelligent young man, who robustly asserted that “I need pure CBT; I don’t want to talk about my past life”, said in a rather defensive manner. Brian found it difficult having me teach him the model. He would talk incessantly and he frequently interrupted when I was speaking.  It was difficult to reorient him to go through the pragmatics of CBT.  He would not do any of the little homework I set him, citing that he was too busy with his course work. Brian flooded each session with descriptive narratives about how his anxiety was crippling him and how this made him feel inadequate. In my counter-transference, I felt rejected and excluded from his world.  There was a palpable sense of Brian sabotaging each session and I began to be acutely aware of the time limitations of the therapy.

In session 3, having been overwhelmed by Brian’s relentless talking, poor engagement with CBT and his repeated reminders of how afraid he was of losing his girlfriend, I suggested this to him “I wonder whether your assertion about not wanting to talk about the past and your deep fear of losing your girlfriend might bring back some painful memories about your other losses, which might be difficult to face”. Brian stopped talking, sat back in his chair with his face down, and paused for several minutes. Then, tears welled up in his eyes and he began poignantly talking about how bereft he felt about his father leaving and how he had started to experience nightmares, which continued until the age of fourteen. The nightmares were of his annihilation by a powerful force coming through the roof and leaving him feeling extremely vulnerable.

Session 4, 5 and 6 were psychoanalytic in frame, with the objective of helping Brian understand his attachments, offering him a safe space to express his feelings about the loss of his father (broken attachment), confronting inadequacy in his current interpersonal relationship (an insecure attachment) and separation anxiety with his mother (ambivalent attachment). These sessions were quite different to the early ones and were very contained. Brian slowed down and engaged with his vulnerability, which had caused him to defend by controlling the trajectory of the therapy in the early sessions. Brian informed me that each time he left sessions three, four and five, he would go home and sob. He did not know the reason for his tears, but said that he felt “cleansed” afterwards.

My supervision confirmed my clinical impression that Brian’s loss of attachment with a primary carer (his father), at an early stage had created an internal working model of insecure attachments. Leaving home, breaking the attachments with his girlfriend and mother, and losing his father when young were all unconsciously and psychologically traumatic for Brian. This disruption in early object relations (Freud, 1917; Klein 1946) had led to interpersonal difficulties in his current life.  Only when Brian had sessions with a psychoanalytic framework, could he understand the unconscious impact these losses had on him, as they allowed him to express some of the painful emotions he had felt, linked to the loss of his father.

From a CBT perspective, Brian held core beliefs that the people in his life would leave him and that he was ‘not good enough’. Hence, the anxiety that his girlfriend would leave and that he was ‘inadequate’. However, this alone would not be enough to address the source of these maladaptive core beliefs. Brian scored very low on all measures -GAD-7, PHQ-9, and University Treatment Outcome Summary. He went on to see a private psychodynamic psychotherapist for longer term psychotherapy following this episode.

A critical discussion of CBT versus psychoanalytic oriented therapies when working with students and current research

The vignette presented above is a single case which gives a snapshot of some of the typical issues with which students present and the common clinical therapeutic pattern.  CBT, which focuses on the external world, can be limiting and therapeutically negative when working with the student client group who may be experiencing an internal loss and a reactivation of insecure attachment patterns (Bowlby, 1969).  Whilst not denying the efficacy of CBT in certain scenarios, I believe that working with students often requires an interpersonal model that addresses the unconscious phenomena and a consideration of attachment and loss, as demonstrated in the presented case.

It could be argued that the clients seen in our service and in the case referred to above are seen for only six sessions and that this may be considered insufficient for drawing more general conclusions and therefore my hypothesis lacks validity.  I acknowledge the legitimacy of this argument but I believe that there is urgent need for research, specifically with student client groups and modalities, which may strengthen the case for psychoanalytic approaches.  Unfortunately, at present, there is no such research available to support the hypothesis I am making. However, Coren (1996) strongly argues that short term psychodynamic psychotherapy is preferable when working with students, suggesting that it minimises commitments and procrastination and limits the potential for pathologizing.  Malan, Heath, Bacal, and Balfour (1975) acknowledge the therapeutic gains of a single assessment session in a psychodynamic framework, as it enables the client to understand the nature of their deficits and to embark on future planning to address them.

Searle et al. (2011) conducted an influential study, offering four psychodynamic psychotherapy sessions to young people aged 16-30, at the Tavistock and Portman. A total of 236 clients was seen. Outcome measures Youth Self Report and Young Adults Self Report forms were used before and after the intervention. The outcome data suggested that there were greater improvements in all subscales, with most improvement noted in the internalisation subscales. The results of this study are applicable to the adolescent/young adult student client group.

Blagys and Hilsenorth (2000) and Shedler (2010) looked at outcome of literature database research that identified features which distinguish psychoanalytic oriented therapies from other therapies. They argued that psychoanalytic oriented psychotherapy enables the client to explore their emotions and recurrent themes and allows an exploration of early attachments.  They also declared that the strong therapeutic alliance in psychoanalytic oriented therapies enables an exploration of other interpersonal relationships. These features are highly relevant to the work with the student client group, many of whom are dealing with issues related to loss and a breakdown of attachments. Shedler (2010) also makes the important point that “intellectual insight is different to emotional insight” (p. 99). Often, students are intellectually aware of their problems, as in the case presented, but lack the emotional connection to address them.  This drives the need for therapists to adopt a more flexible way of addressing clients’ difficulties, rather than focusing on one model.

Another key limitation of CBT with students is their aversion to homework. Most of the students seen are already struggling with completing their coursework. They do not take kindly to being given yet more assignments. The CBT model puts the therapist in the role of an educator or a metaphoric parent, who teaches the child the model. This is a source of angst among students, who are at a stage where they are seeking independence. Unlike CBT, psychoanalytic psychotherapy enables students to work through their loss by negotiating endings in therapy. (Lee, 2004) declares that endings when working with young adults are very important, as they help them deal with their own traumatic ending of childhood attachments.

Extensive research has demonstrated the efficacy of psychoanalytic oriented therapies. Leichsenring and Klein (2014)’s systematic review of psychodynamic therapy for specific disorders illustrated trough RCTs show that psychodynamic psychotherapy is effective.   Abbas, Hancock, Henderson, and Kisely (2006) carried out a Cochrane database meta-analysis, studying the effects of short term psychodynamic psychotherapies with 23 RCTs, involving 1500 patients.  The results showed greater reduction in symptoms, which was maintained in medium-long term post follow up. Leichsenring and Leibling (2007)’s systematic review on the efficacy of short to moderate term, manual guided psychodynamic psychotherapy, with 23 RCTs, concluded that psychodynamic psychotherapy was as effective as CBT and in some respects superior to it.

The study by Taylor (2008) suggests that psychodynamic psychotherapies were as effective as CBT, coupled with medication. Guthrie et al. (1999) studied the cost effectiveness of short term psychodynamic psychotherapy and demonstrated improvement in special functioning, fewer contacts with services, and reduced use of medication. Durham, Chambers, and Power (2005) carried out a study in Scotland on the durability of CBT, which concluded that effects of CBT erode over time and there is no advantage of CBT over other therapies.

Key psychoanalytic perspectives on psychopathology and their application to the student client group

Psychoanalytic theories enable us to understand the sources of psychological problems, but they can also give us an insight into the internal mechanisms of ego development, specifically the importance and complexity of the successive accomplishments of certain crucial developmental tasks. Failure to accomplish these developmental tasks is a key factor in psychopathology in later life (Klein, 1932; Fairbairn, 1944; Winnicott, 1945; Bion 1962). Psychoanalytic theories therefore enable us to formulate and conceptualise our clients’ difficulties, as well as identify the most appropriate treatment for them.  This notion suggests that psychoanalytic oriented therapies are more likely to achieve positive outcomes than other therapies.

Klein (1932; 1946) argues that psychopathology in later life stems from the infant’s difficulties with negotiating the depressive position from the paranoid-schizoid position, in relation to the breast, its first object relation. Klein hypothesises that the infant must deal with primitive persecutory anxieties of a psychotic nature, due to the mother’s breast being experienced as both gratifying (good) but frustrating (bad) leading to its splitting into both a loved and hated object. Due to the death instinct, the infant develops annihilatory fears and as a result unleashes sadistic oral attacks on the satiating breast, which is also resented.  Winnicott (1945) agrees with Klein’s idea that the infant’s early ego lacks cohesion and is susceptible to disintegration. Through the mechanisms of introjection of the good (loved) and bad (hated) breast, together with the realisation that the breast is one object, the infant’s ego becomes more integrated.

Having developed the awareness that the breast is one object and psychically introjecting it as a whole object, the infant is then able to transition into the depressive position, which is dominated by feelings of reparation, guilt, shame, and mourning. Klein (1945) asserts “The synthesis between loved and hated aspects of the complete object gives rise to feelings of mourning and guilt, which imply vital advances in the infant’s emotional and intellectual life” (p. 100). Until the infant negotiates the depressive position, the ego lacks cohesion and is vulnerable to disintegration. An individual’s personality, emotional life and psychopathology in later life are all shaped by how the infant negotiates the depressive position. Looking at depression as a psychological illness, Klein (1946) hypothesises that the “violent splitting of parts of the self into others is what causes depletion of the ego, triggering feelings of loneliness and depressive feelings” (p. 104).

Freud’s (1917) theory of mourning and melancholia is a cornerstone in understanding the psychogenic processes associated with normal mourning and pathological disposition of mourning, known as melancholia. Freud views normal mourning as a reaction to a loss-relationship, a loved person/object, including emigration away from the individual, which is in the consciousness. Normal mourning is associated with painful feelings and reality testing that the object has departed. As time goes on, the ego withdraws all its libido and attachments, becoming free again. One is then able to cathex the libido into a new object and is then capable of relating healthily to others. In line with Freud’s theory of mourning, following the loss of an object, Winnicott (1965) views an “inability to mourn and feel concerned as secondary to the infant’s inability to achieve maturation and integration of the self” (p. 220).

In melancholia, the sufferer cannot perceive what is lost and it remains in the unconscious. What distinguishes melancholia from normal mourning is the “profound painful dejection, cessation of interest in the outside world, loss of capacity to love, inhibition in all activities, a lowering of self-regard, self-reproachment and a delusional expectation of punishment to the self” (Freud, 1917, p. 252). In melancholia, the ego becomes consumed by these feelings and is severely impoverished. This leads to a splitting of the ego, where part of the split-off ego becomes the lost object. Freud believes that withdrawal of the libido into the ego and the splitting of the ego, which is identified with the lost object, is what leads to the sadistic attacks on the lost object, which is also the self.

According to Freud, that fixation, the narcissistic object relation, and ambivalence towards the same object are key factors which lead to lack of conscience and berating of the split- off self. Freud views melancholia, and other neurotic psychopathologies as complexities in the object relationship, which cause a disturbance of the normal process of dealing with loss. Fairbairn (1941) agrees with the idea of ambivalence in object relation, causing psychological disturbances in asserting that “difficulties with schizoids is how to love without destroying by love and with depressives is their inability to love without destroying by hate” (p. 271).

As pointed out earlier, many students leave home to start university in their late adolescence, which is identified as one of the key stages of developmental achievements in psychoanalytic theories, due to the complexities related to mourning the loss of the child and transitioning into adulthood, which also involves “loss of one’s position in the family” (Brice, 1982, p. 317). Wolfenstein (1966) argues that each developmental stage involves mourning the loss of the old self. Every experience is unique and not everyone goes through these complex stages smoothly. Psychoanalytic theories suggest that glitches in these processes could contribute to adult psychopathology. It appears that students, who are in the adolescent stage, are already developmentally vulnerable. The loss through leaving home and the consequent challenges in attachments, compound the complexities of this stage, triggering a psychological breakdown. Blos (1967) views the adolescent stage as the ‘second individuation stage,’ where the adolescent disengages from infantile love objects to cathex the libido into more mature object relations.  This psychological leap from child to adult is what makes adolescence particularly complex.

Freud’s key developmental theory postulates that the infant develops through oral, anal, latent and adolescent stages before reaching the adult stage of psychological maturity (Freud, 1905). However, there is now evidence in neuropsychology that the human brain continues to grow into the early 20s (Dahl, 2004). This gives weight to the idea that, though adolescents (students) might appear physically mature, they may be underdeveloped mentally, cognitively, and psychologically and are consequently lacking the ego strength to deal with emotionally challenging situations.

The transitioning into adulthood from the adolescent stage also evokes some very deep-seated issues related to adaptive character formation and establishing oneself as an individual (Blos, 1968, p. 250). (Frankl and Hellman, 1962; Laufer, 1966) all assert that the adolescent’s separation from parents leads to a mourning process, as the adolescent must libidinally detach themselves from the parents, as they transition into adulthood.  Laufer (1966) goes on to suggest that in response to failure to mourn the originally attached parental, oedipal relationship, additional defences are employed, particularly in adolescence, leading to a distortion of reality (p. 288).  This view gives an insight into some students’ internal difficulties.

Conclusion

Delivering psychotherapy interventions to students is a specialism, which considers the nature of their difficulties, which are, in most cases, linked to internal loss and a breakdown of attachments. In the current climate, CBT is being prescribed for most students, as it is considered effective and is evidence based. However, the difficulties experienced by some students as identified in this paper, can be best worked with and reframed from a psychoanalytic perspective, which addresses the unconscious dynamics. Understanding the impact of loss of attachments on individuals is crucial, as are the psychogenic processes in the adolescent developmental stage. Psychoanalytic theories and attachment theories have been seen as complementing each other, both clinically and in research. This paper concludes that the therapist needs to develop an open mind, regarding the model that is used when working with adolescent students, but strongly advocates psychoanalytic oriented psychotherapies. Employing an approach such as CBT, which treats symptoms without addressing the origins of the client’s difficulties is an inadequate response to their problems. Psychoanalytic trained therapists need to garner more research evidence to give greater credibility to claims of the efficacy of psychoanalytic oriented psychotherapies with specific client groups and pathologies, putting it on a par with CBT.  Research has already suggested that psychoanalytic psychotherapies are effective. The introduction of DIT in the NICE guidelines hopefully marks the beginning of a change in clinical practice which may lead to widespread acceptance of the valuable contribution which psychoanalytic psychotherapy can make in the treatment of the specific client group discussed in this paper.

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