Approaching Mortality

How do you understand what is happening to you?

What is your worst fear?

What is most important to you?

What sacrifices are you prepared to make?

In recent months, I have been providing a counselling service to patients and family members at a local hospice and I recently came across this book:

“Being Mortal: Illness, medicine, and what matters in the end” by Atul Gawande

I was so struck by the humanity and experience of the writer that I was wondering if a review of its contents might be useful for some of my readers. 

Who might benefit from this book?

Anyone living with life threatening illness, living with someone with a life threatening illness or working in palliative care.  Anyone who is mortal.

What are the main ideas?

Modern medicine struggles to deal with mortality. For this reason, it runs the risk of neglecting care at the end of life.

However Atul Gawande argues that, in life, endings can be more important then the countless moments that come before.

In end of life care, endings matter. This is true for both the one with a life threatening illness and for those closest to them.    

Gawande suggests that being mindful of endings eases or limits suffering by supporting individuals to:

·      Negotiate over-whelming anxiety about death, about suffering, about loved ones and finances.

·      Reach acceptance of the limits and possibilities, leading to a greater sense of empowerment.

·      Share memories, pass on wisdom and keep sakes, settle relationships, establish legacies, make peace, ensure that those who are left behind are ok. 

·      End on their terms

Difficult conversations

Gawande advocates courage in having difficult conversations with individuals and family members.

"I am worried"

He argues that facts can be daunting and confusing. According to him, people are more interested in the meaning behind the facts. He suggests that the words “I am worried that the illness is still there” convey more then any medical detail.

 The most important questions

How do you understand what is happening to you?

What is your worst fear?

What is most important to you?

What sacrifices are you prepared to make in order to hold on to what is most important?

It seems as if these questions cannot be asked too early or too many times.

Time has a habit of altering all answers and everyone, without exception, has a habit of moving unconsciously through life and of limiting the choices that they make about how they live.

These ideas will be all the more meaningful to those amongst us with a heightened sense of their mortality. If this describes you, then you might appreciate this book.

Supportive links

http://www.counselling-directory.org.uk/counsellors/rachel-lewis

http://www.macmillan.org.uk

https://www.alzheimers.org.uk

http://www.amazon.co.uk/Being-Mortal-Illness-Medicine-Wellcome/dp/1846685826/ref=sr_1_1?ie=UTF8&qid=1454602807&sr=8-1&keywords=atul+gawande

How to Argue

As a marital and family therapist, I sometimes consider it my job to help people to have a good old-fashioned argument. It’s no easy matter, as there seems to be a real knack to getting it right.

Not all families argue but it can be a helpful way of maintaining closeness. It helps people to regulate negative emotions and allows opportunities for family members to feel heard and accepted.

If you grew up in a family where the smallest thing could result in a full blown fight or if you rarely saw anyone in your family get angry, then this article might be for you.

It will look at common and unhelpful conflict styles and will suggest ways in which we can win arguments without letting our relationships lose out.

Volcanoes, Gas Tanks, Tortoises and Hedgehogs.

Every one uses different styles of dealing with anger. I have divided these different styles into categories.

Volcanoes:

A volcano stores up anger, resentment and bitterness until it all get’s too much to control and the volcano has to blow. This can be pretty explosive leaving both the volcano and other members of the family stunned and hurt.

Volcanoes learned a long time ago that the best way to deal with a problem was to keep perfectly calm. This approach can be highly successful at work and in many situations at home.

However the mounting tension can be exhausting. Family members may also be unaware that anger is building up leaving the volcano feeling misunderstood and frustrated and adding further to their anger.

Gas Tanks:

Gas Tanks tend to carry a lot of volatile material around with them and can explode with the slightest spark. They can be very sensitive to having their feelings, hurt or ignored and have found in the past, that the only way to address hurt, fear or sadness is by losing their temper.

If you live with a gas tank, you may find yourself feeling anxious not to hurt or offend in any way. You may also find yourself treading on eggshells a lot of the time.

Hedgehogs:

Hedgehogs are good at not exposing any part of themselves that feels vulnerable. They have learned as children that expressing their feelings can be dangerous and can lead to rejection or abandonment.

The trouble is that hedgehogs can be extremely prickly to the touch. If you live with a hedgehog, you may be used to getting your feelings hurt. It is unintentional but can be experienced as sarcasm, the cold shoulder, insensitivity, or humiliation.

Tortoises:

Tortoises plod away and take everything in their stride. They have a tough outer shell and seem to be immune to feelings.

If you live with a tortoise you may feel lonely and ignored. You may feel misunderstood and wonder if they really care. Paradoxically their outer shell is there to protect them from caring too much.

A vicious circle can develop where family members take pot shots at the tortoise in order to make them react. However this can only make them retreat further into their shell.

Of course this is an over simplification. In fact there are crossovers between the styles and we often find ourselves adopting more then one in family arguments.

The trouble is that each style feeds off the other. They are self perpetuating, leaving family members caught in escalating conflict or bitter withdrawal.

How not to be a volcano, gas tank, hedgehog or tortoise.

We have all caught ourselves, or someone we love using these argument styles. However it takes a great deal of tolerance in a relationship to endure this for long.

John Gottman has done a thorough study of happy couples and has noted that happiness in relationships is not found through avoidance of arguments but in the adherence to certain unwritten rules.

It’s not whether you argue but how. With this in mind, I have extrapolated some ground rules for family conflict.

Win/ win

Many people think that in order to win an argument, someone else has to lose. In fact the win/lose approach often results in both sides losing. Arguments can become entrenched, leaving people feeling exhausted and hopeless about finding a solution.

Instead of being on separate sides, therefore, try to imagine that you are looking for a way back on to the same side. If you allow your loved won to win you over with their argument, it is very likely that they will do the same for you.

Lids with safety valves.

Gas explosions are never helpful in arguments so try and put a lid on it. If you feel like a volcano and can sense the pressure building up then release it gently and effectively using assertiveness and empathy. If you are about to blow then use time out.

Assertiveness

Be assertive. There is no need for profanity, insults or abusive tactics. Try not to make the argument about the other person or point the finger of blame. Focus on what happened, how you feel and why this is so important to you.

Empathy

Arguing without empathy is a bit like shaving with no sense of touch. Without empathy, how do you know how sharp your words are and how hurt your loved one feels? Arguments can escalate so easily without this essential ingredient.

Take time out

If you become too agitated then take time out. Acute stress makes it hard for us to think clearly. So if your temperature goes up, or you hear the blood pounding in your ears, take a break.

Notice if you are hungry, or tired. This can greatly affect your ability to keep a lid on things. You may find it helpful to eat something or have a sleep. Writing your thoughts down in a letter may help you to calm down.

Useful links

http://www.canadianparents.com/article/seven-secrets-to-a-happy-marriage

http://www.gottman.com/?gclid=CMzFnp7k_aQCFaP92AodZVC2hg

http://www.suite101.com/content/resolving-conflict-a214421

http://www.suite101.com/content/overcoming-conflict-avoidance-a52146

http://www.suite101.com/content/arguing-positively-a91233?sms_ss=email&at_xt=4cc9a5a3e27b2c76,0

http://www.suite101.com/content/four-negative-behavior-patterns-in-marriage-a231804?sms_ss=email&at_xt=4cc9a2eeb9e423a4,0

The Reality of Virtual Adultery.

Have you or your partner ever flirted or indulged in sex with another individual?Have you ever watched porn over the internet or developed an intimate relationship online with someone you have never met?

Lately, I seem to be getting more and more referrals of couples reporting virtual adultery. This seems to coincide with a swathe of new communication technologies. It seems that it has never been easier to have an affair.

If you have ever been negatively affected by these issues, then this article is aimed at helping you to make sense of feelings that you might be experiencing. It will highlight some effects of virtual adultery and will flag up some of obstacles for couples in staying together after an affair.

If you belong to a couple affected by cyber adultery then this post may bring up discomfort and a host of other emotions. No matter what your role or stake in it has been, reading this will take some courage. You have done enough to make it this far.

Why are virtual affairs becoming so common?

We live in a communication age. A quick search on Google demonstrates how easy it has become to initiate a sexual or flirtatious encounter with someone you have never met. Advancing technology now means that these liaisons can occur at any time of day or in virtually any place.

Communication technologies bring with them the ability to conceal or misrepresent one’s identity. The anonymity that this affords enables one to explore aspects of one’s sexuality that would ordinarily not be expressed.

It enables people to indulge in powerful fantasies. They can be whatever they want to be: tall, slim, attractive, considerate, and supportive. Online, these identities are worn like a second skin and have the power to be utterly convincing.

The intoxication of these fantasies can be highly addictive. It has even been suggested that hyper-stimulation during cyber sex, interacts directly with the pleasure pathways to the brain increasing vulnerability to sexual addiction.

Discovery of the Affair

Internet affairs cannot be hidden forever and it is often the graphic details of a sexual encounter that get discovered first.

Some have likened this experience to trauma. Trauma is associated with the experience of a life-threatening situation. It is argued that, a close bond with a life partner is an advantage for survival and that adultery puts this bond at risk.

This argument offers an explanation for the experience of depression, anxiety, or the sense of betrayal that some feel after the revelation of an affair. 

Flashbacks to the moment of discovery can occur without warning. Individuals may be plagued by obsessive and distressing thoughts and images and become hyper-vigilant for signs of further betrayal.

The ease with which the adultery took place; the manner in which it was concealed; and the level of intensity of the adulterous relationship can pose problems. How can one compete with a virtual rival? What assurances can be given that it will not happen again? What assurances can be believed?

For the one who has been unfaithful, there may be guilt, shame, depression anxiety. There may be fear of losing an important relationship, either with one's spouse or the adultery partner. Paradoxically, there may be relief because the need for secrecy is now over.

The Effects on Your Couple

It is not hard to imagine the strain that can be put upon a couple once a virtual affair has been revealed. It is possible that the affair has unleashed a Pandora’s box of blame, criticism, denial and minimization.

In the aftermath of the discovery, both sides of the couple may blame and criticize each other for what has gone wrong. They may minimized each other’s feelings or minimize the effect that this has had on the other.

For the one feeling betrayed it is understandable if hurt ends up expressed as rage. For the one who has been having the affair, it might feel like they are going to be punished for the rest of their life. They may try to limit the hurt by denying that this was a real affair. They may use distance to avoid further attacks.

The mixed emotions faced by both sides in the relationship can create a roller coaster ride leaving neither one nor the other feeling hopeful or safe to seek comfort in their relationship.

Rebuilding the Relationship

The following suggestions are intended as guides. It may be hard to avoid opening that Pandora’s box of blame, criticism, denial and minimization. If this is the case, an individual or couple therapist might be helpful:

Establish Safety

It is important to understand how this affair has affected both of you. The more you can show that you acknowledge and understand the consequences of what has happened, the more safe you both will feel.

Remember, those who feel betrayed have one of the hardest tasks. It is understandable to feel ambivalent about the relationship. Unfortunately, the more you express this as blame and criticism, the more anxiety and distance gets created in the couple.

An important factor in easing your anxiety and hurt is the establishment of clear boundaries. This means finding ways of making sure that the affair is over.

It will also mean being clear about whether or not and how to reestablish a physical relationship with each other.

Establish Communication

Only once safety in your couple has been established, can you begin to address the factors in your relationship that led up to this. The following questions might help to guide your conversations with each other:

• · Have either of you recently experienced a difficult transition such as the bereavement of a loved one or change in life? How has your couple supported you through this?
• · Is there any buried anger or hidden resentment that either of you have not been addressing?
• · Do you find it hard to approach the other person for comfort, warmth or support?
• · Do you ever feel criticized, blamed, undermined, misunderstood or forgotten?
• · Do you feel comfortable in your own skin?
• · Are you satisfied with your sex life? http://freshpagetherapy.blogspot.com/2010/10/low-sexual-desire-in-relationships.html

It can be hard to move on from an affair. However, couples that do manage to do this report feeling stronger in their relationships as a result. Don’t forget that there are a number of experienced therapists out there to help, should you get stuck.

Resources:

To find a therapist:

http://therapists.psychologytoday.com/rms/

Books:

http://www.amazon.com/Seven-Principles-Making-Marriage-Work/dp/0609805797

http://www.amazon.com/Relationship-Cure-Strengthening-Marriage-Friendships/dp/0609809539/ref=pd_sim_b_3

http://www.amazon.com/After-Affair-Healing-Rebuilding-/dp/0060928174/ref=sr_1_1?s=books&ie=UTF8&qid=1288206982&sr=1-1

Blogs and Websites:

http://www.affairs-help.com/self_assess.html

http://www.aamft.org/families/consumer_updates/infidelity.asp

http://fatherhood.about.com/cs/dadsandmoms/a/affair_proof.htm?terms=extramarital+affairs

http://www.truthaboutdeception.com/recovery-and-repair/rebuilding-trust/timing.html

http://www.gregswensonphd.com/infidelity.htm#7

Low Sexual Desire in Relationships: Where Has the Passion Gone?

Sex is everywhere. In marketing, it sells everything from cars to chocolate. It brings audiences to the big screen and drives people’s fantasies.

In happy couples, sex is a good way of expressing love, acceptance, caring and desire for the other person. It can forge feelings of connection and partnership. It can be pleasurable and fun.

In unhappy couples it provokes feelings of rejection, mistrust, anxiety, loneliness, shame and disappointment.

If you are asking yourself where all the passion in your relationship has gone, then this article may help you to talk about it with your loved one and to start exploring possible causes and solutions.

1. Break away from cultural myths:

There is a cultural myth that real men do not experience low sexual desire. This myth is being put to the test, as growing numbers of men in the US express concern over their falling sex drive.

By contrast, women are the ones who are often accused of having low libidos. This has often led to clichéd accounts of women withholding sex in order to frustrate their male partners.

Popular myths can cause real problems when it comes to addressing concerns about sex. It places unrealistic expectations on both members of the couple. It can lead to disappointment or resentment, fuelling a negative cycle of blame and shame and spiraling down to even less desire and satisfaction.

In an attempt to sort fact out from fiction, I am often asked to comment on what is normal. The truth is that when it comes to desire, normality encompasses a broad range of experiences.

The most important thing is to forget about what you’ve been told. Find out whether or not you and your partner, are satisfied with your current sex life. This is the best place to start in defining the problem and looking for a solution.

2. Look at biological factors

Here are some factors, which can influence your body’s ability to feel desire. To assess them, it might help to consider when lack of libido started becoming an issue. It is always best to consult your doctor in case there are medical problems that need to be treated.

• Fatigue
• Increased alcohol intake
• Poor health
• Stress
• Lack of sleep
• Certain medications such as antidepressants,
• Depression
• Certain medical conditions such as endocrine disturbances

3. Get to know the sexual life of your couple

Talking about sex can be daunting. When there are so many cultural taboos around sexuality, many individuals fear that they will be rejected or ridiculed when they share their private thoughts.

However getting to know the sexual life of your couple is about getting to know how sex is experienced by both of you. There are many things to think about that could be relevant to your relationship. The following ideas, if sensitively explored, could be used to guide conversation.

• Have either of you had prior sexual experiences that have influenced how you or your partner, feel about sex today?
• Have either of you lost a child, had an abortion or miscarriage?
• Have there ever been problems with fertility?
• Have either of you ever worried about your body image?
• Has sex ever been painful?
• Have either of you ever experienced physical or sexual abuse?
• How do your ideas and beliefs about sex compare to one another?
• Are you able to know or talk about what turns you or your partner on?
• 
  

4. Check the emotional pulse in your relationship

This point is often overlooked but is extremely important. In fact the bedroom is often the arena where difficulties in the emotional life of a long-term relationship get expressed.

This is because intimacy requires complete trust. To be naked with your partner; to be honest about your sexual desires and needs; to fully express your sexuality; requires honesty about your emotions and acceptance of and sensitivity to your partner’s feelings.

So now is the time to sort out everything that has been piling up in the kitchen sink. That includes looking at any unexpressed anger, resentment or disappointment in your couple.http://freshpagetherapy.blogspot.com/2010/11/how-to-argue.html

5. Accept your differences.

The more open you are to hearing what your partner has to say, the more openness there will be in your couple. This is about accepting difference and that includes the differences that you both experience in desire.

There is often change in desire as couples mature. This can result from age-related factors which are experienced differently and at different times by men and women.

It can also result from the changes in body chemistry that are experienced as couples move from the passion of first encounters to a more stable and enduring sexual relationship. In fact, it is often at this stage that couples first notice a difference between themselves in terms of sexual appetite.

6. Focus on the solution

If your idea of sexual satisfaction is vastly different to your partner’s, then it may be helpful to start looking for some common ground. By focusing on what you want rather then what you don’t want, you move away from negative patterns of blame and shame and towards a level of intimacy built on sensitivity and respect.

And Finally

If you and your partner need support in exploring some of these issues then contact a qualified marital and family therapist http://therapists.psychologytoday.com/rms/prof_search.php. We are there to help.

Play, Family Life and Emotional Well Being

As children go back to school and homework agendas take the place of the carefree, less structured weeks of summer. I ask if we shouldn’t be allowing more time in our family lives to play.

Play is often ignored by adults, who may see it as pointless. Yet play is satisfying, pleasurable, fun. It is an intrinsic part of childhood and a child's natural medium of self expression. Play is often how children make friends, forming relationships that often span years.

Through play, children learn to be themselves. They explore aspects of their personality, they develop skills which make them feel good about themselves. What we know is that when engaged in play the child often becomes so engrossed as to lose awareness of his/her time and surroundings becoming immersed in an imaginary or symbolic world.

Play starts with a relationship. Between mother and infant, mirroring smiles and gurgles lend movement and sound to a time-honored dance. In this early play, children learn that they are lovable and special, that others are loving, caring and trustworthy, that the world is an exciting place to explore. As children develop, games become more elaborate including face making, role playing and physical games.

It is a safety mechanism to let off steam. Through play a child can express his anger whilst feeling safe from retaliation. 

For many families, play introduces humor at times of severe stress. It helps them cope with irritability, sadness and even fear. It has the potential for parents and children to build deeper connections with each other through laughter, imagination, and creativity.

"Play stirs things up, [states professor and psychotherapist Catherine Ford Sori] gets families …trapped in their left brains to use the creative spontaneous and playful aspects of their right brains". Play allows family members to see things from different angles, to explore new roles for themselves, to approach family problems with greater flexibility and maturity.


I don’t know when we lose our ability to play but maybe our children have something to teach us after all.

References

Sori, C.F. (2006) "Engaging Children in Family Therapy" Routledge: Taylor and Francis Group

Cognitive Behaviour Therapy: What is it and how does it work?

“The mind is its own place, and in it self can make a Heaven of Hell, a Hell of Heaven.”

~John Milton, Paradise Lost

Many of you reading this blog will hear a ring of truth in the quotation above. Perhaps you are plagued by negative thoughts that circle almost constantly in your head. Perhaps moments of creeping anxiety or even sheer panic make your life unliveable.

CBT (Cognitive Behaviour Therapy) was devised to get to the heart of each individual’s personal hell. It provides a method of changing the way we look at things and of changing our experience of life as a whole. I use it to work with anxiety where it has shown to be a useful approach.

Its central philosophy is that beliefs about ourselves, about others, or about life in general have a direct impact on what and how we feel and on how we behave. CBT describes how this can create a kind of a feedback loop, where a person’s beliefs and their physiological, emotional and behavioural responses all interact with each other in ways, which perpetuate and maintain the problem.

Imagine for example that you are walking into a bar one day and a man turns to look at you. What do you think?

“He’s noticed how I look.”

“What does that guy want with me?”

“This does not look like a safe bar.”

“That guy must be waiting for someone. He must have wondered if I was that person walking in”

On the surface, it’s impossible to judge which of the above thoughts might be true. However they each reveal something about our general outlook towards life, towards others or towards ourselves.

Supposing one were to think “He’s noticed how I look.” This thought may come from a variety of different outlooks. Someone, for example, who generally sees the world as an unfriendly place might be prepared for the possibility that others will laugh at him. If he then goes out and sees people looking at him, he might automatically think that they are judging him.

At this point there is often a physical response. The person might go red, they might feel a lump in their throat, a tightness in the chest, or feel short of breath. Their heart might pump harder. They might shake or sweat. They might experience stomach pains or a sense of unreality. This in turn emphasises the impression that others are looking and leads to feelings like, embarrassment, shame, anxiety, sadness or anger.

In response, he might start a fight or duck into a corner. He may attempt to deflect attention by having a loud conversation with the bar man. According to CBT, the way we behave in response to these events only goes to reinforce the beliefs that caused such a reaction in the first place.

It sparks a vicious cycle that can lead to spiralling negative thoughts and escalating psychological and physical discomfort.

Although we all have beliefs that guide our general outlook in life, we are rarely aware of them. This is because they are always acquired when we are very small and don’t have the language to question them.

So they get hardwired to a part of the brain, which operates automatically. CBT is about gaining control through finding these beliefs and making them conscious.

Cognitive behaviour therapists help their clients to examine their beliefs either through carefully devised questions or through behavioural experiments.

Behavioural experiments involve exposure to the events that elicit the discomfort. The theory goes that by facing up to our beliefs in a concrete way we reach parts of the brain that other therapies can’t reach rewiring our belief system and creating possibilities for long term positive change.

What is Solution Focused Therapy and How Does it Work?

Solution focused therapy (SFT) was devised in the 1980’s by Steve de Shazer (O'Connell 1998). It is often used as a form of brief therapy.

I often integrate SFT into other forms of therapy. It can be helpful in setting the goals of therapy. It can also be useful in helping family members to break entrenched conflict or in introducing conversations about intimacy.

The philosophy behind the approach came from 2 surprising observations that were made by De Shazer’s team.

1. Clients are not necessarily helped, by talking about the problem or it’s origin.

2. The solution does not have to fit the problem

A problem focused approach, they argued tended to limit clients and their therapists to old ways of talking about and viewing a problem. Therapy, they noticed, could often appear stuck in the past offering scant vision of what changes needed to be made in the future.

De Shazer maintained that positive changes could be made in a person’s life without defining the problem at all. For a solution to be found, it was enough to ask the client to imagine their future without the problem.

We cannot successfully steer a bicycle without looking in the direction we want to go. Nor can we navigate ourselves out of life’s pitfalls, without a sense of the future and of how different we want things to be.

Things that you may notice about an SFT session are that it is very focused. The therapist will be actively inviting specific ways of talking that he or she believes are most conducive to solution finding.

A typical session will focus upon what you would like to change. It will invite you to think of a hypothetical situation when the problem does not exist. You will be asked to focus on very concrete changes; such as the differences that you or others will see or hear. Finally you will be invited to define the first step that needs to be taken in reaching this future.

Therapy takes as long as it takes. However emphasis is placed upon the client’s competences, strengths and sense of autonomy. The aim is to not keep anyone in therapy longer then is needed.

References

O'Connell, B. (1989) "Solution Focused Therapy" Sage:London