Issue One 2011 ISSN 1835-937X
and the Body
Journal of the Counsellors and Psychotherapists Association of NSW Inc
G de ain ve pr lop ofe me ss nt ion Transactional Analysis 101 Weekend Workshops po al int This two day Introductory Workshop is for individuals interested in understanding the theory s and practice of Transactional Analysis (TA). This workshop is a comprehensive experiential introduction to Transactional Analysis and its application. The application of Transactional Analysis covers a broad spectrum of uses for people working with the public. Dates: 4th and 5th June, 2011 Cost: $275 (includes GST)
The Edge Workshop Where the Edge of the Pyschotherapist meets the edge of the client working in the realm of uncertainty A great deal is written and spoken about how the therapeutic relationship is the most curative factor in our work. Many of us have been well trained in counselling and psychotherapy theories and practice. However, this does not salvage us from those moments where we come face to face with our clients and are left with feelings of helplessness and hopelessness. Dates: Group 1: 12/02/11, 02/04/11, 28/05/11, 25/06/11 Cost: $275 (includes GST) a day x 4 = $1,100 for the four days
Supervision: The Relational Approach This seminar is part of a program which identifies different methods of supervision. They are the Contractual, the Relational, and the Open Space, sometimes known as the Role of Analysis approach. Each seminar can be done independently. While the relationship is important in each approach, the Relational model pays particular attention to the unconscious process in the relationship while working with transference and counter transferential dynamics. Dates: 25th and 26th March, 2011 Cost: $550 (includes GST)
Working with Children & Families from an Integrative Approach Child and Adolescent treatment brings certain challenges in terms of the complex systemic processes that surround and affect the two-person experience. Date: 21st May, 2011 Cost: $275 (includes GST)
Supervision : The Critical Incident Approach This supervision seminar is another part of the ACIS supervision program on methods of supervision. The Critical Incident Approach, sometimes referred to as the â€˜open spaceâ€™ approach, looks at the broader thinking of supervision, i.e. diagnosis, multilayered issues and problem solving. It is probably the most misunderstood of techniques, as contracting for outcomes is not popular; however, association and interpretation are. Curiosity in exploring and the zeal for playing with meaning and potential meaning are central in this approach. Dates: 11th and 12th June, 2011 Cost: $550 (includes GST) Venue: All the abovementioned workshops are held at 3 Church St, Waverley
For further information and courses visit our website: www.acissydney.com.au
3 Church St, Waverley, NSW 2024 P: (02) 9386 1600 E: firstname.lastname@example.org W: www.acissydney.com.au
A new year, a new Editor, a new look, and new perspectives on offer in Therapy and the Body, the theme of this issue of The CAPA Quarterly. Since the body is the focus of the therapeutic approaches explored here, we start with ‘Finding a Home in the Body: Therapy from a Somatic Perspective’ by representatives of the Australian Somatic Integration Association (ASIA) Meredith Pitt, Jean Gamble, and Gerry O’Sullivan. British psychotherapist and philosopher Emmy van Deurzen presents and Existential perspective. CAPA member Liz Dore shines a light on the often overlooked issue of the psychological issues, and especially the sexual needs, of people with disability. British therapists James Lawley and Penny Tompkins, specialists in the Clean Language approach to client-therapist dialogue, present a fascinating look at ‘Metaphor, the Body, and Healing’, and physiotherapist AnnaLouise Bouvier, one of the specialists who recently brought us the ABC series ‘Making Australia Happy’ here expands on her monitoring of physical factors that influence mental states in ‘Working with Minds and Bodies’. Our Professional Development coordinator Juliana Triml reviews the most recent PD presentation, by Christine McCabe, and last but never least, our regular ‘Business of Therapy’ columnist Clare Mann addresses the question, ‘How Can Technology Help Us Avoid Burnout?’ As always, there is CAPA news and a host of notices that will be of interest to members and other readers. As your new Editor, I hope you enjoy this, my first issue of The CAPA Quarterly. I am pleased and honoured to be a part of this team, and to have a hand in bringing you fresh insights you may find useful for your practice. I don’t do this alone. The members of the Executive Committee are always ready to help when asked, our regular columnists provide helpful suggestions in each issue, and our contributing authors do so without compensation, sharing their professional knowledge and experience generously, and accept with good grace my nit-picking edits. Our new Advertising Coordinator is a welcome addition to the team, bringing in much needed revenue to make this journal possible, and our Office Manager is a stalwart. I am grateful for all these people, without whom I could not do this job. We bid farewell for now to regular columnist Jacinta Frawley, with gratitude for her many contributions and the hope that she’ll be back with us when her other commitments allow. This journal is for you, our valued members, and I enthusiastically encourage your active participation in the professional dialogue and sharing that this journal and the accompanying blog pages provide. Please have a look at the upcoming themes announced here and on the blog and have your say on the topics that interest you. Another innovation is being introduced: February issues have now been designated as Open Forum rather than being dedicated to a theme, so that no matter what therapy topic you wish to address, we can accommodate it in this journal. Journal articles are, by the nature of page space, limited, and early contact with me improves the chances of your contribution being included, but blog publication, of either articles or comments and responses to others’ articles is also very February 2011
valuable and can be done at any time. Dialogue is welcome and encouraged. If you’d like to contribute to future issues, please contact me at email@example.com. See the Calls for Contributions for copy deadlines. The blog is still being run by former Editor of The CAPA Quarterly Gabrielle Gawne-Kelnar, and for this ongoing volunteer service we are very grateful. Please visit the blog and give your feedback on line. (http://thecapaquarterly.blogspot.com). Laura Daniel Editor Laura Daniel, BA, JD, is a Sydney-based publishing professional with more than forty years’ experience in the industry, both in Australia and overseas (http://www.editorsnsw.com/esd/ae1445523.htm). In addition to editing, as time permits she also designs, writes, mentors, composes, paints, sculpts, photographs, sings, dances, walks, rides horses, does yoga, meditates, and occasionally appears in minor film roles and commercials.
Upcoming themes in The CAPA Quarterly What will you contribute? Who are the experts in the field? Send expression of interest to firstname.lastname@example.org as soon as possible in order to ensure inclusion. Death and Bereavement – Issue Two 2011 This issue is now complete. Mailout: May Virtual Therapies ~ Issue Three 2011 Peer reviewed submissions due: 1 April Non-peer reviewed submissions due: 1 May Mailout: August Working with Addictions ~ Issue Four 2011 Peer reviewed submissions due: 1 July Non-peer reviewed submissions due: 1 August Mailout: November Open Forum ~ Issue One 2012 Peer reviewed submissions due: 1 October Non-peer reviewed submissions due: 1 November Mailout: February Sex ~ Issue Two 2012 Peer reviewed submissions due: 1 October Non-peer reviewed submissions due: 1 November Mailout: February NOTE: Peer reviewed submissions are due four months ahead of the issue month. Non-peer reviewed submissions are due three months ahead of the issue month. All submissions are due on or before the 1st day of the month.
Contributor guidelines: http://thecapaquarterly.blogspot.com /p/contribute.html or contact email@example.com. Advertising enquiries: http://thecapaquarterly.blogspot.com /p/advertise-with-us.html or contact firstname.lastname@example.org
CAPA NSW Executive and Staff President Maxine Rosenfield email@example.com Vice-President Linda Magson firstname.lastname@example.org Secretary Jennifer Heward email@example.com Treasurer Campbell Forsyth firstname.lastname@example.org Ethics Chair Jeni Marin email@example.com PD Coordinator Juliana Triml firstname.lastname@example.org
Contents Welcome 1
CAPA News 3 4 5 6
From the President’s Desk Meet CAPA’s New Vice-President CAPA Update: Lobbying Working Party Report Rural and Regional Report ~ Phil Hough
Member Profile 7 Meredith Kitson Features 8
inding a Home in the Body: Therapy from a Somatic Perspective F ~ Meredith Pitt, Jean Gamble, and Gerry O’Sullivan Representatives of Australian Somatic Integration Association (ASIA)
Membership Chair Beate Zanner email@example.com
12 A Fully Embodied Life: An Existential Approach to Therapy ~ Emmy van Deurzen
Regional and Rural Liaison Chair Phil Hough firstname.lastname@example.org
Administrative Assistant Christine Rivers email@example.com
18 Therapy and People with Disability ~ Liz Dore Therapeutic Techniques
Advertising Coordinator Jennie Maxwell firstname.lastname@example.org
20 Metaphor, the Body, and Healing ~ James Lawley and Penny Tompkins 26 Working with Minds and Bodies ~ Anna-Louise Bouvier
The CAPA Quarterly http://thecapaquarterly.blogspot.com
The Business of Therapy
Editor Laura Daniel email@example.com
30 How Can Technology Help us Avoid Burnout? ~ Clare Mann Professional Development 32 What is Useful and Essential in Sexual Trauma Counselling? ~ Review by Juliana Triml 33 Professional Development Events Noticeboard 35 Classifieds 40 Conference Calendar
Cover artwork by Jim Frazier Design by embassy creative The CAPA Quarterly respectfully acknowledges the Gadigal people of the Eora Nation, the traditional owners and custodians of the land on which the CAPA NSW office is located; and the traditional owners of all the lands through which this journal may pass.
© CAPA NSW 2011. Copyright is held with CAPA NSW and individual authors. Please direct permission requests to the editor. Opinions expressed in The CAPA Quarterly do not necessarily represent those of the editor or of CAPA NSW. While all reasonable care has been taken in the preparation of this publication, no liability is assumed for any errors or omissions. Liability howsoever as a result of use or reliance upon advice, representation, statement or opinion expressed in The CAPA Quarterly is expressly disclaimed by CAPA NSW and all persons involved in the preparation of this publication. The appearance of an advertisement in The CAPA Quarterly does not imply endorsement of the service or approval of professional development hours from the service. Advertisers are advised that all advertising is their responsibility under the Trade Practices Act.
The Capa Quarterly
From the President’s Desk Following the frantic pace of life towards the end of 2010, a few weeks’ rest was welcome. We closed the CAPA office and we all took a break. Keeping you up to date with life in CAPA, in November we were delighted to welcome Linda Magson onto the CAPA Executive Committee. Linda has taken the role of Vice President and you can read more about her on page 4. Also in November we established the Lobbying Working Party. This is being chaired by Tessa Marshall. We had less interest in the website working party but we will e-mail members again later this year to see if more people would be able to give time to help us with our thinking. Meanwhile, we are reviewing our database and hope to make changes in time for this year’s renewals period, which should simplify administrative processes. Just before the holiday season, I met with Ione Lewis, PACFA President. We are trying to resolve some matters significant to ensuring that our members comply with PACFA requirements, and we welcome Ione’s interest in issues specific to CAPA NSW. As we all
know from our professional roles, open communication can only assist matters, and I am pleased that Ione has accepted my invitation to speak and answer questions at our AGM in August. It is likely that the Medibank Private provider numbers will be issued to eligible members in March. Those of you who have already sent in documentation can be assured it has been forwarded to PACFA , and those of you who are still submitting paperwork, please note that we will continue to send documents to PACFA on an on-going basis at present, although from the 2011 renewals period, we are likely to be submitting documents on a quarterly or half-yearly basis, depending on the system agreed between PACFA and Medibank Private. Until we have reviewed our website, we will continue to make DVDs of our PD events for regional and rural members to access in groups. If you know other practitioners in your area and you would like to host a small gathering at which the DVD can be shown and you have discussion time after the viewing, you can then receive
Subscribe today eer reviewed papers on therapeutic p approaches articles on therapist and client issues interviews with practitioners therapeutic techniques professional development updates practice management tips book reviews
PD hours and certificates for your
attendance. For more information please contact Phil Hough, the Chair of our Regional and Rural Committee (firstname.lastname@example.org). Looking farther ahead, this winter will be interesting for our profession with Sydney hosting the 6th World Congress for Psychotherapy in August. The Executive would like CAPA NSW to have a presence at this event and we are discussing options with the organisers. This will be an amazing opportunity to network, share, and learn from colleagues in practice around the world. I hope you all have a healthy and successful 2011, and look forward to meeting many of you at our PD events.
Maxine Rosenfield President email@example.com
Even if you’re not a member of CAPA NSW, you can still subscribe to The CAPA Quarterly and receive:
conference listings and much more All for $12.50 per issue or $40.00 for an annual subscription (including GST). Just contact CAPA NSW on (02) 9235 1500 or firstname.lastname@example.org
Organisational subscriptions are also available.
Meet CAPA’s New Vice-President
Welcome to I look forward to working closely with CAPA’s Executive Committee as their new Vice-President. I believe CAPA NSW plays a vital role in supporting members and enhancing high professional standards in the field of counselling and psychotherapy. My role will include supporting all aspects of CAPA’s activities, assisting Maxine, our President, and liaising with members and newly formed working parties. I valued the experience of being a member of CAPA’s Ethics Committee and having direct input into developing ethical guidelines for CAPA members with Jeni Marin and her team. I gained valuable insights and perspectives on ethical decision-making in our profession and enjoyed meeting many of you at our conference workshop last year, at which I presented issues that require ‘ethical mindfulness’ in the space between ethical practice and complaint. As a counsellor, I have worked in schools, in the drug and alcohol addiction sector, and in private practice
Linda Magson (Linda Magson Counselling) in Glebe. Like many CAPA members, I came to counselling as a second career, seeking a more meaningful way of working with people and engaging with my profession. From musician and educator to counsellor and coach, I enjoy transforming my creativity and using myself as an instrument of change. Relevant studies included a postgraduate diploma in counselling from ACAP (I was thrilled to receive the postgraduate ‘Outstanding Achievement Award’), a postgraduate diploma in psychology from the University of Sydney, and other postgraduate diplomas in social communication and education. I also have a Masters in Music and combine my music and counselling skills to work with musicians and adult beginners to realise their musical potential or master their performance anxiety. I look forward to serving on the Executive Committee and supporting the development of CAPA NSW as a strong professional body that fulfils members’ needs.
Meet The CAPA Quarterly’s New Advertising Coordinator Welcome to Jennie Maxwell
President: Maxine Rosenfield Secretary: Jennifer Heward Treasurer: Campbell Forsyth Ethics Chair: Jeni Marin Rural and Regional Liaison Chair: Phil Hough Read their profiles online at www.capa.asn.au
The CAPA Quarterly is ‘moving forward’ with the welcome addition to our team of a dedicated if part-time Advertising Coordinator in the person of Jennie Maxwell. Jennie was formerly CAPA’s membership renewals assistant. She comes from a background in the travel and tourism industry. On addition to being a busy mother of three, she also acts as Office Manager for her husband’s small part-time business. Starting with this issue, Jennie is handling all the ads, classified and display, from both members and non-members, and is expanding our reach, bringing in relevant product and service advertising to help us enhance our professional practices and to generate revenue to support the publication of the journal. Thank you, Jennie! Contact Jennie about any ads you want to place or change. Rates and deadlines are published on page 36. 4
Journal ads and PD hours Please note that advertisements in the journal do not necessarily comply with CAPA’s professional development (PD) requirements. As with all workshops/ courses/conferences, please check their eligibility using CAPA’s ‘Professional Development Policy 2009/2010’ in the members area of the website www.capa.asn.au. If you have any queries, please contact CAPA’s Membership Chair on email@example.com The Capa Quarterly
ate d p U A P CA
Lobbying Working Party Report
Do you know of key NSW based stakeholders/decision-makers who make referrals to, or employ, counselling services but that currently overlook CAPA members or counsellors altogether? • L ast year CAPA secured recognition for our Clinical Members to be NSW Work Cover Providers. ow we want to build on that • N great work coming up to the NSW Election to secure recognition along with other providers who currently don’t recognise our services. Some examples are the Victims of Crime
service, the Surrogacy Act, NSW Public Health Recruitment. ho else should we target? • W Are you aware of specific NSW agencies within Youth, Rural, or Gambling services? We really want to engage the voice of all seven hundred CAPA members and seek recognition from the agencies that matter to you. Please email Tessa Marshall at tessa@ marshallcoaching.com.au, Chair of the Lobbying Working Party to advise your recommendations regarding specific agencies.
Membership Total as at 8 February 2011
Code of Conduct for Unregistered Health Practitioners
As counsellors and psychotherapists, we are legally required to display two documents in our practice(s): • the NSW Code of Conduct for Unregistered Health Practitioners • information on how clients can make formal complaints to the Health Care Complaints Commission. Both are available online in the members area of the CAPA NSW website: www.capa.asn.au The Code of Conduct is also available in several community languages on the Health Care Complaints Commission website: www.hccc.nsw.gov.au These legal requirements are set out in the ‘Public Health (General) Amendment Regulation 2008’ under the NSW Public Health Act (1991), and came into effect on 01/08/2008. Ethics Checkout the CAPA NSW website for information on: • Ethics and Counselling • Problem Solving Steps • Client Confidentiality and Privacy and Relevant NSW and Commonwealth Legislation • Duty of Care • Workplace Bullying and Violence • Mandatory Reporting • Keeping Track of Paperwork • Information for Counsellors who have been served with Subpoenas • Complaints Form for Submission of Complaints and Grievances by a CAPA Member Just login to the members area of www.capa.asn.au and click on the “Ethics” button on the left.
Rural and Regional Report In November, Rural and Regional attended the New South Wales Mental Health Network meeting in Sydney. We do this on a regular basis to represent CAPA. For me, this showed the essence of Australia and the roots of what we are about. Not just our farmers, but also our rural communities, had just officially finished one of the worst droughts ever— and survived. At this time, there was some rain, and the prospect of earning an income again, only to find that there is a long road ahead. As I write this, the floods have come. The hard work continues. There was much focus on the Murray Darling Basin Plan, which, if not implemented fairly, may cause another, man-made crisis, of a longer term than the drought, and is seen by some as even more cruel as it is imposed rather than natural and may extend the effects of the drought. Some concerned discussion took place. And yet the mood in the room, and presumably in the country, was committed and strong: an example of ‘finding the gold’, and working with it. For CAPA’s part, we are: •M apping our members’ locations to identify gaps in service provision.
Special Invitation from the Editor to Rural and Regional Members The August 2011 issue of The CAPA Quarterly is devoted to the theme of ‘Virtual Therapy’, looking at a few of the myriad ways that modern cyber-technology can be involved in counselling and psychotherapeutic practices. Technology can provide invaluable assistance in connecting counsellors and their clients in therapy, particularly for those practitioners located in areas where populations are more geographically scattered and distance and travel become an issue for some people in need of such services. Contributions to this journal from Rural and Regional members are always welcome but your insights, experiences, and suggestions for using communications technologies in your practice are being especially encouraged for this Virtual Therapy issue. Join the conversation. Please see the Call for Contributions on page 38 for deadlines and access to Contributor Guidelines. I look forward to seeing you in these pages! 6
• Providing support to our members via web access and access to local Professional Development. • Providing an e-mail network for Rural and Regional members which is dispersing information. • Providing a teleconference for Rural and Regional members. • Providing this regular page in our Journal, in which we invite and encourage RnR members to participate via contributions and feedback. • Responding to RnR members who contact the office with any requests. For both City and Country members, we offer our support and an invitation to become involved in Rural and Regional NSW—be it by telephone counselling, face-to-face, web based or community based. There is a huge need in our Regional community for our humanity as well as our dollars. Be a part of it. Phil Hough
Regional and Rural Liaison Chair
RnR PDE Weekend May 12-14 Port Macquarie The RnR Committee is booking a dinner for participants on Saturday night (13) at own expense. Topics planned: · DVD of Sandplay Workshop by Gail Pemberton presented at 2010 AGM. · Workshops/speakers on Regional & Rural Issues, such as grief, loss & isolation · At time of printing we are also attempting to include a session on youth suicide as Port Macquarie has just recently had 3 close together. This PDE has been planned with thoughts in mind for regional/metropolitan members to come for a weekend away at a nice place with/without partners. Start time will be 10am Saturday, finish midday Sunday (allowing for those travelling distances). Bookings through CAPA Office. Enquiries at firstname.lastname@example.org This is the last CAPA-organised opportunity for PDE hours before the 31 May registration deadline.
The Capa Quarterly
If the body had been easier to understand, nobody would have though that we had a mind.*
Meredith Kitson, Som.Psych, M.App.Sci, CMCAPA, RMPACFA, is a registered somatic psychotherapist, counsellor and supervisor in private practice in Sydney. She has been a somatic psychotherapist since 1998. She trained in Somatic Psychotherapy, has a Master’s of Applied Science–Social Ecology, majoring in Critical Perspectives in Psychological Practices, Degree in Anatomy and Physiology, Practitioner Diploma in Myofascial Release Therapy, Craniosacral Therapy and Polarity Therapy Bodywork trainings. The PhD is just waiting for her to shorten her clinic hours! Meredith works most frequently with stress, anxiety and depression, as well as eating disorders, relationships, grief, abuse, trauma, anger and relationships. She feels that her past studies, qualifications and training in teaching, interior design and marketing are part of a ‘past life’ and yet believes that they still underpin much of her business experience within her psychotherapy practice.
www.somatictherapy.net I came to Somatic or Body-Oriented Psychotherapy through a very circuitous path. It followed from a career that spanned teaching, a successful senior corporate direction, diverting into studies in interior design and running my own business. Then in the mid 90s a number of personal disasters occurred and took away much of my world as I knew it. With my life in turmoil, I needed serious emotional assistance. I had considerable experience with psychiatrists, as my father had been seeing them all my life, but I wanted something different from what he had received. To give a little background history, I had grown up in a household with a mother who developed multiple sclerosis when I was five, a father who struggled with ongoing and significant depression, leading eventually to his suicide, and a brother with learning difficulties. This did not directly set me on the path to study psychotherapy, but it certainly provided a wealth of experience and learning in physical, psychological and emotional challenges. February 2011
My levels of vigilance at the smallest changes in energetic, physical, emotional or verbal cues became sharpened in attempts to avert the overwhelming outcomes I would, even as a small child, learn to cope with. Doing my own personal therapy highlighted many things I had unconsciously registered and acted upon over the years and this encouraged me to study Somatic Psychotherapy—initially only for my own benefit. In these studies, I learnt both cognitively and, more importantly, experientially about the interrelationship between the mind, the body, and the soul. I found a sense of groundedness and bodily awareness that allowed me to rest down in a way that I had never known. This allowed for my spiritual awareness and exploration to truly awaken. We also studied several types of bodywork, and I was fascinated and excited for the potential it offered. I became hungry for more knowledge in this area and so completed another two years studying a most fascinating course in Structure, Metaphor, and Alignment. This covered how the structural, anatomical, and physiological constraints of the body present—showing how these physical symptoms or limitations are often clear metaphors for what is occurring in our lives—and alignment, being the body’s innate need for physical, emotional, and spiritual connectedness to achieve aliveness. Having completed my initial training, my private practice seemed to grow organically. I was fortunate to have some doctors, psychiatrists, psychologists, physiotherapists, and body workers referring people to me for traditional psychotherapy. In time, some of these professionals also referred patients who were not responding to treatments for particular physical symptoms, as they realised these may be underpinned by deeper emotional issues. Their belief in my work and their enthusiasm with their patients’ results has further stimulated my continuing and extensive research in the body/mind domain.
Through my work, I continue to learn that appropriate touch in therapy has the potential to open doorways beyond cognitive awareness. Our bodies, our very cellular structure, can recall without judgement. The conscious mind is so adept at abridging, refining, and being selective about what we recall or retain. I find that using touch confirms this direct experience—that the body carries a wisdom of its own and holds crucial relevance to healing. I use touch together with a number of verbal and cognitive modalities, to guide and explore bodily held narratives, work with both emotional and injury-based trauma and its recovery and, where necessary or appropriate, as an alternative form of communication. I may also use touch to mobilise a client’s energy or increase/decrease the charge held within, enabling his or her awareness to reach a different level of consciousness—a somatic awareness. This expanded awareness allows clients to become observers of their inner realms, recognising bodily held contractions or patterns that block movement and feeling, opening up new ways of being. By using both touch and verbal meaning-making, we are able to access deeply held and often securely buried stories that are embedded within the human organism and its structure. Often these stories, when accessed, require verbal articulation to make meaning of them, and at other times this is not necessary. It does seem, however, that when these narratives are moved or retrieved there is a greater ability for an integrative process to occur. Even as I write about body-oriented psychotherapy, I notice that I still experience the same excitement about how profound and rewarding this work is. Thank you for allowing me to share my passion. *Rorty, R 1979, Philosophy and the Mirror of Nature, p. 239 Princeton University Press. Princeton, New Jersey
Finding a Home in the Body: A body that is not exclusively a vehicle for the mind but a body searching to become. A body that needs another body in the room to deconstruct itself and to remake itself. ~ Susie Orbach, 2003
We come into being growing a body from within a body, forming our individual selves in relation to other bodies, and so it would make sense to include our bodies and our clients’ bodies within the therapy hour. “The body that is not received, the body that has no body to meet its development becomes a body that is as precarious, fractured, defended, and unstable as a precarious psyche” (Orbach 2003). Somatic Psychotherapy, also known as body-oriented psychotherapy, has its roots with Wilhelm Reich, Alexander Lowen, and Gerda Boyesen (amongst others). Strong attention is given to the body, not as a vehicle for the mind but the body as body. Somatic Psychotherapy takes a holistic approach to the person in therapy. We work with his or her cognitive processing, emotional life, physical body and relationship with it, and energetic awareness of self and embodiment. To live a healthy life, we need to feel what is true in any given moment and to act on that feeling. The mind is susceptible to conditioning by the stories (untruths) from which it formed itself and, if this was an unsupportive environment, the mind will have decided that what the body feels does not matter. Survival/ wellbeing would have been dependent on accommodating those around us. Talking therapies do challenge the configured untruths which clients have embraced; in addition, connecting directly with their bodies can be most helpful. Some unconscious memories of traumatic experiences are held in the tissue and access to these experiences can explain and reverse core decisions about how to be in the world. By reconnecting with the body, its sensations and feelings, clients can be taught to discern how they actually feel and to live life from their perceiving instrument. The process of becoming a Somatic Psychotherapist involves reconnecting 8
with the body, and it is through this embodied and grounded practitioner that clients can have a more direct experience of their own bodies. For clients to allow themselves to feel, they need to know, not just be told, that they are welcome to move us, for us to feel their pain and not shy away, but instead to stay with them in it, so that they can feel the pain and move through it, acknowledging it and learning from it. They are then free to celebrate their newfound abundance of life gained through feeling life through the body. The combination of experiential training— incorporating the trauma and provocation of the group process and the requisite personal therapy—equips the practitioner to allow the client to feel met and held in the strong emotions evoked during sessions when they connect with their distress. In addition to knowledge and understanding of psychotherapeutic theory, the training provides the ground to hold the space and welcome the emergence of clients’ strong and frightening feelings. The therapist continues to hold this space, always conscious that the ultimate goal is for clients to be able to contain and self-regulate their own emotional states without the aid of the practitioner. Paying attention to our client’s body, how he is in and with his body and where there might be splits in his inhabiting of his body, can give us valuable clues and directions for therapy. Specific techniques of Somatic Psychotherapists involve tracking their own bodily sensations and those of their clients. This additional attention to the counter-transference as sensation within the practitioner’s own body heightens awareness of what is not ours, and we have more access to what may be happening for the client, which they may not as yet be aware. Gently bringing this into relationship can be useful. Our clients are ‘using our bodies’ just as they ‘use our psyches’ in their rebuilding of themselves (Orbach 2003). A body knows what cannot yet be expressed consciously and therefore will enact or evoke it. The frame of the Somatic Psychotherapist is quite strict. Regular weekly, twice weekly or fortnightly
appointments, with four weeks notice of absence and strong boundaries around changing or missing appointments and paying for sessions are not dissimilar from the analytic frame. The constant regular visits encompassing affirming, mirroring, reparation and the client’s experience of consistently being seen, felt, heard and remembered helps to build the resources and safety necessary for her to consider venturing back into or discovering her body as a feeling, perceiving instrument to guide her through life. Focusing attention towards the bodily experience of emotion is a reliable technique for accessing strong feelings in emotionally constricted patients (Herman 2003). Our intention as therapists is to contact the storyteller—not the story. Where there is much froth and bubble, clients can remain out of touch with themselves, staying separate from their direct experience of themselves. If a client is prone to ‘live in his head’ he can be helped to move into his sensed bodily experiences—his world of sensations—noticing how he organizes his experiences. If he has been frightened out of his body, for example by shock— drawing in breath moving up and out of pelvis—he sure as hell won’t be frightened back into it! So gentle encouragement to return to body is useful. When the body is energetically abandoned it becomes afraid, and then returning is resisted as the being becomes aware of the fear or rage. For example, when sitting with the wall of words from a client, ask the client to pause for a moment, notice her breath, feel her bottom and back against the chair, her feet on the ground, become aware of her spine, feel what might be happening in her gut and wiggle her toes. Then ask her to speak from her body. Regularly remind her of her body, maybe even by asking her to show you with her body how a particular situation feels or have her talk from a particular part of her body. The Capa Quarterly
Therapy from a Somatic Perspective
Meredith Pitt, Jean Gamble, and Gerry O’Sullivan Representatives of Australian Somatic Integration Association (ASIA)
For a client to learn to have the body as a lived experience and to understand that body feelings matter can be a powerful realisation. Many clients have learned to ignore, dismiss, or numb the feelings that are their guide to life. To pay attention within the therapy hour to the client’s body, acknowledging the changes that can be seen or felt can be a way of teaching clients that their bodies are important and can assist them in becoming more embodied and grounded within their bodies and their lives.
The Touch Taboo “By not using touch in psychotherapy we leave our clients with their unresolved issues around touch and it is then up to them to sort these out in their most private moments, though they are confronted by the deepest needs and discomfort through their issues with touch” (Eiden 1998). There is a plethora of research about the essential nature of touch for a newborn baby. The question then is: when does the need for touch cease? Touch can assist in building trust, safety, attachment, containment, and remind a body where its edges are, that it is being acknowledged, or just simply that it is, encouraging it to come into or back to the present moment. Somatic psychotherapists are trained in the use of touch—touch with the therapists being present first in and with our own bodies, then inviting the clients to be present in their bodies. This can be as simple as feet to feet contact, tracking this with the client, encouraging them to feel what it is like to have contact. This way, the “therapist initiates a ‘soma-to-soma’ conversation—an intersomatic dialogue—a direct, inaction, intersubjective communication that opens a window into unconscious, unrecognised and unarticulated energy patterns and their representations, into the somatic substratum of conflicts, defences, and resistances“ (LaPierre 2006). February 2011
A client was exploring his tendency to go into a freeze and feel overwhelmed when things became difficult. Lying on a futon, he reported experiencing pressure on his chest. Initially “it felt like a stake in [his] chest”. In a later session, exploring this same pressure, the therapist placed a hand on his chest asking how she could emulate the pressure. The client directed her to apply the amount of pressure and the circumference of the pressured space. After several minutes, the client reported he was at the bottom of a swimming pool and the pressure was the water. At the next session, the client had spoken to his mother, who confirmed that he had nearly drowned at age three. The client then made meaning of his decision that he felt overwhelmed, and within several weeks had tackled and completed some tasks at work which had felt overwhelming to him.
When a client is re-experiencing a distressful situation, the therapist can sometimes guide him to a different outcome from the actual one experienced. In the above example—in the actual experience—the 3-year-old lay motionless on the bottom of the pool until he was scooped up by his father. When reexperiencing that trauma, the client lay motionless on the futon with the pressure of the therapist’s hands on his chest. The therapist asked the client to make eye contact and realise, without bringing him out of the actual experience that he was not alone (to avoid re-traumatisation). In response to the therapist’s question of what he could do, the client had no input. Gently guiding the client towards a different outcome— because there is now no father to scoop him out of the current-day overwhelming difficulties—the client suggested he try to scrape his fingers on the bottom of the pool. The client took some time to move his frozen fingers and finally managed a sort of scraping motion, which then, with the therapist’s subtle encouragement, became a pushing up from the pool floor and finally a sitting up and gasping for breath. It is possible that surviving the re-experiencing, combined with the re-patterning of the
different outcome, contributed to the positive changes experienced by the client. As practitioners, we are informed by a combination of ‘talking therapies’— including Self Psychology, Object Relations, Attachment, Intersubjective, Trauma, and Relational modalities— to work psychodynamically together with Vegetotherapy and Bio-Dynamic Massage with an ear to the psychoperistaltic gurglings. Biodynamic massage is a psychotherapeutic massage technique that facilitates the client’s process with touch, holding, movement, and breath. It can be used to harmonise a provoked state, to stimulate feeling in a closed down/armoured body, and between these two extremes to bring a client more directly into contact with himself by rebalancing the autonomic nervous system—reminding the system of a time when it felt in harmony. The organism can then, over time, remember to move to this state from one of anxiety. Psychoperistalsis: the sounds in the intestinal tract of the processing and digestion of built up tensions and stresses. As tension switches from the sympathetic to the para-sympathetic, the increase in parasympathetic digestive activity can be heard more easily by the placement of a stethoscope above the descending colon. “Neither CBT protocols nor psychodynamic therapeutic techniques pay sufficient attention to the experience and interpretation of disturbed physical sensations and pre-programmed physical action patterns’ (van der Kolk 2006). Vegetotherapy allows a client’s process to arise from her own unconscious, via her breath or body sensations. The process then facilitates its progress sometimes with movement, breath and/or sound (often without words), or any creative ways that arise as a way to be with the client in her process and allow the process to cycle through to a completion at that time. As a therapist, it is vitally 9
important during this process to not only track the client’s mental and emotional process—muscular tensions, posture, facial and body expression and, of course, breath—but also to track, as therapists, our own psychic and bodily processes. After all, emotions are supposed to move us, be that as an energetic response or a more physical movement response. It is important to honour the force of the emotion that arises in the moment as a way to bring it to conscious awareness and therefore have a bodily understanding of how things affects a being on all levels. Somatic Psychotherapists are trained to use touch in relationship with the client. It is not so much the practitioner ‘doing something to the client’ as a collaborative effort to explore feelings/ sensations/experiences and facilitating the client’s emergence from the unconscious. Often we will be touching a client while interacting verbally; it does not happen separately from the therapy but is an integral part of it. During a session, the client may become aware of a tension or pain in the shoulder and the therapist might ask permission to place a hand on that shoulder. This sometimes facilitates a more direct experience of the feelings in the tissue that can then come to consciousness. The touch happens repeatedly, appropriately, and with permission over many sessions—not as a one-off marvel. Trauma/Neuroscience The impact of PTSD on the lives and bodies of the people suffering from it can be wide-reaching. There can be long-term elevated heart rate, constant over-release of cortisol, muscular holding, sleeplessness, depression and anxiety, etc. In order to guide the client towards overall health and balance and therefore relieve some of the suffering we use the client’s body as a door in, also known as ‘bottom-up processing’, or healing the being through the body first rather than the mind. A client presented with PTSD symptoms of stuttering and a sort of hiccoughing in the throat when she tried to speak. Over several months, she discussed her abusive relationship with her ex-husband and how these symptoms were triggered when she was forced to reconnect with him during 10
a custody issue. Several months into the therapy, the client was lying on the massage table, and I offered to hold her brain stem gently in my hands to harmonise the Central Nervous System. She sensed a pressure on her throat and asked me to remove the fabric there. There was nothing touching her throat. I asked her to focus on this area and requested permission to place my hands on her throat. I then requested her collaboration in making my hands mimic the sensations she was feeling. This resulted in her re-experiencing her ex-husband trying to strangle her. This experience had never been shared with me in the therapy, and she had not remembered him doing it until this moment. I asked what she could do about this, and she said she was powerless. Sensing her frozen, powerless state, I suggested that she take some time and muster all her force to get out of the situation and was mightily surprised when she drew up her legs and twisted out of my hands at the same time as forcefully pushing my hands away from her throat. She then began sobbing. After some harmonisation and integration, she left and later reported that the symptoms were not triggered when she next saw him. Recently, there was press coverage detailing how an international study led by Australian researchers found that deactivating the nerves in the kidneys using radio waves may in turn regulate the salt and water retention and can assist patients with high blood pressure (Corderoy 2010). From a somatic perspective, we would have the client relax on a futon or a massage table faceup and, with explanation and permission, gently cradle his kidneys in our hands, through his clothes. After a time of both bodies relaxing with each other, one body learning from the other, and the kidneys being attended to, the client will feel much more relaxed, present and safe with himself. To do this as a regular part of therapy can enable clients’ bodies to initially benefit from the extra attention and rest and gradually to learn to carry this more relaxed state into their lives; and clients can learn to relax their own kidneys with the regular attention and feeling from the therapy hour. We encourage clients to use the body as an anchor to come back from a dissociative state. Asking the client who knows she is dissociated if she can track
where she leaves from—i.e., which part of the body does she exit from when she leaves—can, over time and with practice, help the client to catch the dissociation before she is completely away. When a long-term client was describing the abusive environment of his childhood home, he became dissociated. Asking what was happening and how he felt did not bring him out of this state. I asked permission to touch him and, both standing, gently squeezed his shoulders whilst making eye contact and asking him to look at me. The client came back into his body with an increased awareness of how he dissociates. “The desomatizing process depends, first and foremost, on the therapist’s ability to enable these patients to tolerate rather than dissociate from their bodily sensations. Dissociation is the patient’s response to levels of arousal that threaten to exceed the window of tolerance. In the relative safety of the therapeutic relationship, we modulate such excessive arousal and help undo dissociation both by encouraging the patient to observe the body’s sensations as they change and by translating the language of the patient’s body into words. In so doing, we help the patient build a vocabulary that describes physical experience” (Wallin 2007). PTSD responses vary: studies showed about 70% of participants experienced an increase in heart rate while recalling the traumatic memory, while the other 30% showed a dissociative response with no concomitant increase in heart rate. However, it was also noted that in clinical practice some patients might exhibit different responses to different traumatic scripts (Lanius and Hopper 2008). “It is therefore crucial to assess dissociative pathology and to provide interventions that reduce dissociative symptomatic responses to traumarelated stimuli before commencing exposure-based treatments. Failure to do so can exacerbate PTSD and related symptoms, including dissociation, and can increase the patient’s overall distress and functions impairment” (Lanius and Hopper 2008, citing Foa, Keane and Friedman). The Capa Quarterly
A client, who had been sexually abused in childhood, was describing her provocation around her sexual attraction to a young man with whom she worked. She became quite distressed and then became dissociated. Placing both hands on her shoulders and one foot on the client’s foot, the therapist lifted and shook the shoulders gently whilst maintaining eye contact then released the shoulders. The client became embodied again and said, “I think I’ve just dropped into my pelvis.” For clients to have the solid ground of their bodies to rely upon can, over time, allow them to use their bodies as a resource when they are feeling overwhelmed, anxious, or in the grip of a flashback, and can be a breakthrough in therapy for the client. This can be a greater part of the therapy for the abused client, firstly learning to be kind to their bodies, to listen to the needs of their bodies, to keep them warm (cold can raise the fear response) and fed appropriately. All this can take some time. Often, in addition, clients need to “learn to uncouple trauma-related physical sensations from reactivating trauma-related emotion and perceptions” (van der Kolk 2001). Later “the ability to relate their sensations to their feelings can help these patients to use internal experience as a basis for understanding themselves and communicating with others” (Wallin 2007). Exposed to traumatic reminders, subjects had cerebral blood flow increases in the right medial orbitofrontal cortex, insula, amygdala, and anterior temporal pole, and in a relative deactivation in the left anterior prefrontal cortex, specifically in Broca’s area, the expressive speech centre in the brain, the area necessary to communicate what one is thinking and feeling. This, and subsequent research supporting those findings demonstrated that when people are reminded of a personal trauma they activate brain regions that support intense emotions, while decreasing activity of brain structures involved in the inhibition of emotions and the translation of experience into communicable language (van der Kolk 2006). February 2011
Conclusion ‘Soma’ is a Greek word meaning the living body. Somatic Psychotherapy, whilst inclusive of ‘talking therapies’ can also be informed by bodily experience and somatic techniques including the recognition of nonverbal signals and sounds and, with permission, appropriate therapeutic touch. Somatic work can assist clients to integrate their thoughts, feelings, and actions. Clients can, over time, find a reassuring home in themselves, within their bodies, using this ground to venture into their lives with renewed enthusiasm and freedom. Some clients will gradually inhabit their bodies and their lives, feeling for the first time ‘in the driver’s seat’ and will experience aliveness in their bodies that will excite them. It is likely clients’ creativity will be unleashed and their curiosity and playfulness will flourish. Often, due to the work, a client’s actual body shape will change, due to the muscular holding and defences being released, often becoming more fluid and comparatively more evenly distributed in energy and muscles. Neuroscience can now prove what somatisists have felt and known for decades: that the body holds memories, emotions, trauma, and intelligence in its own right. To honour the intrinsic wisdom of the body can facilitate profound and lasting changes for clients, and, as bodies influence bodies, the therapist’s own being as well. When anxious or traumatised one’s organic pulsating rhythms are restricted, and bringing movement, breath, and sound to the shutdown organism helps to restore the pulsation of the rhythms towards self-regulation and fulfilment of life’s potential. ASIA: www.somaticassociation.org.au References Corderoy A 2010, ‘Researchers go back in time to find treatment for high blood pressure’, Sydney Morning Herald, 18 November 2010 (citing ‘Renal sympathetic denervation in patients with treatmentresistant hypertension (the Symplicity HTN-2 Trial): a randomised controlled trial’, The Lancet 376(9756):1903-1909) Eiden B 1998, ‘The Use of Touch in Psychotherapy’ Self & Society, The Association for Humanistic Psychology in Britain, London Herman JL 2003, ‘Craft and Science in the Treatment
of Traumatized People’ Working Draft March 2003 Victims of Violence Program, Dept of Psychiatry, The Cambridge Hospital, Cambridge, Massachusetts Lanius RA and Hopper JW 2008, ‘Functional Brain Imaging Research—and Clinical Implications’, Psychiatric Times, 25(13) (also citing Foa EB, Keane TM, Friedman MJ ‘Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. 2nd ed., Guildford Press, New York) LaPierre A 2006 ‘From Felt-Sense to Felt-Self: Neuroaffective Touch and the Relational Matrix’, Issue 16-17, Hakomi Institute Forum, Hakomi Institute Australia, Sydney Orbach S 2004, The John Bowlby Memorial Lecture 2003: ‘The Body in Clinical Practice Part One: There is no such thing as a body’, from Touch: Attachment and the Body, Kate White (ed) Karnac (Books) Ltd, London van der Kolk, BA 2001, ‘The Assessment and Treatment of Complex PTSD’, Ch 7, Traumatic Stress, Rachel Yehuda (ed.), American Psychiatric Press, Arlington, Virginia _____ 2006, ‘Clinical Implications of Neuroscience Research in PTSD’ New York Academy of Sciences Journal IV:1-17 Wallin, DJ 2007, Attachment in Psychotherapy, The Guildford Press, New York
Meredith Pitt Dip Som Psych, Dip EH, Dip BT, is a somatic psychotherapist in private practice in Cremorne. Meredith has experience working with parenting issues, custody, child abuse, mental illness in families and providing emotional support to members of the wider Australian community through telephone support work. Her approach is psychodynamically based with a strong body focus and is complimented by her studies in Energetic Healing and Bowen Therapy, along with her passion for writing poetry and prose. Jean Gamble MASIA, MYTA, PACFA Reg, Dip Som Psych, Dip Adv Som, Grad Dip Systemic Therapy (Couples), Dip RM, Jean works with both Integrative Psychodynamic Psychotherapy and Body Oriented Psychotherapy with a wide lens of attachment theory. She has Diplomas of Somatic Psychotherapy, Advanced Somatics, Remedial Massage and a Graduate Diploma of Systemic Therapy (Couples). She has also undertaken studies with the Institute of Child and Adolescent Psychotherapists, including a two year infant observation. She has a private psychotherapy practice in Mosman. Gerry O’Sullivan MASIA (President), PACFA Reg, Dip Som Psych, is a Somatic Psychotherapist in Private Practice in Crows Nest, and has been seeing clients for 15 years. Gerry came to psychotherapy after a 30 year career in the Information Technology industry. She trained with the College for Experiential Psychotherapy and went on to do advanced training in Zapchen Somatics with the Machodpa Institute. Gerry has been on the executive of Australian Somatic Integration Associations for many years and is the current President. She has been included on the PACFA Register as a Clinical member since 2003.
A Fully Embodied Life:
Introduction Emotional well being and health are not extras that we can take or leave. They are fundamental to a good life and the very essence of our existence. Our quality of life is determined in large part by the quality of our mental, emotional and physical health (Deurzen, 2009). It is a mistake to believe that health mainly belongs to the domain of medicine, for the domain of medicine is that of illness. Doctors concern themselves with the healing and repair of the body when it is defective or injured. Guarding and improving our physical, mental and emotional health is an existential challenge that concerns us personally on a daily basis. None of us can afford to neglect this fact entirely, but few of us attend to the basics of our existence in a constant and continuously reflective manner. Psychotherapists, counsellors, and coaches can all improve the work they do by attending more carefully to the four dimensions of existence and by becoming better at working with the tensions that reign at each level. To live a good life requires us to live in a fully embodied manner and to be attuned to the hidden laws of physical nature. This does not just mean to be deeply connected to the physical dimension of our existence so that our bodies are in close contact with their own needs and we are in top form. It means to be aware of our inner nature and our inter-subjective existence as well. It means to monitor our closeness and contact with others, our attitude to ourselves and our attunement to the world and its many demands and contradictions. It means to be aware of the way in which our selves are embedded and embodied in the world, through our emotions as well as through our sensations. It also means to become aware of the way we make sense of all this, through our thoughts and intuitions, our ideas about the world and our beliefs about the world and how we should live in it. Ultimately this is all about integration.
Classical views of health When we look at how different classical authors defined health, we find that opinions rather vary, but there seems to be a general agreement that health is one of the foremost objectives of a good life. Hippocrates, the Greek father of medicine took the view that a wise man ought to realize that health is his most valuable possession. The Roman satirist Juvenal defined health in the broadest sense as being about the unity of body and mind, and he famously spoke of the need for us to have a sound mind in a sound body. Socrates, in Plato’s Protagoras, also reminded us that health of the body is ultimately based on the psychological health of the person and in particular on his or her level of self-knowledge and ability to moderate needs and habits. He said the most important aspect of health is to start by knowing oneself, in accordance with the famous inscription at the temple of Apollo in Delphi. 12
This idea of careful living in harmony with one’s own nature and with nature itself is a persistent one which is still relevant today, although we may be more out of touch with its reality than ever before. At the height of Greek culture, the objective of a healthy life was considered to be that of eudaimonia, which means to live in harmony with the good forces of life. For Aristotle, this meant something very similar to finding the right balance between two extremes: neither to be a glutton, nor a person who abhors food and drink, neither to be reckless nor cowardly. That was his recipe for the good life. Most of the Hellenistic philosophers, be it Stoics or Epicureans or Aristotelians, saw moderation in some form or shape as the objective of good living (Nussbaum, 1994). But this is not the case only in Western thinking. In Buddhism, the same practice of detachment from desires is pursued, so that a middle way between extremes can be maintained. Today such ideas are every bit as relevant as they were in ancient times. It is clear to most people for instance that to pursue fitness to an extreme is every bit as unhealthy and counterproductive as neglecting one’s health and that owning too much is as dangerous for our well being as is owning too little and living in poverty. Existential guidelines Facing up to human existence in all its complexity requires us to ponder the purpose and meaning of it all. We need to take account of the opposing forces of life and death and the paradoxes of nature. We need to live with vitality, and yet we need to know when to let go. The philosopher Heidegger in his early work propounded the concept of resoluteness as the way to live well, in anticipation of death. In his later work he emphasized the opposite of resolutness: ‘releasement’, or the ability to accept things as they are and put oneself in touch with the truth of being. It is that tension—between being resolute and prepared to put in effort on the one hand and being observant and noting the realities we have to accept on the other hand—that is required if we are to live a life in balance. A number of existential authors, such as Jaspers (1951), Tillich (1952), May (1983) and Yalom (1980) have particularly recognized the usefulness of working with limit situations or ultimate concerns. They have mostly agreed on the most important limits and boundaries of human existence, in spite of some inevitable variations in emphasis. Jaspers said about these limit situations: In our day-to-day lives we often evade them, by closing our eyes and living as if they did not exist. We forget that we must die, forget our guilt, and forget that we are at the mercy of chance (Jaspers 1951, p.20). The Capa Quarterly
An Existential Approach to Therapy Emmy van Deurzen
There are thus forces we have to take into account, inevitable realities we must confront, if we are going to guard our health and create an atmosphere of well being in our lives. But how are we to do so in practice and at each of the different levels of our lives? How do we insert and maintain ourselves most elegantly in the force field of human existence? The four-dimensional force field of human existence In this force field there are a number of different dimensions of experience. Systematic descriptions of human experience have outlined four dimensions. Heidegger spoke of the different dimensions as those of earth, world, man, and gods (Heidegger 1957). Binswanger (1946,1963) spoke of the Umwelt (environment), Mitwelt (world with others) and Eigenwelt (personal world), whilst a spiritual dimension (Uberwelt) is also implied in his work (Deurzen-Smith, 1984). In essence philosophers have recognized that human experience is multiple and complex and takes place on a number of different levels. Firstly there is our involvement in a physical world of objects, where we struggle between survival and death, health and illness. Secondly there is our activity in a social world of other people, where we struggle with the contradictions between our need to belong and the possibility of our isolation, finding our way between love and hate. Thirdly there is a personal dimension where we grapple with the tension between integrity and disintegration, strength and weakness. Finally there is a spiritual dimension where we seek to find meaning against the threat of meaninglessness and we also seek to manage the tension between good and evil. On each of these dimensions we have to learn to stand in the tension between opposites, discovering that we cannot have life without death, love without hate, identity without confusion, and wisdom without doubt. Dealing with negatives is every bit as important as maximizing positives. As Paul Tillich once said: The courage of confidence takes the anxiety of fate as well as the anxiety of guilt into itself (Tillich 1952:163). Existential anxiety Anxiety or Angst is a core concept in existential philosophy, which sees it as the basic ingredient of vitality. Learning to be anxious in the right way, i.e. neither too much nor too little, is the key to living a reflective, meaningful human life. As Kierkegaard put it: Whoever has learnt to be anxious in the right way has learnt the ultimate (Kierkegaard 1844:155). Anxiety has to be distinguished from fear. The former is a generalized feeling of Unheimlichkeit (Heidegger 1927), of not February 2011
being at ease, of not being at home in oneâ€™s world, whereas the latter has a concrete object. Anxiety is about nothing, whereas fear is about something specific. But it is precisely nothing that worries us the most, much of the time. We are uneasy about life, because it is always lived in the shadow of potential death; and yet, it is precisely anxiety and our awareness of danger that helps us to become conscious. It is anxiety that allows us to define ourselves as a separate person and to become responsive and responsible as well as aware and alert. Although we may become overwhelmed with anxiety, so that it becomes counterproductive, on the whole, anxiety is to be seen as a positive breakthrough towards the goal of the fully lived human life. How do existential therapists work with these paradoxes? Existential psychotherapists do not reassure people when they come to talk about the predicaments and conflicts in their lives. They encourage them to consider their anxiety and their problems as a valid starting point for the work that has to be done. They show themselves capable of facing down the negatives as well as developing the positives of life. When people wonder what is wrong with their lives, it is tempting to treat such questioning as symptomatic of emotional problems, but existential psychotherapy sees it as an attempt at coming to grips with philosophical dilemmas and getting better at living. Most of us encounter such dilemmas sooner or later, and people should be assisted in getting clarity on how they want to live when such issues arise. People easily lose their sense of direction. Moral and ethical problems are often ignored and obscured, but they need to be dealt with squarely. Nietzsche (1883) called us to challenge and re-evaluate all values. He insisted that our thinking had gone astray and that much which people took for granted had to be reconsidered. He thought it crucial to consider afresh what a good human life consists of. In order to do so, it is useful to turn to the map of human existence that can be pieced together from the writings of existential philosophers, so we can find our way through the obstacles of human living without losing our bearings. So letâ€™s look at each level of life in turn. Health in the physical dimension When we speak of the physical dimension of our existence, we are in some ways just talking about our existence tout court. We cannot live without our bodily existence, as far as we know, and thus the body is the alpha and omega of our aliveness. This is obvious in the existential approach by the emphasis that is put on the tension between birth and death. Living is primarily about living in an embodied manner. With the demise of my body comes the end of my being. But death 13
Features is not just the end or the completion of my life. The reality of our mortality is one of the fundamental characteristics of our being-in-the-world. Heidegger said: Death is a way to be, which Dasein takes over as soon as it is. “As soon as man comes to life, he is at once old enough to die” (Heidegger 1927, 245). Indeed death is a phenomenon of life that reminds us how we exist as bodies in the world. As potentiality-for-Being, Dasein cannot outstrip the possibility of death. Death is the possibility of the absolute impossibility of Dasein. Thus death reveals itself as that possibility which is one’s ownmost, which is non-relational, and which is not to be outstripped [unüberholbare] (251). Death remains the foremost reminder of our potential for authenticity. It frees us from the They and confronts us with anxiety. It makes us aware of the fragility of our existence and the discomfort, or unease of our constant need. Heidegger was well aware also of the importance of our embodiment, as it happens at a more concrete everyday level in relation to our being thrown into a world. He described how we are always in a situation, at a certain distance and in a certain position in relation to the world. Our bodily existence is also constantly apparent from our sensory perception, our Befindlichkeit, our state of mind, which is actually better translated as disposition: the way in which I find myself. One could easily add: the way in which I find myself in relation as a body in a world. In Being and Time he generally stuck to the view that it was Being-towards-Death and anticipation of our death that would make us live authentically. This is how resolute living was defined. As mentioned above, Heidegger eventually came to see that we needed to release ourselves to forces greater than the human, allowing Being to show us the way rather than death. In his study on Hölderlin, he said: Man is the one who is who he is precisely in the attestation [Bezeugnung] of his own existence… But what should man attest? His obedience to the earth [Seine Zugehörigkeit zur Erde] (Heidegger 1971, p36). It was Merleau Ponty, however, who really came to grips with the fundamental nature of our bodily existence. He observed that our body is one with the world and always enmeshed and intertwined with it. Our hands can touch and be touched. Our eyes can see and be seen. Our body is at that point of interaction with the world where being comes to light, where life is embodied. In Phenomenology of Perception he gives the following definition of body: The body is solidified or generalized existence, and existence a perpetual incarnation (Merleau Ponty, 1945, p166). He spoke of body as flesh. In The Visible and Invisible, he said: The flesh is not matter, is not mind, is not substance. To designate it we should need the old term ‘element’, in the sense it was used to speak of water, air, earth and fire, that is, in the sense of a general thing. … The flesh in this sense is an ‘element’ of Being (Merleau Ponty, 1968, p.139). 14
We are fundamentally in the world as body. If there is no ontic security, we cannot manage our lives. I have elsewhere discussed what R.D. Laing termed ontological insecurity, which is actually ontic insecurity. Laing recognised in his Divided Self (1960) that we need to be able to make ourselves ontically secure in order to live our lives. We cannot live with high death anxiety all the time: if we cannot make ourselves safe and look after our physical needs, it will become very difficult to make good relationships or have any sense of identity and personhood as well. The individual in the ordinary circumstances of living may feel more unreal than real; in a literal sense more dead than alive, precariously differentiated from the rest of the world, so that his identity and autonomy are always in question. He may lack the experience of his own temporal continuity. He may not possess an over-riding sense of personal consistency of cohesiveness. He may feel more insubstantial than substantial and unable to assume that the stuff he is made of is genuine, good, valuable. And he may feel his self as partially divorced from his body (Laing, 1960). It is not just the health of our body, but its safety and our independent ability to look after it that is the sine qua non of vital living. We need to attend to all the vital functions—for instance: • Food and survival • Sex, pleasure and procreation • Relaxation and stress and the need for optimal tension • Illness, health, the dangers of medicine and the inevitability of the weakening and ageing of the body over time. Health in the social dimension R.D. Laing did not just stick with the physical dimension. He focused a lot on how our mental health is determined by the way in which we enact our social relationships. He recognized that the person who is ontologically (ontically) insecure is also at risk of others’ impact. The fear is one of being (1) Engulfed, (2) Imploded, (3) Petrified. It is possible to just cut off from human relationships all together in the face of the threat of the other. He based a lot of his work on Sartre’s writing (Sartre, 1943). Sartre pointed out how human relationships happen in one of three ways. We deal with the threat to our existence that other people inevitably pose to us, by using either: • sadism, • masochism or • withdrawal. In other words, we either try to dominate or submit or remove ourselves from relationships altogether. In Sartre’s later work he recognised that we can actually manage our social world a great deal better when we use the principle of generosity. Then we can collaborate with others and discover the principle of reciprocity. Heidegger spoke of our human relationships as initially based on the erroneous assumption that others are part of ourselves. We are the other but do not know this yet and assume that the anonymous ‘they’ needs to be obeyed. This is The Capa Quarterly
remedied only when we learn to live authentically, listening to life itself rather than to the power of an imagined other. To live healthily at the social dimension then is to learn to live with a sense of relativity about the power of other people and a commitment to the reciprocal nature of our exchanges.
that makes us virtuous when it is lived to the full. Virtue, then, coincides with health—a health of body and soul—even though the body may be injured or broken or old, and even though the soul may have been much hurt and is tired and full of doubt.
Health in the personal dimension Our existence is always our own. My body is always mine. Yet we become alienated by the fear of rejection by others and by the sense of our own deficiency and lack of strength. Our personal existence only fully emerges when we can establish a clear and open self-reflective relationship where we are generous to ourselves and learn that we are capable of change and improvement. This takes time to establish and therapy can help in doing so. Self is what we experience as the narrative centre of balance that is ‘mine’: the place where we find our equilibrium within a world that constantly changes and challenges us to change with it. To love our lives and the self that we constitute is important and this is certainly a task for existential therapy.
Conclusions: A total view of health and a dialectical approach Body and soul are one. All four dimensions interact and are only different aspects of the same experience.
One must learn to love oneself—thus I teach —with a wholesome and healthy love, so that one can bear to be with oneself and need not roam (Nietzsche, 1883:192-3). Health in the spiritual dimension Health and well being cannot be had without clarity about the spiritual dimension of life. This is not to be confused with the religious dimension. It is merely about the recognition that human beings are not sufficient in themselves and that the light of life that we shine during our lifetimes is a reflection of something beyond us. Augustine, in his Confessions, put it like this: The soul of man, although it bears witness of the light, is not the Light (Augustine, 2008:144). We cannot be sufficient to ourselves, ever, for our own mental and spiritual health. There has to be a wider framework of meaning into which we insert our lives, be that a scientific framework, a political framework, a religious framework or some other ideology (Deurzen, 2009). We have a need to reach out to the beyond. Kierkegaard spoke of the infinite in this context and argued that without such a dimension or polestar to find our direction we become lost: What we call worldliness simply consists of such people who, if one may so express it, pawn themselves to the world. They use their abilities, amass wealth, carry out worldly enterprises, make prudent calculations etc, and perhaps are mentioned in history, but they are not themselves. In a spiritual sense they have no self, no self for whose sake they could venture everything, no self for God—however selfish they are otherwise (Kierkegaard, 1885:65). To be authentically aware we have to acknowledge the limits of our own lives and the relativity of values. Nietzsche urged us to re-evaluate our values. He challenged the old values as worn out and rigid. Virtue, he reminds us, is not obedience, or laziness, or fear, or pride; it is to live with awareness and a willingness to reassess our lives at all times. The reality is that virtue is hard to come by. It is life itself February 2011
‘Body am I and soul’—so says the child. And why should one not say what children say? But the awakened one, the one who knows, says: ‘Body am I purely and simply (ganz und gar), and soul is only a word for something in the body’ (Nietzsche, Z, 1:4; 39.5-9). The sense of self we have is the constantly changing core at the centre of gravity of the shifting three-dimensional view generated by the physical, social and spiritual. A dialectic rule of thumb for the good use of psychotherapy is to be aware of both sides of the coin. Remember to look for strength in weakness and weakness in strength. When there is sickness, find out what happened to health and where the potential sickness is within the apparent health. Make sure that you explore a person’s attitude to death so that he or she can truly come to life. In all this, keep in mind the tragedy and comedy of life: we all need to be at ease with the importance of going up and down, of being capable of both tears and laughter. As a therapist, you need to have an equal sense of the serious and the comical. Approaching psychotherapy from an existential perspective is to see that a dialectical process manages all these tensions of human existence. Conflicts are constantly generated and then overcome, only to be reasserted in a new form. Paradoxes are inevitable, and life flows out of contradictory forces working against and with each other. To find a satisfactory direction for one’s life, with a full recognition of the paradoxes and conflicts that are inevitable, is to find well being and health. Ultimately, the therapeutic search is about allowing the client to reclaim personal freedom in the face of a complex world. Authentic living, with courage (Tillich 1952) and in humility, would be a suitable existential objective. Learning to reflect for oneself and communicate effectively with others is another (Buber 1923, 1929). Existential psychotherapy can take many different shapes and forms, but it always requires a philosophical exploration of what is true for the client. When this exploration is conducted satisfactorily and fully, it often leads to a greater recognition of what is true for human beings in general, affording the beginning of a genuinely philosophical stance, which may make it easier to tackle life’s inevitable darkness and adversity. In time it may even lead to that elusive objective of all philosophy, which makes everything worthwhile: hard-earned human wisdom. This can happen only if the therapist is prepared to keep learning about life too, facing new challenges on a daily basis. Physician heal yourself; thus you will heal your patient too. Let his best healing-aid be to see with his own eyes him who makes himself well (Nietzsche, 1883:102). 15
Augustine 2008, The Confessions, trans. Chadwick, H, Oxford World Classics, Oxford Aristotle 2004, The Nicomachean Ethics, trans. Barnes, J and Thomson, JAK, Penguin Classics, Harmondsworth, UK Binswanger, L 1946, ‘The Existential Analysis school of thought’, in Existence, ed. May, R, Angel, E, Ellenberger, HF 1958, Basic Books, New York Binswanger, L 1963, Being-in-the-World, trans. Needleman J, Basic Books, New York Buber, M 1923, I and Thou, trans. Kaufman W, 1970, T&T Clark, Edinburgh Buber, M 1929, Between Man and Man, trans. Smith RG, 1947, Kegan Paul, London Deurzen, E van 2009, Psychotherapy and the Quest for Happiness, Sage Publications, London _____1988, 2002, Existential Counselling and Psychotherapy in Practice, Sage Publications, London _____1997, 2010, Everyday Mysteries: Handbook of Existential Psychotherapy, Routledge, London _____1984, ‘Existential therapy’, In Dryden, W (ed.) Individual Therapy in Britain, Harper and Row, London: Frankl, VE 1946, Man’s Search for Meaning, 1964 Hodder and Stoughton, London _____1955, The Doctor and the Soul, Knopf, New York _____1967, Psychotherapy and Existentialism, Penguin, Harmondsworth, UK Heidegger, M 1927, Being and Time, trans. Macquarrie J and Robinson ES, 1962, Harper and Row, London _____1971, Erläuterungen zu Hölderlins Dichtung, Vittorio Klostermann, Frankfurt am Main _____1957, Vorträge und Aufsätze, Neske, Pfullingen Jaspers, K 1951, The Way to Wisdom: trans. Manheim R., Yale University Press, New Haven Kierkegaard S 1844, The Concept of Anxiety, trans. Thomte R., 1980, Princeton University Press, Princeton, NJ
Kierkegaard S. (1855), The Sickness unto Death, trans. Lowrie W, 1941, Princeton University Press, Princeton, NJ Laing RD 1960, The Divided Self, Tavistock Publications, London May, R, Angel, E., Ellenberger, H.F., (1958) Existence, New York: Basic Books. _____1969, Existential Psychology, Random House, New York _____1983, The Discovery of Being, Norton and Co., New York Merleau Ponty, M 1945, Phenomenology of Perception, trans. Smith C., Routledge, London ______ 1968, The Visible and the Invisible, trans. Lingis A., Northwestern University Press, Evanston, IL Nietzsche F 1886, Beyond Good and Evil, 1966, Vintage, New York _____1883, Thus Spoke Zarathustra, trans. Tille A, 1933, Dutton New York Nussbaum MC 1994, The Therapy of Desire: Theory and Practice in Hellenistic Ethics, Princeton University Press, Princeton, NJ Plato ___ Protagoras, trans. Taylor C.W.W. 2009, Oxford World Classics, Oxford Sartre JP 1943, Being and Nothingness: An Essay on Phenomenological Ontology, trans. Barnes H., 1956, Philosophical Library, New York _____1939, Sketch for a Theory of the Emotions, 1962, Methuen & Co., London Tillich P 1952, The Courage to Be, Yale University Press, Newhaven Yalom, I 1980, Existential Psychotherapy, Basic Books, New York
Emmy van Deurzen is a psychotherapist, counsellor, chartered psychologist, and a philosopher working in the Existential tradition. She directs the New School of Counselling and Psychotherapy in London, and is an honorary Professor at Middlesex, Sheffield, and Schiller International Universities. She is an invited speaker at the 2011 World Psychotherapy Conference. Emmy will be conducting a two-day workshop on 22 & 23 August for the Centre for Existential Practice centred on her latest book Skills in Existential Counselling & Psychotherapy (Sage 2010).
The Capa Quarterly
Therapy and People with Disability Liz Dore
Universal feelings The desire to love and be loved, whether as a friend or an intimate companion, is a drive that defines a person in a way that no disability ever can. People with a disability have the right, like everyone, to form relationships and have positive sexual experiences. People with disability want to be considered attractive, have a partner and sexual fulfillment. They face the same issues as other people when it comes to body image and relationships, but may also have additional barriers to overcome. Therapy can help, if tailored to their needs. People with physical disability often suffer from some grief associated with the limitations of their body. This may be a necessary focus of some counselling sessions. Many have a specific desire to find a partner without a physical disability. This may be due to a silent prejudice they have about themselves and people with disability in general. For others, it is for practical reasons, such as it being easier to go out, having independence as a couple and being able to coordinate sex more easily. Questions I sometimes pose to these clients include: “I’m curious about what you would do if someone you shared an interest with and you found attractive, but had a physical disability, were to ask you out? Are you looking for a partner that will also be your carer? How would you feel if someone you were interested in said she or he liked you but didn’t want to go out with you because you had a disability?” I don’t believe that people with disability should all partner with others with disability, but I do believe that if prejudices underlie their wish to date someone without a disability it should be challenged. A prejudice against people with disability may be, although not necessarily, a reflection of their own negative self-esteem and body image. Situation-appropriate thinking I have an interest in working with people with intellectual disability and 18
autism. In the past, people with these disabilities have been referred to as ‘eternal children’. This perpetuates the myth that they don’t have sexual feelings like their peers without disability. The majority of people with disability (with some exceptions) go through puberty at a time similar to their peers and therefore have similar feelings and attractions. It’s important for families and therapists to consider the age of the person and to refer to positive peer role models. I have heard parents and teachers say “but he’s got the mind of a 7-year old”, when my male client is 17, has been through puberty, has hormones raging, and is staring at and commenting about the breasts of a girl in his class. We need only to read the papers to know that having a higher IQ does not necessarily mean a man makes good decisions about whom he should touch or ask out and when. People with disability need to have their desires respected while being supported to develop relationships appropriately and safely. The clients referred to me are considered vulnerable and are often overly protected, but they also have a right to the dignity of risk. They have additional barriers to having a relationship, but it is best that they have the support to be able to develop one. I have met couples with intellectual disabilities who are successfully dating. One male client said, “I want to get married, but Mum and Dad are getting in the way.” I have also had clients who have been in abusive situations that may have been avoided had they been supported to develop relationships with peers. These include one male in his thirties who was groomed by a staff member into believing she was his girlfriend and that they were lovers. He was left damaged and confused when she was sacked (for another reason). Other clients have ended up having sex in toilets. This may have been avoided had they had a welcoming environment at home. I have seen a married couple in their
fifties who, after a long and successful sexual relationship, had negotiated that it was okay for him to go to see a sex worker, as she had had an operation and no longer wanted sex. “I don’t mind if he goes to the Night Worker. I just don’t want to have any more sex.” This was their solution, but it can be one that staff or families sometimes have an issue with. The Sex Worker Outreach Project is a network of registered sex workers who have been offered disability awareness training. The organisation People With Disability has a list of those registered and a wealth of information on disability resources and services. Raji: a case study I worked with Raji, who has an intellectual disability, over 12 sessions regarding grief and relationship issues. Her father brought her to me because she had gradually stopped speaking and was having difficulty relating to other people at work and in social activities. In the first ten minutes of the first session, I suspected she was grieving for her mother, who had died when Raji was in her mid teens. Her grief had been compounded by another death in the family. Over time, and after two counsellors (one who didn’t think she was grieving and the other who said she couldn’t work with someone who wouldn’t speak), Raji stopped speaking altogether. I used approaches that have been adapted from systemic, narrative and emotion-focused therapies. Raji likes to write, so together we used a diary, life story and emotional expression pictures and worksheets. I entered into a counselling journey with her, including her father in the first and final ten minutes of each session. She expressed feelings of sadness regarding her mother’s death and of excitement about planning her 30th birthday party. By about the ninth session she began speaking. One of Raji’s goals is to have a boyfriend. Due to her vulnerability and barriers to forming relationships, The Capa Quarterly
I suggested and followed through with an assessment of relationships and sexuality knowledge, and she attended a Relationships and Private Stuff workshop for further education. If a client with an intellectual disability has been referred for sexuality issues, I often use the Assessment of Sexuality Knowledge (ASK) to determine the client’s level of knowledge and understanding of relationships. This is useful if there is possible past sexual abuse, as a client will often disclose in response to standard assessment questions. It also assists us to develop counselling goals. In what was to be her final session, Raji wrote her birthday speech, including her feeling of sadness that her mother could not be there and thanks at the love her father had shown her. Her father spoke to me by phone after the party to report that Raji read her speech confidently, while many shed silent tears of sadness and relief. I didn’t expect to hear from Raji or her father again, and therefore put her file in storage. However, Raji’s Dad rang a few weeks later to request counselling for his daughter regarding recent sexual abuse. I was angry with the perpetrator and sad that Raji has been abused and taken advantage of. The counselling and education she had received did not prevent the sexual assault, but maybe it influenced the fact that she had the words to describe the violation by a man she knew, and that her father had the trust and confidence to believe her. Raji now faces the difficulty of following through with legal proceedings without losing her voice again. Sexual Abuse and disability A media release following the ABS 2005 first national safety survey reported: “In the 12 months prior to the survey it was found that 1.6% of women (or 126,100 women) and 0.6% of men (46,700 men) experienced sexual violence (includes being threatened or assaulted)” (Australian Bureau of Statistics 2006). A South Australian study conducted February 2011
in 1989 of 158 adults with intellectual disability found that they were predictably more vulnerable, and that sexual assault occurred at a rate 10.7 times that of the average population (Wilson & Brewer 1992). People with disability are less likely to report a sexual assault, and when they do, they are less likely to believed. Three of my clients have disclosed sexual abuse by staff members. Each was tricked into believing that the staff member wanted a relationship with them. One said the staff member had showered and washed the sheets after each incident. If someone discloses abuse to me, I always believe them and generally limit my questions to, “What happened? Who did this? When did it happen?” and “Where did it happen?” and I write down as much detail as possible. When I was interviewed by police regarding this last case, the officer said that maybe my questions led my client to make up this story. This case did not proceed to court. Counselling for grief and depression followed. Good relationships are possible The workshops I conduct on Friendship and Dating Skills have benefited some people who have had difficulties understanding social rituals. In these workshops there are opportunities to practice conversation skills, and discuss relationship development and dating tips. There is also a practical component where participants are asked to invite someone to the local coffee shop. After attending a workshop, one man with Aspergers returned 3 months later to say he had been taking it in turns to ring a young woman; they had been dating and he now wanted to know when to kiss on the lips. In spite of the high incidence of the violation of the bodies and minds of people with disability, I have witnessed the development of a number of positive relationships. One of my In spite of the high incidence of the violation of the bodies and minds of people with disability, I have witnessed the development of a number of positive
relationships. One of my clients with intellectual disability made a follow-up appointment in order to inform me of a current relationship issue, and of the fact that their parents were getting in the way of them moving in together. Another couple I interviewed, for the Family Planning Love and Kisses DVD, openly discuss their relationship of nine years. Louise explains that they do kiss and cuddle on the lounge at night. They also have sex if they both want to, but not if she’s tired or if her partner has a bad back. It’s this type of respectful relationship that many people with and without disability could learn a lot from. Notes: Names and scenarios have been changed to protect the privacy of clients. References Centre for Developmental Disability Health Victoria, Monash University Victoria, 2004. ‘Assessment of Sexuality Knowledge (ASK Tool)’ http://www.cddh. monash.org/assets/ask-order-form.pdfCentre Murray, S & Powell, A 2008. ‘Sexual Assault and Adults with a Disability: Enabling Recognition, Disclosure and a Just Response’, Issues Paper 9, Australian Centre for the Study of Sexual Assault. http://www.aifs.gov.au/acssa/ pubs/issue/acssa_issues9.pdf Pilkington, N 2008., ‘People With Disability and Sexual Assault: A review of the literature’, Family Planning NSW, Ashfield Australian Bureau of Statistics 2006 ‘First national personal safety survey released today: ABS, Media Release 10 August 2006 www.abs.gov.au/austats/abs@. nsf/mediareleasesbytitle Wilson, C. & Brewer, N. 1992, ‘The incidence of criminal victimisation of individuals with an intellectual disability’, Australian Psychologist, 27:714-26 DVDs of interest are Untold Desires featuring stories from people with physical disability and Love and Kisses including drama and interviews with people with intellectual disability, available from FPNSW Healthrites Bookshop (www.fpnsw.org.au/bookshop). For other resources and information about workshops for people with disability and professionals see www.relationshipsandprivatestuff.com
Liz Dore has worked for over twenty years with people with disability in education, employment, residential, legal rights and in recreation programs. She has experience in sexual and reproductive health promotion and professional education. Liz has a Degree in Special Education, Graduate Diploma in Systemic Counselling and numerous sexuality certificates which inform her Relationships and Private Stuff work. Liz now has ten years’ experience counselling and providing training in relationships and sexuality to people with intellectual disability and autism spectrum disorders, family members and professionals.
Metaphor, the Body,
A book on psychotherapy called Metaphors in Mind calls on therapists to work with their patients’ metaphors like: ‘I have a sensitive radar for insults’ and ‘I’m trapped behind a door’. ~Steven Pinker, The Stuff of Thought
In the last 30 years, the research of many cognitive scientists and linguists has revolutionised our understanding of metaphor and the role it plays in embodied cognition. Four key findings have been: •M etaphor is far more common in everyday language than has previously been realised. People often use one metaphor for every 10 to 25 words— that’s about six metaphors a minute (Cameron 2008). • “ In all aspects of life ... we define our reality in terms of metaphors and then proceed to act on the basis of the metaphors. We draw inferences, set goals, make commitments, and execute plans, all on the basis of ... metaphor.” (Lakoff & Johnson 1980, p 158). • I t is next to impossible to describe internal states, abstract ideas and complex notions without using metaphor, yet speaker and listener are mostly not conscious of the metaphors being used (Lakoff & Johnson 1999). •M etaphors are not arbitrary. They are used systematically and are mostly drawn from how people experience their bodies and how they interact with their environment (Kovecses 2002). James Geary concludes that “Our bodies prime our metaphors, and our metaphors prime how we think and act” (Geary 2011, p 99). Modern metaphor Cognitive Linguists distinguish metaphor from other linguistic forms by its two-ness. A metaphor is an expression where one experience is used 20
to describe, understand, and reason about another kind of experience (Lakoff & Johnson 1980). For example, ‘being punched in the stomach’ might be used metaphorically to describe a physical symptom of anxiety. As a rule, metaphors are drawn from everyday embodied experience in order to shed light on abstract or difficult-to-describe experiences. Thus a client referred to their lethargy as like being ‘stapled to the bed’. While metaphor is commonly thought of as a linguistic device, people also use a huge range of nonverbal metaphors: they do this through gesture, posture, facial expression, etc. (e.g. a client discovers that a finger held across the lips is symbolic of an injunction to ‘keep the peace’); and through physical symptoms (e.g. excess weight is revealed to be a kind of body armour). David Grove’s approach In the 1980s, New Zealand therapist David Grove discovered three things. First, all his clients used metaphor to describe the nature of their problems. Second, he could not ask ordinary questions when working with their metaphors. If a client says, “It’s like I’m going through the dark night of the soul,” it was no good asking, “Oh, what night was that?” Instead, Grove devised a new approach which preserved the exact language of the client’s metaphor and invited it to “confess it’s strengths”. He called this Clean Language. His third discovery was that if he worked entirely within the logic of the metaphor, profound changes often occurred of their
own accord (Grove & Panzer 1989). Grove’s approach can be distinguished from other metaphor and visualisation processes because it relies on the client, and only the client, to identify and evolve his own metaphors for distress and health. Also, Clean Language prevents the therapist from (unwittingly) imposing her own metaphors and constructs on the client’s inner world. While metaphors are commonly represented as words and images, his approach incorporates metaphors expressed by feelings, gestures, sounds, drawings, physical objects, etc. One fascinating aspect of Grove’s therapeutic wizardry was his use of Clean Language to communicate directly with client’s nonverbal expressions and their physical symptoms. See the sidebar for a summary of Clean Language Guidelines for working with clients’ nonverbal expressions and physical symptoms. A comprehensive description is in our systemisation of Grove’s work, Metaphors in Mind: Transformation Through Symbolic Modelling (Lawley & Tompkins 2000). Nonverbal expression Nonverbal communication is a natural, universal, and mostly out-of-awareness process. Recent research suggests that as much as 90 percent of speech is accompanied by gestures of some kind (McNeill 2005). Grove realised this and postulated: In every gesture, and particularly in obsessional gestures and tics and those funny idiosyncratic movements, is encoded the entire history of that The Capa Quarterly
and Healing behaviour. It contains your whole psychological history in exactly the same way that every cell in your body contains your whole biological history (Grove interviewed by Tompkins & Lawley 1996). Below, we describe how psychotherapists and counsellors can use their voices and bodies to honour and utilise ways clients express themselves nonverbally via: (1) a mindbody-space; (2) the body as metaphor; and (3) physical symptoms. Mindbody-Space Just as our bodies learned to orientate in physical space, we also learned to orientate in the mind-space of our inner perceptual world. You can think of clients having a perceptual space around and within themselves. Their spatial metaphors—the most common metaphors in all languages (Pinker 1988)—and their bodies will indicate where symbols are, in what direction these symbols move, and how they interact. It is the relationship between client and mindbody-space that prompts their bodies to dance within its perceptual theatre. When a client’s mindbodyspace contains symbolic content, we call it a Metaphor Landscape. Aligning to a client’s mindbody-space Given the chance, clients unconsciously orientate their bodies to their physical surroundings in such a way that windows, doors, mirrors, shadows, etc. correspond to symbols in their Metaphor Landscape. We start each session by February 2011
James Lawley and Penny Tompkins
asking clients where they would like to sit in the room and where they would like us to be. This gives them an opportunity to align their perceptual and physical space and place themselves where they instinctively feel most comfortable and safe. It also sends a meta-message: for the duration of the session we are going to set aside our perceptual space in favour of yours. As Grove said, “space will become your co-therapist if you pay it due regard” (personal communication 1998). Since you want to keep clients mindful of their Metaphor Landscape, it is vital that your marking of space aligns with their perceptual space and not yours. This is an unusual thing to do and requires you to notice how clients use their bodies to indicate the location of symbols within and outside their bodies. Then you can refer to these symbols as if they exist in those places—which, for the client, they do. When a client follows your hand gesture, glance or head point she should be led to the precise location of one of her symbols. By making your movements congruent with her perceptual space the client becomes familiar with how her inner world operates. For example: Client: It’s scary. Therapist: And it’s scary. And when it’s scary, where is it scary? C: [points down to his right] T: And when scary [point down to client’s right], whereabouts? [point down to client’s right]? C: Down there. [points with right foot] T: And when down there [looking to where right foot pointed], whereabouts down there? [continuing to look]
C: About 6 inches away. T: And when scary is about 6 inches away there [looks there] that’s scary like what? C: Like standing at the edge of a sheer drop. To keep your language ‘clean’ it is preferable, as in this example, to reference a client’s behaviour nonverbally until they have converted it into words. This encourages symbols to lay claim to their own “patch of perceptual real estate,” as Grove referred to it, and in this way the client’s space becomes “psychoactive”. Lines of sight Another important nonverbal indicator of a symbol’s location in a client’s mindbody-space is a ‘line of sight’. By noticing where clients look and the focal point of their gaze you can gather information about the location of symbols inhabiting their Metaphor Landscape. Lines of sight are most easily observed when the client fixes his eyes in one particular direction (such as staring out of a window), or at one particular object (e.g. a mirror, book, door handle), or is transfixed by a pattern or shape (e.g. a spot on the carpet, wallpaper motif, shadow) or gazes de-focused into space. However, even a momentary glance into a corner or over the shoulder is unlikely to be a random or meaningless act, but rather a response to the configuration of his symbolic world. A client may also orientate his body and view to avoid looking at a particular space or direction. For example, a client 21
entered our consulting room and sat at the right-most end of a sofa. He crossed his legs and angled them to his right. His shoulders inclined right as well. For most of the session, he held his left hand beside his left eye, like a horse’s blinker. When his hand momentarily dropped away he glanced to his left, and was asked, “And where are you going when you go there? [looking along the client’s line of sight]” He looked to his left for a few seconds and a massive sob emerged from deep within him. When he had recovered his breath, he said, “Oh God, there’s something there [glance to left] and I don’t know what it is. I haven’t been there in a very long time. If I look there, I will be trapped and it will be compulsive viewing.” Later, the client realised that wherever possible, in meetings, walking down the street and at home, he would arrange to have people he was with on his right. Given the choice, where a client sits and how he orientates his body will often be determined by his dominant lines of sight. Investigating these can reveal information that would otherwise be unavailable to his conscious mind. Body As Metaphor As well as delineating and interacting with their perceptual space, clients’ bodies express all sorts of other symbolic messages. Nonverbal metaphors can be expressed by the arrangement of any part of a client’s body, by a particular posture, by an idiosyncratic movement, or by the way he or she interacts with physical objects. We recommend you see clients’ behaviour as an expression of symbolic patterning that helps them make sense of their interior worlds, rather than as ‘body language’ to be read. By making a body expression the focus of a Clean Language question, this patterning can be explored and, if appropriate, named by the client (usually with a metaphor). The therapist simply asks, “And what kind of [replicate client’s nonverbal expression] 22
is that?” Grove noted that nonverbal metaphors have a “short half-life,” so questions about them must be asked while the client is doing the behaviour, or immediately afterward. For example, at his first session, a client delivered an unbroken half-hour description of his predicament. He ended with, “So that’s how it is,” and looked up expectantly. He was then asked, “And so that’s how it is. And when that’s how it is, that’s how it is like what?” He looked away, his head turned to the left, chin pointed up high. While he was considering the question, his mouth started to open and close in a rhythmical fashion without sound. He was still deep in thought when he was asked, “And when [replicate angle of head and mouth movement] that’s like what?” The client returned to the mouthing movement a few times and said, “I feel like a goldfish coming up for air in a de-oxygenated pond.” He had captured his entire predicament in a single paradoxical metaphor; and his body had acted it out before he was conscious of it. Now he could work with the metaphor rather than swimming round and round, suffocating in the detail of his description. Sometimes clients cannot describe their experiences in words because they were encoded pre-verbally, or related to an unspeakable traumatic event, or connected with a mystical experience. In such cases, Clean Language is an effective means for direct communication with nonverbal behaviour without the clients ever needing to express themselves in ‘ordinary’ words. Physical Symptoms The use of metaphor and symbol in healing stretches back thousands of years. Today autogenic (self-generated) metaphor has been found to be particularly useful in “functional or stress-related illnesses, those in which no specific micro-organism has been identified as the source of physiological
breakdown. It is estimated that 50 to 80 per cent of all physical illnesses requiring medical attention are stress-related or functional in nature” (Hejmadi & Lyall 1991). Below we describe how Symbolic Modelling can be used to explore the nature of physical symptoms and to promote healing. Metaphor in health consultations People often use metaphor spontaneously in conversation to describe their symptoms. A study of the metaphors used by doctors and patients in the UK recorded 373 consultations of 39 medical practitioners. They analysed the 965 different metaphors used and concluded that “there were some clear distinctions between doctor and patient metaphors” (Skelton, et al 2002). Doctors tended to use metaphors that assume the body is a machine (the urinary tract was the ‘waterworks’, bodies could be ‘repaired’, joints suffer ‘wear and tear’); illness is a puzzle (symptoms are ‘clues’ to ‘problems’ that have to be ‘solved’); and a doctor is a controller (they ‘administer’ medication to ‘manage’ symptoms and ‘control’ disease). Patient metaphors, on the other hand, were more vivid, expressive, and idiosyncratic (‘It’s like Satan’s got into her’, ‘I’m the cotton wool man’, ‘It’s like a Chinese burn, it just gets tighter and tighter’, ‘It’s as though my body has been pummelled’). Patients used embodied metaphors such as ‘dull’, ‘stabbing’, and ‘sharp’ to describe aches and pains, but these words were not used by the doctors. From this we can conclude that doctors and their patients use different languages. No wonder so many patients do not feel heard, and that in the USA “more hospital patients die each year from preventable medical errors ... than from breast cancer or motor vehicle accidents; more than half of those deaths are preventable ... Errors result from prescribing mishaps, communication gaps and a distracted staff” (Cohen, et al 2001). The Capa Quarterly
Although patients spontaneously use metaphor to describe their symptoms, sometimes they need to be invited to use such language. While giving a Healthy Language course for a group of nurses who specialised in Multiple Sclerosis, we were told that their patients often had difficulty describing the bizarre nature of their symptoms. We suggested they ask them, ‘And when it’s difficult to describe your symptoms, those symptoms are like what?’ When the nurses asked this question, they got responses such as “It’s like ants running all over my body” and “It’s like cheese wire wrapped round my legs.” Further questions, such as ‘And is there anything else about that [patient’s metaphor]?’ or ‘And what kind of [patient’s metaphor] is that?’ encouraged the patients to describe their strange sensations in greater detail. The nurses were surprised at just how relieved the patients felt when they could explain their symptoms in this way. Some patients said it was the first time they felt someone had really understood what it was like to experience their illness. Similarly, therapy clients can benefit from having metaphors for their distress elicited, developed. and evolved into metaphors for health. Clean Language not only preserves the client’s description, it prevents practitioners (like the UK doctors) from introducing their personal preferences for certain types of metaphor. Because the therapist or counsellor does not introduce any content, rather than ‘guided visualisation’ the approach is more ‘accompanied exploration’. As many have discovered, metaphor can play a vital role in the healing process. Through Symbolic Modelling,1 the conflict, imbalance, or dis-ease inherent in the client’s metaphor finds its resolution in unexpected and organic ways. When this happens, the individual usually experiences a corresponding change in her symptoms; sometimes immediately, and sometimes in the following days or weeks. February 2011
A Case Study: From a Cross to a Willow The following account was written by a client during a workshop2 which used a combination of Symbolic Modelling and Pilates bodywork with participants’ physical symptoms: I had pain in my upper back that had started a year before I finished writing my book. I so wanted to finish the book, I used my will to keep working, even though my back was worsening. The first Clean Language question I was asked was: “And what would you like to have happen?” I replied, “I wanted to be free of this bloody pain so I could be comfortable while wearing a shoulder-strap handbag again.” I was asked questions that helped me get clear about my symptoms—I described them as “tight, grinding, abrasive”—and then I was asked “And that tight, grinding, abrasive back pain is like what?” I replied, “It’s like I have a cross on the inside of my body. My spine is the long part of the cross, and the cross bar goes through my shoulders.” In describing this metaphor, words, pictures, and movements came naturally, unbidden by me. As I became engaged with my metaphor, I realised, “It’s not the cross that’s the problem, but the cross bar is bolted on with four huge metal bolts. There is no flexibility at all. Every time I move against one bolt, they all are put under strain and it hurts.” At this point the symbols ceased to be symbolic— they took over my reality!
Q: And what kind of cross is that cross inside your body? Me: It’s a wooden cross. Q: And is there anything else about those four huge metal bolts?
Me: They refuse to move. Q: And when there’s a wooden cross and four huge metal bolts refusing to move, what would that cross like to have happen? Me: It needs to be willing to be flexible yet grounded. Q: And can it be willing to be flexible yet grounded? Me: No, the bolts won’t let it. Q: And what would bolts like to have happen when they won’t let it? Me: They need colour and support before they can let go.
After more questions, and more insights, I was asked to draw a picture of my metaphor, and to use a dictionary to look up some of the words I had used (e.g. cross, refuse, bolt). When I considered the word ‘re-fuse’ I realised it had an electrical connotation, and a mass of multi-coloured electrical wires suddenly appeared between the four huge bolts. I added this new image to my drawing. I then did gentle Pilates exercises, all the while focussing my attention on my metaphor
The next day, more Clean Language questions were asked, and more developing of the metaphor resulted, until at some point I leaned forward in my chair. When I came back up, the most amazing thing happened. I could feel the bolts in the cross releasing. It felt like ‘ping-ping-ping’. I just sat there, aware that change was happening in the moment. When the ‘ping-ing’ stopped, my back pain was gone. I thought we were finished; but thankfully the questions continued, because they helped me become aware of the effects of the change. The crossbar was now attached by rubber bands wrapped around it at all 23
angles. This meant that as I moved, the crossbar was flexible and could move with me.
Q: And as rubber bands wrap around at all angles, what happens to the cross? Me: It’s becoming heavy on the bottom. Q: And as it becomes heavy on the bottom, then what happens? Me: It’s growing roots. Q: And as it’s growing roots, then what happens? Me: Up-and-over branches are beginning to sprout from the top.
This continued until I had a full, embodied sense of my cross turning into a willow tree, with electrical wires beautifully woven through the trunk— flexible, stable, graceful, and strong. Every question increased my bodily awareness of this change.
Since this workshop I have had a few twinges in my back, but these disappeared as I focussed my attention on my willow tree and did my Pilates exercises. I still have my willow (will-o!) and, yes, I carry a shoulder-strap bag, and wonder of wonders, I can even wear a backpack! 24
To Conclude It used to be thought that the mind had little or no effect on the body. The field of psychoneuroimmunology has led even the most traditional medical practitioners to acknowledge that mind and body are linked and that changes in one affect the other. It is possible to go further and to recognise that mind and body are simply different expressions of the same unity, and that all illness is, in one sense, mindbody illness, and that all healing is mindbody healing. Metaphor and symbol are natural ways to describe symptoms and health. There are great benefits for professionals who learn how to recognise the metaphors people use, how to work within the logic of these metaphors, and how doing so can influence healing and well being. Metaphors used by clients may be idiosyncratic but they are not random. They contain an organisation that represents the mindbody system that produced them. ‘Symbolic Modelling’ a client’s nonverbal behaviour with Clean Language is invaluable for identifying, developing and evolving client-generated metaphors. It acknowledges their way of being, provides them with information about how they make sense of their inner world, and enables them to establish a context—a Metaphor Landscape— within which changes can take place. Once this happens, their new symbols and metaphors continue working for them long after they walk out of your consulting room. James Lawley and Penny Tompkins have been UKCP-registered neurolinguistic psychotherapists since 1993. They are also supervisors and coaches in business. They co-authored Metaphors in Mind: Transformation through Symbolic Modelling and a training DVD, A Strange and Strong Sensation. Their website www. cleanlanguage.co.uk contains more than 200 articles.
References 1. When using Symbolic Modelling with physical symptoms, we always recommend clients continue to seek advice from their medical practitioner. 2. The workshop leaders were Caitlin Walker and Catherine Saeed, www.trainingattention.co.uk. Cameron, L 2008, ‘Metaphor and Talk’ in The Cambridge Handbook of Metaphor and Thought (ed Gibbs, R.W. Jnr), Cambridge University Press Cohen, MR, et al 2001, ‘How to prevent medication errors’, Journal of American Academy of Physician Assistants, 14(11):47-55 Geary, J 2011, I Is An Other: The Secret of Metaphor and How It Shapes the Way We See the World, Harper Collins, New York Grove, D & Panzer, B 1989, Resolving Traumatic Memories: Metaphors and Symbols in Psychotherapy, Irvington, New York Hejmadi, AV & Lyall PJ 1991, ‘Autogenic Metaphor Resolution’ in Bretto C. et al. (eds) Leaves Before the Wind, Grinder, DeLozier & Associates, Bonny Doon, California Kovecses, Z 2002, Metaphor: A Practical Introduction, Oxford University Press Lakoff, G & Johnson, M 1980, Metaphors We Live By, University of Chicago Press Lakoff, G & Johnson M 1999, Philosphy in the Flesh, Basic Books, New York Lawley, J & Tompkins, P 2000, Metaphors in Mind: Transformation through Symbolic Modelling, The Developing Company Press, London McNeill, D 2005, Gesture and Thought, University of Chicago Press Pinker, S 1998, How the Mind Works, Penguin Books (The Softback Preview), London Pinker, S 2007, The Stuff of Thought, Allan Lane, London Skelton JR, et al 2002, ‘A concordance-based study of metaphoric expressions used by general practitioners and patients in consultation’, The British Journal of General Practice, 52(475): 114-118 Tompkins, P & Lawley, J 1996, ‘And what kind of man is David Grove?’, Rapport 33.[Sidebar] James Lawley and Penny Tompkins are the developers of Symbolic Modelling, which incorporates the Clean Language of David Grove. They are authors, UKCP registered psychotherapists, supervisors, certified NLP trainers and coaches in business. They are leading authorities on the use of selfgenerated metaphor for personal and professional development, and have trained Symbolic Modelling and Clean Language to psychotherapists, counsellors, coaches, managers and teachers throughout the world. Their book, Metaphors in Mind, is a comprehensive guide to their approach, and is supported by a training DVD, A Strange and Strong Sensation.
The Capa Quarterly
Clean L anguage Guidelines for Using Nonverbal Expressions and Physical Symptoms To reference a client’s nonverbal symbols: • Use your gestures, looks and voice to denote the location of symbols in the client’s Metaphor Landscape from their perspective. • A sk Clean Language questions using the following syntax: “And when/as [‘X’], [ask clean question]?” ‘X’ = replicates client’s nonverbal expression or exact wording for a physical symptom. Use the following Clean Language questions to: Ask for a metaphor And ... that’s ‘X’ like what? Ask for attributes/qualities
And ... is there anything else about ‘X’? And ... what kind of ‘X’ is that ‘X’? Ask for location And ... where is ‘X’? And ... whereabouts? Move time forward And ... then what happens? And ... what happens next? Move time back And ... what happens just before ‘X’? And ... where could ‘X’ come from? Ask for an intention And ... what would ‘X’ like to have happen? Ask about a line of sight And where are you going when you go there [look or gesture along client’s line of sight]?
A full list of Clean Language questions is available at www.cleanlanguage.co.uk
Working with Minds
How Integrating Both Mental and Physical
Strategies Can Optimise Wellbeing
Anna-Louise Bouvier spent 11 years working in a traditional physiotherapy model largely in the area of chronic recurrent back and neck pain. She became increasingly frustrated that many of the issues that patients had revolved around their inability to make the changes to their habits and lifestyle. Patients were socialised to be ‘treated’ by the therapist, and were often resistant to suggestions for longer-term solutions such as embarking on self-guided exercise protocols. In 1995, she decided to create a new model for treatment. The aim was to change the paradigm for management from one of therapist-delivered treatment to one of education and exercise in a safe, medical environment. Instead of individual sessions, patients came for classes which not only retrained their aberrant movement patterns, but also sought to educate and motivate them to make long-term changes to their everyday sitting, standing and moving habits. Over the years, the Physiocise program has grown from 1 class a week in a local golf club, to 2 studios in Sydney teaching over 1200 clients a week in over 120 classes, with 16 professional staff. Her recent book The Feel Good Body (Bouvier 2010) has been published by Harper Collins and she was subsequently asked to be one of three experts in the ABC documentary Making Australia Happy.
of the physical interventions we instituted, but more importantly outline some simple strategies that you as therapists can implement with your clients as you guide your clients on the path to wellbeing.
Wellness / optimal performance
How the mind affects the body In my area of expertise, patients present with physical symptoms such as chronic recurrent back pain, neck pain, headaches, muscle tension and associated general body breakdown. While the patient describes these physical symptoms as their main issue, our initial assessment often reveals high levels of stress and anxiety within the context of their daily life. The so called ‘yellow flags’ such as catastrophisation, inappropriate belief systems regarding pain, and high levels of fear-avoidance behaviour have been shown to contribute to high levels of
chronicity in the progression of back pain (European Guidelines for the management of acute non specific low back pain in primary care 2004). Conversely, clients who present for psychological therapy may also be experiencing physical symptoms which are contributing to their general low levels of wellbeing. Clients with high levels of anxiety, fear, and catastrophisation will also often have physical symptoms associated with high sympathetic nervous system activity such as high respiratory rates, increased muscle tension, increased heart rates, poor sleep patterns and physical postures which often reflect their mental state. Using the mind to help the body In our work at Physiocise, we use a combination of evidencebased techniques to decrease fear,
Pain Muscle tension Blood pressure Cortisol Sympathetic nervous system activity Blood pressure Catastrophisation Fear avoidance behaviour Threat levels Anxiety Inappropriate belief systems
Illness / body breakdown
Much of the wellbeing literature has focused on psychological strategies in the quest to improve mood and resilience to stress. There is now an increasing body of evidence examining the impact of physical interventions. Research is showing that these strategies may not only improve self-reported levels of wellbeing but may also contribute to changes in biochemical markers associated with wellbeing such as blood pressure, cholesterol, cortisol, melatonin and brain activity. My role in the ABC science documentary Making Australia Happy was to monitor and improve some of the main physical areas that have been shown to impact emotional wellbeing. They are exercise, sedentary lifestyle, sleep, breathing and posture. One of the most exciting aspects of the series was the changes in these markers. Cortisol, blood pressure, and cholesterol levels dropped markedly, reflecting lowered Sympathetic Nervous Activity SNS, higher exercise levels and better coping strategies. Melatonin levels rose an average of 60% across the group, reflecting healthy lifestyle changes and better sleep. Immunoglobulin antibodies in their saliva increased reflecting stronger immune system responses and finally MEG scans of their brains pre and post the project period showed a marked decrease in neural activity, reflecting “a quiet brain is a happy brain” (Grant 2010). In this article, I will briefly discuss some of the evidence behind each
Table A: A simple continuum of physical and psychological factors affecting illness and wellness.
The Capa Quarterly
and Bodies catastrophisation, and anxiety levels in our patients in order to maximise their return to full function (Main 2008). Our patients have usually had years of ongoing problems, often with little relief. It is understandable that they do feel anxious and pain-focused as a result of their issues. However, in our experience, providing clear education about back pain, providing an avenue to talk to other patients with similar issues, giving them physical strategies to help them control and ease their symptoms, and setting expectations about reasonable outcomes, all make a huge difference in their long-term prognosis. A large body of research using fMRI to evaluate the effect of a psychosocial approach in the treatment of pain has found significant reductions in pain centres in the brain. An excellent resource for therapists and patients is the book Explain Pain (Moseley & Butler 2004). Our practice is currently engaged in a large cohort prognosis study with Sydney University evaluating the effectiveness of using this integrated psychosocial and physical approach as part of a total treatment plan for chronic low back pain. Using the body to help the mind Just as using the mind can assist in physical recovery, we are increasingly aware that the body can help improve mental wellbeing. During the series, we used a high-tech armband called a SenseWear® monitor, which has a series of accelerometers and galvanic skin responders measuring activity, energy expenditure, sedentary time, and sleep efficiency (Johannsen 2010). We used a scientific version in the series, but the commercial version has recently been released under the name Body Media Fit (www.bodymediafit.com. au). It is incredible as it can provide a 24-hour overview of a person’s total February 2011
physical life. As a tool for motivation for physical change it is excellent. It can also be used to track energy output versus input and is being used in that way in weight loss programs (www. bodymedia.com). Exercise On a physical level, the benefits of moderate levels of exercise are astounding. Moderate exercise has been shown to decrease the overall risk of cancer by 50%, (Khan 2007) decrease the risk of falls by 60% (Brown, Liu-Ambrose, & Tate, 2004), decrease the risk of cardiovascular disease (Taylor, 2008), decrease tiredness (Rosemarie Kobau & Zack 2004), and even decreases erectile dysfunction by 60% (Cheng & Ng 2007)! The psychological impact of exercise is also widely documented. The famous SMILE study (Babyak, Blumenthal, Herman & Khatri 2000) (Standard Medical Intervention and Long-term Exercise) followed 156 patients between the ages of 50 and 77 who had been diagnosed with major depressive disorder (MDD). SMILE showed that exercise was as effective as antidepressants in treating depression. Follow-up studies found that the antidepressant effects were strongest when the exercise training was longer than 9 weeks, of higher intensity, and performed over a greater number of days per week (Landers 1997). An extraordinary 32-year perspective study done in Sweden tracked the effects of physical activity and wellbeing in women between the ages of 38 and 60. Those with lower levels of physical activity not only had higher morbidity and mortality rates but also impaired wellbeing in a longitudinal perspective. Interestingly, this study found that the level of exercise needed to improve psychological wellbeing
did not need to be high. Sedentary individuals improved by adding a 10-minute walk 3 times a day (Blomstrand 2009). Again, adding a little more exercise seems to improve benefits. An 8-year Scottish Government Study of 20 000 people found 20 minutes of daily moderate exercise led to a 40% decrease in selfreported anxiety and stress. You can further improve the effects of exercise if you get outdoors. Researchers from the University of Essex found that as little as five minutes of a ‘green activity’ such as walking, gardening, cycling, or farming can boost mood and selfesteem. They found that the greatest health changes occurred in the young and the mentally ill, although people of all ages and social groups benefited. The largest positive effect on selfesteem came from a five-minute dose of ‘green exercise’, particularly if it was near water (Pretty 2010). Why does it work? Many studies initially felt that mood elevation as a result of exercise was due to the effect of endorphins on the brain, specifically serotonin. New research is now finding this may be a simplistic view. Studies are now focusing on how exercise potentially remodels the brain. A study done on rats, found that the rats which ran regularly had much higher levels of resistance to stress. The theory is that the positive stress created by physical exercise encourages neural remodelling in the brain, which helps it cope with mental stress (Greenwood 2008). Can you do too much? Two of our volunteers were doing huge amounts of intense running. When I took this into consideration along with their psychological profiles, which showed high levels of anxiety and poor sleep, I felt that their intense 27
Therapeutic Techniques exercise regimes were a metaphorical reflection of their attempts to run from their stressors. I made the decision to decrease their aerobic exercise and instead add yoga and Pilates exercise to their routines in an effort to make their exercise more mindful and breathing-based. This was an incredible psychological challenge for them, one which they both resisted initially. However, 6 months postproduction they are both continuing their practice, in combination with their aerobic exercise, and have had sustained benefits both mental and physical. They have both found that their mindful exercise is an excellent way for them to “check in” on their brain/body state. Main exercise tips • Exercise lifts mood, decreases anxiety, and increases resilience to stress • Even 10 mins 3 x a day makes a difference • The more you do the greater the benefits, up to a point • 30 minutes , 5 x a week of moderate to vigorous exercise is ideal • Exercising outdoors, especially near water, is ideal • Breathing and mindfulness based exercise such as Yoga, Pilates and Tai Chi can be excellent adjuncts for stress relief Sedentary Lifestyle Where the big health message of the last decade was move more, increasingly we are discovering that sitting less is almost as critical. Research showed people who spent 4+ hours a day watching TV have a 46% higher risk of premature death and an 80% increased risk of death from heart disease (Healy 2008; Dunstan 2010) While this study dealt with TVwatching it may be extrapolated to all types of sitting, especially in front of computers. One of the key findings is that the effects of sitting are not just physical. As the body slows down from longs periods of metabolic inactivity, it may also be affecting the brain. Sedentary women in particular were at greatest risk of depression (Azar 2009). In the Happiness series our armband data showed that 6 out of 8 of our volunteers were exceptionally 28
sedentary, some up to 93% of the day. Interestingly, while many people felt they were breaking their sedentary time by making a cup of tea or going to the bathroom, research shows you must be on your feet for longer than 2 minutes in order to come out of the sedentary zone. The Active Couch Potato Syndrome Because many of us have taken on the health message of moving more, we feel that exercising once a day is negating the effect of a sedentary lifestyle. Researchers have now coined the word active couch potatoes, to describe people who are achieving the current minimal physical guidelines of 30 minutes of exercise 5 x week, but are sedentary for most of their day. Unfortunately the risks associated with prolonged sitting were not necessarily counteracted by exercise. One study showed that people watching 3–4 hours of television per day were at great risk of major health issues, even if they spent 30 minutes at the gym (Dunstan 2010). Sleep One of the single biggest issues people talk to me about is feeling tired. It seems to be the symptom of our generation. During the Happiness series, we were able to measure the sleep efficiency of our volunteers using the SenseWear® armband data. We also recorded their melatonin levels, which were found to be very low, reflecting their poor sleep efficiency. Sleep efficiency compares how long you are in bed against the time you were actually in a deep sleep. We saw two major patterns, which reflect the experience of many people. The first group were going to bed between 12am and 2am and would rise between 6 and 7am. They had fewer hours in which to get quality sleep, and some had sleep efficiency of only 50%. This meant they had only 2–3 hours of quality sleep a night. The typical pattern with these people was that they were using the computer, watching TV and sometimes texting as well, until a few minutes before hitting the pillow. Their sleep pattern typically showed them having light, disturbed sleep with very few deep sleep cycles. In this group, establishing better sleep health routines, which
gradually prepare them for sleep, were imperative. Turning off all stimulating electronic devices at least an hour before bed, and gradually, naturally winding down were an important part of developing a better sleep strategy. Techniques such as mindful breathing prior to lying down helped decrease SNS activity and prepared the body to move towards restorative parasympathetic activity. Extending the amount of time available for sleep was also important although what is the optimum amount of sleep still varies between individuals. Tips for staying out of the sedentary zone • Buy a pedometer and try to meet the recommended 10 000 steps a day target • Log on to www.10000steps.org and track your progress • Move your office and desk around to force you to stand up when you are going to the printer, photocopier, or phone • Plan ‘walking’ meetings outdoors with colleagues • Investigate a sit/stand desk www.sitstandsolutions.com.au • Stand up in commercial breaks when watching TV • Get out of the car and onto your feet, walk wherever and whenever you can The second group went to bed earlier, often dropped into a deep sleep initially but then roused at about 1–2am with a period of wakefulness which could last a few hours before dropping into a poor light sleep to finish. I call this ‘stressy sleep’, as the person is often extremely tired when they go to bed, but their mind hasn’t switched off. They may have had some wine to help ‘switch them off’ but by early morning, the effect has lifted and the stressy brain is in full flight worrying about the day’s issues. In these people, physical exercise can have an excellent beneficial effect in helping sleep, as they go to sleep with a tired body, which can help relax the mind for longer periods. The evidence for this has shown that ‘fatiguing daytime activity’ (i.e. exercise) is compensated for by a deeper more restful sleep, and greater ease in getting to sleep (Kubitz & Landers 1996). The Capa Quarterly
Tips for a better night’s sleep • Go to bed 30 minutes earlier than you want to sleep • Keep the room dark or dimly lit • Practice some slow, mindful breathing prior to lying down • Play a relaxation CD/track to help you relax • Never watch TV or use the computer in bed • Try a warm bath or shower to relax you prior to bed • Avoid stimulating activities or conversations in the hour prior to going to bed • Avoid overheating during the night. If possible use blankets rather than doonas • Try to do some outdoor physical activity every day Are there other reasons you can’t sleep? There are myriad pathological reasons which can affect a person’s ability to sleep. While snoring is a very common issue, in more severe cases it can be a sign of sleep apneoa where a person’s ability to breath at night is compromised. Chronic sinus issues, allergies, asthma, chronic rhinitis, a deviated septum, polyps, obesity and genetic narrowing, can all lead to problems in getting enough oxygen to the brain at night. Consequently, the brain rouses the person at frequent intervals, leaving them feeling exhausted in the morning. If you feel this may be the issue for your client, it may be worth referring them to their GP for specialist assessment, or they could contact the Woolcock Clinic, a not–forprofit medical research clinic specialising in the diagnosis and treatment of sleep and breathing disorders. http://www.woolcock.org.au Breathing The breath is the interface between the mind and the body. Often the first indication of a change in perceived threat level is an increase in Sympathetic Nervous System SNS activity, which automatically increases the respiratory rate. High rates of SNS activity produce higher levels of cortisol, one of our stress hormones. Breathing training is one way of calming this physical response to a psychological trigger. Many patients who I see in my clinic have chronically poor breathing patterns. While psychological changes affect the breath, physical influences, such as slumped sitting posture, sedentary February 2011
lifestyle, scoliosis, asthma, and poor exercise levels compromise lung function and result in inefficient breathing patterns that lock the patient into a cycle of lowlevel SNS overactivity. Furthermore, the diagram has now been shown to play an integral role in core stability. Poor breathing has now been shown to result in poor core control and high incidence of chronic back pain (Chaitow 2004). High rates of SNS activity also produce higher levels of cortisol, the hormone we produce in response to stress. Breathing training is one way of calming this physical response to a psychological trigger. Getting the most out of mindful breathing Much of the mindfulness literature focuses on bringing the patient back to the breath. This is an excellent, portable way to get clients to use the body to calm the brain. After years of teaching breathing training, I have found that you can get even better results by improve the quality of the breath. Simple things like not allowing people to slump when practicing their breathing, immediately allows ease of inflation of the lower lobes of the lungs. These are some simple cues that I use to teach optimal breathing. Your best breathing training: heart rate variability Heart Rate Variability (HRV) is a complex concept which has been found to be intrinsically linked to the breath and the stress response. Breathing training focused at increasing HRV has been showed to be highly beneficial in increasing resilience to stress. HRV is trained by first finding a client’s best breathing rate. Once this is done, breathing at this rate for increasing
periods of time, to an ideal level of 20 minutes per day has been shown to decrease stress, increase focus, improve sleep, and reduce pain response for up to 48 hours. An excellent evidence-based tool is My Calm Beat, a simple device which has an attachment to the ear to measure heart rate and can be uploaded to a computer or iPhone to train HRV via breathing training. www.mybrainsolutions.com.au Postures of Emotion Studies have found that up to 85 % of communication is non-verbal. How we sit, stand, and move tells the world a lot about how we are feeling. The simplest and most basic postures are the negative postures of emotion. Studies have shown that nearly 80% of people can accurately identify negative emotions such as anger, sadness, fear, surprise, and disgust just by looking at a person’s posture. These are often called the closed postures. Open postures are more likely to be associated with positive emotions like happiness and confidence but are often harder to identify. For various reasons, many of them related to sedentary lifestyle, we have become a nation of slumpers. Slumping closes off your body. This postural position triggers off a whole range of physical and emotional responses. Slumping increases the load on our spines and creates muscle tension and pain. It closes off our diaphragm, which affects our breathing. It switches off our deep postural muscle system, which creates further load on our joints; and a recent study found it even decreases our perceptions of confidence in our own abilities. (Briñol 2009). There is a self-perpetuating cycle of emotional (continued on page 34)
When sitting or standing imagine there is a light shining out between your breasts and gently shine that light directly forward in front of you.
This keeps the thoracic cage aligned and the lungs in an optimal position. This is also very useful in increasing awareness of slumped postures in people with depression. Do not allow the client to lift the light to the ceiling as this increases their lordosis and will give them back pain.
Imagine your diaphragm is an umbrella. With every in-breath gently open it front, sides, and back. With every out-breath feel it gently closing.
This encourages use of the lower lobes and diaphragm.
As you take a breath in, be careful not to let your shoulders lift towards your ears. Keep focusing the breath down into your diaphragm.
This stops people using the accessory muscles of the neck and jaw to breathe, which stops tension build-up in these areas, which is very common in people with high levels of anxiety. 29
The Business of Therapy
How Can Technology Help Us It might seem an unusual question to ask, since people often believe that in our busy, technology-filled lives, technology actually contributes to increased demands, overwhelm, stress, and possible burnout. However, technology, when used wisely, can actually contribute to simplifying and standardising therapy practice. Additionally, it opens up opportunities to work with clients in ways that previously did not exist. The reality of running a successful practice today includes creative integration of technology since younger clients in particular use the internet and mobile phone devices as their main media of communication. Thus, if they are to find therapists and communicate with them, they will naturally use these media. Put aside any assumptions you might have that technology limits or inhibits positive therapeutic outcomes; instead, see it as the framework within which you can have a successful and sustainable practice.
or email questions like: Do you work weekends? Can I pay by credit card? and so on. Create a Frequently Asked Questions (FAQ) page with typical questions that 90% of clients ask. Research has shown that people interested enough to peruse a website may often find answers to their questions on the various pages, but they somehow don’t register that information. They then turn to the FAQs page to have their questions answered.
Some of the ways in which technology can assist us include:
A templated e-mail can easily be personalized to the individual and save enormous time writing individually to clients. They have the additional benefit of avoiding human error in conveying important information to a client.
Websites Having an effective website with standard information that all likely clients will want to know avoids your having to answer directly by phone 30
E-mail Templates Creating standardised templates is a valuable way of sending information to clients regarding: • Confirmation details of booked sessions • Directions to your practice • Insurance or Medicare rebate scheme details • Receipts for insurance purposes • Housekeeping details like travel advice or parking options
Message Taking Systems Having an answering service is an effective way of managing your time and control when you are not available to speak to clients on the phone. Consider that both existing and new clients may hear your message, so ensure that it is relevant to both. Including a phrase like ‘I will endeavor to get back to you in the same working day, but certainly within 24 hours’ avoids clients’ anxiety over when they will hear from you and when they should call again if they have not heard back within the hour. Serviced or virtual offices provide excellent message-taking systems and give the impression of a professional front to your practice, especially when you don’t have a receptionist. New clients often feel comfortable speaking to someone rather than an answer machine and someone answering on your behalf gives you the option of deciding when you will reply. 1800 (toll-free) numbers are an excellent way of providing clients with information about your service, a product, or forthcoming event. A message of several minutes can be left and provides callers with rich information from which they can make decisions about whether to make further contact. This is especially valuable for clients who do not use the Internet or prefer to use the telephone. The Capa Quarterly
Avoid Burnout? Clare Mann
Today, many clients expect to contact you by text, e-mail or mobile phone. Some therapists feel it is too informal to communicate with a client by text. I encourage people to put aside that assumption, yet be mindful of keeping professional boundaries when replying. Clients may use texting to say that they are running late, to make or change an appointment or tell you about something that has happened to them. It is important to keep strict boundaries regarding contact outside of sessions. However, some therapists offer contact between sessions to clients who are facing particular traumas. If you do allow this, I suggest you ask those clients to text you and tell them that you will call them as soon as possible for a five-minute talk. It isn’t wise, nor is it helpful to a client, to make yourself available repeatedly and at their demand. Maintain boundaries, even if you offer this facility to clients who are facing problems that warrant it. Billing Systems As a practice grows, it is important to invest in an effective system of billing and managing finances. A system like MYOB can be valuable and save you an enormous amount of time billing clients, providing receipts and collating information for bookkeeping purposes. February 2011
Skype Communication Many therapists use Skype to conduct therapy sessions. This undoubtedly extends the possibilities for you to do your work. It can reduce your travel time if you are able to work from home, maintain sessions for clients who travel regularly, and reduce your costs if you hire rooms on a daily basis. Conducting sessions by Skype must be carefully planned, ensuring, for instance, that you regularly look at the camera rather than the client’s picture, otherwise you will not have eye contact with him or her. Additionally, privacy in conducting sessions is essential in terms of background interference or unknowingly providing clients with inappropriate personal information about you gleaned from things in the background. It is also valuable to ensure that the background doesn’t change from week to week. As with face-to-face therapy, maintaining the security of the consistent therapeutic crucible assists the process of change. These are some of the ways in which technology can assist you in streamlining your work, managing your time, reducing overwhelm and stress through travel, interference and continual requests for standard information. You can then concentrate on ensuring that your physical and
psychological health is maintained. Compassion fatigue is avoided, and you can concentrate on what you love— counselling clients to transform their lives.
Clare Mann is a psychologist, author and professional speaker who helps psychologists and counsellors run successful and sustainable private practices. Through her teaching, workshops and writing, she ensures therapists attract the clients they love to work with. For a free CD or MP3 on ‘ 7 Secrets of Attracting Therapy Clients call toll free 1800 637 599 or visit www.besttherapypractice.com +61 2 9006 3336. Read Clare Mann’s blog at: www.thesydneypsychologist.com/blogs
What is Useful and Essential Chris McCabe from the Education Centre Against Violence (Health NSW) gave this professional development presentation on 22 November 2010 at the CAPA Professional Development Evening Review by Juliana Triml Chris McCabe works as Statewide Educator for the Mental Health/ Sexual Assault Centre. Her presentation was an excellent refresher, and several new thoughts illuminated and enhanced our therapeutic approach to sexual trauma. Chris noted that for some persons in the audience, this presentation may trigger some emotional reaction. If that should occur for anyone, she hoped that we, as professionals, have developed a strong degree of selfsoothing capacity and would be able to deal with it or ask someone else for assistance. All present received a copy of Chris’ PowerPoint presentation, and what follows puts it all in context to give us a story. She begun with statistics, which show that one in three girls and one in 4–5 boys will have experienced some form of sexual assault by the age of 18. However, this area appears widely unreported, and newer statistics (Dr Michael Flood) indicate that Domestic Violence and Sexual assault affects half women. Inherently, individual interpretation of what a sexual trauma or assault actually is will vary. Fergusson, Boden, Harwood (2008, reference not available) conducted a study of an association between exposure to childhood sexual abuse and rate of mental health problems 32
at the age of 18–21. They found that there was a high rate of Major Depression amongst adult survivors (50%+), followed by suicidal ideation (around 40%) and substance abuse (around 30%). Sexual assault is a legal term that is an umbrella for all forms, including rape or incest. It often occurs in a child’s home (absolute access and opportunity) and begins with non-physical contact, then touching, then followed by repetitive sexual assault and penetration. Manipulation or threats result in the fact that a majority of children will not make a disclosure until adulthood, when better understanding is gained about what was happening. Furthermore, only some people would seek professional help, and often for other issues. Chris suggested that it may be useful to ‘find’ whether any sexual assault may have occurred in a client’s early years. Factors that influence the disclosure process are a) gender (females are more likely to disclose), b) developmental stage (understanding of what is happening), c) relationship to the perpetrator and fear of negative consequences. For example, impacts of sexual assault on a child are likely to include anxiety, nightmares, inappropriate sexual behaviour (sexualized play), fear, aggression, and regressive behaviour, amongst other forms. Adolescents express their traumatized mind through depression, suicidal ideation, shame, running away, and substance abuse. Adults who have been sexually assaulted are likely to experience many symptoms listed under Post Traumatic Stress Disorder (PTSD). At this point, Chris invited
participants to form small groups to discuss how individual therapists approach this type of situation. Upon debriefing, most of therapists agreed with Chris that what influences outcome is believing the person unconditionally (but without putting words into their mind) and, very importantly, formulating with this client a relationship that fosters trust and safety. The process of disclosure in therapy is often fragmented with contradictions, ongoing over a period of time, often commencing with less painful events. Emotions that have been repressed over long time may be expressing themselves in a somatic form (breathing difficulty, skin disorders etc). My own observation is that many clients who lived through sexual trauma as children have ‘learned’ to dissociate to avoid the painful feeling. They continue to dissociate when experiencing anxiety or intimacy in adulthood (avoidance) when being ‘present’ would be more beneficial for them. It needs to be noted that when sexual assault occurs during childhood, it often impacts on mental and emotional development while the young person attempts to deal with a love-hate relationship with the offending family member (including secrecy and anticipatory anxiety). One young client said, “I don’t want dad to leave us, I just want him to stop doing it.” Later adult relationships are often affected by the lack of boundaries, assertiveness, and flashbacks. Mental processes formulated during the years of repetitive assaults are likely to impact on one’s capacity to experience intimacy and equality in an adult relationship. The Capa Quarterly
in Sexual Trauma Counselling? Review by Juliana Triml
What works? Chris concluded with few recommendations: provide safety to explore, listen to what is not being said, pay attention to somatic symptoms, show and encourage clients to practice mindfulness. It is useful for the therapist to observe her/his own processing and to notice quality of therapeutic relationship. It was also suggested to ask the client what worked or didn’t work in any previous therapy (if applicable).
Reading literature on the topic also assists therapists to gain a deeper understanding of this complex issue. References: Fergusson DM, Boden JM, Horwood LJ 2008 ‘Exposure to childhood sexual and physical abuse and adjustment in early adulthood’, Child Abuse Negl. 32(6):607–19 Dr Michael Flood, Dept of Sociology, University of Wollongong email@example.com 3 155 people reserved. Please e-mail PD Coordinator if further details required.
Juliana Triml is the CAPA NSW PD Coordinator. If you have any suggestions regarding future professional development events, please contact her at: firstname.lastname@example.org
CAPA NSW Professional Development Events CAPA NSW members must complete twenty hours of approved professional development each year. To help members meet this requirement, CAPA is hosting PDEs on the following dates: Monday 21 March 2011 7.00 pm–9.00 pm PD hours: 2 ‘Focusing: Enhancing the Body-Mind Connection in Therapy’ Jane Quayle Certified Focusing Trainer, B. Counselling and Human Change, Dip. Dru Yoga Therapy Usually, we refer to our thoughts and feelings to guide us in life and yet there is a deeper level of knowing, our ‘feltsense’. Focusing is a process that enables us to access this level of knowing. Focusing is a body-oriented process of self-awareness and emotional healing. Your body never just holds your struggles, it also holds the way forward. Through Focusing you naturally arrive at your own healing and a lasting and deep change in your relationship with yourself. You can use the skill of Focusing to enhance your own life and to enhance the work that you do with clients. It is a method which can be integrated with and supports any modality of psychotherapy. The importance of bodysensing in healing was discovered by Dr Eugene Gendlin in collaboration with Carl Rogers at the University of Chicago in the 1960s.
Jane is a psychotherapist and bodywork therapist with a background
in information technology and training. She has more than ten years experience as a counsellor and psychotherapist and has been teaching counselling skills and Focusing at tertiary level for the past six years. She is committed to assisting people to live their lives in fuller, deeper and more self-accepting ways.
Wednesday 15 June 2011 7.00 pm–9.00 pm PD hours: 2 Existential Therapy topic tba Alison Strasser November 2011 (date to be confirmed) 7.00 pm 9.00 pm PD hours: 2 Bookings: (02) 9235 1500 or email@example.com Please book as soon as possible. Spaces are limited due to Occupational Health and Safety requirements. Cost: Free for CAPA members. $30 for non-members Venue: Crows Nest Centre, 2 Ernest Place, Crows Nest, Sydney (unless otherwise stated) If you have any suggestions for future PDEs, contact CAPA’s PD Coordinator, Juliana Triml, on firstname.lastname@example.org CAPA is also exploring more convenient options for members in rural and regional areas. Please email the Regional and Rural Committee with your suggestions email@example.com.
Therapeutic Techniques (continued from page 29)
postures which many people don’t even realise they adopt. I call it The Negative Cycle of Postural Emotion. Often, as people drop into negative postures, the load on their physical system produces aches, pains, and tension, which then generate negative psychological information. The worse they feel, the worse they look. The solution is to become more aware when you are in this circle and then use your body to help break the cycle of your negative mindset. feeling bad on the inside
develop physical symptoms
the negative cycle of postural emotion
physically close off
feeling less confident on the inside
Best tips for breaking a negative postural emotion cycle • Do regular opening stretches like rolling your shoulders backwards, lifting your chest and stretching your arms backwards • Take 5 slow deep breaths after stretching, to expand the diaphgram • Once you are physically ‘up’, smile even if you don’t feel like it (it releases endorphins) • At the end of the day, lie on the floor face up with your mid back over a pillow to open your diaphragm and release muscle tension
For more information about Anna-Louise’s work Bouvier, A 2010, The Feel Good Body, Harper Collins, Sydney www.physiocise.com.au or www.annalouisebouvier.com.au Making Australia Happy Series www.abc.net.au/makingaustraliahappy (DVD), ABC Enterprises, Sydney The book of the series Grant, DT 2010, Eight Steps to Happiness, Melbourne University Publishing (Victory Books), Melbourne References Azar, D 2009, Lower physical activity particpation linked to depression 14 October 2009, at http://sma. org.au/2009/10/lower-physical-activity-participationlinked-to-depression/ [Retrieved 2009] Babyak, M, Blumenthal, JA, Herman, S, & Khatri, P 2000, ‘Exercise Treatment for Major Depression: Maintenance of Therapeutic Benefit at 10 Months’, Psychosomatic Medicine 62(5):633-638 Blomstrand, A 2009, ‘Effects of leisure-time physical activity on well-being among women: a 32-year perspective’, Scand J Public Health 37(7):706-712 Body Media Fit (n.d.). Retrieved from www.templehealthcare.com.au Bouvier, A 2010, The Feel Good Body, Harper Collins, Sydney Briñol, P 2009, ‘Body posture effects on selfevaluation: A self-validation approach’, European Journal of Social Psychology, 39(6):1053–1064. Brown, AK, Liu-Ambrose, T, Tate, T & Lord, S 2009 ‘The effect of group-based exercise on cognitive performance and mood in seinors residing in intermediate care and self-care retirement facilities: a randomised controlled trial, Br J Sports Med 43:608–614 Chaitow, L 2004, ‘Breathing Pattern Disorders, Motor Control and Low Back Pain‘, Journal of Osteopathic Medicine, 7(1):34-41. Cheng, J & Ng, E 2007, ‘Body mass index, physical activity and erectile dysfunction: an U-shaped relationship from population-based study’. Int J Obes (Lond), 31(10):1571-8 Dunstan, DW et al 2010, ‘Television Viewing Time and Mortality: The Australian Diabetes, Obesity and Lifestyle Study (AusDiab)’, Circulation, 121:384-391 Creer, David J et al 2010, ‘Running enhances spatial pattern separation in mice‘, PNAS, 107(5) Grant, DT 2010, Eight Steps to Happiness. Melbourne University Publishing (Victory Books), Melbourne Greenwood BN & Fleshner, M 2008, ‘Exercise, learned helplessness, and the stress-resistant brain’, Neuromolecular Med., 10(2):81-98 Available at: http:// www.researchgate.net/publication/5552350_Exercise_
learned_helplessness_and_the_stress-resistant_brain Healy GN, et al 2008, ‘Television time and continuous metabolic risk in physically active adults’, Med Sci Sports Exerc., 40(4):639-45 Johannsen DL, et al 2010, ‘Accuracy of armband monitors for measuring daily energy expenditure in healthy adults’, Med Sci Sports Exerc., 42(11):2134-40 Khan, K 2007, ‘Exercise the anti-ageing polypill’, Australia Physiotherapy National Congress, APA, Cairns Kubitz, K & Landers, D 1996 ‘The Effects of Acute and Chronic Exercise on Sleep: A Meta-Analytic Review’,Sports Medicine, 21(4):277-291 Landers, D. 1997, The Influence of Exercise on Mental Health‘, PCPFS Research Digest, 2(12), Arizona State University. [Retrieved 2010, from http://fitness.gov/ mentalhealth.htm] Main, C 2008, Pain Management, Elsevier, Philadelphia Moseley, LG & Butler, D 2004, Explain Pain, Noigroup Publications, Adelaide Pretty, BJ 2010, “What is the Best Dose of Nature and Green Exercise for Improving Mental Health? A MultiStudy Analysis‘, Environmental Science and Technology, 44(10):3947–3955 Kobau R, et al 2004, ‘Sad, blue, or depressed days, health behaviors and health-related quality of life’, Behavioral Risk Factor Surveillance System, 1995– 2000, Health and Quality of Life Outcomes, 2:40 Babyak, M, Blumenthal, JA, Herman, S,, et al 2000 ‘Exercise Treatment for Major Depression: Maintenance of Therapeutic Benefit at 10 Months’, Psychosomatic Medicine 62:633-638 (2000) Taylor, A & Johnson, M 2008, Physiology of Exercise and Healthy Ageing.,Human Kinetics, Champaign, IllinoisTulder, M & Becker, A 2004, ‘European Guidelines for the management of acute non specific low back pain in primary care‘, 5th Interdisciplinary World Congress on Low Back and Pelvic Pain (pp. 56-79), Congress Committee, Melbourne Physiotherapist, Anna-Louise Bouvier, BachAppSc(phys), is a well known media commentator appearing regularly on the Today Show, with James Valentine’s on ABC 702 as well as across Australia on ABC local radio. Her new book The Feel Good Body (Harper Collins) was released in 2010. She has been Australian Fitness Presenter of the Year and was a keynote speaker at the World Congress of Low back and Pelvic Pain in Barcelona, Spain.She also consults to the Wallabies, NSW Waratahs and writes the Qantas Comfort Zone Series. She developed the Physiocise program 14 years ago and now runs two studios, at The Sydney Football Stadium and Willoughby, where 16 physios teach over 1100 clients a week how to improve their bodies and decrease aches and pains.
Noticeboard Brookvale New building behind Warringah Mall, suit counsellor, coach, psychologist. Room available most days, half day or full day. Client parking available. Call Peta on (02) 9938 5860 or email firstname.lastname@example.org Crows Nest Modern, bright, fully furnished room and large, fully equipped group room available in an established practice on the Pacific Highway. Metered/free parking nearby. Half, full and multiple day rates available. Contact Eve on 0412 011 950 Crows Nest Well presented consulting room in brand new clinic located in the heart of Crows Nest. Excellent parking and public transport. Sessional and permanent rates. Also available: group space for up to 14 people. Fair rates. Please contact Sabina on 0419 980 923 or email@example.com Glebe Warm and inviting, well-presented consulting rooms available for reasonable rates on a permanent, weekly or part-time basis. Large, pleasant waiting room, good facilities and great location on Glebe Point Road in the midst of Glebe village. Public transport at the door and ample off-street parking. Contact Lee on 0407 063 300 Lane Cove Rooms/room available to rent on a daily basis in a beautifully renovated health care clinic. Ideal for a Professional Health Care Provider. Flexible lease agreement. Unrestricted and ample parking. Please contact Peter on (02) 9427 1785 Mosman Beautiful practice room at the heart of Mosman, close to public transport and easy parking. Available on a daily basis with good rates. Please contact Eva on 0411 498 468 or firstname.lastname@example.org Parramatta Four airconditioned and well appointed counselling rooms and a group room are available at hourly casual rates (from $25) or on a permanent basis. Rooms are located in George St, Parramatta and room bookings can be made on our website www.lifexplored.com.au. Contact John Carroll on 0419703410 or email@example.com Sydney CBD Stylish consulting rooms in landmark Macquarie St building, in Sydney’s prestigious medical district. Polished wooden floors, air
conditioning, waiting area, kitchen amenities and printer/copier/phone/fax. Bright, leafy outlook and nearby public transport. Opportunities for cross-referral and crosspromotion. Full day, half day and casual sessions. Photos available. Contact Susie on (02) 9221 1155 or firstname.lastname@example.org Woolloomooloo – CBD Two comfortable, spacious consulting rooms to choose from. One room complete with sandplay tray and figures. Large group/ workshop/training space also available. Close to transport and ample parking. Photos available on our website under Room Rentals. www.gloo.org.au Full day, half-day or weekend rental available for workshop venue. Contact Tanya on 0425240928 or email email@example.com SUPERVISION Supervision – Penrith and Richmond Experienced supervisor and adult educator offers supervision for counsellors, group workers, community workers etc. Penrith and Richmond. PACFA Reg. Contact Jewel Jones on 0432 275 468 or email firstname.lastname@example.org Web: www.jewel-jones.com.au Supervision – Disability and Sexuality Individual and group supervision for counsellors, group leaders and those supporting people with a disability or Asperger’s syndrome. Twenty years’ experience working in disability field; seven years in relationships and sexuality counselling and education including working with victims and perpetrators of sexual harassment and assault. CMCAPA. Burwood and Newtown. Contact Liz Dore on 0416 122 634 or email@example.com or visit www.relationshipsandprivatestuff.com Supervision – Newtown Available for those doing individual, couples and group work. Over twenty years of clinical experience. Accredited in Professional Supervision (Canberra Uni), Registered member PACFA. Contact Vivian Baruch on (02) 9516 4399 or email via www.vivianbaruch.com Supervision – Brookvale and Glebe Experienced supervisor for counsellors and group leaders. Qualified trainer and supervisor, CMCAPA, Registered member PACFA. Call Jan Grant on (02) 99385860 or email firstname.lastname@example.org Supervision – Chatswood West Supervision for individual, couple and group work, including counselling, psychotherapy and coaching approaches. Flexibly designed to suit your needs. Over twenty years of clinical
experience. Clinical Member CAPA/Reg. PACFA. Contact Gemma Summers on 0417 298 370 or email email@example.com. Web: www.goodmind.com.au Counsellors/Hypnotherapists Just graduated and looking to go into private practice? Supervision and business coaching available to help you on your way. Also rooms for rent on sessional/permanent basis. Contact Lidy@northernbeachescounselling. com.au or phone (02) 9997 8518 or 0414 971 871. Supervision for working with Adolescents and Parents – Coogee and telephone Individual and group supervision for counsellors, educators, allied health workers, group leaders and parents. Fifteen years in private practice as psychotherapist/counsellor; eighteen years working with pre-teen/teen girls and their parents,addressing developmental issues and popular culture/media’s impact on girls’ body image. Registered clinical member PACFA. Contact Shushann Movsessian on (02) 9665 4606. Web: www.shushann.com and www.letstalkgrowingup.com.au Supervision Experienced supervisor. Registered member PACFA. Accredited supervisor with Australian Association of Relationship Counsellors (AARC). Available for psychotherapists, counsellors and group leaders. Caringbah. Contact Jan Wernej on (02) 9525 4434 or email firstname.lastname@example.org Counselling, Psychotherapy and Supervision For personal and professional development, self-care and mentoring. Thirteen years’ experience in private practice. PACFA Reg.20566. Location: Mosman. Contact Christine Bennett on 0418 226 961 or email email@example.com Web: www.cb-counselling.com.au and www.caring4couples.com.au
Mental Health Connect Essential Training for those who are working on an ongoing basis with people with mental health issues. Sydney 7-8 February, 4-5 April, 23-24 June 2010. Details www.mhcc.org.au or 02-9555 8388 ext 106
Mark your calendars: The CAPA Annual General Meeting will be held on Saturday 13 August 2011. Details tba in the next issue of The CAPA Quarterly and on the blog. Check out the PACFA website at www.pacfa.org.au for an update on all their current events.
online Visit The CAPA Quarterly’s blog for the latest journal updates, bonus articles and links to related resources.
Check out the PACFA website at
www.pacfa.org.au for an update on all the things that are current events
Call for Contributions August 2011 – Virtual Therapies
February 2012 – Open Forum
How is technology changing the options for therapy? What are the latest innovations in this arena, and how are they best applied? How can clients interact meaningfully with therapists through electronic and digital media? Can this approach provide benefits equal to those of face-to-face counselling? Are there ways in which virtual therapy is preferable? What about internet-based interactive programs that do not involve a therapist? And what of those that are specifically prescribed by doctors or counsellors for an individual’s treatment? At this point in the development and evolution of such possibilities, there are more questions than answers, but the conversation about these possibilities is crucial to best use of the world of new options opening up with increasing speed and frequency. Join the discussion with a contribution to The CAPA Quarterly’s August 2011 issue.
Do you have an insight to share about the practice of therapy, but haven’t been able to align it with any of the announced themes for The CAPA Quarterly? Now we have an Open Forum each February so that articles on any aspect of therapeutic practice can be welcomed. Share your knowledge with your peers and open up discussion on topics of importance to you. Peer reviewed papers due by: 1 October Non-peer reviewed due by: 1 November
May 2012 – Sex
With the prevalence of drug and alcohol in the news, the word ‘addiction’ tends to conjure images of chemical dependence of one sort or another, but we as humans can become addicted to many other things, both physical and behavioural. Addiction is a phenomenon that touches us all in one way or another, and researchers are continually searching for ways to help people cope with and overcome their addictions. Counsellors and therapists are on the front lines in such battles. Join the discussion by sharing your experiences and observations of the addictions confronted by your clients and how they did or did not deal with them effectively with your contribution to The CAPA Quarterly’s November 2011 issue.
In our multicultural society and global community, many people have personal and societal challenges around sexuality —sexual attractiveness, sexual performance, sexual orientation, and sexual identity as well as sexual abuse. Such issues often find their way into the therapist’s rooms as clients search for clarity and resolution, comfort and confidence. Sex can be a tricky subject, but it is fundamental and can arise in many contexts for both children and adults. Sexual issues can also be buried —hidden behind other issues more amenable to revelation and discussion. Clients, may suffer anxiety or depression, or may even act out violently in response to unresolved sexual issues of one sort or another. Some therapists specialise in sexual issues; others prefer to avoid them. Does best practice necessarily include dealing with the subject of sex? How does a therapist identify such issues when the client doesn’t voice them? How are the varieties of sexual issues best approached and discussed in therapy? Join the discussion with a contribution to the May 2012 issue of The CAPA Quarterly.
Peer reviewed papers due by: 1 July Non-peer reviewed due by: 1 August
Peer reviewed papers due by: 1 January Non-peer reviewed due by: 1 February
Peer reviewed papers due by: 1 April Non-peer reviewed due by: 1 May
November 2011 – Working with Addictions
Deadlines are for articles that have been accepted, not for new ideas.
Please send expressions of interest as soon as possible, to maximise your chance of inclusion. Contributor Guidelines: http://thecapaquarterly.blogspot.com/p/contribute.html or contact firstname.lastname@example.org
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Looking for a Conference? To include your free conference listing, contact email@example.com
Some prominent psychology conferences in Australia and elsewhere this year are listed below. For a more comprehensive list of psychology conferences worldwide, visit http://www.conferencealerts.com/psychology.htm
1–4 March 2011 Melbourne
12th International Society for the Study of Personality Disorders (ISSPD) Congress ‘Personality Disorders: Bridging Research and Practice’
4–5 March 2011 Melbourne
Australian Association of Relationship Counsellors (AARC) Symposium ‘You’ve Really Got a Hold on Me: Love, Desire and Obsession’
12–13 March 2011 Sydney
Hypersexuality—Disorder & Interpersonal Phenomenon
18–20 March 2011 Brisbane
10–13 April 2011 Cairns
Australian Health Promotion Assoc. 20th National Conference ‘Health Promotion and Determinants of Health: Strengthening Action’
14–17 April 2011 Manly
Society of Australasian Social Psychologist 41st Annual Conference
18–20 April 2011 Adelaide
International Society of Critical Health Psychology (ISCHP) 7th Biennial Conference
1–6 May 2011 Perth
Spiritual Care Australia Conference ‘Ethics and Chaplaincy–Unravelling the Myths’
26–27 May Johannesburg
1st International Congress of Coaching Psychology: The Southern Hemisphere Event
18–20 May Sydney
Australian Society of Rehabilitation Counsellors (ASORC) National Conference ‘Challenging Perceptions’
16–17 June 2011 Brisbane
4th Annual Happiness and Its Causes Conference ‘The Psychology of Happiness & Goodness’
22–25 June 2011 Miami, USA
9th International Conference on Grief and Bereavement in Contemporary Society ‘Making Connections: Dying, Death and Bereavement in the Global Community’
11–13 July 2011 Adelaide
4 th Australian Conference on Spirituality & Health ‘Forgiveness, Spirituality & Health: From Brokenness to Wholeness’
13–15 July 2011 Salvador, Brazil
10th International Narrative Therapy and Community Work Conference
12–13 August 2011 Brisbane
Cult Information and Family Support (CIFS) National Conference ‘Assessment, Diagnosis and Treatment’
24–26 August Gold Coast
12th International mental Health Conference ‘Personality Disorders: Out of the Darknesss’
24–28 August 2011 Sydney
6th World Congress for Psychotherapy ‘World Dreaming’