I’ve been doing pyschotherapy since last December. It’s not something I talk about often, because it’s deeply personal and because of the stigma associated with mental health. But there’s things I’ve learned that have changed things for me significantly, so I want to try and share.
I need to begin with a couple of disclaimers. I’ve been doing this work with a clinical psychotherapist every week for the past ten months. I have homework assignments. It’s intensive and it requires commitment.
It’s not really possible to share the knowledge I now have in a thousand words, but I want to try and cover some of the key things I’ve learned.
Obviously, I’m not a medical professional, and I’m talking strictly about things that work for me. But they could be useful for others.
When I first started psychotherapy, I had very little faith it would help me. I’d tried numerous counselling services before, and I was convinced none of it worked. My anxiety was who I was. There was no way out of that.
(Note – counselors and clinical psychotherapists are, obviously, different things. Counselling did little for me. I was lucky to be able to see a psychotherapist. I know that it’s a privilege and that’s why I work so hard).
Of course, the idea that you can’t change is the illness talking. It’s got a lovely little voice that convinces you that not only can you not get well – you don’t even want to. It tells you that you’re made this way.
When I read Ruby Wax’s Sane New World, I learned all about neural plasticity. Turns out those thought patterns you believed were hardwired into your brain can be totally overwritten. That was a revelation for me.
Today I want to talk in particular about distress tolerance. I have never been good at coping with high anxiety situations. – I was ‘distress intolerant.’ I didn’t have any skills for dealing with intense emotions.
Distress is linked to personal triggers so it’s different for everyone. I recognise when it’s happening for me because the voice in my head says things like “I can’t cope with this,” “I must make it stop right now,” and I start desperately looking for ways to fix the situation and stop feeling the distress.
Key learning: Figure out what your distress warning signs are. Recognising that this is what’s happening is the first thing to helping you step outside the situation and deal with it.
Distress tolerance – ‘dealing with it’ – is not necessarily about immediately improving things or making the emotions going away. (though of course it is different if you are in immediate danger).
My first step to recognising what was happening was to confront my beliefs about distress – ie that strong emotions are inherently bad and that I can’t cope with them.
To do this, I started doing these Overcoming Distress Intolerance workshops with my psychotherapist. They are a bit patronising at times, but they are extremely helpful, and all available online at the Centre for Clinical Interventions. (They also have a whole bunch on worrying and anxiety, which I might do a separate post about).
The first module (Understanding Distress Intolerance) has stuff about personal beliefs around distress. Interestingly, I have conflicting beliefs. A part of me can’t tolerate it at all, and will do anything to not feel that way. Another part of me has romanticised that intensity of feeling and will sometimes use ‘coping’ mechanisms that actually make it worse.
I had a real problem with ‘reassurance seeking.’ This is when you try to soothe the intense emotion by getting other people to join in, and to tell you everything is ok. I got myself intro trouble with this a few times by discussing personal arguments on Twitter, in order to try and get reassurance I was right or behaving well. Inevitably, the other people involved find out and you’ve made everything worse before you know it – because you gave into the urge to try and get rid of the distress in the quickest way possible.
Key learning: our brains literally do not work the same when we are distressed. Therefore, we can make decisions we would not normally make. Don’t beat yourself up if you do something you later regret. Just try to remember to “do the opposite of the urge.”
Reassurance seeking can be a good skill, but it is best to try to give this to yourself first. Getting others to do it is often like trying to put a bandaid over an open wound. They can say nice things til they are blue in the face, but if you don’t believe in them inside yourself, it won’t change a thing.
If you can’t do that, the next best option is to speak one-to-one with a close friend or support person.
Key learning: distress tolerance is not about making the feelings go away. It’s about getting through without using coping mechanisms that actually make things worse.
I ask myself the question: How do I be effective right now? What action will be effective for me in getting through this?
(For me, it’s much more effective to reassure myself that I’m doing the best I can, or to receive those words from a close friend, than to have a whole bunch of people online who don’t really know me say the same.)
If you’re going to have a look through the modules (do!), please be aware I spent at least a month on each one, under the supervision of a professional, and I did them in the recommended order.
The first skill is understanding the distress, your beliefs around it, and why you might find it difficult to deal with. The second is learning to accept that it’s an inevitable and even useful part of life. The third is how to improve the distress, often by doing the exact opposite of what your usual coping urge is. And the final module on tolerating distress brings everything together and guides you through creating your own personal Distress Tolerance Kit.
I scoffed at this idea when I first heard it, not going to lie. But it has been incredibly useful. I haven’t even had to use it yet, but knowing that, if something happens, I have a whole bunch of things right at my fingertips to help me get through it gives me a lot of confidence. It’s my own Little Book of Calm. (snap if you get that reference!)
My Kit is in a clear leaf folder. I feel a bit embarrassed talking about what’s in it, but I guess I should give an indication. It’s got:
- A list of songs I know make me feel better
- Names of people who I can chat with
- Chamomile tea bags
- Ideas for soothing or distracting activities – going for a walk, having a shower, reading poetry etc.
- Some useful things I can say to myself, like “I’ve got through this before, and will again.” “These are just emotions and they will pass.”
As I said, I haven’t had to access it directly yet – but I know what’s in it, so sometimes I can put those things in action as soon as I hear the voice telling me I can’t cope with something.
I got asked recently why I wasn’t comfortable talking about my mental health in the newspaper, when I do it here anyway. I guess the thing is, here I get to write it exactly how I want it. I get to edit it a million times. I get to make absolutely sure I can cope with any response I might get before I hit publish – and I have control over the comments.
The reason for all that worry is stigma. I take my career seriously. I take my role as a columnist seriously. I know very well that there are people who would love to say that, because I have depression and anxiety, my work carries less weight or integrity, or is less trustworthy. That’s pretty much my worst nightmare.
So, I will hesitate now, before publishing. I know I’ll go ahead with it, because I want to be able to share what I have learned. I am really hoping it might make a difference. It’s all too easy to write off “talk therapy” – I certainly had. I was privileged enough to then end up with someone who approached everything in a scientific, structured way that worked for me.
If you think any of this might be helpful, ask your GP. Ask your PHO. Look up the modules. It could do for you what it’s done for me.
One other thing I do really regularly: Mindfulness meditations and guided body meditations. I am shit at relaxing, so this stuff is magic. I used to think meditation was BS, so don’t worry if you cringe at the word – but I’ve found a few good ones I use over and over for dealing with anxiety.
Meditations to download
These total body relaxation ones (last page) are really good for insomnia.
Also – rain or white noise on Spotify.
If you’ve got other sites, tips or ideas, feel free to add them in the comments.
This is interesting, and may help some people. I am happy for you, Sarah, that you have access to a psychotherapist. I have had experience with counsellors, same as some others I know, and yes, while some can be good and helpful, that is not the case with all. And it is not easy to find a good “match” with a counsellor that has sufficient understanding and appreciation of every client’s complex needs and personal makeup.
Psychotherapists and also psychologists do often have better training and experience, as their education gives them a more rounded, and in-depth qualification.
The problem is, they are not always that easy to access, especially when you depend on a WiNZ benefit. I know that WiNZ pay some disability allowance towards costs, but some do not get their whole costs paid, for some reasons, so they have to meet the rest by saving on food or other stuff they need.
That is not how it should be.
And then there are often only limited professionals available, as community mental health services tend to only focus on very extreme cases to treat. People who may not have quite so severe conditions then have to resort to making compromises, and perhaps see a counsellor, which again may in some cases lead to disappointment.
Also is there still a shortage of people needing drug and alcohol treatment, and also do some of the counsellors and clinicians in that field lack some sound psychological and psychiatric training.
This is an area that definitely needs more resources. Of particular concern is that the new increased expectations WINZ have in people being ready for work can lead to people with psychological and psychiatric illness being misdiagnosed and put at great risk. Conditions may show symptoms, but not always, and some people may appear “fit” and healthy on the surface, at least at times, but inside carry much pain and suffering.
The advice offered here may help some, but not every treatment is working with every person. CBT (cognitive behavior therapy) CDT (cognitive dialectic therapy) are in fashion, but it is important to find out what works. So if one thing does not work, do not give up, and perhaps try another form of treatment.
I meant to say, there is also a shortage of places available for persons that may need drug and alcohol, or other addiction treatment, there is certainly not a shortage of people having a need for such treatment!
I came across an ambient noise masterlist on tumblr. Adding here in case it is useful to any readers.
Really helpful thank you Sarah.
Some interesting issues regarding counselors, psychologists, and psychotherapists are raised here and I would like to offer some observations about the differences between them, what each are qualified to do, what the law allows them to do, and what they actually do in practice.
Counseling is unregulated in NZ so anyone can actually set up as a counselor with or without formal training. Counseling has its origins in work traditionally done by educators and clergymen, not in psychology. Its objects are providing help and guidance for people to resolve personal problems and to make their own decisions about such things as relationships and family issues, life choices, and career guidance. Counselors are as a rule not formally trained in the therapeutic methods of resolving mental health issues which is properly the field of clinical psychologists and psychiatrists. In practice, as long as they refer to themselves as counselors, not psychologists, which is a legally protected term, they can get away with involving themselves in mental health treatment. This is of some concern as at best they will probably achieve little and at worse can do a lot of harm. Given that it is unregulated, counselors are inevitably a bit of a mixed bag, some can be recommended and some you should have nothing to do with.
People referring to themselves as psychotherapists are actually a separate category form psychologists, and are regulated separately by the HPCAA and they have their own registration board. They are also usually counselors and the therapy they offer has its origins in Freudian psychoanalysis. Almost invariably they do not have qualifications in psychology and they are affiliated with counselors rather that psychologists.
Psychologists have moved away from psychodynamic methods which began with the theories of Sigmund Freud, and CBT is now the dominant paradigm. There are sound reasons for this, CBT has a scientific basis not a speculative one like psychoanalysis, and empirically it can be shown to have a fairly high success rate. There are many variations of CBT, all of which may potentially be useful. The gold standard for resolving emotional problems of the type Sarah has described is Marsha Lineham’s Dialectric Behavioural Therapy (DBT), however other forms of CBT can be effective. DBT is a proprietary method, meaning it is taught privately and not in universities, so this tends to limit its availability. Traditional psychodynamic therapies when used for treating serious emotional problems have been found to be counterproductive, often triggering the unwanted emotional responses rather than teaching methods of managing them. This is one of the reasons for the move away from them.
Psychologists must be registered and come under the control of the HPCAA. There are three scopes of practice, clinical, general, and educational. In practice there is quite a bit of overlap and nobody seems quite sure where the boundaries are. For example psychologists employed by the Corrections Dept are usually registered in the general scope but the work is strictly speaking clinical. Not really an issue as long as they are competent. Academic standards to qualify for clinical training programmes are very high and the training rigorous, so this does lead to a greater level of confidence in the practitioners.
Psychiatry is the medical specialty concerned with treating mental disorders, so all psychiatrists are registered medical practitioners. In NZ psychiatry is very much orientated towards pharmacological treatment, not CBT and psychodynamic therapies. In practice in NZ psychiatrists tend to treat the major psychopathologies such as schizophrenia and bipolar disorder, whilst phobias, anxiety, and personality disorders are seen more as the province of clinical psychologists. Depression is a field common to both. Whether this is appropriate, or if there should be such heavy dependence on pharmacological treatment is something that could be debated for a long time.
So for help with personal issues and life choices that are unrelated to mental health, seek out a good counselor. For help with emotional problems and anxiety only a psychologist is likely to be able to give effective long term help. A counselor that professes to be able to resolve these types of problems is probably fairly questionable. There are also alternative practitioners in mental health as there are alternatives to conventional medicine. Both the people involved and the methods used seem fairly dubious. In the final analysis the most important factor in whether or not the therapy is successful is the therapeutic relationship between client and therapist, rather than the specific method. If this is not working out it is best to find a therapist that you are happy with.
Thank you for all this info! I think a lot of people don’t know the difference between all the types of help you can access. It’s a good idea to research them all, and then, if you have the ability (privilege!) to do so, try a few different things to see what works for you. Everyone’s different and a mix-and-match approach (like mine) can also be really good.
Thanks ACDC –
You summarised it very well indeed. I made some slight mistakes, or left out some needed clarifications.
Yes, there definitely is a significant difference between counsellors and psychologists and of course psychiatrists.
But at least some counsellors belong to the New Zealand Association of Counsellors, who uphold some standards. And a proper counsellor actually needs to do some formal training also, for a year or two.
Yet I fear there are still some “cowboy” operators out there.
A bit about the concept of change is in order because I think there is a little general confusion about what CBT actually aims to achieve. People may feel they can’t change hence there is nothing to be gained from therapy. What needs to be realised is that CBT cannot and does not aim to change personality, but instead aims to change ways of thinking which is quite a different thing. Personality, which in a nutshell refers to such things as introversion-extraversion, how emotional a person tends to be, and how agreeable and empathetic they tend to be towards other people, is only subject to gradual change over a long period of time. The basic axiom of CBT is that many mental health issues are the consequence of what the textbooks dispassionately describe as “persistent maladaptive cognitions and patterns of thought”, or to put that in simpler and kinder terms, interpreting situations in the wrong way and always thinking about things in a negative self critical way will cause problems.
The object of therapy then is to firstly to identify these problematic ways of thinking, and then guide the client towards new more healthy ways of thinking. Obviously this is involved and will take time. Simply telling a client that their ways of thinking are wrong and suggesting alternatives will not work, and the problem is much more involved than this. The therapist has to challenge the client’s way of thinking in such a way that they come to the realisation themselves that their way of thinking is not helpful, and then help them replace the old patterns of thought with new healthier ones. Since the concept of CBT was first devised by Dr Aaron Beck in the 1960s various methods for achieving this have been developed, but they all essentially have the same basic aim. Some people may find the process a bit intrusive and critical, but it is after all done with the best of intentions, and unlike psychodynamic therapies the therapist’s aims are quite transparent to the client.
So at the end of therapy the client is still the same person, but hopefully with new and more productive ways of thinking and managing what were previously problematic situations. A final point, what I have described is strictly speaking cognitive therapy as distinct form cognitive behavioural therapy, usually therapy also incorporates a behavioural component as well based on established principles of behavioural psychology and behaviour modification, hence the name. This is particularly true where therapy for phobias and anxiety is involved.
I came across this some time ago, and it is worth a read:
“Counselling can do more harm than good”, NZ Herald, 19 August 2014
So counselling may help some in some cases, but it pays to be cautious and to evaluate the service being offered, and how it may work.
Thank you again for this Sarah, incredibly helpful post and resources. Really appreciate you sharing your experience.
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