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Psychothérapie pour l’anxiété généralisée

Cedric Bouet-Willaumez — Tue, 20 Sep 2022 13:21:23 +0000

L’anxiété chronique et ses manifestations ponctuelles, les crises d’angoisse, peuvent être très handicapantes. Mais comme le réflexe anxieux ne nous dit rien de ses raisons, il est difficile d’avoir une approche rationnelle pour l’endiguer. C’est pour ça qu’une psychothérapie pour l’anxiété généralisée aborde le problème d’une manière tout-à-fait différente, aussi créative que spontanée.

1- Qu’est-ce que l’anxiété ?

L’anxiété est l’émotion qui accompagne la mobilisation de nos ressources physiques en réponse à un danger imminent. Cette mobilisation produit d’important changements physiologiques : notre rythme cardiaque s’accélère, notre digestion est suspendue, et notre système sanguin s’adapte rapidement pour alimenter notre cerveau au détriment du reste de notre corps.

Cette réponse à un facteur externe de stress est tout-à-fait naturelle, et la plupart du temps, elle est également utile en dépit de son caractère désagréable.

Nous pouvons alors devenir pâles, avoir le tournis, ou être saisis de tremblements. Ces réactions sont normales. Elles témoignent de l’investissement énergétique que représente le réflexe de “lutte ou de fuite” (le “fight or flight”).

Cette réponse à un facteur externe de stress est tout-à-fait naturelle, et la plupart du temps, elle est également utile en dépit de son caractère désagréable. Car même si nous ne vivons plus sous la menace de grands prédateurs, l’anxiété nous sert encore au quotidien : par exemple, elle nous permet d’être plus performants pour une présentation importante, un examen ou une activité sportive. L’anxiété est néanmoins problématique dans certains cas, que nous allons passer en revue dans ce court article.

2- Anxiété ou angoisse ?

Tout d’abord, un point de vocabulaire pour mieux comprendre le phénomène de l’anxiété et commencer à l’aborder sous l’angle de la psychopathologie. Les mots “anxiété” et “angoisse” sont souvent utilisés de manière interchangeable et décrivent une émotion apparentée à la peur. Ils partagent d’ailleurs une étymologie, comme nous le rappelle le psychiatre Christophe André : “le mot latin angere, qui signifie serrer et qui renvoie aux conséquences physiques de ces états mentaux(1)”.

L’angoisse, en somme, peut être vue comme un pic d’anxiété.

Cependant, ils ont un sens un peu différent, et il convient de le rappeler ici. André explique : “En général, on parle d’angoisse pour renvoyer à une expérience psychologique ponctuelle, déstabilisante et intense, faite d’un sentiment de perte de contrôle et d’imminence d’un danger grave (2)”. L’anxiété, elle, décrit “un état moins déstabilisant mais plus chronique, consistant en un souci difficile à contrôler(3)”. Donc, le terme d’angoisse met l’accent sur la réponse physiologique, et celui d’anxiété sur la réponse psychologique.

L’angoisse, en somme, peut être vue comme un pic d’anxiété. Là ou elle paraît nous paralyser pour un moment, l’anxiété, elle, peut nous miner pendant des semaines, voire des mois ou des années. Et c’est elle, puisqu’elle ne passe pas, qui amènera le plus souvent la personne anxieuse à chercher de l’aide. Il est heureusement possible d’entamer une psychothérapie pour l’anxiété généralisée.

3- L’anxiété généralisée

L’anxiété qui “mine”, c’est le Trouble Anxieux Généralisé, (TAG), ou anxiété généralisée. Cette anxiété-là, “persistante, […] ne survient pas exclusivement, ni même de façon préférentielle, dans une situation déterminée (l’anxiété est “flottante”(4)).” On parle également à ce moment-là d’anxiété chronique.

On aura alors l’impression d’un cercle vicieux, où on a, en quelque sorte, “peur d’avoir peur”.

Ansi, la personne souffrant d’un trouble anxieux généralisé subira, en quelque sorte, une triple peine. D’abord, elle ressentira les symptômes anxieux de manière plus aigüe. Ensuite, ces symptômes seront plus vécus comme des intrusions incompréhensibles, ce qui, à son tour, créera une anxiété supplémentaire, qui ira renforcer le fond anxieux, et ainsi de suite. On aura alors l’impression d’un cercle vicieux, où on a, en quelque sorte, peur d’avoir peur.

Ceci est une conséquence de la nature même du réflexe anxieux : ses symptômes ne nous renseignent malheureusement pas sur ses causes. L’anxiété se contente en effet de marquer la mobilisation de notre corps pour la fuite ou le combat : elle n’est pas là pour nous apprendre quoi que ce soit. Dans ces situations d’anxiété chronique, il est donc inévitable qu’on se sente désarmé, voire désespéré. C’est dans de telles situations qu’il convient de rechercher une aide professionnelle.

4- Comment traiter l’anxiété généralisée ?

Plusieurs approches sont régulièrement recommandées pour traiter le trouble anxieux généralisé. Elles tombent sous deux grandes catégories : la première, favorisée par le système de santé britannique, cherche à contenir puis maîtriser le symptôme dans une intervention à court terme. La deuxième, pratiquée de manière plus extensive en clinique privée, va privilégier la recherche des sources du trouble anxieux plus que ses manifestations externes.

C’est dans notre inconscient que résident et se transforment les processus qui nous font avancer, comme ceux qui nous tiennent en échec.

Cette différence d’approche s’explique, dans une bonne partie, par des considérations financières. Les thérapies cognitives et comportementales sont en effet des interventions à court terme visant des résultats concrets et assez rapides. Les thérapies psychanalytiques ou intégratives, par contre, bien qu’elles soient très efficaces et qu’elles apportent des résultats durables, sont des traitements dont les effets se font sentir à long terme, et pour lesquelles les mesures de succès sont plus vastes, plus complexes et plus nuancées.

5- Le rôle de l’inconscient dans l’anxiété

Avant d’en dire plus sur la psychothérapie pour l’anxiété généralisée, il faut faire un point sur le rôle de l’inconscient dans l’anxiété. “L’inconscient”, c’est est le nom qu’on donne aux processus mentaux qui se déroulent à notre insu – le psychanalyste Jacques Lacan avait d’ailleurs proposé qu’on adopte ce terme d’ “insu” pour parler de l’inconscient.

La plus grande partie de notre vie mentale est inconsciente. Et c’est bien normal : nous n’avons tout simplement pas assez de bande passante pour être au fait de toutes nos émotions, pensées et sensations, et notre mémoire est trop vaste pour que nous nous la gérions entièrement de manière consciente. Les choses, en quelque sorte, “se font toutes seules”, mais d’une manière qui nous est unique à chacun, et qui est façonnée par nos expériences les plus anciennes.

Le but d’une psychothérapie, qu’elle soit psychanalytique ou intégrative, est d’aider la personne à découvrir, comprendre et changer son fonctionnement inconscient sur la durée.

Par conséquent, nos motivations, nos compétences, notre capacité à travailler et à être en relation avec nous-mêmes et les autres, sont le produit de processus que nous ne maîtrisons pas. C’est dans notre inconscient que résident et se transforment les processus qui nous font avancer, comme ceux qui nous tiennent en échec. C’est donc à l’inconscient que la psychothérapie va s’adresser.

Le but d’une psychothérapie, qu’elle soit psychanalytique ou intégrative, est d’aider la personne à découvrir, comprendre et changer son fonctionnement inconscient sur la durée. De cette manière, l’anxiété sera abordée à partir de la racine, et non à partir du symptôme. Et, à mesure que la psychothérapie suit son cours, ce dernier sera de plus en plus susceptible de réduire en intensité ou de disparaître.

6- Le travail sur l’inconscient dans la psychothérapie

Quelques questions s’imposent cependant : si l’inconscient est hors de notre portée, comment le découvrir ? S’il est “insu” et qu’il le reste, comment le comprendre ? Et s’il ne nous obéit pas, comment changer la façon dont il fonctionne ?

L’inconscient ne peut, en fait, être abordé qu’en ses propres termes. C’est à dire que, puisqu’il ne nous obéit pas et se dérobe à notre faisceau conscient, il faut, pour s’en rapprocher, et pour développer une intimité avec lui (et donc, avec soi-même), non pas aller le chercher, mais avoir la patience qu’il se montre. Et à ce moment-là, il est possible de le reconnaître et de le comprendre. Une psychothérapie fournit les conditions pour que cela se passe.

Dans une psychothérapie, on privilégie ce que Freud appelle la libre-association, c’est à dire, le fait de dire ce qui nous passe par la tête sans chercher ni à filtrer ni à comprendre – c’est plus difficile et plus libérateur qu’il n’y parait. Le thérapeute donne l’espace à son patient de partager ce qui se présente, que cela paraisse important ou trivial, drôle ou douloureux, que cela fasse du sens ou que cela sorte de nulle part.

7- Que veut dire “aller bien” ?

A propos de libre association, Lacan écrit : “Dans une phrase prononcée, écrite, quelque chose vient à trébucher. Freud est aimanté par ces phénomènes, et c’est là qu’il va chercher l’inconscient.(5)” Lacan nous dit donc que l’inconscient se manifeste quand on “trébuche”, c’est à dire, quand on relâche son attention et qu’on fait une “erreur”.

Suivre une psychothérapie pour l’anxiété généralisée, c’est en fait se donner une opportunité d’éprouver notre présent à sa mesure exacte; c’est se libérer progressivement de l’empreinte, de l’étreinte de son passé.

Ces erreurs jettent la lumière sur des vérités qu’on se tait à soi-même. Quand on se “trompe”, le masque tombe alors qu’on manifeste son psychisme de manière spontanée : sans les défenses, les dénis ou les fioritures habituelles. C’est la fonction du thérapeute que d’aider la personne à voir sa vérité au détour de ses erreurs, et s’apprécier à sa juste valeur, dans sa totalité, et, à terme, à faire la paix avec son inconscient.

Aller bien, c’est fonctionner au quotidien sur cette base-là, c’est à dire, faire la part du présent et du passé pour nous mobiliser de la manière la plus efficace, la plus appropriée et la plus créative. Suivre une psychothérapie pour l’anxiété généralisée, c’est en fait se donner une opportunité d’éprouver notre présent à sa mesure exacte; c’est se libérer progressivement de l’empreinte, de l’étreinte de son passé.

Notes

¹ https://www.psychologies.com/Moi/Problemes-psy/Anxiete-Phobies/Articles-et-Dossiers/Faire-face-a-nos-angoisses/Le-sens-des-mots-angoisse-ou-anxiete

² Ibid.

³ Ibid.

⁴ https://icd.who.int/browse10/2008/fr#/F41.1

⁵ Jacques Lacan, “Les quatre concepts fondamentaux de la psychanalyse”, Editions du Seuil, Paris, 1973

En moins de 100 mots

Au départ, l’anxiété est là pour nous aider à vivre
L’anxiété chronique est persistante et parfois sans rapport avec notre situation présente
Une psychothérapie pour l’anxiété généralisée s’attaque aux racines du problème, et le traite sur la durée.

Comme l’anxiété chronique est d’origine inconsciente, la traiter passe par l’écoute de l’inconscient
La fonction du psychothérapeute est d’aider le patient à développer cette écoute
La psychothérapie équipe la personne pour vivre plus librement

Cédric Bouët-Willaumez est psychothérapeute à Londres, exerçant en cabinet privé depuis plus de 20 ans. Vous pouvez le contacter pour prendre rendez-vous au +44 7876 035 119, ou en suivant ce lien.

The post Psychothérapie pour l’anxiété généralisée appeared first on Psychotherapist Central London - Cédric Bouët-Willaumez.

Psychothérapie pour la dépression

admin — Tue, 17 May 2022 13:06:28 +0000

Une psychothérapie en profondeur est un traitement approprié et efficace pour la dépression. Mais bien que les symptômes de la dépression soient bien connus, le déroulement et les effets d’une psychothérapie pour la dépression sont entourés de mystère. Cet article en décrit et illustre quelques principes.

1 – Les symptômes de la dépression

C’est un des maux de l’âme les plus répandus, puisqu’une personne sur cinq en sera affectée au cours de sa vie. Et comme c’est une souffrance encore stigmatisée dans bien des cas, on peut hésiter à se l’avouer, et surtout à rechercher un diagnostic formel. On parle plus volontiers de “mauvaise passe”, de “coup de mou”.

“Je suis d’un humeur telle que, si j’étais sous l’eau, c’est à peine si je bougerais pour remonter”.

John Keats

Pourtant, les symptômes, pour la plupart bien connus, peuvent être très difficiles à vivre. Philipe Labro illustre ce mal avec éloquence dans son livre “Tomber sept fois, se relever huit”, où il fait le récit de sa propre expérience. “Perte du désir, je n’ai plus goût à rien. Manger est une épreuve, boire une punition. La mandarine n’a plus de goût, la purée ne passe pas à travers la gorge, le café laisse des traces d’amertume”.

Ce mal physique s’accompagne le plus souvent d’une tristesse qui dure, et qui paraît parfois ne pas avoir d’objet ni de cause ; de ruminations ; d’une difficulté à se concentrer, voire à penser ; d’une irritabilité. Le poète John Keats résume bien la condition quand il écrit à un ami : “Je suis d’un humeur telle que, si j’étais sous l’eau, c’est à peine si je bougerais pour remonter”.

“Même si un épisode dépressif peut paraître limité dans le temps, la condition chronique sous-jacente doit être traitée pour éviter une rechute. Si ce n’est pas fait, cela se produira dans 75% des cas”

Les mots de Keats illustrent un des aspects les plus difficiles à vivre de la dépression : la perte de toute perspective, de toute force, de tout espoir. Il est difficile alors, voire impossible, d’imaginer qu’on puisse nous aider, et qu’il soit possible de ressentir autre chose un jour.

Pourtant, l’aide est bien là, et elle peut être très efficace. Elle est aussi nécessaire. Car même si un épisode dépressif peut paraître limité dans le temps, la condition chronique sous-jacente doit être traitée pour éviter une rechute. Si ce n’est pas fait, cela se produira dans 75% des cas.

2 – Le traitement médicamenteux

Tous les patients qui m’ont été adressés par des médecins pour une psychothérapie interpersonnelle pour la dépression se sont vus d’abord recommander un antidépresseur. La plupart d’entre eux avaient décidé de suivre cette recommandation en même temps qu’ils suivaient une psychothérapie.

“Il est recommandé de consulter un psychothérapeute, qu’on suive un traitement médicamenteux ou non.”

Le médicament peut être très utile, et “marche” souvent, même s’il y a un vrai débat sur cette efficacité et sur la meilleures manière de la mesurer. Au mieux, il permet d’atténuer les symptômes les plus difficiles à gérer, et de continuer à “fonctionner”.

Mais s’il peut endiguer un épisode dépressif, il ne constitue pas un traitement de fond de la dépression. C’est pourquoi il est recommandé de consulter un psychothérapeute, qu’on suive un traitement médicamenteux ou non.

3 – La psychothérapie pour la dépression

Traiter la dépression au moyen d’une psychothérapie peut représenter un investissement considérable. C’est parce que c’est une approche rigoureuse qui va au delà du symptôme – sans l’ignorer – pour aborder en profondeur tout l’ensemble du psychisme de la personne.

C’est une démarche qui s’inscrit dans le temps et dans la régularité, et dont les effets peuvent être très profonds. Par exemple, j’ai noté qu’une personne peut devenir plus calme, plus résiliente, plus libre et créative si elle a suivi une psychothérapie.

4 – Des “clés” dans le psychisme ?

Mes patients en début de traitement me demandent souvent que je les aide à trouver des “clés”. Dans l’imaginaire de beaucoup d’entre eux, ce sont d’anciens traumatismes enfouis dans l’inconscient qu’il suffit de mettre au jour pour que le mal soit neutralisé. Ces choses existent bien, mais c’est très rarement le cas qu’il suffise d’une pour expliquer – et soulager totalement – une expérience aussi complexe que la dépression.

“Le thérapeute saura s’intéresser à ce qui paraît inintéressant, et aidera le patient à trouver le fil rouge dans ses pensées, même si elle paraissent décousues.”

C’est ce coté imprévisible et irrationnel qui sollicite beaucoup la personne et lui demande le plus de persévérance. C’est d’ailleurs souvent ce qui motive leurs demandes de solutions concrètes et rapides. Mais le thérapeute saura garder à l’esprit que, pour écouter l’inconscient, il faut agir et penser indépendamment des pressions conscientes.

Le thérapeute saura s’intéresser à ce qui paraît inintéressant, et aidera le patient à trouver le fil rouge dans ses pensées, même si elle paraissent décousues.

5 – L’irrationnel dans la psychothérapie

Ce désir de trouver la clé, c’est en partie le résultat de la mystique qui entoure le travail de Freud, qui est souvent représenté de manière incomplète. C’est aussi un message du patient qui veut aller mieux vite, car vivre une dépression peut parfois être insupportable et mener à l’irréparable. Le risque de décès par suicide est effectivement multiplié par 25 chez les personnes souffrant de dépression.

Donc, il n’y a le plus souvent pas une seule clé, mais une multitude, et elles se trouvent rarement où on les attend. C’est pourquoi la psychothérapie ne se contente pas d’une enquête méthodique et rationnelle sur le passé de la personne. Il s’agit de suivre l’inconscient au plus près, tel qu’il se manifeste spontanément au détour du discours et du comportement conscients lors de la séance, dans la digression, le lapsus, l’improvisation.

6 – Le déroulement d’une thérapie

Il n’y a pas de parcours type. Mais on peut dire que le fonctionnement d’une thérapie est à l’image de l’amélioration qu’elle propose, et que Philippe Labro décrit avec ces mots : “elle est invisible, inaudible. Elle arrive à tout petits pas sur les toutes petites pattes d’un tout petit chat, on ne l’entend pas venir”.

L’aspect le plus important d’une psychothérapie est d’apprendre à se voir de manière juste. A cet égard, il n’y a pas de détail qui soit insignifiant. Le thérapeute aidera le patient à developper cette discipline jusqu’à ce qu’elle aussi devienne inconsciente. Comme le dit enfin Labro, “si vous avez cru discerner le murmure assourdi des pattes du petit chat, ne l’oubliez pas”.

¹ https://www.inicea.fr/la-depression-chiffres-cles#chapitre

² Philippe Labro, “Tomber sept fois, se relever huit”, Folio, Paris, 2003, p. 37

³ https://www.inicea.fr/la-depression-chiffres-cles#chapitre

⁴ https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/antidepressants-on-trial-how-valid-is-the-evidence/E94E7663ACBC91A287A462E06B7B12EC

⁵ https://www.inicea.fr/la-depression-chiffres-cles#chapitre

⁶ Philippe Labro, “Tomber sept fois, se relever huit”, Folio, Paris, 2003, p. 178

⁷ ibid.

En moins de 100 mots

Un problème rencontré par beaucoup
Les symptômes en sont connus (tristesse qui dure, perte de désir, d’énergie, irritation, troubles de la concentration et de la mémoire)
Une très forte chance de rechute si le problème n’est pas traité

Si le médicament peut endiguer un épisode dépressif, la psychothérapie pur la dépression est un traitement de fond qui s’adressera au problème chronique
Pour être efficace, le traitement demandera une certaine persévérance
Le but sera d’aider la personne à développer une vue juste et cohérente de sa personne
Une psychothérapie interpersonnelle pour la dépression apporte des changements graduels

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Article Review: Remote Working During the Pandemic (Gillian Isaacs Russell, 2020)

admin — Thu, 02 Sep 2021 10:33:37 +0000

In this Q&A with the board of the British Journal of Psychotherapy (BJP), psychoanalyst Gillian Isaacs Russell, author of the 2015 book Screen Relations, discusses changes to the experience of psychotherapy brought about by the twin factors of the Covid-19 pandemic and the abrupt shift to “mediated communication” by phone or video conferencing (p. 1). Implicitly, the author writes from the standpoint that, beyond providing for continuity of care, there are no therapeutic opportunities inherent to technologically mediated treatment for either patient or therapist, and expresses the hope that “the value of co-present relating has been rediscovered and reasserted” (p. 10). This short review hopes to provide some element for patients and practitioners who wish to put this in perspective with their own experience.

1 – Technologically mediated relationship and the “as-if” relationship

In the first part of this Q&A, Gillian Isaacs Russell describes how circumstances and her wish “to transcend space and time” brought her to start working online, and how, through the analysis of her own practice and extensive research she came to the position that it is “crucial to recognise the differences between embodied communications in a shared environment and mediated communication” (p. 2), which we understand, reading on, as more likely than not to be detrimental to patient, practitioner and treatment.

Indeed, considering the pre-pandemic trend in the practice of psychotherapy, she declares: “There has been a paradoxical drive to delete the body from the therapeutic interaction in the name of such things as convenience, democratization, continuity, and cost-effectiveness”. She regrets that: “we have been learning simply to accept simulated relationships, ‘as if’ relationships”, and issues a warning that, unlike her earlier self, we should not “sleepwalk into the use of technology for treatment” (p. 2).

2 – Do technologically mediated relationships undermine core principles of therapeutic work?

The sudden shift online was a forced choice which “found many of us unprepared and vulnerable” (p. 3). Gillian Isaacs Russell describes how, for example, the blurring of the boundary between work and home lengthened the working day by three hours for workers in the US and two hours in the UK, and how, amid the novel phenomenon of Zoom fatigue, there is “little time for silence, solitude and recalibration”.

The Q&A predictably comes into its own when the theme of intersubjectivity is broached. The author tells us, poignantly, that the disappearance of most non-verbal cues means that “online, we sometimes feel alone in the absence of the other”. Grounding her statement in recent research in neuroscience, she explains that online media create “a loss of presence” (p. 5) that affects our ability to ascertain whether or not we are experiencing the other as truly ‘outside’ of us, rather than a hallucination. This piece of research lends more weight to her earlier assertion that technologically-mediated relationships are ‘simulated’ or ‘as-if’. It would have perhaps been useful for her to make this link more explicit.

She also lists useful steps to take to mitigate the distracting effects of ‘partial attention’, such as turning off notifications on all devices and putting to sleep those that are not used during a session (p. 6), or ensuring that there is some time allocated on both sides of a session so that it is better committed to memory (p. 7).

When asked what may happen to “the core analytic principles of free association, evenly suspended attention and reverie” when treatment happens remotely, the author spells out what feels like a central aspect of her position, namely that “the ability to move away inside your own thought process and reconnect underlies a mutual ongoing sense of reliable presence that enables reverie. This is not always possible with the effort or anxiety of concentration that accompanies work with technology” (p. 5).

At this stage, and considering ample anecdotal evidence that this is an experience shared by many therapists and patients, it would have been very helpful if the author had tapped further into her understanding of the neurobiology of mediated relationships, and expanded on how she felt it affected phenomena like mutual regressions (such as described by Allan Schore), which are the focus of the most exciting new research, and which are increasingly seen as the implicit underpinning of the therapeutic encounter.

Indeed, informal reports by patients and therapists as well as my own experience suggest that, as the share of verbal communication proportionally increases when carrying out psychotherapy online, and as most of the physical cues are lost, affective attunement operates on a narrower range and sessions will tend to be more ‘left brain’ (i.e., mostly on secondary processes and rational operations) as a result. For some patients, this will feel less containing. For more resistant patients, it may offer an opportunity to engage more freely with a treatment that will appear less intense and threatening.

3 – Psychotherapy and the perception of time and place

Building on her overall argument that vigilance is the only way to approach technologically mediated communications, the Interviewee then shares additional research that establishes the link between mental and physical functioning, namely that “the richer our embodied experience of acting and moving in space, the more profoundly it affects our perceptions, consciousness and memory” (p. 8). She adds: “the unchanging stasis of lockdown (what one person described to me as a ‘soup of experience’), without much movement in space or change in routine or environment, affects our memories and our perception of past, present and future”.

This is a very interesting point, and, if we go back to her assertion that remote work takes place in the context of an ‘as-if’ relationship, as well as to the point that she makes about the relative unreliability of the therapeutic container undermining core principles of therapeutic work, we may be left with the overall impression that a session of psychotherapy given remotely may become a fleeting moment, poorly committed to memory, of simulated relationship, based on an “illusion of presence” (p. 5), with limits on the reliability, extent and safety of communication.

So, should we even bother?

The Interviewee seems to be of the opinion that, despite the serious limitations of the medium, continuity of care is a good enough justification to consider offering treatment online or over the phone. She adds that that it is beneficial to talk about its technical limitations of with patients. In my experience, this is particularly helpful when it serves as a further exploration of existing issues such as powerlessness, intimacy and loss, that a patient may be working through.

4 – The complex influence of shared experiences on the therapeutic relationship

This Q & A concludes with useful thoughts about how the shared experience of the pandemic and the advent of online psychotherapy as a mainstream practice challenge the traditional functions of patient and therapists when it comes to maintaining the boundaries of treatment and the safety of the therapeutic container.

In respect of the latter, she explains that “It is unreasonable to expect the patient to be able to provide a safe setting for themselves, if they have never had that basic experience of safety and cannot even imagine it” (p. 7). Gillian Isaacs Russell does not say how we can go about making provisions for this, or even if therapy itself can, in some cases, become an unreasonable undertaking.

It would have been beneficial for this Q&A to include questions about making decisions on continuity of care in cases where patients, who rely on a more primitive “defensive armoury” that includes “splitting, projective identification, denial and disavowal”, would be seen to struggle too much to engage with therapy in an environment that offers a narrower and looser framework for affect regulation.

When it is however possible to conduct psychotherapy under those new conditions, there is something that we may view as a silver lining: both the medium we now have to consider in delivering psychotherapy and the circumstances in which it has become indispensable seem to foster a levelling of the relationship – psychotherapy should indeed be a relationship of equals, where the therapist’s function does not confer status. Both patient and therapists are there to “bear witness to the realities of the world situation that we all share” (p. 8) while having the “very real shared experience of danger from an invisible intruder, uncontrolled and menacing, and perhaps literally existing in the other” (p. 6). As the nightwatchman in Albert Camus’ The Plague says:

“oh! If only it had been an earthquake! A good shake and that’s it. One counts the dead, one counts the living and the whole things over and done with. But this rotten bastard of a disease! Even those who don’t have it, carry it in their hearts.”

For better or for worse, whether we are ill or well, we are now very obviously ‘in this together’. It is my view that the loss of co-presence induced by the movement online of much of psychotherapy during the pandemic should be put in perspective with the benefit of introducing the need for a discourse on – or at least a mutual implicit recognition of – the fraternity of the therapeutic pair, of its shared vulnerability. The frailty of the act of relating is brought to the fore in a very potent way for both parties to psychotherapy, irrespective of their function. As the nightwatchman says, “they carry it in their hearts” and it is therefore an essential aspect of the transferential relationship.

There is also another important facet of the impact that technologically mediated work has on the therapeutic relationship that Isaacs Russell does not mention, which is that it can amplify certain aspects of the transference and countertransference. I gave a paper several years ago, based on a case study of “dual” online and offline work, highlighting how both the choice of ‘platforms’ and the experience of the work itself were consistent with the patient’s unresolved childhood issues. In the case I wrote about, technology had been brought in at the patient’s request to facilitate her travel patterns and, unconsciously, to create a relational context that was very well suited to the concreteness of her thinking about rootlessness, miscommunications and longing for presence.

Conclusion

In this Q&A, Gillian Isaacs Russell makes very interesting points, and her open question about the ‘realness’ of the online therapeutic encounter is vital to anyone involved in psychotherapy and needs keeping in mind. We can also only empathise with her longing for a form of normalcy to return as we reacquaint ourselves with the benefits of co-presence. It seems that she would like this to be a watershed moment in the rediscovery of what is essential about psychotherapy.

However this Q&A does not provide much food for thought to the practitioner or the patient who have a positive experience of technologically mediated work, and even though the media is deemed good enough by virtue of necessity, it is still perceived as a handy workaround rather than a bona fide means of therapeutic engagement.

The attitude of ‘making do’ may resonate with the motivational social discourse of wartime thrift and resilience while being consistent with much of the experience of remote work, but it is also born out of the conflation of a trend (the advent of technologically mediated communications) and a contingency (the global pandemic and the lockdown). The pandemic will end, but the means of overcoming some of the great difficulties it created for psychotherapy preceded it, as Gillian Isaacs Russell acknowledges (p.2) and won’t go away. We should, as a society and as individuals, heal from infection, illness and isolation, but we shouldn’t feel that a gradual – and partial – shift to technologically-mediated communications is something to recover from.

Psychotherapy is ultimately a never ending exercise in searching for the truth to one’s experience by means of a relationship. The status of co-presence as the only viable vehicle for this exercise has been challenged deeply in this pandemic, but the jury seems to be still out as to what the upshot of this challenge is going to be. Indeed, in contrast to the interpersonal grounding and subtlety that co-presence affords, technologically-mediated relationships may seem to be the flaky, concrete and clunky vehicle for the no less significant experience of co-absence.

But, limited as it may be, I would suggest that the experience that technology offers is not just contingent and derivative but a quintessential aspect of human relations. Language itself could be construed as a means of just making do with separateness and absence if we consider that, when we utter a word, we simultaneously invoke the reality of an object while acknowledging its intractable separateness from us. In using language, we soothe ourselves of the pain of absence as we enter into relationship, and the experience of receiving and providing psychotherapy online and over the phone offers just that.

The work of linguist Daniel Everett, whose field study of the Pirahã language is summarised in his book Don’t Sleep, There are Snakes, can be usefully referred to in an attempt to confer a “legitimacy” to the experience of relating through technology. Everett indeed describes how:

“There are five […] channels in Pirahã, each having a unique cultural function. These are whistle speech, hum speech, musical speech, yell speech, and normal speech—that is, speech using consonants and vowels”

Each channel is designed for use in certain circumstances: when out hunting, for example, whistle speech is best used, and nursing mothers will tend to use hum speech with their infants. These make for very different experiences of relating through language, and I would suggest that technologically mediated communications could be considered as a specific channel in any language, and not just a degraded form of communication.

If we take this view, while keeping in mind how this particular channel amplifies certain aspects of our shared experience while muting or cancelling out others altogether, we would feel compelled to challenge Gillian Isaacs Russell’s overall outlook, if not her research and clinical observations. Co-presence is indeed an essential, and perhaps central, foundation to a therapeutic relationship. This has been highlighted by how its total disappearance during lockdown has brought in sharp focus the need for a radical reengagement with the workings of psychotherapy.

Isaacs Russell seems careful not to push her point stridently, and her conservative position should be contrasted with the apparent humorous tone she uses to describe how she initially conceived of her own shift online as a means “to transcend space and time”. Maybe she acknowledges with good enough grace that psychotherapy online is still psychotherapy, but it will be for others to make the explicitly positive case.

Notes

1) Allan Schore: “The Growth Promoting Role of Mutual Regressions in Deep Psychotherapy”, lecture given in London, 2018 (nScience UK)
2) Alistair D Sweet, Elements of Psychotherapeutic Assessment and Treatment with structured and under-structured personalities, British Journal of Psychotherapy, 27, 1 (2011) 4-18
3) Albert Camus, The Plague, Penguin Modern Classics, (2002), p. 88.
4) Daniel Everett, “Don’t sleep there are snakes”, Profile Books, 2009, p. 185

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Depth in Psychotherapy

Cedric Bouet-Willaumez — Tue, 25 May 2021 13:42:17 +0000

In the practice of psychotherapy, practitioners must ensure that they are able to work at a level that matches the depth of interactions in a patient’s past and present life.

All human contacts change us in depth, from conception onwards. Our personalities, memories, habits and traits are a direct function of the personal history we have with anyone we ever came into contact with, no matter how briefly or remotely. Our parents, siblings and friends matter most of course, but it is still possible to be profoundly changed by an encounter that lasts a fraction of a second – be that high-fiving a star performer from the first row of their show or being the victim of a pickpocket.

This is why the crucible of the therapeutic relationship can only effect change in depth, and this is why the psychotherapist will make every effort to provide the best possible conditions so that this change is beneficial to the patient. In few words:

1- The stance of the psychotherapist

Psychotherapy is yet another relationship with a stranger, albeit a stranger who will receive payments to suspend the gratification of their own needs for the length of a session and make their minds completely available to the person coming to them for help. The psychotherapist is there purely to attend to their patient and nothing else.

2- The importance of the unconscious

In his foreword to Ginot’s Neurobiology of the Unconscious, renowned psychiatrist Allan Schore reminds its that “Far from serving a defensive function, unconscious processes are ever present and widespread and in essence are the neuropsychological force behind most of our mental and behavioural operations”(1). This means that our unconscious is not just a mental storage space away from our awareness, where unwanted memories are gathering dust. It is involved in all that we do – it is really is in the driving seat.

This is why, during sessions, it does not matter if the material that is presented by a patient is well thought-through and elaborate, or, on the contrary, coarse and chaotic. All material, verbal or otherwise, speaks of the patient’s conscious and unconscious experience in the session and therefore is susceptible of being brought into further light by the therapist.

3- Why repetition matters

First, much as every contact changes us deeply, it is the relational experiences that we have within our closest circles that founds most of our psyche. By repeating sessions regularly and for as long as we can, we are more likely, by unconscious association, to bring up material that is closest to our relational foundations, and therefore most active in our minds.

Second, repetition is the foundation of all learning, at all ages. Psychotherapy certainly allows to develop deep and lasting insight into ourselves, but beyond intellect and comprehension it focuses on a form of learning that is mostly unconscious and emotional – where the hurt lives and works on us.

4- How repair ‘works’

In relation to the last point, it is highly desirable but not enough to ‘know yourself’ in the common sense of the word. This form of knowledge is precious but, people will often find that they get better in ways that they don’t quite understand. Psychological repair is founded on the repetition of affectively reparative experiences, that is, experiences that help integrate the person’s emotional world with the rest of their psyche. These principles are held in mind by the therapist, who will be attuned to the patient’s emotional as well as intellectual needs.

(1) Ginot, E., “The neurobiology of the unconscious”, 1995, W.W. Norton & Co., p. XIII

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Psychological Effects of Brexit, some thoughts

Cedric Bouet-Willaumez — Thu, 14 Jul 2016 09:49:00 +0000

On 23 June 2016, a majority of the British electorate chose to leave the European Union. The economy and political landscape in Great Britain are changed dramatically, and beyond this, individuals can find themselves deeply affected.

One of my patients, an english man who has been seeing me for several years and has been thinking about bringing his therapy to a conclusion, told me after the results of the referendum: “I can’t make a decision either way at the moment, because with all the buzz about remaining and leaving, it’s hard to listen to my own mind”.

As therapists, we tend to look at our patients’ past to help them see how it shows up in the present. With the current events unfolding, we need to be very mindful of the effect that social movement and discourse can have on individuals.

“With all the buzz about remaining and leaving, it’s hard to listen to my own mind”.

This summary describes three effects of this crisis on the individual psyche.

1 – The disappearance of a safe and secure environment creates a void, which is filled with past memories

A Russian patient told me a few years ago about what he experienced when the Soviet Union was dissolved on Boxing Day 1991: “I woke up one morning, and my country had disappeared”. The European Union may still exist, but I have heard many other people voice a similar sentiment in respect of how they are perceiving its impending partial breakup.

The safe and secure environment that EU citizens have enjoyed up to now has changed dramatically. Another patient, a young french man, tells me: “I’ve studied in an international class from age 10, studied on an Erasmus programme, I’ve lived and worked here for five years and never asked myself any questions. It’s not just that the conditions of my stay here have changed: I feel like the foundations of my education and culture are challenged. What is going to become of my generation of young Europeans?”

“I chose to emigrate to the UK at 20, so I could take control of my own destiny, and here I am in the same situation again. I’m ten years old, my future has been robbed and I don’t know what to do”.

A vacuum has appeared in society because some of things that existed to ensure the safety of some of its constituents have disappeared. Memories of past experiences can then fill this vacuum. For example, people who, as children, have had to live through their parents’ separation, however amicable, will inevitably re-experience in the present some of the anxiety that comes with a challenge to the integrity of their family, or of their broader environment.

A polish woman, who fled communist Poland as a child in the early eighties, explains: “my parents kept their plan a secret, so that I wouldn’t give them away at school. I thought we were going on holidays in the Eastern bloc but, when we found ourselves in Stuttgart, they calmly told me we’d stay here to live, and that everything would be OK, which it wasn’t. I chose to emigrate to the UK at 20, so I could take control of my own destiny, and here I am in the same situation again. I’m ten years old, my future has been robbed and I don’t know what to do”.

2- A new vulnerability resonates with a vulnerability from the past

For a number of months, EU citizens have been called “Migrants”, and have found themselves conflated with the stream of refugees risking their lives in the mediterranean. The perspective of an effective withdrawal from the EU will also mean that this newly labelled population will be submitted to additional controls. Disempowered groups of citizens also find themselves likely to be used as collateral in withdrawal negotiations.

A country hitherto perceived as stable and nurturing for EU nationals is now acting like a volatile parent, making up rules as they go along. This is likely to resonate with past experiences of parental inconstance, and bring up ways of thinking and feeling that are closer to the experience of an infant rather than an adult. This is compounded by the increased feeling of powerlessness and dependence upon an external authority, which are also childhood experiences.

Any sweeping, black and white statements about “brexiters”, “remainers”, foreigners, governments etc. needs to be seen as a resurgence of an infantile way of experiencing relationships.

Infants slowly learn to handle ambivalence and complexity in their relationships. For them, it is not just puzzling that someone good could do a bad thing. It is literally un-thinkable. So, to manage the emotions linked to their mother, for example, they split her in their minds into an entirely good and entirely bad mother, which bear no relation to one another. It is the task of the mother to help her child merge the two mothers into one figure, that can be good and bad at the same time.

Any sweeping, black and white statements about “brexiters”, “remainers”, foreigners, governments etc. needs to be seen as a resurgence of an infantile way of experiencing relationships.

3- Beyond “Them and us”: grieving and re-engaging with the other

This infantile, binary organisation of the psyche and binary discourse, damages relationships. Boundaries, which were fluid and constantly negotiated within relationships of mutual curiosity, have crystallised into an uncomfortable “them and us”. Young and old, rich and poor, town and city, find themselves pitted against one another on either side of a suddenly concrete and frozen boundary.

EU citizens were part of an “us”, and now find that they are “them”. It is tempting to buy into this, especially since powers of adult judgement are being challenged by the regressive experience of vulnerability and dependency. So, it’s for us to do our best to remain intellectually and emotionally honest adults in the face of this experience, and to remind ourselves that they black and white world that has taken shape is a conceit that seeks to hide complexity and to attack our capacity to be in relationship with one another.

“we need to go beyond our regressive experience and actively grieve for our recent past if we are to develop peaceful relationships in good faith”.

Importantly, we also need to actively engage with our new situation. It is a case of grieving an old order of things and welcoming what is emergent. Psychiatrist Elizabeth Kubler-Ross (1969) understood that a grieving person will go through 5 stages: denial, anger, bargaining, depression and acceptance. It is easy to apply this model to post-referendum Britain:

in denial, both EU and UK citizens feel nothing will change. The result is a narrow victory and does not mean anything. Sadiq Khan tells EU Londoners that they are welcome as before. People think there may be a second referendum, or that article 50 may never get triggered.
In anger, hostility arises and the ‘”them and us” takes shape.
At the stage of bargaining, we may feel that if we do certain things, everything will be as before. We will feel secure again, empowered and welcome. This is where people apply for passports, apply pressure on their MPs
During the phase of depression, powerlessness and vulnerability consciously sink in.
Acceptance is the time for an active engagement with the new situation.

As Jean-Paul Sartre illustrates in his 1944 play “No Exit”, bad faith is the reason why two consciousnesses cannot communicate. He adds later that this “incommunicability” is the source of all violence. It is this very bad faith that can prevent us from seeing that we are free to choose our positions, at a time when they seem dictated by the collective will, and which makes the Other disappear as a person to know intimately. It is also this same bad faith that fuels the first four stages of grief in Kubler-Ross’ model.

Therefore, we need to go beyond our regressive experience and actively grieve for our recent past if we are to develop peaceful relationships in good faith.

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The Initial Consultation

Cedric Bouet-Willaumez — Sun, 15 Jun 2014 15:47:29 +0000

The initial consultation is more structured than the “typical” session of therapy, which tends to meander as it follows the course of the unconscious. Despite being more “protocol-heavy”, it is still unique to each individual, both in what it contains and in the way it unfolds.

1- What we know at first glance

People who come to see me for their first consultation of psychotherapy often say right at the beginning: “I’ve never done this before, what happens now?”. This is not very surprising. We hear more about people’s experiences with their doctors, lawyers or even their plumbers than we hear about their experiences with their therapists. I have even become quite convinced that psychotherapists willingly cultivate an air of mystery around their practice.

«Working with a person’s expectations of a relationship is a key aspect of psychotherapy, and it starts “working” before the protagonists (patient and therapist) have even met.»

If you have indeed been looking for a therapist online and have visited their websites and blogs, you may have noticed that little appears to be said about what exactly goes on in therapy. Therapists write, as do I, about their principles, ethics and theoretical frameworks. They write about how, in general, psychotherapy can help people with certain common ailments such as anxiety and depression, but more rarely about what it is that really forms the interaction of patient and therapist in the fifty minutes of a session.

While researching this, you may have come across Irvin Yalom’s lively and thoughtful accounts of existential psychotherapy practice, or perhaps watched three of the old masters, Fritz Perls, Carl Rogers and Albert Ellis, respectively demonstrating in the film “Gloria”, gestalt psychotherapy, person-centred psychotherapy and rational emotive behaviour psychotherapy. A lot has been – and is being – written, and professional journals will abound with what is dryly called “clinical material”, but, unless this material makes its way to paperback or interactive media, there is little chance that someone willing to undertake psychotherapy will be readily presented with it by professionals.

2- The useful paradox of not saying too much

Undeniably, there are three upsides to this. First, when therapists stay vague about what happens in a consultation, they give a greater opportunity to the person considering psychotherapy to imagine what it could be like, and then to confront what they have imagined, with what is happening in reality. Working with a person’s expectations of a relationship is a key aspect of psychotherapy, and it starts “working” before the protagonists (patient and therapist) have even met.

Second, it is genuinely difficult, and some would argue, unhelpful, to be precise about the course of a session. Sessions are conversations between two people, where one has the function of attending to the other’s needs. And whatever patterns may emerge in a conversation between two people rarely applies neatly as a template for another conversation.

Third, allowing some degree of mystery about psychotherapy is consistent with, and respectful of, the fact that the forces that the individual feel are at play in their psyche may feel like a personal mystery. Psychotherapy aims to help a person develop an interest in this mystery, so that its workings becomes known, so that they can grow beyond the experience of helplessness that often characterises their life before therapy.

The scarcity of material relating to what happens during a session seems to be both unavoidable and beneficial to the unfolding of a person’s psychotherapy. So, is it possible to write something that informs, and perhaps inspires, while respecting the frame of mind of the person looking for help, and acknowledging the unique character of each session?

I will attempt to do this by offering some bearings about what happens during the initial consultation.

3- The importance of following the patient’s pace

This initial consultation is the easiest to describe, as it often appears to follow more of a formula, as there are things that I will be interested with every new person. It is a first contact between patient and psychotherapist, and the aim is for both the therapist to find out if they can help the patient, and for the patient to form an opinion, or at least get a sense if the therapist can help them. At the end of this session, I am in a position to make a recommendation to the person in respect of psychotherapy, and to establish together what the frequency of the sessions should be, and perhaps the term of the treatment, if this is important for the person at the time.

In this consultation, it is important for me to get an understanding of what is troubling the person who has come to me for help, and to know more about their current circumstances and the history of these troubles and how they fit (or not) in the person’s life story.

«I don’t need to know everything about a person in the first fifty minutes – In fact, it has happened quite a few times that a patient tells me something quite important about themselves much later in their therapy – sometimes, several years after the initial consultation.»

I will be interested in hearing the person’s perception of their life so far, and to see if anything stands out for them in some of the key relationships that contribute to forming one’s personhood, such as parents, siblings, significant relationships at school, college, the workplace, and any other significant setting.

In my experience, this can take many different shapes. Some people choose to tell me stories about themselves and do it with ease, (and sometimes gusto), some like talking about themselves in a less structured way, some have very accurate memories and others quite vague ones. Some people don’t like talking about themselves at all and find it difficult to put into words what it is that they struggle with and what makes them seek help. This is all fine.

Indeed, while it is important that I know some basic facts about a person’s personal history and current circumstances, so that I can establish if psychotherapy is a suitable form of treatment or if the person should be referred to another professional, I don’t need to know everything about a person in the first fifty minutes. In fact, it has happened quite a few times that a patient tells me something quite important about themselves much later in their therapy – sometimes, several years after the initial consultation.

4- A “vignette”: initial consultation with “K”

I recall a first contact with K., a young man who seemed to be struggling to answer my questions. Generally, I ask open questions, so that the person has the space and time to give whatever shape they wish to their discourse. It also informs me greatly about their state of being to see how they use the space that I provide for them. I have found that asking too many precise questions right away tends to give impression that psychotherapy is a data collection exercise, where there are right and wrong answers.

This young man would answer my questions in a very vague, perfunctory manner. His childhood was fine, his parents supportive, his partner was nice, he sort of liked his job… it was just that he needed to turn his life around by making a bold decision about where to live and work, and he found himself unable to make this decision, without knowing why. This was all said quite briskly in the first few minutes of the session, and once I was done asking him questions, he looked at me expectantly.

I told him that, on account of how fast he’d run through the story of his life, I had the impression that he didn’t seem to find it worth saying too much about it. He didn’t reply directly, and told me that he just wanted to stop feeling rudderless and indecisive all of the time. I asked him more questions about his experience of indecision. Again, his answers were quite perfunctory. I smiled and made the observation that it seemed that I was more interested in him than he was. He seemed quite puzzled by this, and reiterated that, really, he’d come to see me to sort this particular problem out, and didn’t feel that talking about himself would be helpful at all. As for his childhood, he didn’t remember much before the age of 10 anyway. But he did have some facts about it, which he shared with me.

«This young man’s apparent inability to talk to me about himself during the initial consultation was a live, “here-and-now” illustration of how he had been shaped by his earlier life.»

He explained that he was the youngest of three siblings, who had been born quite close together. His parents argued a lot throughout his childhood, and began separating when he was eleven. They divorced when he was eighteen after a protracted custody battle that involved both children needing to “take sides”. He also told me that, after offering his mother constant emotional support throughout his late childhood and early teens, he had chosen to stop doing so for his own sake.

It became apparent to him that his inability to make big decisions in the present was consistent with his earlier experience of his parents involving him in their own. On the one hand, he was to act like an adult by supporting his mother and then choosing which parent he would live with. On the other hand, he felt he was being treated as a child because those decisions were being imposed upon him. If his parents had taken an interest in him, they would have understood that all that he wanted was for them to make up ask him how he was.

So, this young man’s apparent inability to talk to me about himself during the initial consultation was a live, “here-and-now” illustration of how he had been shaped by his earlier life. It showed clearly that it was new for him that anyone should take an interest in his person. His reluctance to take the lead in the session also illustrated that, for him, there wasn’t a positive experience of taking the lead in his life, and he wondered whether he would one day be able to do so.

On the day of his last session, five months later, as I was waiting for him to ring the doorbell, I received a call from him. He was at the airport, about to board a plane for New Zealand. He had wanted to have his last session over the phone, saying with humour that it was “so that we are both certain that I’m going to get on that plane!” He was able to muster the resolve that had eluded him for so long, and moved there to live and work.

5- Conclusion

As a conclusion to this short article about the initial consultation, I would like to stress that there is no set, perfect way to go about it, neither for the patient, nor for the therapist. My aim is to offer my patient a space, where they can tell me about themselves and start to see themselves with a greater degree of clarity. This initial consultation shouldn’t be something for patient or therapist to “pass with flying colours”. It is about being curious about the other, in a way that leaves them the space to say what matters to them, or if words are not available to them at the time, to show me with their actions what is holding them back in their life.

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