1- What is social anxiety?

Most online and offline publications will define social anxiety as the excessive fear of social situations. People who have come to see me for help with this problem have also often described that they may feel discomfort in any social interaction, even if this is with “just the one person”. Because of this, I prefer to define social anxiety as the discomfort that relates to the experience of any relationship.

«In every contact, we communicate a bit of ourselves to the other, and the other is there to receive it, for better or for worse. In that respect, every social situation is significant, because it says something about us.»

2- Why does it happen?

We form our person and our character in the context relationships – to the family we were born in, to the community around us, to school, to our chosen communities of friends, spouses and children, to our communities at work. These relationships are not just a backdrop to our lives: by interacting within them, we evolve through them, and them through us.

It is perfectly healthy to feel a measure of trepidation in all forms of contact with other people, whether it is a brief exchange with a waiter, a discussion with a headmaster, or a presentation in front of the board of a company. After all, every personal contact, no matter how brief or apparently shallow, is an  experience that engages our person, consciously and unconsciously. In every contact, we communicate a bit of ourselves to the other, and the other is there to receive our communication, for better or for worse. In that regard, every social situation is significant because it says something about us.

«Psychotherapy, to be effective, must include two aspects at least: reflection on oneself and action on one’s environment.»

3- When does it become a problem?

However, for many, this creates a level of discomfort that can feel difficult to bear, which may lead some to assuming that all social contact will be painful, and therefore to avoiding certain social situations, and sometimes, most, if not all, social situations. This can be extremely distressing and debilitating.

4- Addressing the issue

It is my experience that psychotherapy, to be effective, must include two aspects at least: reflection on oneself and action on one’s environment. This is especially true when the concern that needs addressing is social anxiety. Action alone, which can be, for example, challenging one’s assumptions about other people’s thoughts about us and changing the way we interact with them, is not enough to create a deep-seated sense of safety in a social setting. Similarly, reflection alone will not help the person to “land” the insights acquired and create new and more helpful behaviours.

Therefore, I encourage my patients to:

• take a historical perspective on their experience of social interactions
• examine the feelings, thoughts and sensations that they associate with them
• get a deeper sense of who they are as a person, and what sort of social existence they are really meant to live
• observe in detail what they go through as they apply their insights and progressively approach life with others in different ways

The quote by St Francis of Assisi sums quite well my approach to helping people address their social anxiety, as it reflects its progressive nature and the surprises that can arise out of the process:

«Start by doing what’s necessary. Then do what’s possible; and suddenly you are doing the impossible»

Depression is the most prevalent of mental health problems. Studies have shown that it occurs in 1 in 10 adults or 10 per cent of the population in Britain at any one time. It is quite common to experience a depressive episode as a reaction to an event. It also happens that depression sets in “out of the blue”, and does not seem to go away by itself.

This experience can be deeply painful; poet John Keats wrote to a close friend: “I am in a temper that if I were under water, I would scarcely kick to come to the top”. It is part of life’s requirements that we should be able to tolerate periods of low mood, and it is to be expected that sometimes we find ourselves challenging the value of things and of life itself. If however we have an entrenched feeling of futility and find ourselves disempowered and persistently disengaged from life, this is probably something worth attending to.

In my experience it is possible to understand and successfully to address depression through the process of psychotherapy and counseling. Psychotherapist D.W. Winnicott (1958) wrote of John Keats that:

“[he] was someone who took the risk of feeling things deeply and of taking responsibility. […] If we look at depression this way, we can see that it is the really valuable people in the world who get depressed.”

These words remind us that the experience of depression should be respected in the process of psychotherapy. It is by working it through that its value ultimately appears, along with the fundamental qualities of the individual coming for help.  The goal of psychotherapy applied to depression is to allow insight to emerge and to use the therapeutic space as a “springboard” to reconnect with oneself, with others and with the world.

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.

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.

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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.

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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.

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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.

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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.