29th Sept 2011

Death by terminal illness is an everyday concern in our human existence. We can truly sympathise from afar, acknowledging how awful and how unfair it is for other families but it is only when it comes to our own door, so to speak, that we realise it’s impact. Think how shocked we can be to hear of the death of someone of the same age or younger. It brings the issue of death a whole lot closer to home. ‘It could be me’, as a fleeting thought is abruptly dismissed. We look for reasons why that person might have died that don’t apply to us… a heavy drinker, a heavy smoker, cancer in the family and we can feel the relief at our not fitting into this category. We are safe from death anxiety. This week at Counselling Connections, we take a look at how it is for people who are dealing with their own terminal diagnosis.

Yalom (Professor of Psychiatry & author) talks about facing our own death and the anxiety this evokes in us as human beings. We may think about how it would be if someone close to us dies, like a partner or spouse and we may wonder how we would survive without them. But our own sense of mortality is difficult to conceive. As children we are brought up to believe we are individual and special. This doesn’t fit in with the inevitability that we will all suffer the same fate eventually, that is, death. As children we are brought up to believe that we will be protected from things that frighten us by our parents….as adults we realise we cannot avoid our own death, a frightening concept.

Being told one has a diagnosis of terminal cancer is hard to grasp. In fact most people do not grasp it on first hearing. Even if it is heard, it is not truly believed and most people enter a phase of denial…. ‘Maybe they are wrong’, ‘Maybe they were looking at someone else’s results’, ‘Maybe I should get a second opinion’….all very understandable reactions in the face of death. It is not unusual to feel numb or to experience a whole range of emotions like anger, sadness, fear and anxiety.

A study by Hinton correlates satisfaction with life lived to the lessening of death anxiety. It is much easier generally for us as a society to accept the death of an older person, i.e. one we see as having ‘lived life’ ther than one in his prime,. This is not meant to undermine the pain felt by those who lose older relatives and friends with whom one may have had a close relationship. Often our perspective on our lived life shifts with a terminal diagnosis. We see things differently and can come to terms with regrets in life in a few short days or weeks. Ambivalent relationships are often repaired in the face of death.

As part of therapy, coming to terms with one’s own death requires that the person approach his dread and anxiety over and over again until he has become so familiar with it that it isn’t so scary anymore.  This is why it can be helpful for some people to talk about their death, which isn’t always easy to do. It is important that this is in line with the person’s wishes. Many individuals find it difficult to come to terms with the feelings of helplessness surrounding dying, the lack of control over one’s destiny. While this is a fate we must all face in one way or another, it can help to take control over some of the things in one’s life that are controllable even at this time. Choosing what type of treatment or Doctor, organising one’s funeral and making a will can give a person a sense of accomplishment and peace.  However, making these final decisions is difficult when one’s own death as a reality hasn’t quite sunk in.  There is no right or wrong approach to facing death and no two people do it in exactly the same way. The important thing is that we each do it in a way that feels right for us.

Here at Counselling Connections this week we’ve been getting philosophical. It began with a discussion about how to respond to a question we are often asked about ways in which events from infancy and childhood influence our adult personalities and our emotional lives. We would take it as a given that they do but sometimes the ways this might work are not so obvious and from time to time people ask us about it when considering whether and how psychotherapy or counselling might be of benefit to them. The question is quite a fundamental one and touches on the concept of what makes us who we are.
The philosopher Descartes famously wrote ‘I think, therefore I am’ when addressing fundamental questions of human existence. We propose a variation of his remark when we say ‘I am seen, therefore I am’ and we’ll try to explain that a little further in answer to the question as to how something that we experienced as a baby informs our adult life. We draw largely on the work of D.W.Winnicott in forming our opinion and in working out the effects of our early relationships with our mother and other carers.
Take, for example a baby who is lifted from their cot and held by a caring adult. If this baby looks up into the adult’s face and is met by a smile this will have a positive influence on how the baby feels. In a fundamental kind of way the baby feels good that they are met with smiles, eye contact and attention. In fact, the baby seeks this out as being an essential element in their very survival. The baby is completely dependent and relies on the adult world for feeding and for care. These feelings of being experienced in a positive way by caring adults are reinforced by being repeated over and over again. The baby will not tire of this.
This is not always the way it works though and sometimes the experience of the baby is not a positive one. There are many ways in which a different experience for the baby may reinforce things in a negative way. Firstly, the baby may be left to cry in their cot for some time before being picked up and held. These delays are experienced as being unbearably distressing for the baby. Secondly, the baby might be picked up all right but handled and held impatiently; their hunger or cries being regarded as a nuisance or imposition. Another possibility is that the adult feeds the baby all right but fails to maintain eye contact or engage with the baby in any way. All these things, when repeated over and over again will have a negative effect on the baby and their sense of security and trust in the world around them.
A key thing in this regard seems to be a level of consistency in the care that the baby receives. Generally speaking if the care can be regarded as ‘good enough’ things will work out satisfactorily. The important thing here is that the experiences that influence these things are repeated and if they are not good the baby will develop anxieties which will endure and resurface through life. These can be experienced in adulthood as a kind of anxiety; of not feeling safe; not being listened to or heard or of not being understood. They present in our relationships at home or in work and may result in feelings of isolation or even depression. It is hoped that the experience of being listened to and understood in a therapeutic setting can help to recover a sense of self. To be seen; to be listened to by another human being can set in motion a repair of something very fundamental inside us which addresses the very fact of our existence and experience as a human person.
Counselling Connections, Dundalk.

In the current economic climate, there are many people who are in difficulty with their mortgage repayments and run the risk of losing their homes. It can be a very stressful, difficult time as couples and individuals try to live their everyday lives with often huge financial burden weighing heavily on them.
Here at Counselling Connections, this got us thinking about how the idea or threat of losing one’s home affects us and the meaning we attribute to our houses. Home is somewhere we retreat to relax and unwind. Behind these four walls we can be ourselves, removing the mask we often show to the world. It is our necessary safe place. There is no doubt having such a place helps us to maintain a healthy lifestyle both physically and psychologically.
We can pour a lot of ourselves, our time and energy into the décor of our houses trying to make them look and feel right. Hence one’s home can become an extension of oneself and when these emotional ties are threatened through the possibility of this being taken away, it can feel like our very person is being attacked.
Historically, one’s home was a statement of social class and here in Ireland the residue of eviction by wealthy landowners has been passed down unconsciously to subsequent generations. To own a piece of land on which your house was built meant you were somehow in control, no one could remove you from your own house. This eliminated the awful pain inflicted on families who were thrown out of their homes at short notice and left with nothing. In recent times this threat has been resurrected with the banks issuing letters of warning of legal proceedings should one default on mortgage repayments.
A recent view from the window of a plane coming into Dublin to land helped to put some perspective on the housing situation. Monopoly houses streamlined to fit into confined areas seemed insignificant from the air, that is, from a different perspective. While in no way minimising the threat of losing one’s home, an alternative might be to look at it in a different way, in order to help us to cope. This can be true of all problems and stresses that we may feel trapped by. When we have exhausted all practical avenues, it can be of help to try to take a ‘bird’s eye view’. Sometimes it is hard for us to see things clearly when we are ‘in it’, so to speak. It can take an objective view to really help us see how we can change the way we feel by changing the way we view certain situations. Psychotherapy can help you to do this. In therapy as counsellors we firstly try to see and feel things from our client’s perspective in order to understand what their life is like and the problems they face. The next step is to help our clients form new perspectives in order to facilitate real change.
There’s no doubt we all get caught up in material things, some of which are necessary and basic. However we need to be careful that we don’t get so caught up that we lose our sense of what really matters. For example, in relation to the current housing situation it can help to remember that a particular house does not define you; rather it is you who defines it. It is your presence in the house, your energy poured into it that makes it what it is. If this is true then that energy can be reclaimed and reinvested somewhere else if you so wish. You can be in control from the inside amidst crisis on the outside by changing your perspective and focusing on what really matters.

Here at Counselling Connections this week we have been reflecting on endings. When a therapy is coming to an end it almost inevitably brings up reminders of life’s previous losses and endings. If this is negotiated well and talked through as part of the ending it can be a wonderful experience. It can represent, at last, the ending of a cycle which we may have been repeating throughout life. It may also contain all of the pitfalls that have kept such a cycle going for many years. If you can sit with discomfort around the ending of a therapy and express it as its happening it honours the work that has been done; the achievements of therapy and your relationship with your therapist.
This relationship with the therapist is one of the key things in psychotherapy. If you feel you can form a relationship with your therapist where you can reveal yourself to them it will make the therapy more meaningful and worthwhile. From time to time a client will report feelings of dissatisfaction with their therapist. If the relationship is good, these can be explored and worked through together. Sometimes we realise that the strength of our anger or frustration with our therapist is disproportionate. At times like this we can reflect on our relations with significant others. We may discover that feelings have gone unexpressed leaving residues which enter into subsequent relationships.
This can work in the same way with positive feelings towards our therapist. Again, it is not unusual in therapy for a client to go through a phase when they have nothing but positive feelings towards their therapist. In the white heat of the therapeutic relationship the experience of being listened to and fully heard can be exhilarating and we can for a time lose ourselves in admiration for the therapist. This can then be accompanied by what can feel like a sudden unblocking of pent up life force which is expressed towards the therapist. It can be painful but again there is great learning in exploring these feelings and working through them with the therapist.
There can be different kinds of endings in therapy. Sometimes a client feels after a period of time that they have covered quite a lot of ground and although they might not be completely finished with therapy for good that they want to bring the current phase of it to an end. This client may return to the same therapist at a later time or sometimes travel between a few therapists until they feel they have worked through what they wanted to. At other times the therapy can feel like its going through a phase where the material being uncovered is quite uncomfortable. We may have to struggle with the temptation to flee at times like this. If we can stay and manage to talk about it the hope would be that the issues which have come up can be dealt with and some finality can be achieved.
And then of course there is the therapy which has run its course and comes to a natural end. Rather than fight with the temptation to flee as in the previous example this time we may have to battle with the temptation to stay. In a secure therapeutic relationship it is a time of mixed feelings. There can be sadness as the end approaches. It is not unusual at this time to feel a warm regard or fondness for the therapist. The nature of these feelings will be quite different from the positive feelings described above. These are feelings of accomplishment; of a journey travelled together and of mutual respect. It can feel hugely empowering to feel that you are ready to leave; are ready to let go and make your own way in the world strengthened with all that has been gained as part of a good therapeutic relationship.
Counselling Connections, Dundalk.

Here at Counselling Connections this week our discussions have been about the stigma associated with depression or mental illness generally. Even to put it in those terms is to point to the problem because to label something as ‘depression’ or ‘mental illness’ is the kind of thinking that leads to stigma. The history of mental health and ill health is replete with various conditions being described, categorised and labelled. Mental illness has not been well understood and those unlucky enough to be given a diagnosis were often removed completely from society. If these things were discussed at all it was in whispered tones.
This kind of denial pointed to the fear surrounding anything concerned with mental health. Some would say that this fear is really about our own personal concern that we might catch it ourselves. It is probably fair to say that we seek reassurance in this regard and that our wish is that any bout of emotional ill health can be cleared up simply and quickly. We like to believe that there are definitive solutions that can return a person to ‘normality’ without delay. Whatever the reason for this it can lead to an ‘us and them’ attitude towards those affected by what is called mental illness. Not talking about it and not wanting to know about it has probably led to a generally poor level of understanding about the whole area of mental health.
Clients often report feelings of discomfort or fear if they have to miss work because of depression or stress. It can be felt that employers take a dim view of absence for mental health reasons and that these conditions can be easily feigned. Return to work interviews after a period of illness can be especially difficult as can the prospect of facing work colleagues again. Often the temptation is to try to hide that real reason for the absence.
There can be apprehension that a trust in the employee will be broken and that they will never be regarded the same way again. The fear is that this can mean being discriminated against; maybe being passed over for promotion or regarded as unreliable. We have heard examples of employers showing an enlightened attitude to these matters. A supportive and understanding response will of course bring its own rewards and will make it easier for the person involved to return to a fuller participation in all aspects of their lives.
People also report difficulties in their personal lives following, for example, a prolonged period of depression. Friends may drop off and avoid contact because they run out of patience or because they find it difficult to know what to do. Sometimes this involves blame and recrimination as personal relationships become fraught and difficult to manage. These are understandable because it is difficult at times to know what the right thing is to do or to say. However, this loss of friendship at this time can be experienced as yet another deeply felt personal rejection.
Stigma is like a mark that we put on someone who is judged to be suffering from mental illness. It can be difficult to remove once it has become attached. However, stigma can be tackled through education and understanding. If ‘breakdown’ and different forms of ‘mental illness’ were better understood we could have a society which was more accepting of it. The counselling and psychotherapy community have a responsibility to help get this message across. Mental ill health can be temporary and with good care a full recovery is achievable. An open, accepting, and non-judgemental attitude will alleviate a great deal of suffering and facilitate better outcomes.