Medication and Counselling by Dr Elizabeth McCardell, M. Couns., PhD

Sept 2010

     I often hear about people who have been advised to go and get counselling and medication for depression; who go on antidepressants and then decide not to have counselling or psychotherapy as well because they feel better. What they don’t realize is that their problems aren’t going to go away; feeling “better” through medication wont change fundamental things much. The ideal situation involves looking after the whole self, and not just the chemicals in the brain.    

     Antidepressants certainly level a person’s mood, but the highs go as well as the lows. When they are deeply distressed this levelling can be very welcome. Over time, though, not being able to feel much can be quite disturbing. Because we are expressive  responsive beings, the sense of being disengaged can impact greatly on special relationships and even just in everyday encounters. A loved one can feel left out, in some subtle way and the depressed one is not even aware of this happening.  By expressive responsive beings, I am describing the beautiful  lively interplay that occurs in every face to face encounter where each person responds to the other, back and forth. When one person isn’t so engaged – as when their affect is flattened – the other person can feel excluded. This partially  blocked interplay is even more clearly evident when one person has had a stroke and their face is immobilized (as literature on face recognition describes it).

     Another aspect of this is the diminishment of a sense of being able to regulate one’s moods, and not recognizing what moods are within the normal range and what is outside the normal range.

     Several years ago, I knew a woman who had been on antidepressants so long that she no longer knew which of her thoughts and moods were reasonable and which were outside the experience of most of her friends. Any feelings of anger  were attributed by her as requiring increased doses of her medication. This is so topsy turvy and fundamentally wrong.  Psychotherapy would have given her a more accurate sense of what is real and what is imagined. It would have put her in touch with her inner world, giving her awareness of anger as a useful emotion with its own energy for changing the dysfunctional in her world. Instead she felt eruptions of anger as if these feelings came from somewhere else and increasing the medication had the unfortunate effect of deadening her creative encounters with her world even more.

     Antidepressant medication can be useful in cases of prolonged grief, such as sometimes occurs after the death of a beloved, but here again, it should accompany counselling of some kind. Just the chance of talking about the death with someone who will listen deeply is nurturing. A counsellor generally will not shrink away from meeting a person at such a profound place.

     Loss of career, of hope in relationships, of despair, loneliness, and a sense of powerlessness can contribute to feeling depressed. Maybe such depression merits going on medication, but more is needed.  The chance to develop other ways of seeing and instituting fundamental change is an important part of counselling and psychotherapy.  Counselling and psychotherapy moves one’s internal dialogue from societal and family ideas of loss equals failure and all the introjects of “get a grip on yourself,” “put on a stiff upper lip and you’ll get through this,” and “think of the starving millions with greater problems than you”, and so on, to actually finding new and creative ways of being really here in this place, now, with your integrity intact.

     Some, but not all depression serves a purpose: it tells us when we are out of kilter with our uniqueness; when we are not fulfilling our individual lives in ways truer to ourselves. Some depression is actually more chemical than psychological (endogenous depression), but here again, just going on medication is insufficient.  Dialogue in counselling is very useful, in bringing awareness to feelings and thoughts about feelings, as well as interactive communication with others.

Ghost Catching with a Dress

Nov 2013.

     I'd watched a video of a very beautiful conversation among therapists and others talking on the death of mothers. The phrase ‘ghost catching with a dress’ came up in relation to finding clothing, letters, and treasured objects belonging to mothers who had died. I was very moved by the image, for I have such items from my own mother. Indeed, most of the crockery and utensils I use on a daily basis were from the cupboards of my mother. Hanging in my wardrobe is a red coat my mother made herself of the lining of officer’s coats during the war, there are gloves she made,  and there is a dress she fashioned from silk that I only very vaguely remember her wearing to a party once or twice. She was an extraordinary seamstress; a skill I entirely lack.

     Ghost catching with a dress is, for me, the catching of glimpses of my mother’s life and story and those others I have known and loved. Glimpses sewn into the gossamer of memory – sometimes poignant and painful, sometimes sweet and tender. 

     Life, death. What are these? When people talk of death, premature or after a long rich life, like my mother’s, I wonder yet again, what it all means.

     The taking of one’s own life, throws another angle into the mix. There are many therapists who express deep concern for those who contemplate their own death, and while I too am disturbed by this, I am brought yet again to the existential place that I face on a daily basis: What of life, what of death?  I cannot see those who contemplate taking their own life as a sign of mental illness. I cannot, for the same reason that I acknowledge death as intrinsic to life and life intrinsic to death. What gets thrown up into the air like wind in fallen leaves, is the integral mystery of existence itself. I cannot sweep this knowledge, this subtle awareness I have, into a neat pile to be put discretely into the rubbish bin. This is the greatest mystery I know of. Death is not a medical problem and suicide is not a medical condition. Death is, as life is, and relationships are.

     What is caught in suicide are ghost catchers of clothes, of toys, bric a brac, books and letters; of the tears in memories, of  hearts broken, of anger, resentment, bewilderment, lots of questions unanswered. These are perhaps more poignant than even the caught ghosts of those who died a normal death.

     I have had friends who have died by their own hand and know something of the strangeness of this. One man, I had shared a meal with only a fortnight before he gassed himself.  Was I partly to blame? I could not think so, for as the ghosts in cloth unravelled after the funeral, the threads emerged of a life of disconnect, of  feelings of alienation and lostness.  This poor friend could not speak of what he suffered and it is here that my feelings are stirred, and it is now here that I offer myself as a therapist to hear and share the burden of pain.

     Death, and life, are touched by the living in a fluid process and grief and loss are felt as those we’ve loved move into another dimension. It is not so much the death bit that shakes me, but the threads of life that are not always seen and understood; threads that need, somehow, to be shaped into a dress to catch the ghosts of real flesh and blood people in our stories, recollections, and a need for some kind of farewell. We living need to let go and yet to remember and to let go and yet to recollect. Our grief is not to be discarded mindlessly, but to be brought into the fabric of our life to enrich us and also, mysteriously, give us the courage to let go, let be that majesty that is  life.

Therapy as Magic Realism by Dr Elizabeth McCardell, M. Couns., PhD

August 2018

I had a friend, Tom, who I met at university when both of us were doing our PhD. He being far more organized than I. finished writing his thesis a couple of years before me. The locus of his work was on the magic realism in the early writings of Jorge Luis Borges (1899-1986), the Argentinian author.

Tom’s PhD thesis was examined and passed with flying colours. We spoke once, at the completion of it, and then he disappeared, literally. I couldn’t find any information about where he went; even his  parents and brother had no clue. No death notices, no life notices, nothing.

In a fantastical effort to discern where he went, I scattered, upside down, a set of animal druid cards. In that set are two blank cards, there to encourage its users to create a couple of animal narratives of their own. The two blank cards came up. I picked up a third, and it was “the fox”. The fox is an elusive being, known for hiding among grasses, and disappearing when he wants. I felt then that Tom just didn’t want to be found, and no online searches could unearth anything. There are, it seems, three men with the same name, but none of them living in our time frame.

How extraordinary, really, that his fox-like disappearance fits so well with the nature of his academic work!  He, or rather I, made a myth from him simply being/not being there.

Magic realism is a genre of literary fiction characterized by the matter-of-fact inclusion of the richness of a  psychological imaginary into an otherwise realistic and ordinary framework. Tom’s life had that quality: he  showed me how to use a computer by playing with it, we ate meals together, we walked the campus together, and he tripped while walking downhill, somersaulted mid-air, and landed on his feet like a finely tuned cat, while I, on a different evening fell and broke both hands. We got on well and once he celebrated passing his PhD, he disappeared.

Magic realism situates itself neatly in the discourse of psychotherapy. I note here that I am not talking of magical thinking. Magical thinking is defined as believing that one event happens as a result of another without a plausible link of causation. This is unconscious thinking.  Magic realism, on the contrary, is an actual  and conscious tool in literature and, I suggest, in psychotherapy in order to engage a person more richly in a life not fully lived.

Active imagination, as practiced by Jungians and others, including me, could be said to be a  magic realism tool, and  is used as a bridge between the conscious and unconscious mind. It is  a method for visualizing and fleshing out unconscious issues  by drawing upon the imagination. This is a very useful tool and has the capacity to build meaning, new memories and connection in the field in which the client lives.

Much of what we do, as psychotherapists, is pragmatic and here and now, and yet it merges the ordinary subtly into landscapes of the imagination and dreams, for a purpose. The mind, decorated with elaborations of enriched memory, becomes a luminous space of possibilities and our exploration of these, transforms ordinary reality.  This is why I ask my clients what they love to do, and whether they paint, play music, write, dance. I want to know what magic they engage in and how can we use that for their healing.

There can be a danger in the making myth of life events, but properly and ethically handled, it is a very powerful tool.  I think once more of Borges’ writing and his emphasis on containment and playful control of words and sentences. Nothing is wasted and nothing slops over into a messy unconsciousness, and yet …   And so, with Borges I say, “I know what the Greeks do not know, incertitude”  for the bridge between this world and the world of the imagination is always open and what is learned in this here-and-now world and the imaginary is always magical and very real.

Dispelling Dream Clouds

July 2018.

     Most of us, most of the time, are caught up in clouds of anxiety, thoughts, memories, feelings of shame… general inner noise. These clouds whirr around us in a vortex of “what ifs”, “should I”, “and then”… making us increasingly confused. A lot of my work is about sorting through these clouds and making real what needs to be real, and releasing what is inessential, and thus freeing my clients from much unnecessary anxiety.

     The making real is grounding the something into a tangible form; something that can be worked with, and something rich with actual possibilities.

     In my own life in recent times I spent months of wanting, of craving, to travel again to Europe, mulling, thinking, planning, changing those plans, mulling, dwelling on, dispelling: essentially caught up in swirling clouds of possibilities. And then, a mid-September conference in Heidelberg, Germany beckoned (a time of Autumnal cooling and dancing red-bronze leaves and ripened berries), and I thought maybe I will/maybe I wont go, and so the churning continued. Then in the middle of one night, clarity came: go to the conference, and then work the rest of the journey out from that point. I registered with the conference people and booked my accommodation, and then a few days later, booked my plane flights.

     In this time of observing my own inner processes and noticing with clearer insight the processes of my clients, I began again thinking of the Tibetan Buddhist cosmology, or three planes of existence (trailokya): the desire realm (Kāmaloka), the form realm  (Rūpaloka), and the formless realm  (Arūpaloka). Of particular interest in so far as this article is concerned is the desire realm. Here, is populated with lurid hell beings, of demons, ravenously hungry ghosts who can never be satisfied, demi-gods, animals and humans, all in a state of suffering.

     I can see elements of Kāmaloka in the horribly confusing and tormenting psychological states some clients bring to our sessions together; states dominated by anxiety, fear, self doubt, shame, and longing.  I certainly can identify aspects of it in myself.  Until they are identified, spoken about, even written about, they just undermine our capacity to move on in our relationships, our jobs, our life.

     This work has parallels in the Buddhist practice of dream yoga, or Milam. Dream yoga  is, in essence, the art of bringing consciousness into the dream state and learning to observe and control the dream, and then be free of it. Working with the unconscious (from where dreams arise) is a fundamental tool of psychodynamic psychotherapy and that work is about bring consciousness to ordinary and unordinary life. I’ve certainly noticed this in my own personal work, begun decades ago. I used to write my dreams down in journals and over the years collected dozens of them (big handwriting). I notice the quality of my dreams changed as I brought the light of conscious awareness to them. I also noticed that I was becoming aware that I was dreaming while asleep, and that I could change the course of dreams.  And then came an awareness that I didn’t need to dream quite as much as previously and also that I understood the meaning of the dreams I had with greater clarity.

   What I’ve found is the bringing concrete reality, through clearer insight, and tangible actions like keeping notes, or requesting actual documents, or preparing an action, dispels the dream clouds.

   Developing consciousness in dreaming begins with the learning to know that we are dreaming, and then, gradually working towards shaping what we dream, and then the art of lucid dreaming and travelling via the dream horse to anywhere we wish, or nowhere at all.

     The dream state in Buddhism refers not only to rapid eye movement dreaming in sleep, but to the arising of phenomena itself in every day life. In The Tibetan Book of the Dead, the account of the stages we pass through from life to death, from this moment to that moment, is the exploration of the bardo state (the “in-between”). The bardo describes the transitional, liminal state. This is a rich place of engagement, whether conscious or not, not an empty space. It is in here, however, that the silence of awareness is possible.

     The progression of sleep and dream yoga is something like this: first you learn how to remember your dreams; then you learn how to wake up in them; then you train your mind in the dream; then you learn how to stay awake in dreamless sleep.  All the while you are taking the insights from the night and transposing them into the day.  Not only are you transforming the night into meditation, but you begin to transform your life.  You start to wake up, in the spiritual sense.

Epoché by Dr Elizabeth McCardell, M. Couns., PhD

June 2018

     I have a friend who when confronted by a single sight of something fabricates a whole story around it, filling in details that seemingly come out of nowhere. For example, he and I were driving together through the forest around here and came upon a woman hitchhiking at a really awkward corner where there was no way we could pick her up, so we kept on going. A few minutes later my friend came up with a whole story about this woman where she was escaping from a horrible marriage where the man beat her. I said, we don’t know that, her car might’ve broken down, or she might’ve hitchhiked there and now was wanting to leave, or maybe prefers to hitchhike, or any other unknown reason.

     Making up stories is less about doing it for the fun as attempts to see things according to a pre-existing idea, experience, or hypothesis about human situations in ways that do not consider alternative possibilities. This is known as cognitive bias, or confirmation bias. The single idea is elaborated on in order to see it in recognizable ways.  My friend concocted his story to fit something familiar to himself.

     I need to add some background here. My friend was visiting a relative who also lives here whose marriage had broken down. He had also spoken to me of the imminent divorce of a young Perth friend of his (a young woman he helped rear). So, marriage breakdowns were very much on his mind. The random encounter of a woman on the side of a forest road was made to fit a pattern and situation that was preoccupying him.

     This is fairly common tendency that is quite useful when trying to make sense of the behaviour of other people when we don’t know the full story as it allows for a seeding of empathy for others in the community and it is a time saving exercise. It is one, however, that is open to misuse. When we construct a story around a single observed fact about a behaviour, we risk stereotyping others with our own bias.

      The psychotherapist has to deliberately abandon cognitive biases. For a therapist to run with a preconceived idea is to not listen to what is actually being presented. Indeed, we are trained to put aside our preconceptions, to suspend our beliefs about how the world and its inhabitants “should” be according to our own worldview, so as to hear how the other person actually operates in the world. This is what we call epoché. If we, in this profession, don’t suspend our judgement, we are no good to anybody.

     Effective therapy begins with the close hearing of the texture and resonance of voice, the words chosen, whole body demeanour, the capacity for listening, their willingness to enter the therapeutic conversation, the heaviness or lightness of being (too heavy, too light), avoidance, confrontation, repeated accounts, and so on. We need a sensitivity to be present with the person with us, and a not too ready desire for resolution. We have to hold back solutions, because if we go in with what we consider good solutions without having actually understood where the person is coming from, then we have effectively lost them. We also need to be able to say we don’t know sometimes and even to enter the dark place of ignorance and sit with it to see what emerges.

     There is something of the scientist in the epoché, but only in the sense that here practiced dispassionate detachment is actually being very present, caring, and listening deeply to the other person. What must be realized though that to achieve it, we have to know our own mind, with its predilections, biases, assumptions and this means that to practice psychotherapy we should (at least as I and many others see it) have experience of our own therapy and also engage in regular supervision. We need a clarity of vision and self awareness to be good at what we do and this practice of bringing awareness to our own lives needs to be continued throughout our whole working life.

Nearly forgotten, but not quite

May 2018.

     Suddenly I realize I’ve practically forgotten the copy deadline for May’s article. It’s after midnight and Friday. Yikes.  I haven’t missed an issue of The Nimbin Good Times since writing for this paper in March 2009, and I can’t start now. So, what to write about?

     I’ve been thinking a lot about intergenerational trauma in recent times as I see the effects frequently among my clients. I have people coming to me with feelings of high anxiety, sleep issues, and accompanying digestive problems that are not easily simply understood from personal histories, per se, but suggest that something more is going on.  Some deep questioning from me often reveals a pattern of anxiety and depression shared by the parents and grandparents of my clients, and often shaped by war experiences and alienation from family at critical times.

     I remember working some years ago, with a man with sleep problems and associated weight issues (weight problems is identified in the literature as being associated with long term insomnia) whose mother experienced bombs going off in London as a little child. She couldn’t trust enough to sleep properly and was, and remains, always on edge and anxious. Her cortisol levels must have been through the roof.

     Cortisol is a hormone that is released in response to stress and is known as the ‘flight or fight hormone’.   It is also associated with maintaining blood pressure, and anti-inflammatory and immune processes. Interestingly, cortisol also works in tandem with the hormone insulin to manage constant blood-sugar levels, so it plays a part in digestion.  High cortisol levels are associated with diabetes, a condition my client also had.

     At an epigenetic level, my client was likely affected by the experiences of his mother a nearly three decades before his birth, and not just from the stories that she may, or may not have told her son. Epigenetics is the study of heritable changes in gene function that do not involve changes in the DNA sequence itself. Bodies don’t forget, it seems, and they hand down the generations their imbalances created by trauma. Trauma upsets nervous systems across the board that impact on the whole health of the descendents.  It becomes critical that those who seek counselling receive it with reference to trauma therapy and not merely symptom control. Good therapy is thus, in my view, a depth psychotherapy that really helps shift those levels of fright-flight-fight reactions to more than manageable levels.  Really good therapy frees up the whole self so that the energy previously captured in iterative anxious responses now becomes available for creative output and innovative work and play practices.  Clinical hypnotherapy is often useful alongside counselling in this process, but that is the client’s choice.

     I am always interested in that coming to a place of playfulness from the tensions of hardline panic because then the whole being of the self is softened, loosened, and ready for new experiences. The client can then move on to what really excites and motivates them, and, what’s more the memories of difficulties are practically forgotten.  It’s a curious thing, this forgetting, because it is possible to see that there has been fundamental change at a more than cellular level. The whole person is lively, fitter, glowing, and sort of bouncy. What was once a stuck problem story is now recounted with how things once were, with only a little bit of the pain previously experienced.

      Remembering the trauma experienced by an antecedent family member or members helps the client recognize that their own symptoms don’t necessarily reflect anything they themselves have done, or not done, and this fact often contributes to a freeing up from some aspects of the symptoms of anxiety they have felt. It shifts the experiences to a sense of something that can be witnessed as opposed to drowned in. So a chance to speak of such things to a therapist is really useful.

     Another side effect of doing therapy with a counsellor is that the changes experienced translate into changed family dynamics and even family members realign to more healthy choices. Interesting stuff. And now to bed.

    

Relationships and the matter of grief

April 2018

     The stages of grief a person goes through after the death of someone known to them are typically described as: Denial, Anger, Bargaining, Depression, and Acceptance, or DABDA. This is the formula taught to medical students and grief counsellors the world over, since it was first described in 1969 by Elisabeth Kübler-Ross in her book On Death and Dying.  DABDA advanced our understanding of the grief process, for sure, and did much to illuminate what had become an embarrassing situation for dying patients and their families alike. Death in our society, after all, is often felt as a somewhat awkward life event, treated in subdued tones behind closed doors. With the advent of research and the institution of counselling sessions for those who have suffered the death of a friend, spouse, parent or child, the five stages of grieving became the bench-mark for not merely understanding the emotional process of facing death, but practically prescribing how it will be.  Non-DABDA responses to death such as relief and or even joyfulness came to be “read” by some as not facing facts, thus practically pathologizing what might be a right response for that person according to the quality of relationship they had with the person who died.

     There really isn’t a “right” way to grieve and we need to recognize this. Loss can be liberating, it can engender sadness and happiness at the same time, it can be felt as desperately sad, it can be felt as not much at all. The rubric of DABDA doesn’t recognize the complexity of relationships, and thus the multiple possibilities of feelings and expressions of loss. This matters because we are often quick to judge those who do not express feelings of loss, as being hard hearted, unsympathetic, robotic – and sometimes impute, wrongly, an intent that may be utterly fanciful (the person wanted the other dead, or maybe they did it, or some such). May not a relationship fluctuate between love and hate? May not a person die in stages and that a final cessation of being be greeted with relief and not grief?  May not the dead person have already been absent for many years (“dead” to family and friends) before their actual passing? Maybe one's spouse died suddenly after a violent argument, or maybe they died just before divorce. One may indeed have felt deep love once, but the release from a profoundly difficult situation may well have elicited plain relief rather than grief. Loss is not always simple and grief may not be always present.

There is considerable social pressure put upon those who experience relief, rather than grief – such is the pressure of the social expectations encapsulated in the DABDA concept – so that they may go on to wonder about the authenticity of their own responses. Perhaps there is something wrong with them, perhaps they ought to feel pain, why don’t they feel pain, they might think.  Those looking on may wonder at this silence of a response and suggest it hides inner turmoil, denial, even depression perhaps, and yet who is to say that there is conflict there at all? The pressure brought to bear from within oneself and from family, friends, and counsellors, can hinder an honest, authentic statement about what is really felt. Maybe, the very act of getting real  with a client or friend about death could liberate actual feelings in the pair of them. The listener can do well to provide that space for deep listening. We really do have to listen to what is actually said and not be too quick to suggest that a response is lacking in some way. Maybe until we do that our judgement is clouded by our own discomfort.

There are no rules to how grief is to be done; there are only responses to the quality of the relationship a person had with the one who has passed. That is what is important here; that is what matters.