Bibliotherapy during quarantine

If you can’t go outside…go inside!

What better occasion than quarantine to use our precious time for a little (or not so little) reflection on ourselves, new awareness and personal growth? I believe bibliotherapy is a useful tool in my work, as I often recommend some reads to my patients as support to their psychotherapy. 

Here are some interesting reads to start your inner journey, as they may inspire the changes you were longing for by shedding light on mental functioning.

The courage to be disliked by Ichiro Kishimi and Fumitake Koga

An imaginary conversation between a wise philosopher and a young adult on how to achieve freedom from our mental schemas and increase our happiness, through the lenses of Adlerian psychology. 

A good prompt for reflection on the desire to be accepted and recognised by others, self-confidence and how sometimes we can be the very saboteur to our own happiness.

Emotional intelligence by Daniel Goleman

Daniel Goleman explains why emotional intelligence can actually be much more useful than IQ. 

Emotional intelligence implies the ability to read our and other people’s emotions in order to understand them and use this information as a guide to behaviour and thinking. This emotional muscle is indeed one of the keys to success in interpersonal relationships, both in our private life and the workplace.

The choice by Edith Eger

Dr Edith Eger shares her personal story as a survivor of concentration camps in the Second World War, delving into her struggle healing from trauma and the path to becoming a psychologist to help veterans suffering from post-traumatic stress disorder. An inspiring and heart-touching story delivering an important life lesson: even in the worst possible situation, we can always choose our thoughts and attitude and change the way we perceive reality. 

 The power of now by Eckhart Tolle 

When approaching the concept of mindfulness, being and living in the present moment exerts the ability to stay in the here-and-now, while observing from a detached and non-judgmental point of view what’s going on inside us.

Eckhart Tolle outlines the power of Now, a concept deeply embedded in Eastern philosophies, yet still so foreign and little-known in Western societies. 

Come as you are by Emily Nagoski

Dr Nagoski takes us on a journey into women’s sexuality, debunking false beliefs (and believe me ladies, there are plenty!), as well as inspiring a reflection on what are the brake and accelerator factors in our sexual life. An excellent read to get to know yourself better, understanding how culture, early experiences and stress impact on sexuality by learning that we are all normal, made of the same parts but organised in different ways.

Overcoming low self-esteem by Melanie Fennell

If self-confidence is your Achilles’ heel, this self-help book is for you! 

Melanie Fennell explains how self-esteem develops across the lifespan, starting from early experiences with our caregivers as well as school-peers, and how our beliefs about ourselves influence and mediate almost every aspect of our daily life, such as our attitude in the workplace, with our partner, friends, and so forth. The book contains several practical exercises, based on Cognitive Behavioural Psychotherapy to effectively increase self-esteem.

Staring at the sun by Irvin Yalom

I would recommend literally every book written by Irvin Yalom, yet this may actually be the one that touched me the most. In this book, Yalom offers a little window to his therapy room, sharing true stories of patients dealing with such a sensitive topic like the fear of death. 

Given our human nature, we may well relate to Yalom’s patients, as they live life coping with the certain fact that time on this planet is limited.

Yalom gives us food for thought, drawing on his vast experience in existential psychology and ancient philosophy. 

Covid-19 and online psychotherapy

How can we take care of our mental health while in quarantine? Online psychotherapy could be an important tool.

Until a couple of months ago, no one would have imagined that half of the world was soon going to be in lockdown, that we would be stuck at home with no chances to meet our loved ones, unable to travel and visit friends or family, without an office to rush to in the morning, or schools to leave the kids at … 

Our habits have been turned upside down and after an initial reaction of denial, shock and anger perhaps, now we’re doing our best to adapt to the current situation. 

Coronavirus is an invisible new inhabitant of our world that has altered our perception of time, relationships and sense of security. However, this ‘break’ could really represent a good opportunity to reshuffle our routine and think both our life and habits through.

Is there anything that you wish to leave behind in the pre-Coronavirus times? Were there things you may have taken for granted and not appreciated enough? Was the pace of your life too fast? Were you missing out on the important things? 

The impact of quarantine on our mental health

With quarantine underway, fear of contracting the virus, economic instability, fear of losing or actual loss of our loved ones, forced and prolonged isolation are all significant risk factors that may take a significant toll on our mental health.

Prolonged lockdown is indeed presenting different challenges within different age groups. Apparently young people are mostly struggling with boredom, family conflicts and in complying with social distancing rules, whereas the most vulnerable (the elderly and people with health problems) are struggling with solitude. People in their 40s and 50s seem to find it difficult to handle home-schooling and work altogether (S. Barari et al, 2020). 

Scientific research suggests that the main effects of prolonged quarantine consist in increased anxiety, depression and irritability, plus an increase of post-traumatic stress symptoms in healthcare workers that are exposed to emotionally-charged situations on a daily basis. 

The longer the quarantine lasts, the worse the impact on our mental health may be.

In these difficult times, mental health support becomes even more vital and, given social distancing measures, online psychotherapy is the only viable way to therapy.

How does online psychotherapy work?

Online psychotherapy works exactly like face-to-face therapy.

In parallel with the massive use of technology in our daily lives, mental health support has been recently delivered in non-traditional ways, other than the classic face-to-face offline approach. Phone and video calls, emails and also instant messaging are being used as the means to deliver therapy.

Consultation via video call is the most frequent one and, as I personally believe, the best way to access online counselling. Several GDPR compliant platforms can be used, such as Skype and FaceTime.

The sessions work exactly like face-to-face therapy in terms of duration, frequency, confidentiality and how therapy is held.

Is it more difficult to open up online compared to face-to-face meetings?

Not necessarily. Research suggests that young people feel more comfortable with internet-based counselling, especially via instant messaging compared to other traditional forms of psychological support. Anonymity seems to promote more direct communication while reducing feelings such as shame and embarrassment (Kuka, 2014).  

Will the relationship with the therapist feel different compared to face-to-face therapy?

The idea of talking about inner struggles with a therapist never physically met before may raise concerns in some of us. ‘How can I trust a person I have never met? Will the therapist be able to get a full picture without body language cues?’ are indeed common questions.

The screen may sometimes represent a barrier when reading non-verbal cues, but research suggests that online therapy is as useful as face-to-face therapy and that patients report good rates of satisfaction by using this method. 

After all, if you think about it, nowadays there is an abundance of things happening online. We take on new hobbies, make new friends, exchange ideas with like-minded people, hold group meetings and, sometimes, fall in love, too!

In my personal experience, it is possible to establish a solid therapeutical relationship with a therapist online, despite the traditional face-to-face experience still being the preferred method for some people.

Does online psychotherapy work? 

Personally, I believe in the efficacy of online counselling and my experience so far has been promising. 

Data collected in scientific research suggest that online therapy has the same efficacy of face-to-face therapy. In particular, internet-delivered Cognitive Behavioural Therapy has proved its efficacy for treating anxiety as well as depressive disorders and its effects last over time (Wagner, 2014; Andrews, 2018) .

Is online therapy suitable for everyone? 

Online therapy is suitable for most people, yet it may not be for everyone.

It is not recommended for people with suicidal intent, psychosis or acute psychiatric disorders. In general, online therapy is not recommended for people experiencing acute conditions that may require the patient to seek medical help.

If you wish to try online therapy, a good Internet connection and a quiet and private environment to take the call are important. Feeling comfortable opening up is key, therefore you may want to find a suitable time and place where your privacy is protected.

 Which therapist should I choose?

The process of picking your therapist is a very personal one. Check the credentials as well as the qualifications of your chosen therapist to understand whether their area of expertise matches your requirements. 

Then, in the same way as face-to-face therapy, proceed to book an initial session with a couple of therapists or have a quick phone chat with them to address your questions and see how you feel. Your inner guidance will tell you – the best therapist for you is the one you feel comfortable opening up to.

Andrews G, Basu A, Cuijpers P, Craske MG, McEvoy P, English CL, Newby JM.

‘Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis’, Journal of Anxiety Disorders, vol 55, April 2018, Pages 70-78

Wagner B, Horn AB, Maercker A. “Internet-based versus face-to-face cognitive-behavioral intervention for depression: A randomized controlled non-inferiority trial”, Journal of Affective Disorders, volumes 152–154, January 2014, Pages 113-121

Barari S, Caria S, Davola A, Falco P, Fetzer T, Fiorin T, Hensel T, Ivchenko A, Jachimowicz J, King G, Kraft-Todd G, Ledda A, MacLennan M, Mutoi L, Pagani L, Reutskaja E, Roth C, Raimondi F Slepoi. “Evaluating COVID-19 Public Health Messaging in Italy: Self-Reported Compliance and Growing Mental Health Concerns”

Kuka DL (2014) “Adolescent Help-Seeking: The Promise of Text Counseling”. Retrieved from Sophia, the St. Catherine University repository website: https://sophia.stkate.edu/msw_papers/350

Stress and sleep

When we go through particularly distressful periods of time, our sleep is very often the first habit that can be affected. Given it’s strong role in nurturing our cognitive and physical skills in our daily life, it is important to take care of our sleep habits in exactly the same way we take care of other areas of our lives.

It can happen to anyone to go through particularly difficult periods of time and to experience occasional troubles sleeping.

Indeed, we could have problems falling asleep (the so-called initial insomnia), or we might wake up several times during the night and have problems falling asleep again (middle insomnia) or we might wake up too early in morning, not being able to fall asleep again (terminal insomnia).

Sometimes these problems could be triggered by specific stressful events, by bad habits regarding your sleeping routines or by distorted beliefs about sleep.

No matter what the cause is, if these troubles persist for at least one month and they have a significant impact in your daily life, it is recommended that you take care of the problem and consult a specialist, in order to avoid the chance of it becoming chronic.

Tips for a better sleep

Here are some of the little, but important, tips that are usually recommended in order to adopt a healthy sleep hygiene:

       Check the time spent in the bed

We should not stay in bed for too long if not asleep. Usually the 85% of the total time spent in bed should be ‘sleeping time’; this means that only 15% of this time should be spent awake.

As a consequence, the first tip to keep in mind is that we should spend as little time as possible awake in bed. If you find yourself for an extended period of time awake, with little chances of falling asleep, it is usually better to get out of bed, go to another room or the couch and do something else until you feel sleepy enough to go back to bed.

Why’s this? Our bed should be a stimulus associated only with sleeping. Usually when we have trouble sleeping, we tend to start thinking, worrying and ruminating, fostering our anxiety and waking up our sympathetic system (that definition is not an alli of relaxation and sleep). Spending too much time awake in bed implies indeed the risk of associating it with the experience of being awake and having stressful negative thoughts.

       Stop having naps

Having little naps during the day is not recommended if we tend to have trouble sleeping; think about naps as little thieves, every time we have a daily nap, a portion of our night sleep is stolen.

       Take care of your bedtime routines

If you have trouble sleeping, the preparation before going to bed is particularly important. Try to create some relaxing routines that your body will soon associate to ‘relax/sleep time’ and that can represent a sort of clear boundary between your day time and your night time. Examples could be:

• having a bath or a particular washing routine
• having a chamomile or another soothing drink
• doing something relaxing before going to sleep (listening to music, relaxation techniques, reading a relaxing book etc.)

Looking after your sleep is important. If you feel that you have troubles doing it by yourself, seek help. A psychologist can help you understand the causes of your issues and work on your worries and on the bad habits that could continue to affect negatively your sleep.

How many times have you found yourself in trouble while asking for help, expressing your disappointment to someone or your preferences when making a choice?

Have you ever surrendered to other people’s choices because of guilt or embarrassment? Have you ever acted too aggressively in order to get what you want?

If any of the above applies to you, you might have experienced trouble being assertive.

Assertiveness refers to the ability to be able to express your choices, preferences and critics in an honest and clear way, that respects yourself and other people.

In some instances being assertive can be particularly difficult, especially when close relationships are involved or our performance is at stake. One may be easily scared of not being liked, rejected or negatively judged when expressing a desire or an idea that it is different from the interlocutor’s. Conversely, one may expect other people to think the same way or have the same preferences, therefore not accepting other people’s point of view.

Generally, in social relationships there may be found three different recognisable – and often alternate, depending on the instance – patterns: passive, aggressive or assertive behaviour.

A passive behaviour may imply swallowing emotions, desires or personal preferences as well as adopting someone else’s preferences to please others. Passive people have trouble saying no to people’s requests; they always apologise for every little thing and usually tend to play a passive role in relationships.

Usually, people with a passive behaviour are driven by a fear of upsetting others or breaking their relationship if they express their personal preferences, and are most often afraid of being negatively judged. They might believe that their own preferences are not equally valuable and equally worthy of respect. Predictably, they suffer from low self-esteem issues.

Conversely, people with an aggressive type of behaviour tend to often ignore other people’s point of view and force others to think or act in the way they desire. This kind of behaviour usually brings about relational conflicts.

Contrarily, assertive people are able to express their ideas and feelings in an honest and direct way, while defending their rights and respecting other people’s ones, without experiencing guilt or shame.

How to be assertive?

Assertiveness is not an easy-to-apply skill, as life teaches us that each situation requires a balanced mix of several kinds of behaviour.

Here are some tips that may help you increase your assertiveness skills:

• Recognise which traits you show more frequently. Do you have a tendency towards passive, aggressive or assertive behaviours?
• Think about the reasons why you tend to behave in a passive or aggressive way (e.g. fear of negative judgment, low self-esteem issues, etc.).
• Actively practice assertiveness in your daily life, starting from being honest with yourself about what you want in a relational situation, and ask for it in a clear and respectful way.
• Please, bear in mind that in the same way as every new skill, assertiveness requires practice. So don’t be too hard on yourself if you’re not getting it quite right yet.
• Speak to a therapist if you need help to develop or increase your assertiveness skills or the reasons behind your aggressive or passive behaviours are too complex and difficult to cope with.

Health loss

Grief and mourning are intense experiences that we will encounter on our paths at some stage in our lives. The loss of a beloved one or something important to us can bring forth intense feelings of sadness, emptiness, anger, incredulity, guilt or a mix of these emotions. We all have our own very personal rhythm when going through the stages of loss and the most wanted outcome is to deal with what happened, by accepting and adapting to the big change.

A particularly tough kind of grief is the one linked with the loss of physical or mental health.

Developing specific diseases may be more understandable and slightly easier to accept depending on our personal resources, age, familiarity and the period of life that we are going through. Unfortunately it can happen, that some diagnoses suddenly come up with no preliminary warnings, maybe at an early stage of our life, by bringing severe limitations to our lifestyle.

Accepting to be ill, can be a particularly tough one. Indeed, the discovery of a severe diagnosis brings us back with unexpected violence to the reality of our limits, transience and to the fact that we are indeed human beings. In our daily life, our brain usually works pretty well in keeping these awarenesses far away from our conscience, but getting sick is quite a reality check.

The loss of our idea of health is an intense life-changing element, that we may undergo facing exactly the same struggles as we do when losing a beloved person. It compels us to face our limits and deal with the restrictions imposed by illness. We may realise that our desired future will be different from the expectations we had and that some of our long-term goals may not be easily reachable any more. We may find ourselves forced to change habits, routines and lifestyle, to even take strong medications and potentially experience undesired side effects. We may feel overwhelmed and powerless, as nothing of all this has been directly chosen by us.

Losing our expected future and our expected self, can be a source of intense depressive feelings and it calls forth all our strength and resources to deal with, reset our expectations and mindset in order to accept our new reality and move on to the best of our ability. Dealing with health loss by ourselves can be particularly daunting and overwhelming.

Remember that you are not alone, seek out for help, ask for support from the people who surround you and when this is still not enough, reach out for specialistic help. Psychotherapy can help you deal with this burden and move towards acceptance.

Past, present and future are the three elements of our timeline that strongly influence our self, mind and our psychological functioning. Our sense of self is shaped by our past history, and our expectations and goals are a sort of compass that orientates our present. Our mind constantly navigates among past, present and future and most of the time we are not completely aware of this.

How many times have we found ourselves trapped by worry regarding the future? And how many times was that scary vision of the future not even close in time as it may potentially happen although we are not even sure when?

Or on the contrary how many times have we found ourselves ruminating over and over again on past episodes, on things that happened and that we would like to change, on our mistakes and people’s behaviours?

While worrying about the future typically leads to anxiety, rumination often causes low mood.

Beyond the negative consequences that this mindset has on our mood, it also involves a specific risk: missing out on the present moment – our today.

Being constantly focused on tomorrow or yesterday doesn’t allow us to be present in what is happening in the now hence to appreciate and enjoy the beauty of what we actually have or are experiencing.

Oriental philosophers have been the first to embrace this thought and to transform it into a real mantra for living, using meditation as a daily activity. In recent years, some principles of Eastern philosophy have been adopted and tailored to the Western lifestyle, and it comes with the name of Mindfulness.

Being mindful means being aware of the present moment, being in the here-and-now and it can be practiced through meditation or simply by asking yourself gentle questions in order to bring awareness to your senses.

Beyond the efficacy of stimulating a state of calm and awareness, mindfulness can be a powerful tool to fight and contrast our mind’s tendency to wander into the past or future when such activity is not needed or useful.

If you recognise yourself in this tendency to focus too much on the past or future instead of the present moment, working on being mindful through psychotherapy can be quite helpful in tackling such inclination.

Intolerance of uncertainty

One of the main constructs linked with anxiety is intolerance of uncertainty.

Uncertainty is a peculiar companion of our life, not particularly loved by most of us but surely always present. Daily life situations, economical and political unstable scenarios doubtlessly intertwine to trigger issues related to our threshold of tolerance of uncertainty.

But why is uncertainty such a scary monster for some of us? 

If we look at our daily life through a magnifying glass, we will notice that it is permeated by little daily elements of uncertainty. All things considered, no one has a crystal ball to make well-thought-out decisions and to know for sure what the future will bring. Therefore a dose of uncertainty is normal to experience in life.

We are all different in how we react to uncertainty, but for some of us it can be a cause of intense unease and distress.

If you have trouble dealing with uncertainty, you may find yourself trapped by worry and negative thoughts.

The main feature of worry is that it hinges on a chain of negative possibilities, one followed by another, that brings forth a catastrophic and doomed scenario, in our mind much more likely to happen and scarier than it actually is.

Most of the time habitual worriers believe that thinking and anticipating all the possible negative outcomes helps them feel safer and more prepared if the depicted scenarios become real.

Conversely, relying on worry is usually far from being a constructive strategy, as one may easily get lost among negative scenarios and feel confused and scared.

Among worriers’ preferred coping mechanisms, they also avoid uncertain situations and keep things under control as much as possible. The reason this happens is that we often associate uncertainty with a potential danger and a negative outcome, despite the fact that such outcome might not even occur in the first place.

How to deal with uncertainty? 

Accepting that uncertainty is unavoidable and constitutes an inevitable part of our life is helpful and a good starting point. Focus on what you can actually change and improve (and therefore on what you have control of), such as your reactions to uncertainty: decrease your anxiety level through relaxation techniques, do not avoid situations with potentially unknown outcomes by default and challenge your negative thinking. Talking about it with a therapist may definitely help.

Anxiety traps

Psychiatrist Robert Leahy begins one of his books on anxiety and worry asking the readers quite a particular question: if you had to explain to a martian what anxiety is and how an anxious person resonates, how would you do it? 

Usually we are so trapped by our worries and anxieties that we tend to get hooked on a sense of danger and urgency, not thinking about the thoughts that are causing and/or maintaining this psychological state.

Let’s see which are the common “rules” of thought that anxious people usually obey and that can be themselves, as a matter of fact, anxiety traps. These traps are considered by cognitive behavioural therapists the main constructs of anxiety, thus targeted by treatment.

1.  Personal responsibility: “if something bad could happen, it is your responsibility to prevent it”. Very often anxious people perceive an excessive sense of responsibility, stronger than the actual one.
2.  “Uncertainty is intolerable and there is no space for doubt”. Anxious people tend to avoid situations characterised by uncertainty, as usually they forecast negative outcomes out of it. Getting control over situations is very often the preferred mean to overcome uncertainty.
3.  “Negative thoughts are true and real facts”. This is the so-called thought-action fusion; a cognitive bias where thoughts can be confused as actions and facts, and not as just mere interpretations and subjective constructions of reality. People using this bias often believe that having a negative thought may have a strong (and unrealistic) impact on the actual realisation of that thought in the real world.
4. “If a negative thing happens, it reflects me as a whole person”. Anxious people usually tend to negatively judge themselves generalising a single bad result or behaviour to their person as a whole.
5. “Failure is unacceptable”. Failing, instead of being perceived as a possible source of learning, is seen in a very rigid way, often with no alternative explanations. Making it scarier than what it could be.
6.  “You must get rid of negative emotions straight away, because they are dangerous and you are not able to deal with them”. Painful emotions are often considered as useless and source of further negative emotions. As a consequence, one of the aims of anxious people is often not to feel negative emotions, locking down such important information about their inner world.

If you suffer from anxiety and you recognise yourself in obeying these “rules of thought”, you may start questioning how useful they are and start to change your approach.

Cognitive behavioural therapy may help you change the way you resonate and cope with anxiety in a different way.

References:

R. Leahy, “The worry cure: seven steps to stop worry from stopping you”, 2006.

Relationships: their impact on our life

The powerful effect of having positive and healthy close relationships is very often undervalued.

This can be true especially for young adults working hard in big and international cities, that are often only temporary homes where people come and go, making it very difficult to cultivate close relationships over time. Let’s add work, stress, distances, little free time… and social networks and online dating that sometimes may give people the utopian feeling of being hyper connected with a large amount of people.

But in reality how many of these connections are effectively supportive and close relationships?

In the last century, an increasing number of psychologists and scientists have highlighted the importance of healthy relationships in our well-being: from the development of our personality and identity to its positive effect in mediating the impact of stress and trauma.

Relationships, perceived happiness and life length

Recently, psychiatrist Robert Waldinger found interesting results about relationships from the Harvard Study of Adult Development, a longitudinal study that surveyed the life of around 700 participants during a period of 75 years. Researchers kept track of important variables like the participant’s physical health, quality of their marriages, work satisfaction and social activities.

In this research they found out that the element that impacted the most on the participant’s health and happiness was the perception of having good quality relationships.

Indeed people having positive relationships with friends, family or the community tended to be happier, healthier and to live longer. Secondly, it is the quality of the relationships that matters for people over 30, not the quantity: unhappy married couples described themselves as less happy than people who were not married at all.

Relationships and pain tolerance

Another research study carried out by Katerina Johnson’s group found out that pain tolerance seems to be linked to social network size. Having a good and supportive social network may be linked to the production of endorphins in our brain, helping us to better tolerate pain.

These results highlight the importance of taking care of our relationships, of nurturing and cultivating them, as when they are positive and supportive they can be so beneficial for our wellbeing.
As their positive impact can be so powerful, unfortunately their negative impact can be as intense.

If you feel that you are having troubles in your relationships and you would like to understand better what is preventing you to fully benefit from your social network, you may consider talking it through with a counsellor or a psychotherapist.

References

Johnson K., Dunbar R; “Pain tolerance predicts human social network size”. Scientific Report 6: 25267, 2016.

Lewis T; “A Harvard psychiatrist says 3 things are the secret to real happiness”, 2015. 
http://uk.businessinsider.com/robert-waldinger-says-3-things-are-the-secret-to-happiness-2015-12?r=US&IR=T

http://robertwaldinger.com/