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. 

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.

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/

Fear of flying

Despite being one of the safest means of transport, fear of flying is a common anxiety problem for many of us.

Boeing Corporation found out that 17% of Americans declare to be scared of flying and that this fear is the third most popular reason for avoiding planes (Laker M, 2012). Furthermore, it seems that around 6% of the population suffers from a diagnosed plane phobia, the so-called aviophobia.

This means that if you are afraid of flying, you are most definitely not alone.

Different shades of anxiety

Fear of flying can manifest itself in different ways and its consequences can affect us by impacting several aspects of our life. In less severe cases, it may just generate mild and unpleasant uneasiness when travelling, while for others, it may cause intense anxiety well ahead of time, making our airborne journey a very distressful and negative experience.

Anxiety can be managed using any sort of safety behaviours like choosing a specific seat or side of the plane, or having specific rituals before the flight such as checking the weather forecast, as well as self-medication (homeopathic or non-homeopathic) or a glass of wine aboard to calm the nerves. Again, for others, the idea of flying may be terrifying to the extent that setting foot on a plane is utterly inconceivable.

Triggers of fear of flying

Different factors may trigger this fear, such as being exposed to a traumatic event related to flying (directly or indirectly), or behaviours taught by a “model” of behaviour (the so-called social learning), or suffering from other phobias (i.e. claustrophobia or fear of heights) or other psychological disorders.
Specifically if you suffer from a panic attack disorder and you experience one of them during a flight, it is most probable that you will be very anxious in future flights; instead if you suffer from a generalised anxiety disorder, it is very likely that you will be very distressed when travelling in general.

Cognitive factors

Several psychological factors affect this problem.

Very often, flying phobia stems from the lack of control experienced while on a plane.

Avoiding to fly is a maintaining factor and will worsen fear in the long-term, as fear has to be faced to be overcome. Some cognitive biases can contribute to the fear of flying, like the tendency to catastrophise noises, turbulences and our own bodily reactions and emotional responses (as possible cues of an upcoming disaster), cognitive distortions (by perceiving a low-probability event as a highly possible one) and intolerance of uncertainty.

Fear of flying: treatment

If you feel that your fear of flying is negatively affecting your life, lifestyle, work and relations by limiting your degree of freedom, you should think about asking for help.

A Cognitive behavioural psychotherapist can help you manage anxiety by changing the negative beliefs and biases in which your fear is rooted; psychotherapy indeed can help you to start enjoying the pleasure of flying and travelling again.

References
Laker M, “Specific Phobia: flight”; Activitas Nervosa Superior 2012, 54, no 3-4.

Counselling and psychotherapy

Psychotherapy and counselling are talking therapies, based on the assumption that talking and reflecting about our own thoughts, emotions and experiences are powerful tools to feel better and change. In particular, the role of emotions is fundamental in our daily life and too often they are not considered, mistreated, denied or swallowed. Emotions on the contrary are our own individual compass that indicates how well we are dealing with our life and our goals. Paying attention and taking care of them is a way of assuring a balanced and mindful psychological life.

Emotions’ psycho-education

In cognitive behavioural psychotherapy and in counselling, if the patient happens to be confused, overwhelmed or simply not used to pay attention to emotions, one of the first steps in therapy is acknowledging them. This process is called “emotions’ psycho-education” and it implies getting to know each of our emotions, their role, aim and physiological activation in order to discover how our mind is functioning. This usually works by monitoring everyday our affective reactions and discovering which thoughts and goals are related. Therefore recognising and labelling the emotions we perceive is the prerequisite for regulating them in a healthy way. 

What scientific research is telling us?

Despite being a technique that has been used since the birth of counselling (and even earlier), it is only in recent times that scientific research has found the biological proofs of the powerful effect of labelling emotions. A research carried out by Lieberman et al. in 2007 clearly showed that affect labelling impacts the functioning of specific areas of our brain that are responsible for emotions’ processing and regulation. Specifically, translating feelings into words decreases the activation of a little region of our brain, the amygdala, that is responsible for automatic emotions activation.

On the contrary, affect labelling seems to increase the activity of a specific region of our pre-frontal cortex (the right ventrolateral area) that is responsible for a high-level processing of emotional information. A decrease of the amygdala’s activity and an increase of that specific aerea of the pre-frontal cortex help alleviating emotional distress.

If you find yourself in a period of strong emotional distress, you may consider talking it through in psychotherapy or counselling; talking therapies are an useful tool to better understand what is going on and to find different strategies to better deal with it.

References:

Lieberman M.D, et al., “Putting feelings into words: affect labelling disrupts amygdala’s activity in response to affective stimuli”; Psychol Sci. 2007 May 18(5):421-8.

Relaxation techniques and anxiety

Anxiety is an emotion that activates physical responses in our body, such as a change in heartbeat, breath frequency and muscle tension.

The main reason of these changes stems from the fact that anxiety triggers the so-called primitive fight-or-flight response, which consists of the body’s automatic reactions by either fighting or fleeing the threat when a hazard is identified, to guarantee survival.

As a consequence, our heart beats faster to pump more oxygen to the muscles, our main muscles contract for increased strength and speed and we may perceive troubles breathing due to the contraction of the muscles of the chest.

The tricky facet of the matter lies in the fact that this activation can maintain a high level of anxiety, giving rise to a vicious cycle. Anxious people are very sensitive to these physical changes and may interpret these responses in a negative way, as evidence of something bad about to happen or afoot. These individuals might feel like they are losing control or getting crazy or are affected by a serious disease.

Another component contributing to the vicious cycle is an increase in respiratory rate, which can be regarded to as a maintaining factor, as well. When we are anxious, we are easily prone to hyperventilating, meaning a higher number of breath cycles per minute and breathing using the chest and not the diaphragm. As a consequence, we take in too much oxygen and that may lead to typical anxiety symptoms such as dizziness, confusion, air hunger and so on.

As these psychical changes maintain or enhance pre-existent anxiety, aiming to reach a state of calmness is a useful tool to relieve and prevent anxiety.

Cognitive behavioural psychotherapy tackles anxiety on different levels, either the cognitive, physical and behavioural one.

Relaxation techniques are an effective ally that can be used in therapy while working on the causes and interpretations that create and perpetuate anxiety disorders.

The patient is taught different types of techniques by their therapist and is encouraged to practice as much as possible in their daily life to master stress and anxiety and keep them under control in stressful situations.

Among the most common relaxation techniques, you may find slow breathing, progressive muscle relaxation, isometric relaxation and relaxation through guided imagery.

Slow breathing, as the name itself suggests, helps you thwart hyperventilation through constant breathing at a particular frequency.

On the other hand, progressive muscle relaxation and isometric relaxation focus on relaxing the muscles of our body, alternating contraction and relaxation of specific muscles.

Guided imaginary allows you to relax through imagination, visualising yourself in a peaceful state and place instead.

Relaxation techniques are an effective range of simple and easy-to-learn tools to help you manage anxiety and reach a state of relaxation.

If you are currently going through a bad patch and find it difficult to cope with stress on your own, or if you think that you might suffer from an anxiety disorder, seeking the help of a counsellor or a psychotherapist is warm-heartedly recommended.

Therapy can help you address the issue on different levels and reach a new balance.

First session in psychotherapy

Deciding to start psychotherapy or counselling can bring forth questions and doubts. Above all, most questions permeate in the first session, which is always laden with great expectancy.

Questions like ‘What should I say?’, ‘Should I open up to my therapist straight away?’, ‘Will I feel comfortable speaking to my therapist?’, ‘How can I tell if my counsellor is the right one for me?’, ‘What should I expect from my first session of therapy?’ and so on may arise.

Let’s examine these questions.

Questions and doubts

What should I say? 

Usually the first session is a preliminary consultation that helps both therapist and client introduce each other and see if common ground is found for further collaboration. As the therapeutical process begins during the first interactions in the initial session, the therapist will gather information about the client and the specific reasons that brought them to ask for help. The first session is crucial to the patient too, as they will eventually decide whether the counsellor is a good fit for them.

The therapist will usually guide the client through a series open-ended questions to assess their situation.

Should I open up to my therapist straight away?

There is no straightforward answer to this question as we all tend to follow our own instinct. For example, some try out therapy with a clear idea of their issues while others may feel confused and overwhelmed at the idea of pinpointing their case. Others may have mixed feelings about it and may experience troubles connecting all the dots when outlining their complex inner picture.

Some aspects of our suffering can elicit intense shame or guilt and therefore, building and establishing trust with a therapist has to be an essential prerequisite for opening up.

Some people find it quite easy to open up and talk comfortably from the beginning whereas others may find it tricky as they require more time and trust.

Will I feel comfortable speaking to the therapist? 

Therapists and counsellors are trained to work and help people with psychological issues. They are able to create a comfortable and non-judgmental setting showing an active-listening attitude.

Obviously, each therapist differs from another in personality and type of training, so each counsellor will adopt a slightly different approach to the client. Also, we all have personal preferences when it comes to people.

Some clients prefer a straightforward and direct attitude, others may opt for a female therapist as opposed to a male therapist or vice-versa, or look for a therapist from a specific country or of a specific age.

How can I tell if the therapist is the right one for me? 

The impression you will get from the first consultation will determine whether you want to embark upon the therapeutic journey with that specific therapist.

Beyond the therapist’s qualifications and specialism, the match for you will make you feel comfortable enough to open up by giving you food for thought.

What should I expect? 

From a first session you may expect to start thinking about the reasons that brought you to counselling in the first place, as well as the causes and consequences related to what you regard to as an issue, along with your expectations and ultimately, motivation. Will may expect a welcoming, non-judgemental and confidential setting where you will feel comfortable about expressing your troubles.

But above all, the first consultation will give you interesting insight into the world of psychotherapy as a tool to provide you with a new perspective on and solutions to a particular issue.