Why psychiatrists should be
more like plumbers continued...
was more relaxed in general. She had found squeezing her thumb and forefinger when she felt stressed enormously helpful, and had been assertive in some quite difficult situations, without any longer feeling put upon and victimised. She had stopped having flashbacks of any kind and announced happily that she didn't think she needed to see me anymore. She left my consulting room, highly confident that she was going to be able to put her whole heart into her marriage and her future: she was considering training to be a teacher. It was clear that eliminating the intrusive memories was sufficient to enable her to get on, and be optimistic about, her life.
Alison was a very different sort of person to work with. One of the basic tenets of the human givens approach is to establish rapport at the outset. That begins quite naturally with a smile, being attentive, and encouraging initial small talk rather than poring over notes with bent head when a patient enters the room. But Alison rarely smiled. At our first session her expression was a combination of distress and frustration. I knew from her notes and returned questionnaire that she had been depressed for many years and had been admitted to hospital four times, once for as long as eight months. During that admission she was aggressive and violent on the ward and did so much damage she was threatened with criminal charges. She was now taking an antidepressant and an anti-epilepsy drug, commonly used as a mood stabiliser.
Alison had been with her husband for 20 years and had two teenage boys. She clearly lived for her sons and supported them avidly on the football field but had always found it hard to be physically affectionate. Alison was very bitter about her childhood. She had an older cousin whom her parents treated as the golden child in their extended family, and she felt she was constantly compared unfavourably to him. She wrote poignantly in her questionnaire: "My cousin could do no wrong. I was always bad or wrong. I can remember at the age of about four looking out of the window for my real family. I thought I was adopted and my real parents would come to take me away. I felt I never fitted in and could never please anyone."
Her parents didn't know that her cousin had sexually abused her for three years from the age of seven (when he was 14). During her teen years, she was bullied at school and someone she considered a friend raped her. When she was 17, she went to Barcelona as an au pair and was caught in the vicinity of an ETA bomb. Although she suffered few injuries, she continually relived the memory of being surrounded by dead bodies.
After she returned to England, she married. She hadn't worked outside the home since the birth of her first child, and described herself as a non-person.
The troubling flashbacks
Alison was extremely downcast in the way she spoke. She had difficulty expressing herself and had always had trouble socialising, but what plagued her most were the vivid and intense flashbacks of the bomb blast, the rape and the sexual abuse. It was these, and these alone, that she wanted to work on. The images intruded almost every day, often two or three times a day, and she would feel she was reliving these experiences each time. She was wary of intimacy of any kind, as this often triggered flashbacks of the sexual traumas. Three years of psychoanalytic therapy and 20 weeks of cognitive analytic therapy had not lessened her distress or helped her to cope with it.
In our first session after her assessment, I used the rewind technique for the bomb blast. She gave me little feedback, although she left the room in a calm state. The following week she said matter of factly that the flashbacks to the bomb blast had eased off a lot. When I asked what she wanted to work on that day, she replied tersely, "An incident that happened when I was 14". She said no more about it and, of course, the beauty of the rewind technique is that the patient is not forced to discuss openly anything they would prefer to keep private. I took her through the steps, without knowing what experience she was working through. I don't think she said another word, except to thank me as she left.
At our third meeting, she told me, but only when prompted, that the bomb blast flashbacks, which she had scaled as 10 in severity, were now down to 5. The incident at age 14 she scaled at 7 from an initial 10. She chose to work on another undiscussed incident, which had involved her cousin.
The following week, there was a glimmer of animation in her face when I asked how she had been getting on. "The flashbacks aren't bad at all. I would never have believed it" That week we did a rewind on "an incident in the park".
Though she remained aloof, she softened just a little with every session. We ended up with what I would call a comfortable understanding. At the next session, she told me all her flashbacks had resolved and chose not to have any further sessions. I know from her general practitioner that she looks well and is much brighter. Though she still has difficulty socialising, Alison did not want to address that in therapy. It is patients who must set their own goals, and Alison felt she had achieved what she wanted from her therapy.
Reluctant to recover
In my area of work, it is not unusual to see people who have been shunted around the mental health services for years, and whom professionals despair of helping. Sometimes people don't seem to want to get better. They don't respond well to setting concrete goals or to challenging questions such as, "When you are better, what will you be doing differently?" However, I have been surprised that, by using techniques from the wide-ranging human givens approach, one can always do something to move such people along.
One man for years attended groups at three different day centres every week, regularly saw a general psychiatrist colleague of mine, and was admitted to psychiatric hospitals several times in the course of the previous ten years — all without making any headway with his many problems. The psychiatrist finally decided to refer him to me, to see if I could do anything more.
I despaired when I first saw him. But he has been improving, though very slowly. I first saw him every week but this has now tapered down to every 3 months. I have used the human givens approach of acknowledging but otherwise ignoring his complaints, getting him to amplify what is going well and asking him to explain to me how he has achieved what he has, and the strengths and resources he used to do so. I also work at embedding therapeutic suggestions: "Hello. You look as though you feel better. What have you noticed as you get better and become more able to do things? Can you do more or are you already able to do the best that you can?"
Something is happening because he no longer goes to any day centres and has been discharged by the psychiatrist. He is now in a relationship and has taken on a job for two mornings a week. Quite an advance for someone who, for years, had demanded all the medical attention he could get.
© Farouk Okhai and HG Publishing (2003)
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This article first appeared in Volume 10, No, 3 (2003) of the Human Givens journal.
DR FAROUK OKHAI is a consultant psychiatrist in psychotherapy with the Milton Keynes Primary Care NHS Trust. He is also a founder member of the Associaltion of HG Practitioners in the NHS.
> You can find out more about the human givens, including supporting research and many examples of how the approach is being used, by reading:
Human Givens: a new approach to emotional health and clear thinking
> For details of training in a wide range of essential therapeutic skills, including the rewind technique, and working from the human givens, visit the Human Givens College's website
> The HGI ONLINE REGISTER of human givens practitioners, lists all fully qualified human givens therapists currently in private practice.
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Also see the case history:
The power of deep relaxation and guided imagery