Nature and the therapeutic relationship

I completed my Masters dissertation back in 2014, so it was interesting to re-work it into a journal article several years later. My question was whether working in a natural environment had an impact on the therapeutic relationship. It does, of course, but how?

The existing literature noted seven key themes:

  • 3-way relationship;
  • Nature and the therapeutic process;
  • Symbolism, metaphor and synchronicity;
  • Power;
  • Self/other, inside/outside;
  • Nature and the therapeutic process;
  • Boundaries and containers.

I found all of those in my research, as well as two completely new themes; the turning point and transference. The term ‘transference’ comes from Freud and it describes the phenomena of ‘transferring’ our feelings about someone in our past to a different person in the present. The person in the past is someone of deep importance to us, typically our father or mother. I’d guess we’ve all experienced that, even if we didn’t realize what was going on at the time! My research found something rather odd and potentially very significant: It’s possible to transfer strong feelings about some significant person in our past to a natural object or phenomena. A tree, for example, can come to represent someone’s father or stormy wild weather can powerfully evoke emotional echoes of a mother/son relationship. I wonder if this plays into the idea of ‘Mother Nature’?

people walking in the woods
There’s a key moment in therapy in nature, a turning point where the client and therapist pass a threshold and enter into a liminal space. I draw parallels with anthropological theory about rites of passage, which highlights the importance of that in-between space where the initiate is neither who they were nor who they are to become (Van Gennep). In a rite of passage there’s a midpoint of transition where, for example, the person is no longer a girl, but not yet a women. The anthropologist Victor Turner emphasized the importance of this central liminal phase where the ritual participants are “betwixt and between” (1967).
What has all that to do with therapy? Turner’s notion of liminal space seems to be closely related to what psychotherapist Donald Winnicott calls “transitional space”. Transitional space is “is an intermediate area of experiencing, to which inner reality and external life both contribute” (Winnicott, 1971). Is where therapeutic healing happens?

I’m ending this post with some big questions left open. No apologizes for that: I did the same in my dissertation! Sometimes the value of research comes from the questions it asks rather than the answers it claims to offer. I’ll end here with the same quote from Merleau-Ponty that concluded my dissertation:

“[t]he accomplished work is … not the work which exists in itself, like a thing, but the work which reaches the viewer and invites him to take up the gesture which created it” (1993).

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Left brain – right brain: In therapy

In my previous post I outlined some of the key differences between the left and right hemispheres of the brain and touched on what that might mean for psychotherapy. I’ll now delve a little deeper into that mystery.

While my previous post was based on well established neuroscience, some of what follows is more speculative. That said, it’s all grounded in current scientific understanding.

As I explained last time, part of the role of the right brain is to keep us alert to danger. The right hemisphere is specialized for wide-angle sensory awareness that’s good for scanning for threats: We might say that the right brain is naturally suspicious. Perhaps it’s no surprise that research has found a correlation between depression, anxiety and increased activity in the right hemisphere. A lot of that activity is in the frontal lobe, a region concerned with reward, attention, planning, and motivation. There’s also a high level of right hemisphere activation in PTSD and when childhood abused adults recall unpleasant memories. Another strand of research suggests that PTSD is linked to poor communication between the hemispheres (Cozolino, 2017).

Brain scans

How might therapy help balance and integrate the two hemispheres? When I work with clients, I’m constantly monitoring several channels of communication. The most obvious strand to watch for is the difference what is said and the way it’s said. The structure of language, the way sentences are strung together, is largely a left brain activity, but our tone of voice is more involved with right brain processes. Body language and facial expressions are also more under right brain control. If, or rather, when, there’s some inconsistency between the simple content of what’s said and the wider context, I’ll need to make a judgement call. Suppose a client says “I’m fine about that”, but their facial expression, body language or tone say ‘I’m really not OK”. I might decide to reflect that back to them: It’s as if I’m acting as a mediator between the right and left hemispheres.

Peter Afford suggests that Experiential Focusing – the foundation of my therapeutic approach – may work by promoting the integration of the left and right hemispheres (Afford, 2014). Focusing invites us to drop our awareness into our physical bodies and check for a ‘felt sense’, a feeling in the body that carries meaning. We then sit with any felt senses that arise and gradually begin to engage with them through language. A felt sense is often just a vague sensation at first and I’ll be curious about where it is in my body, its size and shape, and whether it has a colour or a particular emotional tone. I’m initiating a dialogue between an emotional, bodily sensation, which are right brain processes, and the more left brain activities of labelling and seeking details. The next stage is to deepen that dialogue, literally asking the felt sense what it’s about. The linguistic right hemisphere is engaging in dialogue with the more embodied left.

I’ve been watching the therapeutic process over the last couple of weeks and I think I’m seeing lots of occasions where I’m helping my client with some left/right brain integration. I’m not saying this explains how therapy works; there are many parallel processes going on all the time, many of which we may currently be oblivious to. However, I believe the work of balancing and integrating the left and right hemispheres is a key part of therapy and having a greater awareness of how that might happen can enhance therapeutic practice.

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Left brain – right brain: Beyond the myth

Back in the 70’s there was a lot of pop-science chatter about the left and right brain hemispheres. Right brained people, it claimed are creative, while left brained types are analytical. Pretty cool, huh? Cool, but inaccurate and misleading. We now know much more, and the research reveals something much more exciting!

While most systems are integrated across both brain hemispheres there are real differences between the two, but it’s not simply “emotion on the right, reason on the left”. When we talk about the right/left lateralization of the brain, we’re saying that some functions are carried out in one hemisphere more than the other; it’s about specialization. While there are differences between right handed, left handed and ambidextrous people, in general the specialization is as I describe it below.

Areas of the right hemisphere are specialized to deal with aspects of the physical and emotional self. Strong emotions like anxiety and terror activate the right brain. The right hemisphere has many more connections to the emotional heart of the brain, the limbic system. It’s also more connected to the rest of the body, notably the viscera – your gut.

The left hemisphere is specialized in organizing the conscious linguistic self. It’s better at problem solving and is inclined towards positive emotions. The left brain is the more social of the two halves: It’s engaged when someone approaches you and also when you’re angry with someone. The left brain thinks in a linear, sequential way and has less of a connection with the rest of the body than the right brain.

Graphic of the brain

We all have an instinctive ‘fight, flight, freeze’ response to danger, and the right brain is tied into that. Because it processes information in a holistic way, the right brain quickly gets the big picture, and it’s always checking; is that picture safe or possibly dangerous? Perhaps because we’re wired to look for danger, the right hemisphere is more concerned with negative emotions. When you look at a distressing image, the right hemisphere is activated and depression seems to be linked with increased right brain activity. Many right brain specializations are concerned with things outside our immediate awareness, so we can think of it as the home of the unconscious mind. As Louis Cozolino explains:

“When we are awake, the right hemisphere silently provides information to the left, which we experience as intuition, feelings, and visual images” (Cozolino, 2017).

Both halves of the brain have a vital role to play, and mental wellbeing requires a balance and integration between the two. All this has profound implications for psychotherapy. Anxiety, depression and psychosis have all been linked to poor integration between the left and right brain, so does therapy help integration? The short answer is yes, but a more thoughtful discussion will follow in my next blog post.

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The Therapy Turf Wars

“My therapeutic approach is better than yours!” All too often therapists with one particular approach criticize one – or all – of the others, and I’m sick of it. CBT is frequently involved in these turf wars, partly because it’s the favourite of the NHS. Some CBT therapists imply that their approach is vastly superior to all others, ignoring the evidence that supports the effectiveness of other schools of therapy. Humanistic therapists frequently respond in kind, suggesting that CBT is shallow, simplistic and unable to tackle deep rooted issues.

Ruby Wax is an especially irritating ‘turf war’ critic. Ruby is a passionate advocate of Mindfulness Based Cognitive Therapy, an approach I have a lot of respect for. Sadly Ruby feels it necessary to dismiss several of the most important ‘rival’ schools of therapy with funny parodies. Carl Rogers developed the Person Centred Approach (PCA) that unpins most Counselling in the UK today. According to Ruby the PCA is about repeating “whatever you said back to you like a parrot but with love” (Wax, 2013). She goes on to dismiss Gestalt, Existential and Psychoanalytic approaches. Ruby; it may be funny, but it’s not clever!

Triggering my ire today is a book about the Human Givens Approach, which claims that the PCA, Psychodynamic school and CBT are all “piecemeal approaches” and that none of them “are sufficient on its own” (Griffin and Tyrrell, 2007). Their solution is, of course, the Human Givens Approach! The research evidence suggests that PCA, Psychodynamic and CBT can all be effective in certain circumstances. In fact CBT make much of the robust research base that supports it and a Person Centred Approach is one of only four therapeutic modalities approved for the treatment of depression under the NHS.

All this frustrates and saddens me. The Human Givens Approach has a great deal to offer and I intend to integrate it into my own therapeutic practice. But I’m galled that those who developed it feel the need to dismiss other approaches as inadequate. It sometimes feels like I’m back in the school playground hearing one kid saying “My Dad’s bigger than your Dad!” Viewing all this though a psychodynamic lens, I wonder if some therapists have unresolved childhood issues!

Elephant parable ilustration

We need a wide perspective

Given that the human mind is the most complex system in the known universe, is it really plausible that one school of therapy will have the definitive and complete answer to every individual’s unique mental health problems? Maybe one day, but most certainly not yet. Meanwhile I’m adopting a pluralistic approach, learning as much as I can about as many different paths to healing as possible. I try to take a wide perspective, asking myself the question; for this particular client, at this specific moment, which therapeutic lens is going to be the most helpful? This is usually called having an ‘integrative’ approach, but I think I’m best described as a pragmatic therapist: My only interest is what works?

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Five steps to mental wellbeing

As I was walking home earlier this week I saw a card lying in the street. I picked it up and realized what it was; the five steps to wellbeing developed by the New Economics Foundation (NEF). This little card is a brilliant reminder of the 5 steps so I now make sure I see it everyday.

Five Steps to Wellbeing card

The Five Steps to Wellbeing

The five steps are simple and powerful.

Connect – I’ve often written about the importance of connection; in fact I think it may be the most fundamental source of wellbeing. The NEF research concurs: Having less than four close relatives or friends puts you at high risk of future mental health problems. On the other hand, wide social networks “promote a sense of belonging and well-being” (NEF).

Try to connect with the people around you:

  • Talk to someone instead of sending an email or text;
  • speak to someone your don’t know yet;
  • don’t just ask how someone’s weekend was; really listen when they reply.

Be active – In Exeter, there’s no excuse! Walking, cycling, kayaking, climbing, swimming, football or, of course, rugby! You don’t have to take on anything too demanding; just find an activity you enjoy and make it part of your life. I often recommend physical exercise for clients who are experiencing depression: Exercise can boost your endorphins and moderate aerobic exercise can help with emotional regulation (Bernstein & McNally, 2017).

So why not go for a walk, try a sport, take up yoga or maybe tai chi? If you walk to a colleague’s desk instead emailing them, you get a bonus social connection!

Take notice – Research shows that paying attention to your immediate experience and ‘savouring the moment’ enhances wellbeing. It can also deepen self-understanding, thus helping you to assess and reaffirm your priorities. Taking notice is related to mindfulness which has been shown to promote positive mental states and facilitate emotional self-regulation.

  • Cultivate your curiosity; look out for the unusual.
  • Notice the changing seasons.
  • Just pause to notice your sensory experience: Really be with this moment.
  • Remember to check in with your self: How are you feeling right now?

Keep learning – lifelong learning promotes optimism, enhances self-esteem and improves overall life satisfaction. Learning new skills also encourages social connection and is associated with a more active life. Why not join a class, a book club or learn to play an instrument?

Give – Remember the injunction to “practice random kindness”? It seems the Hippies were onto something! Evidence from a range of sources suggest that giving promotes wellbeing. It doesn’t need to be much: Research found that just one act of kindness a week boosts wellbeing. A simple smile or a kind word can count. Start small and maybe you’ll be encouraged to do more, like volunteering for a local community project.

These five steps work beautifully in nature, and the NEF research notes the importance of contact with the natural world for wellbeing. You could easily weave all five steps into a bird watching walk with friends, volunteering for a local conservation group or helping out a neighbour with their gardening!

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Psychedelic psychotherapy: The next big thing in psychiatry?

The UK Home Secretary has announced a review of cannabis for medicinal use. Does that bring psychedelic psychotherapy a step closer? When LSD was synthesized back in the 1950s psychiatrists were quick to see its potential. Research proliferated over the following decade, producing over 1,000 peer-reviewed clinical papers. The results were overwhelmingly positive and “psychedelic therapy was truly considered the next big thing in psychiatry” (Sessa, 2017).

So what went wrong? Several factors came together to stop what could have been a revolution in psychotherapy. Millions of people were taking LSD recreationally, and perhaps inevitably there were casualties. Psychedelics open us to experiences that the more reactionary elements of society find weird at best and even threatening, so it’s no wonder that the press leapt on any negative news. Psychedelics like LSD are the most powerful mind changing substances that exist and deserve to be treated with respect. There are a few basic principles to using psychedelics: Are you in the right mental state to take them? Is this the best place and time for the trip? Carefully considering these essentials – commonly known as set (mindset) and setting – will very much reduce the risk of a ‘bad trip’. In a psychotherapeutic context set and setting are carefully controlled and the whole process is facilitated by a trained professional.

A second factor was the rise of antipsychotic drugs which led to less emphasis on outpatient psychotherapy sessions. Someone with a more conspiratorial turn of mind might also point out that psychedelic psychotherapy promised a permanent cure for many mental health disorders. People who are cured don’t need a daily dose of expensive drugs to keep them feeling (kind of) OK.

The psilocybin molecule

The psilocybin molecule

The good news is that research into psychedelic psychotherapy is undergoing something of a renaissance. Clinical research using psilocybin (the active ingredient of ‘magic mushrooms’), MDMA (ecstasy), ketamine, ayahuasca and LSD is ongoing. Psilocybin looks especially promising. A recent review of seven clinical trials found “large effect sizes related to improved depression and anxiety symptoms” (Thomas et al.) The results overall are encouraging: Psychiatrist Dr. Ben Sessa concludes that psychedelic psychotherapy “is a cost effective way of treating otherwise unremitting mental illness” (Sessa, 2017).

Why is psychedelic psychotherapy so effective? According to one influential paper, one of the key processes is a shift from “disconnection (from self, others, and world) to connection” (Watts et al., 2017). I’m hugely excited by all this, not least because there are some parallels with my PhD research. My research suggests that what inspires and supports many environmental activists is a profound sense of connection. The experience of living close to nature and practices like mindfulness help facilitate this, as does the use of psychedelics like psilocybin. Could it be that a sense of connection – or reconnection – is the underlying mechanism behind our sense of wellbeing?

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Phenomenology: What is it and why should you care?

Would a sentient fish ever wonder what water is? Do you ever wonder what time is? Probably not: Some aspects of our experience are so ‘obvious’ that we just don’t notice them. Phenomenology is a philosophical approach that aims to uncover the obvious. The aspects of our experience that we take for granted can be difficult to identify, but these hidden assumptions and attitudes entwine us.

Phenomenology originated with Edmund Husserl in the early 20th century. Husserl wanted to very carefully examine our experience, teasing out our presuppositions and interpretations to try to get closer to the things themselves. He called our everyday, habitual way of experiencing the world the ‘natural attitude’, and phenomenology offers a way to step back from that. Phenomenology is similar to mindfulness in the way that it invites us to become “aware of the fullness, variety and transiency of experiences in the stream of consciousness” (Patrik). In other ways we might see phenomenology as a scientific project. Husserl saw it a rigorous “science of the essence of consciousness” (Husserl), and there’s some validity to that. Phenomenology is influential in psychology, and has been applied to both Artificial Intelligence and cognitive science.

A fish thinking "What's water?"

Phenomenology is essentially the study of phenomena – that is, things as they appear in our lived experience. It’s grounded in careful observation and description. Phenomenologists investigate all kinds experience, including perception, imagination, emotions and bodily awareness. Phenomenology was foundational in my psychotherapy training and it’s vital in Focusing Oriented Therapy: Being able to pay careful attention to my own experience and that of my client is essential to good therapeutic practice.

Husserl begins with the notion of “intentionality” – the way that all consciousness is “consciousness of something”. That sounds very obvious but that’s partly what phenomenology is about; paying attention to what we think is obvious. It can be quite revealing to pay careful attention to our awareness. Let’s say I’m signing a document. We might assume that I’ll be aware that I’m holding a pen while I’m signing. But let’s look more closely: In the moment that I’m signing, I’m not paying attention to the pen at all. In a strange way the pen is transparent to my awareness. If it stops working, then the pen will leap into the foreground of my consciousness, but if not I’ll just sign my name as I have so many times before.

Phenomenology isn’t just for therapists and academics; it can be usefully applied in everyday life. It can help us avoid errors in reasoning like confirmation bias (preferring perspectives that support our pre-existing views) and projection bias (assuming that most people think just like we do). I invite you to question what seems ‘obvious’ in your own life. My guess is that you’ll become more aware of the nuances of experience that we miss when we rely on the habits and unthinking assumptions of the ‘natural attitude’.

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Bringing Mindfulness in Nature to the City

Both mindfulness and spending time in nature have many benefits, and combining the two – practising mindfulness in nature – creates a synergy that enhances them all. Nature connection, well-being and mindfulness are interrelated: Nature connection is enhanced by mindful meditation and both support well-being.

Current research has focused on mindfulness practice in nature reserves or in the context of wilderness trips lasting several days. Urban natural spaces are typically not considered to be ‘wild’ enough for this kind of approach to work. So while there’s good evidence that mindfulness in nature can enhance nature connection and wellbeing (Unsworth et al.), limiting it to remote ‘wild’ nature puts it beyond the reach of the majority.

Could structured mindfulness practice in city parks enhance nature connection and wellbeing? My personal experience as a therapist and workshop facilitator suggests that it can. My mindfulness in nature workshops draw on a range of approaches including ecopsychology and traditional Buddhism. By combining breath work, walking, sensory awareness and gratitude mediations, participants can develop greater acceptance, compassion and a deeper awareness of our interconnectedness.

On a mindfulness in nature walk. Photo: Adeline O'Keeffe

On a mindfulness in nature walk. Photo: Adeline O’Keeffe

Taking mindfulness in nature into the city makes this valuable practice accessible to those who, arguably, need it the most. To mark Mental Health Awareness Week, I’m co-facilitating two free mindfulness in nature workshops in the city of Exeter. Join Audaye Elesedy and myself on the early evenings of Tuesday, May 15 or Saturday, May 19. Numbers are limited so you need to book.

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The Inflamed Mind

There’s a growing body of research linking mental health and the immune system. In his new book, The Inflamed Mind, Professor Edward Bullmore claims that we need treatments that can break the vicious cycle of stress, inflammation and depression. Speaking on the BBC this morning, Professor Bullmore said it was time to abandon Cartesian dualism and “treat mind and body as if they were more integrated” (Today, Radio 4). Although welcome, this realization comes rather late in the day. Candace Pert recognized that the mind and the body are aspects of a single system back in the 1980’s, and introduced the concept of the ‘bodymind’. That insight has been borne out by neuroscience, embodiment research and embodied therapy, so it’s good that psychiatry is catching up!

The Inflamed Mind book cover

The Inflamed Mind

Candace Pert was the first person to recognize the existence of endorphins, the body’s very own opiates. Endorphins are feel good hormones that are released when we exercise or experience pleasure. The runners high, a chocolate hit and even the kick of a hot curry all depend on endorphins. Endorphins don’t just create feelings of pleasure; they also counteract the effects of stress and play a role in maintaining the immune system.

All this suggests to me that increasing the production of endorphins might be an effective way to treat depression. Kinesthetic meditation – aka ‘the endorphin effect’ – is a simple technique to stimulate the production of endorphins at will. There’s been very little research on kinesthetic meditation, but what evidence we have is intriguing as it was shown to “improve subjective and objective measures of wellbeing” (Bullen et. al., 2006). Kinesthetic meditation also reduces the level of cortisol, a hormone produced in response to stress. This is significant because elevated cortisol is associated with an increased risk of depression and a reduction in the effectiveness of psychotherapeutic treatment.

There’s a complex picture emerging connecting stress, depression, cortisol and the immune system. The interactions between these elements are still unclear, but I think endorphins could play a key role. So could kinesthetic meditation be an effective intervention for the treatment of depression? On paper, it looks promising, but without further research we can’t be sure. Meanwhile it might be worth teaching kinesthetic meditation to people experiencing depression; it has no known negative side effects and it’s free!

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Can ‘Power Posing’ change your life?

Can simply standing in a powerful pose boost your confidence? Back in 2010 psychologist Amy Cuddy, along with colleagues Dana Carney and Andy Yap, claimed that it could (Carney, 2010). There was considerable media excitement, especially after Cuddy delivered a hugely popular TED talk. But subsequent research didn’t replicate the original findings, and suddenly power posing didn’t look cool any more. Dana Carney, the lead author of the original article, abandoned the theory in 2016, announcing that “the evidence against the existence of power poses is undeniable“.

But Cuddy is back with updated research claiming that power posing does have a significant positive impact on “mood and evaluations, attitudes, and feelings about the self” (Cuddy et. al. 2018).

All this is important for several reasons. First, it’s a classic example of how scientific research should work: There’s a claim, it’s tested, refuted and then further research revisits the data. More interesting is how the original research impacted on the public. The media loved Cuddy’s TED talk, with big players like CBS and the New York Times making much of her claims: Sexy science sells. There was much less public reporting when the scientific backlash came and of course now the story is even more complicated!

Man in Power Pose

The author conducts an early Power Posing experiment (c. 1980)

So does power posing work? It probably doesn’t have an impact on behavior: Doing a power pose before you go in for that scary interview won’t enhance your confidence. But a power pose will, on current evidence at least, have a positive influence on your emotional state.

Power posing is a lively topic of discussion amongst trainers and therapists who are interested in embodiment and the body. Power posing is closely related to the work of embodiment trainers like Mark Walsh and Francis Briers. It’s also in line with the kind of embodied therapy that I practice: How a client is sitting, standing, moving or walking says a lot about how they are experiencing their place in the world.

Power posing, embodied training and embodied therapy are all grounded in embodied cognition, the principle that thinking and feeling depend on the body as well as the brain (Robbins and Aydede). Embodied cognition is well supported by cognitive neuroscience and supports the ideas of Merleau-Ponty, Gendlin, Bateson and others who argue that “the body shapes the mind” (Gallagher). Power posing may not change your life, but a better understanding of embodied cognition just might, so keep reading!

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