What’s the relationship between sleep and depression?

Feeling sad is an integral part of the human experience, especially during difficult, stressful or challenging times. However, constant feelings of sadness, anxiety, hopelessness and apathy are all symptoms of depression. Depression affects the way a person feels, thinks, eats and sleeps. The relationship between depression and sleep is a complex one, and insomnia, oversleeping and troubled sleeping are all classic symptoms of clinical depression. Whilst not all depressed people have sleep disorders, many do. For some people, symptoms of depression occur before the onset of sleep problems. For others, sleep problems appear first. Depression may cause sleep problems and sleep problems may cause or contribute to depression. To understand the relationship between sleep and depression better, it is important to understand what happens to us when we sleep.

What happens when we sleep.

We spend on average, a massive 25 years asleep in our lifetime. Sleep is a crucial part of our regular routine, and getting enough good quality sleep, is as essential to survival as food and water.  Without sleep it is more difficult to concentrate, to respond quickly, and to learn and create new memories. Research findings suggest that our brain and body stay particularly active whilst we are sleep, and that sleep maintains the body and brain by removing toxins in the brain that build up while we are awake.

There are two main stages of sleep: rapid eye movement (REM) and non-rapid eye movement (NREM); both are linked to specific brain waves and neuronal activity. These two stages of sleep alternate, and complete a cycle which lasts for approximately 90 minutes; throughout the night, we will have approximately 4-6 of these cycles in a good night’s sleep, with increasingly longer, deeper REM periods occurring towards morning. We spend about 75% of the night in NREM sleep, and about 25% in REM sleep. Sleep is composed of the following four stages:

  • Stage 1 – this is non-REM sleep, and is the transition from wakefulness to sleep.  During this short period of light sleep, our heartbeat, breathing, and eye movements slow, and muscles relax with occasional twitching.  Our brain waves begin to slow down from its daytime wakefulness patterns.
  • Stage 2 – this is non-REM sleep, and is a period of light sleep occurring with the onset of sleep, before we enter deeper sleep.  Our heartbeat and breathing slow down, and muscles relax even further.  Our body temperature drops and eye movements stop.  Brain wave activity slows but is marked by brief bursts of electrical activity.  We spend more of our repeated sleep cycles in stage two sleep, than in other sleep stages.
  • Stage 3 – this is non-REM sleep, and is the period of sleep which is the deepest and most restorative.  It occurs in longer periods during the first half of the night.  During this stage, blood pressure drops, heartbeat and breathing slows to their lowest levels. Our muscles are relaxed and it may be difficult to be woken. Blood supply to muscles increases, tissue growth and repair occurs, and energy is restored. Hormones are released, such as, growth hormones which is essential for growth and development, including muscle development. Brain waves become even slower.
  • Stage 4 – this is REM sleep which first occurs about 90 minutes after falling asleep.  Our eyes move rapidly from side to side behind closed eyelids and brain wave activity becomes closer to that in wakefulness.  Our breathing becomes faster and irregular, and our heart rate and blood pressure increase to near waking levels. Our arm and leg muscles become temporarily paralyzed, which prevents us from acting out our dreams. Most of our dreaming occurs during REM sleep, although some may also occur in non-REM sleep.

The relationship between sleep and depression

Abnormal sleep interferes with mood and energy levels during the day, so it can be difficult to stay motivated, engage with others, exercise, and on some occasions even go to work. To cope, people who are depressed may self-isolate, which can lead to more sleep problems: loneliness itself is linked to fragmented sleep. The cause-and-effect runs both ways.  Even if you are not depressed, lack of sleep increases your chances of depression and other mental illnesses. Depression makes achieving good quality sleep difficult, and it can lead to serious sleep issues and disorders. Research has shown that children with both insomnia and hypersomnia (oversleeping) are more likely to be depressed, to be depressed for longer periods of time, and to experience additional problems such as weight loss. Particularly for young adults, there is a strong correlation between insomnia and depression. In addition to this, teenagers who do not get enough sleep are more at risk of depression and suicide.

Insomnia describes a difficulty falling or staying asleep. Unfortunately, people with insomnia are ten times more likely to develop depression than people without, and 83% of depressed individuals display symptoms of insomnia. Lying awake at night and ruminating on unpleasant thoughts feeds into the cycle of depression and excessive sleepiness the following day, is more likely to reduce general quality of life.

Hypersomnia is the opposite of insomnia and is characterized by extreme oversleeping but still not feeling refreshed despite this. This can be explained by EEG (electroencephalogram) tests showing that depressed patients spend less time in NREM and shift to REM sleep earlier in the night. The more severe the depression, the earlier the shift to REM sleep is during the night. In more severe cases the sequence of sleep stages becomes disturbed and the first REM period occurs before the first deep sleep period. Given the importance of this first deep sleep period to growth hormones and the body’s maintenance, this pattern is particularly detrimental to the depressed person. Hypersomnia occurs in 40% of young adults with depression, and is more common in women.

The worry cycle of depression

The vicious cycle of depression can sometimes be very difficult to break out of. Worrying and ruminating is a key component of depression, which can impact sleep massively. The cycle of depression can be broken down into the following four stages:

 1)    Worrying/Ruminating – too much worrying about things which you have no control over or cannot fix, evokes a strong emotional response and disturbs you. Which leads to:

2)    Increased dreaming – the brain tries to deal with the strain of the worrying and depressed mood by dreaming a lot to process what is happening. Depressed people dream up to three times more than non-depressed people. Which results in:

3)    Decreased deep sleep – too much dreaming means less deep and restorative sleep. Which results in:

4)    Exhaustion – dreaming too much and having decreased deep sleep, will leave you feeling exhausted when you wake up. And then the worrying starts all over again.

To stop going around in circles and getting more and more exhausted, finding ways to stop worrying is essential. An exhausted brain is more likely to use a depressive thinking style, and therefore, it is important to reduce the amount worrying. Reduced worrying will lighten the load on the stressed brain and can break the cycle of depression. To find some suggestions on how to improve your sleep naturally, you can click on my sleep guide for further information. You can also contact your GP or complimentary health advisor for some further ideas on how to improve your sleep.

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Stress: it is sabotaging your life? What stress is, and how to manage it.

Life is normally full of ups and down, and it is more than likely that we have all felt stressed during some point in our life. During periods of stress we may feel overwhelmed or start to feel burned out. We may experience headaches or migraines, have stomach problems or feel tired before the week has barely begun. Feeling stressed can be unsettling, difficult and sometimes even debilitating.

The good news is, that how stressed we get or how often this happens, are two things that we can have an enormous influence over. Without smart habits for dealing with stressful situations, life can be a whole lot more difficult than it needs to be. Effective stress maintenance involves managing what we eat, how we think, the manner we treat our body, what actions we take on a regular basis and how we deal with social interactions. These key factors of stress management are the foundational blocks that help build harmony with ourselves, others and our immediate environment. If we cultivate these factors and apply them to our daily routine, we will find bliss where others find havoc and mayhem.

What is stress?

Stress is our body’s way of responding to any kind of demand or threat. When we feel threatened our nervous system responds by releasing a flood of stress hormones, including adrenaline and cortisol, which arouse the body for emergency action. This triggers the heart to pound faster, the breath to quicken, the muscles to tighten, blood pressure to rise, and our senses to become sharper. These physical changes increase our strength and stamina, speeding up our reaction time, and enhancing our focus. This is known as the “fight, flight, freeze, flop or friend response” (Lodrick, 2007) and is our body’s way of protecting it. The nervous system rouses for emergency action—preparing us to either fight, flee, freeze, flop or befriend the danger at hand.

When stress is within our comfort zone, it can help us to stay focused, energetic, and alert. In emergency situations, stress can save our life – giving us extra strength to defend ourselves or to slam on the brakes to avoid an accident. Stress can also help us to meet challenges and keep us on our toes to achieve the best we can. But beyond our comfort zone, stress stops being helpful and can start causing major damage to our mind and body.

The effects of Chronic Stress

The body’s nervous system sometimes finds it difficult to distinguish between daily stressors and life-threatening events. For example, if we are stressed over an argument with a friend, a traffic jam on a commute, or a mountain of bills, our bodies can still react as if we are facing a life-or-death situation.

When we repeatedly experience the fight, flight, freeze, flop or friend response in our daily lives, it can lead to serious health problems. Chronic stress disrupts nearly every system in our bodies. It can shut down our immune system, upset our digestive and reproductive systems, raise blood pressure, increase the risk of heart attack and stroke, speed up the aging process and leave us vulnerable to many mental and physical health problems.

Health Problems caused or exacerbated by stress include:

  • Depression and anxiety
  • Weight problems
  • Auto immune diseases
  • Skin conditions, such as eczema
  • Reproductive issues
  • Pain of any kind
  • Heart disease
  • Digestive problems
  • Sleep problems
  • Cognitive and memory problems

Signs and symptoms of chronic stress or stress overload

The following table lists some of the common warning signs and symptoms of chronic stress. The more signs and symptoms you notice in yourself, the closer you may be to stress overload.

Causes of stress

We usually think of stressors (situations and pressures that cause stress) as being negative, such as an exhausting work schedule or a rocky relationship. However, anything that puts high demands on us can be stressful. This includes positive events such as getting married, buying a house, going to college, or receiving a promotion.

Of course, not all stress is caused by external factors. Stress can also be internal or self-generated, when we worry excessively about something that may or may not happen, or have irrational, pessimistic thoughts about life. Below, I have listed some common external and internal causes of stress:

Common external causes of stress

  • Major life changes
  • Work or school
  • Relationship difficulties
  • Financial problems
  • Being too busy
  • Children and family

Common internal causes of stress

  • Chronic worry
  • Pessimism
  • Rigid thinking, lack of flexibility
  • Negative self-talk
  • Unrealistic expectations/Perfectionism
  • All-or-nothing attitude

Other factors that influence our stress tolerance

Our sense of control – It is easier to manage stress if we have confidence in our ability to influence events and persevere through challenges. Therefore, hardship or persistent money worries can be major stressors for so many of us. If we feel like things are out of our control, we are more likely to have less tolerance for stress.

Our attitude and outlook – Hopeful people are more often more resilient. These kinds of people tend to embrace challenges, have a stronger sense of humor, and accept change as an inevitable part of life.

Our knowledge and preparation – The more we know about a stressful situation, including how long it will last and what to expect, the easier it is to cope. For example, if someone goes into surgery with a realistic picture of what to expect post-op, a painful recovery will be less stressful than if they were expecting to bounce back immediately.

Improving our ability to handle stress

There are many ways in which to build a tolerance to stress or cope with its symptoms. Unfortunately, many of us try to deal with stress in ways that only compound the problem. We might engage in activities which could be harmful to us, such as smoking or drinking too much, overeating, zoning out in front of the TV for hours or lashing out at people. However, there are many healthier and more effective ways to cope with stress and its symptoms. Below I have listed some of the things we can all do to help manage the stress in our lives:

Emotional awareness – Having the emotional awareness to recognize when we are stressed and then being able to calm and soothe ourselves can increase our tolerance to stress and help us to bounce back from adversity. It is a skill that can be learned at any age.

Get moving – Exercise has been proven to help depression and anxiety, and can be extremely helpful in relieving stress. Exercises such as walking, running, swimming, dancing, and aerobic classes (amongst many others) are all good choices. Regular exercise can lift our mood and help us to find some time for ourselves, so that we break out of the cycle of stress and anxiety.

Connect to others – The simple act of talking face to face with another human can trigger hormones that relieve stress when we are feeling uncomfortable, unsure, or unsafe. Even just a brief exchange of kind words or a friendly look from another human being can help calm and soothe our nervous system. Being helpful and friendly to others also reduces our stress, as well as providing great opportunities to expand our social network.

The quality of our relationships and support network – Social engagement has always been a human being’s most evolved response to life’s stressors. Therefore, it is no surprise that people with a strong network of friends and family—with whom they are comfortable sharing emotions—are better able to tolerate stress.

Set aside relaxation time – Relaxation techniques such as yoga, meditation, and deep breathing activate the body’s relaxation response, a state of restfulness that is the opposite of the fight, flight, freeze, flop or friend response.

Eat a healthy diet – Eating regular healthy meals is important for emotional and mental wellbeing. Cutting out caffeine, processed food and alcohol can really help. Eating a diet full of processed and convenience food, refined carbohydrates, and sugary snacks can worsen symptoms of stress. Whilst eating a diet rich in fresh fruit and vegetables, high-quality protein, and healthy fats, especially omega-3 fatty acids, can help us better cope with life’s ups and downs.

Get your rest – Feeling tired and not getting enough sleep can increase stress. At the same time, chronic stress can disrupt sleep. There are many ways in which to improve sleep. You can download my improving sleep guide in the resource section for some further ideas to improve sleep.

Practice mindfulness – Mindfulness practice is a way of being present in the here and now and has been described by Jon Kabat-Zinn as, “paying attention in a particular way; on purpose, in the present moment and non-judgementally”. Research shows there are huge psychological and physical health benefits such as a reduction in stress and anxiety, when mindfulness is practiced over an eight-week period. You can read more about mindfulness in my blog Anyone for Mindfulness?

Conclusion

Research suggests that stress (especially long-term stress) can cause long term health issues (Cohen, S., et al. 2012). Cohen, a professor of psychology at Carnegie Mellon University in Pittsburgh says:

“We are just beginning to understand the ways that stress influences a wide range of diseases of aging, including heart disease,  metabolic syndrome, type 2 diabetes and certain types of disability, even early death”

However, the impact of stress can sometimes be underestimated by some people. There are many misconceptions about stress, such as “if I was strong enough, I would be able to cope”. The reality is, is that our ability to manage stress is not determined by how “strong” we are, it is normally learnt through our upbringing and environment, which is something we have had no control over as children. The good news is, is that we can relearn how to manage stress, anxiety and demanding situations, by rebalancing our life and becoming more self-aware.

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Further information

https://www.nhs.uk/conditions/stress-anxiety-depression/understanding-stress/?

References

Lodrick, Z. (2007) Psychological trauma – what every trauma worker should know. The British Journal of Psychotherapy Integration. Vol. 4(2)

Cohen, S., Janicki-Deverts, D., Doyle, W. J., Miller, G. E., Frank, E., Rabin, B. S., and Turner, R. B. (2012). Chronic stress, glucocorticoid receptor resistance, inflammation and disease risk. Proceedings of the National Academy of Sciences, 109, 5995-5999.

Anyone for Mindfulness?

In this busy life, we often rush from one thing to another without stopping and appreciating the beauty around us. Commitments, pressures, and worries take over, and staying awake to our present experience become more and more difficult. Mindfulness helps us to stop, breathe, and reconnect with our present experience.

Mindfulness has become more widespread and popular than ever before. This fast-growing phenomenon is being endorsed by celebrities such as Emma Watson, Ruby Wax and Angelina Jolie. Why? Because research is showing time and time again, that if mindfulness is practiced daily for a minimum of 8 weeks, there are huge psychological and physical health benefits such as a reduction in stress and anxiety, and the prevention of depression (Krusche et al, 2013; Baer et al, 2012; Mark et al, 2014; Rycroft-Malone et al, 2014; Williams & Kuyken, 2012; Teasdale et al, 2000)

Where did Mindfulness come from?

In 1979 Jon Kabat-Zinn 1    developed an eight-week Mindfulness-Based Stress Reduction (MBSRprogram to help people with pain management. This course harnessed the fundamentals of mindfulness meditation as taught by the Buddha, but with the Buddhism taken out. In 2002, a psychologist Professor Mark Williams 2  worked with colleagues to combine the US program with cognitive behavioural therapy (CBT) to form an eight-week mindfulness-based CBT course (MBCT). In 2004 this MBCT course was recommended for prescription on the NHS for recurring depression. Mindfulness practice is now approved by the National Institute of Clinical Excellence and is available on the NHS.  

What is Mindfulness?

 “Mindfulness means paying attention in a particular way; on purpose, in the present moment and non-judgementally.”

Jon Kabat-Zinn

Within mindfulness practice, we are encouraged to focus on the present moment in a deliberate and mindful way, to become more aware of arising thoughts, feelings and sensations in the body. Being aware of our present experience in a non-judgmental and compassionate way helps us to acknowledge and accept these thoughts, feelings, and sensations so that we can assess our response before reacting impulsively. Therefore, the practice of mindfulness teaches the mind a new way of relating to thoughts and feelings, so we can choose how to respond to circumstances rather than react.

Mindfulness is practiced by focusing on the body and breath and can also be practiced in everyday activities, like walking or eating. By focusing on the present experience of our body and breath, we teach ourselves to become aware of thoughts, feelings and bodily sensations, acknowledge them, and stay with them as they arise and pass.

Mind full or Mindful?

As adults we often have busy minds which tend to flitter from one thought to another- this is called the “butterfly brain” – our minds jump from one thought to another, making it difficult to maintain focus or concentration. We are normally too busy paying attention to our thoughts and engaging with them, that we neglect to pay attention to our present moment. While we are busy with our thoughts, we may also neglect to notice any arising emotions linked to these thoughts, or may even ignore how these thoughts and emotions may manifest in the body.

In this busy world we live in, we often forget about our bodies, how delicate and precious they are. Psychological and physical illness can sometimes creep up on us because we have learned to ignore our bodies, in favour of the mind. The body sends us signals or flickers, like gentle biological taps on the shoulder, letting us know that something is out of balance. Often in this frantic world, we tend to ignore these flickers or see them as inconvenient irritations hoping that they don’t detract us from the things we need to do. However, these physical signs and symptoms are our bodies way to alert us to deeper imbalances and can often be the manifestation of the thoughts and emotions we experience throughout the day.

Signs of Stress:  emotions, behaviour, feelings, and thoughts

Stress is our bodies reaction to feeling under threat or attack. When we are stressed, panicked, or anxious, a part of the brain called the amygdala 3 is triggered – this is a primitive part of the brain which activates the flight, fight, freeze, flop or friend response. Frequent and recurring activation of this part of the brain floods our bodies with stress chemicals such as adrenaline and cortisol, leading to the symptoms in the diagram on the right. 

Within the practice of mindfulness, we can prevent stress, anxiety and long-term health issues, if we pay attention to how we hold emotions with the body by becoming more aware of the relationship between thoughts, feelings, emotions and the body. If we monitor our body and notice all its fluctuating propensities, then we can become connected from the body, and less entangled with our thoughts.

The Neuroscience of Mindfulness: what does the scientific research say?

MRI scans show that after an eight-week mindfulness course, the brain’s “flight or fight centre”, called the amygdala appears to shrink. As the amygdala shrinks, the pre-frontal cortex (associated with higher order brain functions such as awareness, concentration, and decision-making) becomes thicker.

The connection between these 2 regions of the brain also changes, so the connection between the amygdala and the rest of the brain gets weaker, while the connections between areas associated with attention and concentration get stronger. There is also an increased thickness of the hippocampus which governs learning and memory.

An area of the brain called the insula also thickens with mindfulness practice and becomes more strengthened. This part of the brain is integral to our sense of human connectedness as it helps to mediate empathy for ourselves and others.

How do these structural changes of the brain benefit us in our everyday lives?

The physical and psychological benefits of practicing mindfulness are astounding. Mindfulness boosts the immune system, lowers blood pressure and reduces the risk of heart disease.

Not only does mindfulness reduce stress and anxiety, it increases focus, performance, and memory.  There is an increased sense of calm, and a reduction in worrying, as we learn to stop ruminating about the past and future, and gain greater self-awareness. Empathy and understanding of others also increases, as we become more accepting of ourselves and others.

Going forward with Mindfulness practice

Mindfulness is not an alternative to counselling or psychotherapy. It does not “solve” our difficulties but instead reveals an awareness of the underlying issues we may need to work on. It gives us the opportunity to choose how we respond to these underlying issues, and how we respond to the world.

Mindfulness encourages us to connect to parts of ourselves which we may not like or find too painful to connect with. However, only through true connection with these challenging parts of ourselves can there be real development and growth as individuals

DAILY MINDFULNESS TIPS

  • Start the day with mindfulness – attention to a few breaths before getting out of bed
  • Notice your body while standing or walking
  • Bring awareness to listening or talking
  • Notice changes in your posture throughout the day
  • Bring awareness to eating
  • When you feel tired, frustrated, anxious, angry or any other powerful emotion, bring your attention to your breath
  • Remember to breathe
  • Maintain a daily mindfulness practice
  • Before you go to sleep, bring an awareness to your breath

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References

Baer, R.A., Carmody, J., Hunsinger, M. (2012) Weekly Change in Mindfulness and Perceived Stress in a Mindfulness-Based Stress Reduction Programme, Journal of Clinical Psychology, 68(7), 755-765.

Krusche, A., Cyhlarova E., Williams J.M.G. (2013) Mindfulness Online: An Evaluation of The Feasibility of a Web-Based Mindfulness Course For, Stress, Anxiety and Depression, British Medical Journal, October 2013(3), BMJ Open

Mark, J., et al (2014) Mindfulness-Based Cognitive Therapy for Preventing Relapse in Recurrent Depression: A Randomized Dismantling Trial, Journal of Consulting and Clinical Psychology

Rycroft-Malone, J., et al (2014) Accessibility and Implementation in UK Services of and Effective Depression Relapse Intervention Programme – Mindfulness-Based Cognitive Therapy (MBCT): ASPIRE Study Protocol, Implementation Science

Teasdale et al (2000) Prevention of Relapse/Recurrence in Major Depression by Mindfulness-Based Cognitive Therapy, Journal of Consulting and Clinical Psychology

Williams, M., Kuyken, W (2012) Mindfulness-Based Cognitive Therapy: A Promising New Approach to Preventing Depressive Relapse, The British Journal of Psychiatry

 

Can Transcultural therapy address the issues of racism within psychotherapy?

Current worldwide race relations are not at their best right now. In a study published last year in the American Journal of Public Health, it found that African Americans are almost three times more likely than white people to be killed by the police. Indigenous Americans are also almost three times as likely to suffer such a fate, while Hispanic men are twice as likely. Whilst this is happening in the US, in Myanmar, the Rohingya people are being ethnically cleansed from their homeland by Buddhist aggressors. And meanwhile, in the UK anti-Muslim hate crimes have increased fivefold since the London Bridge attacks in June this year. These examples are just a tiny fraction of the dis-ease that is dominating the world, and provide the perfect backdrop to ask questions about racism within psychotherapy.

It is naïve to assume that the therapeutic relationship somehow can be excluded from the racial tensions in the world; just as the client’s relationships can be played out in the therapy room (transference), why wouldn’t worldwide interpersonal relationships penetrate the therapeutic process?

When we look at the current mental health system, people from black[1] and ethnic minority groups living in the UK are more likely to:

  • Be diagnosed with mental health problems
  • Be diagnosed and admitted to hospital
  • Experience a poor outcome from treatment
  • Disengage from mainstream mental health services, leading to social exclusion and a deterioration in their mental health.

This demonstrates clearly that mainstream mental health services are failing to understand and/or provide services that are acceptable and accessible to black and ethnic minority British communities and meet their cultural needs. These differences can be explained by factors, such as poverty and institutional racism, and highlight that mainstream approaches to counselling and psychotherapy might be so bound up by European assumptions about human nature, that they become irrelevant to people from non-European cultures. Perhaps the influence of slavery, colonialism, and oppression on the development of psychotherapy has been underplayed within the therapy world considering it evolved during the late 19th century when racism was the norm.

For example, racist attitudes were not easily changed after the slavery abolition act was passed in 1833 and, even amongst the well-educated, these ignorant beliefs were difficult to abolish, as reflected in the following quote by Charles Darwin:

At some future period, not very distant as measured by centuries, the civilised races of man will almost certainly exterminate, and replace the savage races throughout the world. At the same time the anthropomorphous apes…will no doubt be exterminated. The break between man and his nearest allies will then be wider, for it will intervene between man in a more civilised state, as we may hope, even than the Caucasian, and some ape as low as a baboon, instead of as now between the negro or the Australian and the gorilla.

(Darwin, 1874 in “The descent of man” p.178)

Sigmund Freud’s work was very much influenced by this kind of literature, and later Jung addressed American therapists in the 1920s, with the following; “the American black has what he calls probably a whole historical layer less” (cited by Thomas and Sillen,1972).

During the second world war, doctors and psychoanalyst refugees who were mainly of Jewish origin were a testament to this kind of racism when the British Medical Association opposed their entry to Britain, when fleeing Germany (Littlewood and Lipsedge, 1989). In time psychoanalysis became a private paying contract between the therapist and the patient, which allowed race to be ignored and ignored social contexts in favour of intrapsychic factors. This experience of the Jewish psychoanalysts became a kind of “ethnic cleansing” where they inversely repeated their past experiences so they became the oppressors by developing a therapy which ignored race.

The question for me, is how do we address racism and cultural bias in the therapy world so that it isn’t re-enacted within the therapeutic relationship? As Littlewood and Kareem (1998) rightly suggest, the history of psychotherapy should not be underestimated. For example, how might a black or person of colour feel when confronted with a European/white therapist and European style of therapy? What emotions does it generate for the client to know that they are faced with their historical oppressors, and with whom they may associate a past of colonialism, slavery, and oppression? How is it to be in a relationship which is therapeutic by nature, but stands as a contradiction historically?

Cultural awareness training is the key to raising awareness of these issues and improving counselling competence (Wade and Berstein,1991). I believe as psychotherapists, it is important to explore one’s own prejudices, assumptions, and issues regarding race and racism (Thomas, 1998) so that our cultural story does not unconsciously spill into the therapy room and prompt clients to disengage from counselling services. Therefore, it is important to have the opportunity to explore and work through our pre-transference in a safe and non-judgemental environment before we engage in the therapeutic relationship. Curry (1964) described pre-transference as fantasies and values ascribed to white and black therapists towards the other race.

Thomas (1998) gives an example of the pre-transference being acted out within the therapy room when he recalls an incident with a white child psychotherapist, who said that she could no longer give black dolls to her black children for play work. After exploration, it became evident that she viewed the black dolls as inferior to white dolls and hence could not give the children something inferior to play with. She wanted to protect the black children from their blackness and protect herself from her whiteness. Some therapists may believe that they must protect their black clients from the race issue, as well as themselves.

We must never lose sight of the economic and social interests being served and mediated by covert and overt racism inside and outside the therapy room.  If therapists ignore race or don’t deal with it adequately, there is a danger of the therapist and client re-enacting historical racist dynamics, and for the therapist to misjudge ‘political’ resistance as ‘therapeutic’ resistance.

Transcultural therapy addresses this political resistance and challenges the dormant racism within psychotherapy and has been described by McKenzie-Mavinga as:

“an understanding and reflection of diverse and intercultural experiences. In this approach, consideration is given to origins and belief systems that mirror and influence identity, personal experience and the social impact of oppressions, within the therapeutic relationship”

(The Handbook of Transcultural Counselling and Psychotherapy, 2011, p30)

Therefore, transcultural therapy is not about a ‘type’ of therapy for black and ethnic minority people, but is about:

  • Becoming aware of our own culture, assumptions, prejudices, and stereotypes
  • Working through the pre-transference
  • Learning about diverse cultures and their histories.
  • Understanding the historical implications of race and racism within counselling and psychotherapy
  • Learning about slavery, colonialism, and oppression
  • Exploring the impact of oppression and race on the unconscious process,
  • Exploring the dynamics of culture, race, and ethnic difference in the therapeutic relationship
  • Reviewing our own practice and considering what is multi-culturally therapeutic

The impact of oppression and racism is far reaching for all cultures, past and present; and, it is essential for everyone to have a safe place to explore and heal from the trauma that has been carried by generations.

Resources

Curry, A. (1964) ‘Myth, Transference and the Black Psychotherapist’. International Review of Psychoanalysis, 45

Darwin, C. (1874) The Descent of Man. Penguin Classics (republished 2004).

Littlewood, R. and Kareem, J. (1998) Intercultural Therapy. Oxford, Blackwell.

Littlewood, R. and Lipsedge, M. (1989) Aliens and Alienists: Ethnic Minorities and Psychiatry, 2nd revised edn. London: Unwin Hyman (originally published 1982)

McKenzie-Mavinga, I (2011) in The Handbook for Transcultural Counselling and Psychotherapy. Eds Colin Lago. Open University Press.

Thomas A. (1998) The stresses of being a counsellor trainer. In H. Johns (ed.) Balancing Acts: Studies in Counselling Training. London: Routledge.

Thomas, A. and Sillen, S. (1972) Racism and Psychiatry. New York: Brunner/Mazel.

Wade, P. and Berstein, B. L. (1991) ‘Cultural Sensitivity Training and Counsellors’ Race: effects on black female clients’ perceptions and attrition’. Journal of Counselling Psychology, 38, 9-15.

[1] Throughout this article, I have interchangeably used the terms ‘black’, ‘ethnic minorities’, ‘people of colour’, in the political sense with its origins in the anti-racist and civil rights movements. Whilst the term ‘black’ originally only referred to people of African and Caribbean descent, the word has come to encompass both Asian and Arab people, seeing commonalities in their shared oppression.

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