Cognitive Behaviour Therapy

Behavioural and Cognitive Psychotherapies are psychological approaches which are based on scientific principles and which research has shown to be effective for a wide range of problems. Clients and therapists work together to identify and understand problems in terms of the relationship between thoughts, feelings and behaviour. The approach usually focuses on difficulties in the here and now, and relies on the therapist and client developing a shared view of the individual's problem. This then leads to the identification of personalised, time-limited therapy goals and strategies which are continually monitored and evaluated. Behavioural and Cognitive Psychotherapists work with individuals, families and groups. The approaches can be used to help anyone irrespective of ability, culture, race, gender or sexual preference.

Behavioural and Cognitive Psychotherapists are usually health professionals such as nurses, psychologists, doctors, social workers, counsellors etc. Whilst all behavioural and cognitive psychotherapists share the above principles, individual therapists may call themselves Cognitive Psychotherapists, Behavioural Psychotherapists, Cognitive Behavioural Psychotherapists or Rational Emotive Behaviour Therapists. These different titles often reflect the preference and training of individual therapists for specific techniques which address problematic thoughts, assumptions and beliefs directly (Cognitive Psychotherapists), address behaviour directly (Behavioural Psychotherapists) or a combination of techniques aimed at addressing thoughts and behaviour (Cognitive Behavioural Psychotherapists, Rational Emotive Behaviour Therapists). Whatever title they use, the approach is commonly referred to as CBT. Most importantly, all therapists aim to help clients achieve desired change in the way they think, feel and behave.

Here is an example of how our thoughts, feelings and behaviour can affect us.
'Sue was nearly asleep and by the time she managed to pick up the phone it had stopped ringing. She had been suffering from anxiety and depression for some time. Her daughter Liz, who had recently moved to London, immediately came to mind. Sue thought: "Something must have happened to Liz! That was the police calling to inform me that Liz has had a serious accident." She felt her stomach churning and her heart pounding at the thought that something could have happened to Liz. Her thoughts raced uncontrollably and she feared she could be losing her mind. She rang Liz's home number several times but there was no reply. Sue took this as further evidence that something bad had happened to Liz. Sue felt so panicky that she stayed up all night, despite taking extra medication. She felt dreadful thinking of all the things that could have happened and even thought of ringing some of the London hospitals. Sue found out from Liz the next morning that she had stayed the night at one of her friends' houses and was fine. Nevertheless, she remained distressed and unsettled and felt unable to go to work.'

WHAT HAPPENS IN BEHAVIOURAL AND COGNITIVE PSYCHOTHERAPIES?

In behavioural and cognitive psychotherapies the therapist and the client work together to:
 develop a shared understanding of the client's problem.
 identify how these affect the client's thoughts, behaviours, feelings and daily functioning.

Based on the understanding of each client's individual problems the therapist and the client will then work together to identify goals and to agree to a shared treatment plan. The focus of therapy is to enable the client to generate solutions to their problems that are more helpful than their present ways of coping. This often involves the client using the time between therapy sessions to try things out.

Therapy is organised over an agreed number of sessions. The number of sessions needed will differ depending on the nature and severity of a client's problem. Typically, sessions are weekly, last an hour and take place over a period of between 10 to 15 sessions, but this can be significantly shorter or longer. After treatment completion client and therapist usually agree to a limited number of follow-up sessions to maintain the progress achieved.

WHAT SORT OF PROBLEMS CAN CBT HELP WITH?

Research on behavioural and cognitive psychotherapies has been carried out extensively. This has shown it to be an effective form of psychotherapy, particularly for the following:

 Anxiety & Panic Attacks
 Phobias (e.g. agoraphobia, social phobia)
 Chronic Fatigue Syndrome
 Depression
 Obsessive-Compulsive Disorder
 Eating problems
 Sexual and relationship problems
 Child and adolescent problems
 General Health problems
 Chronic Pain
 Habit problems (e.g. tics)
 Anger
 Drug or Alcohol problems
 Schizophrenia and Psychosis
 Problems associated with a learning disability
 Bipolar Disorder
 Post Traumatic Stress Disorder
 Sleep Disorders

Behavioural and cognitive psychotherapies can be used on their own or in conjunction with medication, depending on the severity or nature of each client's problem.

History of CBT

In the 1960s, a US psychiatrist and psychotherapist called Aaron T. Beck observed that, during his analytical sessions, his patients tended to have an 'internal dialogue' going on in their minds, almost as if they were talking to themselves. But they would only report a fraction of this kind of thinking to him. For example, in a therapy session the client might be thinking to him- or herself: 'He (the therapist) hasn't said much today. I wonder if he's annoyed with me?' These thoughts might make the client feel slightly anxious or perhaps annoyed. He or she could then respond to this thought with a further thought: 'He's probably tired, or perhaps I haven't been talking about the most important things'. The second thought might change how the client was feeling.

Beck realised that the link between thoughts and feelings was very important. He invented the term 'automatic thoughts' to describe emotion-filled or 'hot' thoughts that might pop up in the mind. Beck found that people weren't always fully aware of such thoughts, but could learn to identify and report them. If a person was feeling upset in some way, the thoughts were usually negative and neither realistic nor helpful. Beck found that identifying these thoughts was the key to the client understanding and overcoming his or her difficulties.

Beck called it cognitive therapy because of the importance it places on thinking. It's now known as CBT because the therapy employs behavioural techniques as well. The balance between the cognitive and the behavioural elements varies among the different therapies of this type, but all come under the umbrella term cognitive behaviour therapy. CBT has since undergone scientific trials in many places by different teams, and has been applied to a wide variety of problems.

What's so important about negative thoughts?

CBT is based on a 'model' or theory that it's not events themselves that upset us, but the meanings we give them. Our thoughts can block us seeing things that don't fit with what we believe is true. In other words, we continue to hold on to the same old thoughts and fail to learn anything new.

For example, a depressed woman may think, 'I can't face going into work today: I can't do it. Nothing will go right. I'll feel awful.' As a result of having these thoughts  and of believing them  she may well ring in sick. By behaving like this, she won't have the chance to find out that her prediction was wrong. She might have found some things she could do, and at least some things that were OK. But, instead, she stays at home, brooding about her failure to go in and ends up thinking: 'I've let everyone down. They will be angry with me. Why can't I do what everyone else does? I'm so weak and useless.' So, that woman probably ends up feeling worse, and has even more difficulty going in to work the next day. Thinking, behaving and feeling like this may start a downward spiral. This vicious circle can apply to many different kinds of problems.

How does this kind of problem start?

Beck suggested that these thinking patterns are set up in childhood, and become automatic and relatively fixed. So, a child who didn't get much open affection from their parents but was praised for school work, might come to think, 'I have to do well all the time. If I don't, people will reject me'. Such a rule for living (known as a 'dysfunctional assumption') may do well for the person a lot of the time and help them to work hard. But if something happens that's beyond their control and they experience failure, then the dysfunctional thought pattern may be triggered. The person may then begin to have 'automatic' thoughts like, 'I've completely failed. No one will like me. I can't face them'.

CBT acts to help the person understand that this is what's going on. It helps him or her to step outside their automatic thoughts and test them out. CBT would encourage the depressed woman mentioned earlier to examine real-life experiences to see what happens to her, or to others, in similar situations. Then, in the light of a more realistic perspective, she may be able to take the chance of testing out what other people think, by revealing something of her difficulties to friends.

Clearly, negative things can and do happen. But when we are in a disturbed state of mind, we may be basing our predictions and interpretations on a biased view of the situation, making the difficulty that we face seem much worse. CBT helps people to correct these misinterpretations.

What form does treatment take?

CBT differs from other therapies because sessions have a structure, rather than the person talking freely about whatever comes to mind. At the beginning of the therapy, the client meets the therapist to describe specific problems and to set goals they want to work towards. The problems may be troublesome symptoms, such as sleeping badly, not being able to socialise with friends, or difficulty concentrating on reading or work. Or they could be life problems, such as being unhappy at work, having trouble dealing with an adolescent child, or being in an unhappy marriage. These problems and goals then become the basis for planning the content of sessions and discussing how to deal with them.

Typically, at the beginning of a session, the client and therapist will jointly decide on the main topics they want to work on this week. They will also allow time for discussing the conclusions from the previous session. And they will look at the progress made with the 'homework' the client set for him- or herself last time. At the end of the session, they will plan another assignment to do outside the sessions.

Doing homework
Working on homework assignments between sessions, in this way, is a vital part of the process. What this may involve will vary. For example, at the start of the therapy, the therapist might ask the client to keep a diary of any incidents that provoke feelings of anxiety or depression, so that they can examine thoughts surrounding the incident. Later on in the therapy, another assignment might consist of exercises to cope with problem situations of a particular kind.

The importance of structure
The reason for having this structure is that it helps to use the therapeutic time most efficiently. It also makes sure that important information isn't missed out (the results of the homework, for instance) and that both therapist and client think about new assignments that naturally follow on from the session. The therapist takes an active part in structuring the sessions to begin with. As progress is made, and clients grasp the principles they find helpful, they take more and more responsibility for the content of sessions. So by the end, the client feels empowered to continue working independently.

Group sessions
CBT is usually a one-to-one therapy. But it's also well suited to working in groups, or families, particularly at the beginning of therapy. Many people find great benefit from sharing their difficulties with others who may have similar problems, even though this may seem daunting at first. The group can also be a source of specially valuable support and advice, because it comes from people with personal experience of a problem. Also, by seeing several people at once, service-providers can offer help to more people at the same time, so people get help sooner.

How else does it differ from other therapies?

CBT also differs from other therapies in the nature of the relationship that the therapist will try to establish. Some therapies encourage the client to be dependent on the therapist, as part of the treatment process. The client can then easily come to see the therapist as all-knowing and all-powerful. The relationship is different with CBT.

CBT favours a more equal relationship that is, perhaps, more business-like, being problem-focused and practical. The therapist will frequently ask the client for feedback and for their views about what is going on in therapy. Beck coined the term 'collaborative empiricism', which emphasises the importance of client and therapist working together to test out how the ideas behind CBT might apply to the client's individual situation and problems.

What kind of people benefit?

People who describe having particular problems are often the most suitable for CBT, because it works through having a specific focus and goals. It may be less suitable for someone who feels vaguely unhappy or unfulfilled, but who doesn't have troubling symptoms or a particular aspect of their life they want to work on. It's likely to be more helpful for anyone who can relate to CBT's ideas, its problem-solving approach and the need for practical self-assignments. People tend to prefer CBT if they want a more practical treatment, where gaining insight isn't the main aim.

CBT can be an effective therapy for a number of problems:

anger management
anxiety and panic attacks
child and adolescent problems
chronic fatigue syndrome
chronic pain
depression
drug or alcohol problems
eating problems
general health problems
habits, such as facial tics
mood swings
obsessive-compulsive disorder
phobias
post-traumatic stress disorder
sexual and relationship problems
sleep problems
CBT does not claim to be able to cure all of the above problems. For example, it does not claim to be able to cure chronic pain or disorders such as chronic fatigue syndrome. Rather, CBT might help people with, for example, arthritis or chronic fatigue syndrome, to find new ways of coping while living with the disorders.

There is a new and rapidly growing interest in using CBT (together with medication) with people who suffer from hallucinations and delusions, and those with long-term problems in relating to others. It's less easy to solve problems that are more severely disabling and more long-standing through short-term therapy. But people can often learn principles that improve their quality of life and increase their chances of making further progress. There is also a wide variety of self-help literature. It provides information about treatments for particular problems and ideas about what people can do on their own or with friends and family.

Why do I need to do homework?

People who are willing to do assignments at home seem to get the most benefit from CBT. For example, many people with depression say they don't want to take on social or work activities until they are feeling better. CBT may introduce them to an alternative viewpoint  that trying some activity of this kind, however small-scale to begin with, will help them feel better. If that individual is open to testing this out, they could agree to do a homework assignment (say to go to the cinema with a friend). They may make faster progress, as a result, than someone who feels unable to take this risk.

How effective is it?

CBT can substantially reduce the symptoms of many emotional disorders  clinical trials have shown this. For some people it can work just as well as drug therapies at treating depression and anxiety disorders. And the benefits may last longer. All too often, when drug treatments finish, people relapse, and so practitioners may advise patients to continue using medication for longer. When patients are followed up for up to two years after therapy has ended, many studies have shown an advantage for CBT. This research suggests that CBT helps bring about a real change that goes beyond just feeling better while the patient stays in therapy. This has fuelled interest in CBT. The National Institute for Health and Clinical Excellence (NICE) recommends CBT via the NHS for common mental disorders, such as depression and anxiety. (NICE is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health.)

Comparisons with other types of short-term psychological therapy aren't clear-cut. Therapies such as inter-personal therapy and social skills training are also effective. The drive is now to make all these interventions as effective as possible, and also, perhaps, to establish who responds best to which type of therapy.

Limitations
CBT is not a miracle cure. The therapist needs to have considerable expertise  and the client must be prepared to be persistent, open and brave. Not everybody will benefit, at least not to full recovery, in a short space of time. It's unrealistic to expect too much.

At the moment, experts know quite a lot about people who have relatively clear-cut problems. They know much less about how the average person may do  somebody, perhaps, who has a number of problems that are less clearly defined. Sometimes, therapy may have to go on longer to do justice to the number of problems and to the length of time they've been around. One fact is also clear, though. CBT is rapidly developing. All the time, new ideas are being researched to deal with the more difficult aspects of peoples problems.

How does CBT work?

CBT is quite complex. There are several possible theories about how it works, and clients often have their own views. Perhaps there is no one explanation. But CBT probably works in a number of ways at the same time. Some it shares with other therapies, some are specific to CBT. The following illustrate the ways in which CBT can work.

Learning coping skills
CBT tries to teach people skills for dealing with their problems. Someone with anxiety may learn that avoiding situations helps to fan their fears. Confronting fears in a gradual and manageable way helps give the person faith in their own ability to cope. Someone who is depressed may learn to record their thoughts and look at them more realistically. This helps them to break the downward spiral of their mood. Someone with long-standing problems in relating to other people may learn to check out their assumptions about other people's motivation, rather than always assuming the worst.

Changing behaviours and beliefs
A new strategy for coping can lead to more lasting changes to basic attitudes and ways of behaving. The anxious client may learn to avoid avoiding things! He or she may also find that anxiety is not as dangerous as they assumed.

Someone whos depressed may come to see themselves as an ordinary member of the human race, rather than inferior and fatally flawed. Even more basically, they may come to have a different attitude to their thoughts  that thoughts are just thoughts, and nothing more.

A new form of relationship
One-to-one CBT can bring the client into a kind of relationship they may not have had before. The 'collaborative' style means that they are actively involved in changing. The therapist seeks their views and reactions, which then shape the way the therapy progresses. The person may be able to reveal very personal matters, and to feel relieved, because no-one judges them. He or she arrives at decisions in an adult way, as issues are opened up and explained. Each individual is free to make his or her own way, without being directed. Some people will value this experience as the most important aspect of therapy.

Solving life problems
The methods of CBT may be useful because the client solves problems that may have been long-standing and stuck. Someone anxious may have been in a repetitive and boring job, lacking the confidence to change. A depressed person may have felt too inadequate to meet new people and improve their social life. Someone stuck in an unsatisfactory relationship may find new ways of resolving disputes. CBT may teach someone a new approach to dealing with problems that have their basis in an emotional disturbance.

How can I find a therapist?

It's possible to get CBT on the NHS in some places, and the NHS Mental Health Service is developing fast. But in many areas this is patchy. Some counsellors and psychologists offer CBT under the NHS. Some nurses, doctors, occupational therapists and clinical psychologists working in community mental health teams can also provide CBT. Some NHS Trusts will have specialist therapy services.

Your GP may be in the best position to give you information about local services. However, waiting lists tend to be long and it's not easy to find practitioners who have good training. There aren't many private practitioners yet, although many private hospitals employ CBT therapists.

There is no legal requirement for therapists to register and be approved, but the British Association of Behavioural and Cognitive Therapy has a register of its members. Therapists on the register have to present detailed information on their training and experience, supported by a qualified practitioner. They have to agree to conditions of ethical practice, to include supervision and continuing professional education. A copy of this register can be obtained from the BABCP. (See Useful organisations.)

There are practitioners working within the UK using other cognitive behaviour treatments. These include Kelly's 'Personal Construct Therapy' and Albert Ellis's 'Rational Emotive Therapy'. These therapies have not received so much scientific attention and they have not developed particular methods for specific problems in the same way.

Can I learn CBT techniques by myself?

Since CBT has a highly educational component, much use is made of reading material in individual therapy and this has been expanded into a large self-help literature over recent years (See References and Further reading). Researchers haven't paid much attention, so far, to whether these books can be helpful. There is one study of The feeling good handbook, which they found effective for alleviating depression. This suggests that it could be beneficial for other problems, in the same way, although this will depend on the severity of the problem and how long it's been going on.

A recent development is using interactive CD-Rom programmes, which can be accessed via your GP or other service-providers. Some of these are very high quality. Some people may prefer them to seeing a therapist, particularly as a first step. They can help with devising relevant activities, and monitor your progress in graphical form, which may be encouraging. They may well come to be more freely available for self-help use.

Cognitive behaviour therapy in action

Mike is a 38-year-old gay man who had suffered disabling bouts of depression, on several occasions in his life, which caused him to make several career changes. He twice tried to commit suicide. He also suffered from a great deal of anxiety and stress, had some drink problems and found it difficult to control his temper, especially when drinking.

Mike was referred for CBT after a typical episode was triggered by stress at work. At his first meeting with his therapist, Mike already knew what he wanted to work on. He had a great sense of failure over his history of depression and what he called his lack of success in his career ('I've really messed up'). He was anxious about his job prospects. He felt unattractive and was worried about ageing and about further losing his physical appeal. He felt his angry impulses were in danger of getting out of control.

In therapy, Mike learned to monitor his actions and his emotional responses. He began to plan activities that gave him a boost and to deal with situations that he had avoided through fear. He learned to identify when he was being extreme or biased in his thinking. He became good at examining his emotion-driven thoughts and reasoning them out so that he got things into proper perspective.

His mood noticeably improved, and he began to tackle longer standing problems. He began looking at job prospects, by planning a more realistic choice of career, and sending in applications. He established a more equal relationship with his partner. He dealt with social situations, without demanding attention and special treatment from friends. Mike had to face up to problems that were difficult to take on board, such as his perfectionism and the unreasonable demands he made on other people. But Mike was highly motivated by the crisis in his life to find alternatives.

This is what he wrote towards the end of his therapy:
'I have had many painful episodes of depression in my life, and this has had a negative effect on my career and has put considerable strain on my friends and family. The treatments I have received, such as taking antidepressants and psychodynamic counselling, have helped to cope with the symptoms and to get some insights into the roots of my problems.

CBT has been by far the most useful approach I have found in tackling these mood problems. It has raised my awareness of how my thoughts impact on my moods. How the way I think about myself, about others and about the world can lead me into depression. It is a practical approach, which does not dwell so much on childhood experiences, whilst acknowledging that it was then that these patterns were learned. It looks at what is happening now, and gives tools to manage these moods on a daily basis.

The work has moved on to look at deeper beliefs, which can dominate one's life and cause loads of problems. For example, I have found that I have a strong entitlement belief [a belief that he is entitled to expect certain things from other people]. This is characterised by low frustration tolerance, anger, and inability to control impulses or be told what to do. It has been a revelation to look back on one's life and see how this pattern has dominated a lot of what I have done. CBT has given me a feeling of being more in control of my life. I am now coming off medication and, with the support of my therapist and partner, I am learning new ways of being in the world. The challenge remains to change these thoughts and behaviours. It will not happen overnight.'

Mike is a man who has applied himself very actively to change. As this quotation reveals, CBT offered him much more then the 'quick' fix that it is sometimes portrayed as giving.

Useful organisations

Hypnotherapy

What is hypnosis?
Within science, there is no debate as to whether hypnosis exists or works. Science simply cannot agree on what it is and how it works, although as The British Society of Clinical and Experimental Hypnosis states:
"In therapy, hypnosis usually involves the person experiencing a sense of deep relaxation with their attention narrowed down, and focused on appropriate suggestions made by the therapist."
These suggestions help people make positive changes within themselves. Long gone are the days when hypnosis was seen as waving watches and controlling people's minds. In a hypnotherapy session you are always in control and you are not made to do anything. It is generally accepted that all hypnosis is ultimately self-hypnosis. A hypnotist merely helps to facilitate your experience - hypnotherapy is not about being made to do things, in fact it is the opposite, it is about empowerment. If someone tells you they can hypnotise you to do something, ask them to hypnotise you to rob a bank, and when they can't, ask them to stop making ridiculous claims.
The following four extracts from Dr Hilary Jones' book, "Doctor, What's the Alternative?", provide an accurate and accessible wonderful description of what hypnotherapy is, how it works and how hypnotherapy can help you change and grow.

Definition of hypnotherapy
Contrary to popular belief, hypnosis is not a state of deep sleep. It does involve the induction of a trance-like condition, but when in it, the patient is actually in an enhanced state of awareness, concentrating entirely on the hypnotist's voice. In this state, the conscious mind is suppressed and the subconscious mind is revealed.
The therapist is able to suggest ideas, concepts and lifestyle adaptations to the patient, the seeds of which become firmly planted.
The practice of promoting healing or positive development in any way is known as hypnotherapy. As such, hypnotherapy is a kind of psychotherapy. Hypnotherapy aims to re-programme patterns of behaviour within the mind, enabling irrational fears, phobias, negative thoughts and suppressed emotions to be overcome. As the body is released from conscious control during the relaxed trance-like state of hypnosis, breathing becomes slower and deeper, the pulse rate drops and the metabolic rate falls. Similar changes along nervous pathways and hormonal channels enable the sensation of pain to become less acute, and the awareness of unpleasant symptoms, such as nausea or indigestion, to be alleviated.

How does it work?
Hypnosis is thought to work by altering our state of consciousness in such a way that the analytical left-hand side of the brain is turned off, while the non-analytical right-hand side is made more alert. The conscious control of the mind is inhibited, and the subconscious mind awoken. Since the subconscious mind is a deeper-seated, more instinctive force than the conscious mind, this is the part which has to change for the patient's behaviour and physical state to alter.
For example, a patient who consciously wants to overcome their fear of spiders may try everything they consciously can to do it, but will still fail as long as their subconscious mind retains this terror and prevents the patient from succeeding. Progress can only be made be reprogramming the subconscious so that deep-seated instincts and beliefs are abolished or altered.

What form might the treatment take?
Firstly, any misconceptions a potential patient may have about hypnosis should be dispelled. The technique does not involve the patient being put into a deep sleep, and the patient cannot be made to do anything they would not ordinarily do. They remain fully aware of their surroundings and situation, and are not vulnerable to every given command of the therapist. The important thing is that the patient wants to change some behavioural habit or addiction and is highly motivated to do so. They have to want the treatment to work and must establish a good clinical rapport with the therapist in order for it to do so
The readiness and ability of patients to be hypnotised varies considerably and hypnotherapy generally requires several sessions in order to achieve meaningful results. However the patient can learn the technique of self-hypnosis which can be practiced at home, to reinforce the usefulness of formal sessions with the therapist. This can help counter distress and anxiety-related conditions.

What problems can be treated by hypnotherapy?
Hypnotherapy can be applied to many psychological, emotional and physical disorders. It is used to relieve pain in surgery and dentistry and has proved to be of benefit in obstetrics. It can shorten the delivery stage of labour and reduce the need for painkillers. It can ease the suffering of the disabled and those facing terminal illness, and it has been shown to help people to overcome addictions such as smoking and alcoholism, and to help with bulimia. Children are generally easy to hypnotise and can be helped with nocturnal enuresis (bedwetting) and chronic asthma, whilst teenagers can conquer stammering or blushing problems which can otherwise make their lives miserable.
Phobias of all kinds lend themselves well to hypnotherapy, and anyone suffering from panic attacks or obsessional compulsive behaviour, and stress-related problems like insomnia, may benefit. Conditions exacerbated by tension, such as irritable bowel syndrome, psoriasis and eczema, and excessive sweating, respond well, and even tinnitus and clicky jaws (tempero-mandibular joint dysfunction) can be treated by these techniques. See list below:
 

Eating & Appetite Disorders: Obesity, Anorexia Nervosa, Bulimia, etc.
 Stress Disorders & Management: Anxiety, Asthma, Hypertension, Arthritis,
 Irritable Bowel Syndrome, Gastric Problems, Cardiovascular Problems, Migraine, Tension Headaches, Decreased Concentration Levels, Energy Depletion, Tension, Frustration, Panic Attacks, Increased Irritability, etc.
 Addictions & Disorder of Habit: Alcoholism, Smoking, Insomnia, Bed-wetting, Nail-biting, Thumb-sucking, etc.
 Lack of Confidence: Public Speaking, Shyness, Stage Fright, Blushing, etc.
 Fears & Phobias: Irrational Fears of Height, Darkness, Snakes, Animals, Insects Water, Rats, Insects, Birds, Dental, Blood, Flying, Closed / Open Spaces, etc.
 Psycho-Sexual Problems: Impotence, Frigidity, Premature Ejaculation, etc.
 Social Disabilities: Speech Disorders, Tics, Tremors, etc.
 Depression & Unresolved Grief: Separation, Divorce, Death of Family Member/ Friend/ Pet, Job Loss, Business Failure, etc.
 Skin Disorders: Eczema, Dermatitis, Psoriasis, Excess Sweating, Warts, etc.
 Gynaecological Disorders: Menopausal Problems, Pre-Menstrual Syndrome, Amenorrhoea, Dysmenorrhoea, etc.
 Obstetric Uses: Ante-Natal Training, Morning Sickness, Heartburn, Labour Contractions & Pain Management, Post-Natal Depression, etc.
 Academic Difficulties: Studying, Exam Nerves - School, Nursing, Driving, etc
 Pain Management: In Acute & Chronic Illness, Burns, Cancer, Dentistry, etc.
 Sports Difficulties: Performance Enhancement, Training Discipline, Event Nerves.
 Executive Stress-Sales Performance-Burn Out-Interview Performance, etc.

The History of Hypnosis

The earliest references to hypnosis date back to ancient Egypt and Greece. Indeed, 'hypnos' is the Greek word for sleep, though actual state of hypnosis is very different from that of sleep. Both cultures had religious centres where people came for help with their problems. Hypnosis was used to induce dreams, which were then analysed to get to the root of the trouble.
There are many references to trance and hypnosis in early writings. In 2600BC the father of Chinese medicine, Wong Tai, wrote about techniques that involved incantations and passes of the hands. The Hindu Vedas written about 1500BC mention hypnotic procedures. Trance like states occur in many shamanistic, druidic, voodoo, yogic and religious practices.

Hypnotic pioneers

The modern father of hypnosis was an Austrian physician, Franz Mesmer (1734 - 1815), from whose name the word 'mesmerism' is derived. Though much maligned by the medical world of his day, Mesmer was nevertheless a brilliant man. He developed the theory of 'animal magnetism' - the idea that diseases are the result of blockages in the flow of magnetic forces in the body. He believed he could store his animal magnetism in baths of iron filings and transfer it to patients with rods or by 'mesmeric passes'.
The mesmeric pass must surely go down in history as one of the most interesting, and undoubtedly the most long-winded, ways of putting someone into a trance. Mesmer would stand his subjects quite still while he swept his arms across their body, sometimes for hours on end. I suspect that this probably had the effect of boring patients into a trance, but it was certainly quite effective.
Mesmer himself was very much a showman, conveying by his manner that something was going to happen to the patient. In itself this form of indirect suggestion was very powerful. Mesmer was also responsible for the popular image of the hypnotist as a man with magnetic eyes, cape an goatee beard. His success fuelled jealousy among many of his colleagues and this eventually led to his public humiliation. Looking back, it is quite incredible that hypnosis survived these early years, because the medical world was dead against it.
Another forward thinker was John Elliotson (1791 - 1868), a professor at London University, who is famous for introducing the stethoscope into England. He also tried to champion the cause of mesmerism, but was forced to resign. He continued to give demonstrations of mesmerism in his own home to any interested parties, and this led to a steady increase in literature on the subject.
The next real pioneer of hypnosis in Britain appeared in the mid nineteenth century with James Braid (1795 - 1860). Primarily a Scottish eye doctor, he developed an interest in mesmerism quite by chance. One day, when he was late for an appointment, he found his patient in the waiting room staring into an old lamp, his eyes glazed. Fascinated, Braid gave the patient some commands, telling him to close his eyes and go to sleep. The patient complied and Braid's interest grew. He discovered that getting a patient to fixate upon something was one of the most important components of putting them into a trance.
The swinging watch, which many people associate with hypnosis, was popular in the early days as an object of fixation. Following his discovery that it was not necessary to go through all the palaver of mesmeric passes, Braid published a book in which he proposed that the phenomenon now be called hypnotism.
Meanwhile, a British surgeon in India, James Esdaile (1808 - 1859), recognised the enormous benefits of hypnotism for pain relief and performed hundreds of major operations using hypnosis as his only anaesthetic. When he returned to England he tried to convince the medical establishment of his findings, but they laughed at him and declared that pain was character-building (although they were biased in favour of the new chemical anaesthetics, which they could control and, of course, charge more money for). So hypnosis became, and remains to this day, an 'alternative' form of medicine.
The French were also taking an interest in the subject of hypnosis, and many breakthroughs were made by such men as Ambrose Liebeault (1823 - 1904), J. M. Charcot (1825 - 1893) and Charles Richet (1850 - 1935).
The work of another Frenchman, Emile Coue (1857 - 1926), was very interesting. He moved away from conventional approaches and pioneered the use of auto-suggestion. He is most famous for the phrase 'Day by day in every way I am getting better and better'. His technique was one of affirmation and it has been championed in countless modern books.
A man of enormous compassion, Coue believed that he did not heal people himself but merely facilitated their own self healing. He understood the importance of the subject's participation in hypnosis, and was a forerunner of those modern practitioners who claim, 'There is no such thing as hypnosis, only self-hypnosis.'
Perhaps his most famous idea was that the imagination is always more powerful than the will. For example, if you ask someone to walk across a plank of wood on the floor, they can usually do it without wobbling. However, if you tell them to close their eyes and imagine the plank is suspended between two buildings hundreds of feet above the ground, they will always start to sway.
In a sense Coue also anticipated the placebo effect - treatment of no intrinsic value the power of which lies in suggestion: patients are told that they are being given a drug that will cure them. Recent research into placebos is quite startling. In some cases statistics indicate that placebos can work better than many of modern medicine's most popular drugs. It seems that while drugs are not always necessary for recovery from illness, belief in recovery is!
Sigmund Freud (1856 - 1939) was also interested in hypnosis, initially using it extensively in his work. He eventually abandoned the practice - for several reasons, not least that he wasn't any good at it! He favoured psychoanalysis, which involves the patient lying on a couch and the analyst doing a lot of listening. He believed that the evolution of the self was a difficult process of working through stages of sexual development, with repressed memories of traumatic incidents the main cause of psychological problems. This is an interesting idea that has yet to be proved.
Freud's early rejection of hypnosis delayed the development of hypnotherapy, turning the focus of psychology away from hypnosis and towards psychoanalysis. However, things picked up in the 1930's in America with the publication with the publication of Clark Hull's book, Hypnosis and Suggestibility.
In more recent times, the recognised leading authority on clinical hypnosis was Milton H Erickson, MD (1901 - 1980), a remarkable man, and a highly effective psychotherapist. As a teenager he was stricken with polio and paralysed, but he remobilised himself. It was while paralysed that he had an unusual opportunity to observe people, and he notice that what people said and what they did were often very different. He became fascinated by human psychology and devised countless innovative and creative ways to help people. He healed through metaphor, surprise, confusion and humour, as well as hypnosis. A master of 'indirect hypnosis', he was able to put a person into a trance without even mentioning the word hypnosis.
It is becoming more and more accepted that an understanding of hypnosis is essential for the efficient practice of every type of psychotherapy. Erickson's approach and its derivatives are without question the most effective techniques..
...Over the years hypnosis has gained ground and respectability within the medical profession. Although hypnosis and medicine are not the same, they are now acknowledged as being related, and it is only a matter of time before hypnosis becomes a mainstream practice, as acceptable to the general public as a visit to the dentist.

Useful Links

Electroconvulsive Therapy

What do I need to know before I have ECT?
The law states that people have the right to make an informed decision about which of a number of treatment options to choose, and whether, or not, to accept the treatment a doctor suggests. To consent properly to a particular treatment, people need information to enable them to weigh up the risks and benefits, in the light of available evidence.

Before any treatment begins, the doctor should provide you with full information about the treatment, any unwanted effects and what the alternatives would be, including the alternative of having no treatment at all. Information should be given in language that you can understand. This means that technical information should be explained, using everyday terms. It also means that if your first language is not English, and your understanding of English is not adequate for you to understand fully, you should be provided with an independent interpreter. Having a relative or friend acting as a translator is not good enough. You should be able to have the information in writing, and have someone go through it with you, face to face. The information should include the specific nature of the treatment, its purpose, the chances of its success, any side effects or risks involved, and the way of administering it.

You should be allowed time, afterwards, to decide whether, or not, to go ahead with the treatment. You may want to talk this through with a relative, friend or adviser, before signing a written consent form specific to the proposed treatment. It can be hard to take in a lot of new information at one go, especially if you are depressed and taking medication. The Royal College of Psychiatrists recommends that you have a friend, relative or advocate with you, when you are given the information, so that they can go over it again, with you. You should not be afraid to ask your psychiatrist, or another member of staff, to explain it to you more than once. The Royal College of Psychiatrists also recommends that, if your relatives or close friends disagree with your treatment, this should be recorded in your notes, together with the reasons for proceeding with the treatment.

When you have signed a consent form, you should be informed that you can change your mind at any stage in the treatment and that, should you do so, the treatment will be stopped. At each stage of the treatment, the doctor should confirm with you that you are continuing to consent.

The ECT Handbook, which has been produced by The Royal College of Psychiatrists, states:
'You can refuse to have ECT and you may withdraw your consent at any time, even before the first treatment has been given. The consent form is not a legal document and does not commit you to have the treatment. It is a record that an explanation has been given to you, and that you understand, to your satisfaction, what is going to happen to you. Withdrawal of your consent to ECT will not in any way alter your right to continued treatment with the best alternative methods available.'

ECT can only be given without consent if you are detained in hospital under the Mental Health Act 1983, and this is authorised by a doctor appointed by the Mental Health Act Commission (a second opinion appointed doctor, or SOAD). This doctor must visit you and consult with your own doctor, a nurse, and another professional involved in your care who is neither a doctor nor a nurse.

The only exception to this is in an emergency. In such cases, treatment can begin, under section 62 of the Act, pending the arrival of the SOAD, for patients without capacity to consent, in a life-threatening situation, where the common law might be invoked. (See Getting the best from your approved social worker ) For more advice on your rights, ask whether there is an advocacy service or patients' council at the hospital. Mind's Legal Unit and your local Community Health Council may also be able to help.

What is ECT and why is it controversial?
ECT involves sending an electric current through the brain to trigger a seizure, or fit, with the aim, in most cases, of relieving severe depression. The treatment is given under a general anaesthetic and using muscle relaxants, so that the muscles do not contract, and the body does not convulse during the fit.

No-one seems to be able to give a clear explanation of how ECT works, and this is a cause of controversy. On the one hand, its critics describe it as a crude treatment that causes brain damage; on the other hand, its supporters defend it as an effective and life-saving technique.

Mind conducted a survey, in 2001, of mental health service users who had received ECT. (Shock Treatment: A Survey of People's Experiences of Electro-convulsive Therapy [ECT].) It reported that as many people found it unhelpful as helpful:

'I would happily die rather than have ECT again.'
(Woman, Yorkshire.)

'If I had not received ECT I would be dead by now.'
(Woman, Staffordshire.)

36 per cent of those treated in the last five years found it helpful in the short term (within the first six weeks of treatment)
27 per cent found it unhelpful or damaging in the short term
43 per cent felt that it was unhelpful or damaging in the long term.
Two-thirds of all those asked, and almost half of those who had had ECT in the last two years, would not agree to have it again.

Many psychiatrists are convinced that it is an effective treatment for seriously depressed people, when no other treatment has been effective or available. They would argue that it is a suitable treatment when it is important to have an immediate effect, for example because a person is so depressed that they are refusing to eat or drink, and are in danger of kidney failure.

Other controversial issues are also discussed later. They include:

differences of opinion about how ECT works
whether, or not, it is always used as a treatment of last resort
whether, or not, it is effective in preventing suicide
the adverse effects, including memory loss, which may be very significant in some people.

What is it used for?
ECT has been used to treat all types of mental distress in the past. It is now most commonly used to treat severe depression and, occasionally, mania, schizophrenia and catatonia.

In treating schizophrenia, The ECT Handbook recommends that ECT should be limited to patients who can't take, or who respond poorly to antipsychotic drugs, when psychotic symptoms (such as hallucinations) accompany a mood disorder (such as depression) or great agitation or immobility. It also states that:
'ECT is unlikely to be effective in the treatment of obsessional compulsive disorders, but may be of benefit to some patients with both obsessive-compulsive and depressive symptoms.'

Because, when it works, ECT usually works very quickly, some psychiatrists think it is the best treatment for severe postnatal depression. It can minimise the time that the new mother is not able to care for and bond well with her baby. (See Understanding Postnatal Depression )

Where will I have my treatment?
People usually receive ECT as inpatients in a hospital, although outpatient treatment is possible. The ECT Handbook recommends that the ECT treatment centre should consist of a suite of at least three rooms. The waiting area should be comfortable and provide a relaxing environment. Accessible from the waiting area should be a treatment room, with a recovery area leading off it. The suite should be organised so that patients are able to move easily from waiting room, to treatment room, to recovery room.

A nurse, who the patient knows and trusts, should escort the patient to the ECT suite and, preferably, stay with him or her during all stages of treatment. In some clinics, relatives or friends are allowed to accompany patients throughout the treatment, if both agree.
 

'A minimum number of trained staff must be present for a treatment session to take place. As well as the anaesthetist and psychiatrist, there must be one person to help with the anaesthesia and one person to recover each person who has not regained consciousness.'

In the treatment room, an electrocardiogram machine, to measure blood pressure and temperature, should be easily accessible. There should also be adequate resuscitation equipment, including a defibrillator (a machine to restart the heart should it stop beating). A standard box of drugs should be kept in the unit, in case of cardiac arrest or medical emergency.

All staff working in the ECT unit need regular training, updating and practice in basic and advanced life support techniques. The ECT Handbook states: 'A senior psychiatrist, preferably a consultant, should be responsible for ECT clinics and, in particular, must advise on appropriate treatment facilities, develop a treatment policy, and train and supervise staff.'

Some psychiatric units fall short of these guidelines. A survey of the 230 sites in England and Wales that provide ECT found that:

20 per cent showed substantial departures from best policy, practice and training
32 per cent did not have a dedicated ECT suite of three rooms
36 per cent did not have a nurse in the recovery room trained in basic life support and resuscitation techniques
27 per cent did not have regular visits from a named consultant psychiatrist
5 per cent did not have either copies of The ECT Handbook (the Royal College's publication) or the hospital's own policy for ECT.

What should I expect from a treatment session?
ECT is carried out under a general anaesthetic and with a muscle relaxant (this is what is known as 'modified' ECT). Because of the anaesthetic, you must not eat or drink anything for at least six hours before ECT. An anaesthetist, a psychiatrist and one or more nurses should be present during the procedure. You will lie on a bed, and your jewellery, shoes and dentures (if necessary) will be removed. You should not be wearing any hair lacquer, creams, make-up or nail polish, or have any metal slides or grips in your hair.

Once you are comfortable, you will be given a general anaesthetic, via an injection. Later, while you are asleep, you will receive an injection of muscle relaxant to minimise the convulsions caused by the electric current. Because of the muscle relaxant, you will be given oxygen, and the anaesthetist will look after your breathing, using a face mask and a pressure bag. Two padded electrodes will be placed on your temples (see opposite page). A mouth guard will be placed in your mouth, to stop you biting your tongue.

Modern ECT machines deliver a string of brief, high-voltage, direct-current pulses, about 60 to 70 pulses a second, for three to five seconds, which results in a seizure, or fit. This will cause you to stiffen slightly, and there will be twitching movements in the muscles of your face, hands and feet. The seizure should last 20 to 50 seconds.

The seizure threshold
The strength of electric current needed to produce a fit is called the seizure threshold. This varies from person to person. It is higher in men than in women, and it increases with age, meaning that older people need a stronger electric current to produce the desired effect. The 'dose' of electric current given to you will be adjusted to take this into account.

Other things that affect it are the exact position of the electrodes on your head, the amount of anaesthetic you have been given, and other medication you may be taking. If the dose is too low (below the threshold), there will be no benefit from the ECT. But the higher the dose, the greater the risk of unpleasant side effects, so it's important to get the dose as close as possible to the threshold.

Immediate after effects
After the convulsion, the mouth guard is removed and you will be turned on your side. The anaesthetist will provide oxygen until the muscle relaxant wears off (after a few minutes) and you start breathing on your own again. You will slowly come round, although you may feel very groggy. You may sleep for up to an hour, after treatment.

The immediate effects of ECT include headache, confusion, nausea, disorientation, loss of memory, apathy, aching muscles and physical weakness (see below).

The immediate effects of ECT include headache, confusion, nausea, disorientation, loss of memory, apathy, aching muscles and physical weakness. If you are an outpatient, you will need to have someone with you to accompany you home. You should not drive, and you should not return alone to an empty house.

What's the difference between bilateral and unilateral ECT?
ECT may be given by placing one electrode on each temple (bilateral) or by placing both electrodes on one temple (unilateral), and this makes a difference to the effect ECT will have. The National Institute for Clinical Excellence (NICE) says there is evidence of cognitive impairment after ECT. This is greater when electrodes are applied bilaterally. In unilateral ECT, electrodes placed on the dominant side of the brain cause more harm than if they are placed on the non-dominant side (see below for more information).

The ECT Handbook recommends unilateral ECT when:

a very rapid response to treatment is less important
you have responded well to unilateral ECT in the past, and
it's thought particularly important to minimise memory loss.
It recommends bilateral ECT when:

a very rapid response to treatment is desirable
previous bilateral ECT has been effective, and
it has not caused significant loss of memory.

How many treatments will I need?
The ECT Handbook says there should not be a pre-set number of treatments, but that you should be assessed after each treatment to see if another one is necessary. Most people respond to a course of between four to eight treatments, although older people and men may need more. It's usual to stop after eight, or so, treatments, if there has been no change at all in the patient's symptoms. The treatments should take place two or three times a week, not daily. The Code of Practice to the Mental Health Act 1983 states that the proposed maximum number of applications of ECT should be written down on form 38, when the patient consents to treatment.

Who should avoid having ECT?
Before a course of ECT treatments, you will need a full medical examination. You will be asked about your medical history, any medicine you are taking, any drug allergies, and whether you are pregnant. If you have any physical problems, these should be treated, as far as possible, before you have ECT.

The ECT Handbook emphasises that the risks and benefits of the treatment must be carefully assessed, and that you and your family should be involved in the discussion. (See below for a checklist of questions to ask.)

Cardiovascular problems
When assessing whether to give you ECT, it's important that doctors take into account any heart and related problems you may have. It may be hazardous to give you an anaesthetic if you have a serious chest disease.

Pregnancy
ECT is occasionally used in pregnancy. However, an anaesthetist may not be happy about giving a general anaesthetic to a pregnant woman, except in a medical emergency.

Medication
The British National Formulary (BNF) advises caution in using ECT if the patient is taking SSRI antidepressants (selective serotonin re-uptake inhibitors), because these drugs may prolong the seizures. Drugs that raise the seizure threshold (so that a higher dose of electric current has to be used) should also be avoided. This includes benzodiazepine tranquillisers.

How does it work?
No theory provides a clear explanation. Some give very little information. The ECT Handbook says:
'[ECT] produces a seizure which affects the entire brain, including the centres which control thinking, mood, appetite and sleep. Repeated treatments alter chemical messages in the brain and bring them back to normal.'

NICE says that it changes the way brain cells respond to their chemical messengers:
'Although ECT has been used since the 1930s, there is still no generally accepted theory that explains its mechanism of action. The most prevalent hypothesis is that it causes an alteration in the post-synaptic response to central nervous system neurotransmitters.'

Psychiatric opinion about how it works is divided. Dr Brian Harris, a consultant psychiatrist and senior lecturer, is quoted as saying:
'No-one knows how it works, but it does; quicker than medication'.

The author, Dr Anthony Clare, has said:
'Interest centres on the possibility that ECT acts on the neuro-transmitters believed to hold the cause of severe depression. ECT certainly affects these monoamines, but in complicated ways, and it has not hitherto been possible to produce a coherent explanation.'

Dr Simon Green, a psychologist, comments:
'It does work through changes in brain chemistry, but comparing this favourably with the current generation of pharmacologically specific drugs would be similar to the assumption that a broken television could be mended as readily with a sledgehammer as with a screwdriver: you might jog the right bit.'

The electrical activity in the brain that ECT causes is accompanied by increases in blood flow, oxygen levels and use of glucose in the brain. The blood-brain barrier also becomes more permeable during ECT. (The blood-brain barrier is a physiological mechanism, which acts to prevent a large number of substances from crossing the protective cell membranes and entering the brain cells. It also becomes more permeable as a result of stress.)

Brain damage
Other psychiatrists believe that ECT works through causing brain damage. People may experience a temporary lifting of mood after ECT, but this can be explained by post-traumatic euphoria, which typically follows head injury. This causes amnesia, denial, euphoria, wide and unpredictable mood swings, helplessness, submissiveness, confusion and disorientation.

Dr Peter Breggin, a well-known critic of modern psychiatry, has reviewed the research conducted on ECT and concluded that it was the brain damage caused by ECT which explained its so-called 'effectiveness'. Ironically, a leading supporter of ECT in the USA, Dr Max Fink, has also blatantly stated that where there is no evidence of brain damage, there is no improvement:
'Where there is no evidence of impaired mental function and no electroencephalographic alteration [changes in recorded brain waves] clinical improvement does not occur.'

Does it save lives?
'It was a life-saver to me, as I was very depressed and highly suicidal.'
(Woman, Wiltshire, ECT six or more years ago.)

ECT does sometimes prevent death when someone is profoundly depressed, no longer eating or drinking, and in a critical state. But there is no good evidence that ECT prevents suicide. Even a paper (by David Avery and George Winokur) often cited in support of the view that ECT prevents suicide, had to conclude that, in their study, treatment was not shown to affect the suicide rate. Other studies have shown that psychiatric hospital admission can increase the risk of suicide.

(If you know someone who is feeling suicidal, you can help by just being there and listening in an accepting way. Discuss strategies for seeking help when suicidal thoughts occur. Creating a personal support list is a useful way of reviewing every conceivable option. Persuade the person to keep, by the phone, a list of individuals, helplines, organisations and professionals they can call when they are feeling suicidal. See Useful organisations, and Mind's booklet, How to Help Someone Who is Suicidal)

What do users say about ECT?
'The effect of the treatment was amazing. All psychotic thoughts diminished, and I started to feel as if I was finally being lifted from the big, black hole I had been in. I honestly believe that, had I not received ECT, I would not be living the full, happy and healthy life that I am living today.'
(Woman, Hertfordshire, ECT in the last two years.)

'Under no circumstances would I choose to have ECT. I would rather go down fighting than submit to that abomination.'
(Woman, no area given, ECT six or more years ago.)

'It just seems to help me out of my depressed state of mind very quickly.'
(Man, no area given, ECT three to five years ago.)

'It was hell on earth.'
(Woman, Dorset, ECT three to five years ago.)

There is a wide split among people who have had ECT about how helpful it is. In Mind' s 2001 survey, of all those asked:

29 per cent found the treatment helpful or very helpful in the short term (within the first six weeks)
36 per cent found it unhelpful, damaging or severely damaging.
Among those who had received ECT more recently, the results were the opposite:

36 per cent found the treatment helpful or very helpful in the short term
27 per cent found it unhelpful, damaging or severely damaging.
Over the longer term, a much higher percentage rated the treatment as unhelpful, damaging or severely damaging:

63.5 per cent of all those asked
43 per cent of those who had treatment in the last two years.
Over the longer term, a much higher percentage rated the treatment as unhelpful, damaging or severely damaging:

63.5 per cent of all those asked
43 per cent of those who had treatment in the last two years.

What are the adverse effects of ECT?
Psychiatry recognises the following risks of ECT: 'Each application inevitably leads to a variable period of drowsiness, confusion and anterograde amnesia [forgetting new information], commonly causes headache and nausea, and may lead to the occasional loss of personal memories; moreover each application inevitably requires a brief anaesthetic that involves additional risks of morbidity and mortality [illness or death] that are slight, but never negligible.'

In its appraisal document on ECT, NICE says that cognitive impairment happens immediately after each session, as well as following a course of treatment.

Both critics and supporters have suggested that ECT works through causing brain damage, or 'acute organic brain syndrome' (see above). Some of the symptoms listed above may subside quickly, but memory loss, apathy (emotional blunting), learning difficulties, and loss of creativity, drive and energy may last for weeks, months, or even permanently.

Loss of memory
Memory loss can mean losing both good and bad personal memories, and having difficulty remembering new information. (It is, perhaps, worth noting that people with epilepsy experience memory loss after a fit.)

Comments recorded in Minds 2001 survey suggested that psychiatrists seriously underestimate the potential extent and devastating effects of memory loss in some people:
Permanent loss of reading and numeracy skills.'
(Man, West Midlands.)

I dont play the piano, organ or violin any more, as I cant remember how to. It seems my long-term memory has gone forever. Memories from my past five years, and more, have become either vague or have gone.'
(Man, Berkshire.)

I qualified as a maths teacher. Following all this ECT, I have no understanding of the maths concepts used in my further education courses, or even O-level standard.'
(Woman, Cleveland.)

I can remember hardly anything about my past life, only very little bits. As for bringing up my three daughters, I cant remember a thing.'
(Woman, Yorkshire.)

According to The ECT Handbook:
The evidence suggests that neither new learning, nor memory for information from the past, are permanently impaired. Objective memory impairment (on specific memory tests) is reversible. Some patients may, however, be left with discrete memory gaps for specific autobiographical events, the explanation for which is unclear.'

However, psychiatric research reflects users' reports that memory loss can persist, and that this is different from the memory loss caused by depression. In one study, more than half of the patients (55 per cent) felt that they had not regained normal memory function, three years after receiving ECT.

An American psychologist conducted detailed autobiographical interviews with 19 people who were about to have ECT, and with a control group who did not have ECT. He then questioned both groups about the same information afterwards. He found that all the 19 patients showed a number of instances of forgetting their former memories, unlike the control group whose memories were unchanged. He followed up half of the ECT patients a year later, and there had been no return of the lost memories.

In another study, it was reported that memory complaints are common six to nine months after bilateral ECT, and were reported by 60 to 70 per cent of patients interviewed.

Bilateral versus unilateral ECT
Research indicates that the two ECT techniques carry different risks of memory impairment. It seems that bilateral ECT causes more severe memory loss than unilateral. In unilateral ECT, the electrodes are applied to the non-dominant side of the brain, to focus energy away from the speech centre. (The speech centre is usually on the left-hand side in right-handed people, but not always.)

Peter Breggin has criticised the theory that unilateral ECT is a less harmful procedure. He points out that non-dominant brain functions include:
'the creative faculties, such as imagination, and the use of metaphor; visual and spatial capacities, as well as musical and motor abilities, such as coordination, dance and athletics; the quality or vibrancy of personality; initiative and autonomy; and insight.'

Other critics have commented that unilateral ECT:
'assumes that one side of the brain is less valuable than the other. Humanistic psychologists would not agree. Instead, they might argue that the non-dominant side is essential to creativity. The placing of the electrodes unilaterally increases the concentration of current in one part of the brain, and the damage to this part is more severe than in bilateral ECT. EEG results one month after unilateral ECT confirm that it is possible to detect which side of the brain is damaged.'

The emotional impact
The emotional and psychological effects of ECT are under-estimated and under-researched. A report from the USA points out that studies measure successful outcome in terms of symptom-reduction, rather than quality of life and social functioning.

Many people feel abused by the treatment:
'I felt very much that I was being punished for not coping and being out of work.
I still feel this. I felt empty and numb.'
(Woman, Birmingham.)

'I was an outgoing, fairly confident person, and now I feel worthless and scared.'
(Woman, England.)

'ECT was done to me, not done for me. Thats the total sense of how it felt. It paralleled sexual abuse, which I experienced as a child. Someone doing something to my body against my will.'
(Woman, Surrey.)

In depression, some people may feel guilt-ridden, and believe they are evil or harmful to others. They may see ECT as being a deserved punishment, and it can confirm the very feelings of worthlessness that characterise depression. In Minds 2001 survey, 22 per cent of recent recipients felt that they were being punished.

Physical injury
Injuries to teeth and mouth are risks associated with ECT, because the electrical stimulus contracts the jaw muscles, bypassing the muscle relaxant. High stresses are produced during the forceful closure of the jaws, and tooth damage or loss may result, in spite of the use of mouth guards.

Spontaneous seizures following a course of ECT are rare, and not more common than in the general population. They were reported by one per cent of the respondents to Minds 2001 survey.

Death following ECT is relatively uncommon, but does happen. Its been estimated that the risk is about 4.5 deaths per 100,000 treatments, or four or five among 16,700 patients. This is no higher than the risk associated with having a general anaesthetic.

Side effects mentioned in Mind's 2001 survey
Not everyone feels damaged by ECT, but for those who do, the feelings can be devastating. Minds 2001 survey was not scientific research, but does reflect the experiences of 418 people, one third of whom found ECT helpful.

The following short-term side effects (lasting up to six weeks) were reported. (They are listed, here, in order of frequency, with the most frequent first):

headaches
drowsiness
confusion
loss of past memories
dizziness
disorientation in time or space
difficulty concentrating
inability to remember new information
suicidal tendencies after the treatment
apathy
inability to recognise people
loss of reasoning ability
fear and anxiety
feelings of helplessness
sense of betrayal
visual problems
loss of previous skills (reading, music, languages)
sleep problems
feelings of worthlessness
neck or back pain
loss of creativity
epileptic seizures
sexual difficulties.
Permanent side effects, again in order of frequency, were:

loss of past memories
difficulty concentrating
fear or anxiety
inability to remember new information
feelings of worthlessness
feelings of helplessness
sense of betrayal
loss of previous skills
loss of creativity
suicidal tendencies after the treatment
loss of reasoning ability
sleep problems
confusion
apathy
headaches
inability to recognise people
disorientation in time and space
personality changes
neck or back pain
visual problems
sexual difficulties
drowsiness
muscle ache
dizziness
nausea
epilepsy.

Cause for concern
Muscle relaxants prevent broken bones and sedate the brain, making it more difficult to induce a seizure. The voltage has to be increased to reach the threshold. Patients are often taking psychiatric drugs, which also raise the threshold. The Royal College of Psychiatrists has stressed the dangers of this and called for more research.

What are the added risks for older people?
There are additional concerns in using ECT for older people, as there are with many medical procedures. The risks of treatment include an increased chance of heart problems, stroke and falls. The effect on an ageing brain is also recognised as potentially more damaging, with a greater possibility of memory loss.

Older people will be at much higher risk of dying than younger ones, but this age group is seen as more likely to be at risk of dying from the inability to eat or drink during severe depression, and so the benefits are seen as outweighing the risks.

ECT is sometimes considered less risky for the elderly than taking tricyclic antidepressants, which can have an adverse effect on the cardiovascular system. Opinion is divided about whether the newer SSRI drugs are any better. A survey of psychiatrists working with elderly people found that those who did choose the newer drugs often did so because of cardiovascular risk. Some psychiatrists believe that, since these antidepressants are so much safer, there is now no reason to choose ECT rather than drug treatment for elderly patients.

Antidepressants and ECT are not the only possible responses to depression. There is a body of knowledge and expertise in counselling and psychotherapy with elderly people, but these approaches are under-used.

What are the alternatives to ECT?
There are many possible causes of depression, including life events, and psychological, social, biochemical and genetic factors. All of these interact to some degree. There are, consequently, various approaches to treatment. If the guidelines of the Royal College of Psychiatrists are being followed, you will only be offered ECT (in most cases) if you have tried other treatments and found them unsuccessful, unhelpful or unacceptable.

Most psychiatrists take a primarily biochemical approach to treatment, and offer antidepressant drugs. If these do not work, they then suggest ECT. They will not always try all the available types of drugs, nor will they always consider other approaches, such as talking treatments, arts therapies, and other alternatives or additions to medication.

The problem with treating depression in this way, as an illness with a biological basis, is that it often follows a stressful life event, such as bereavement, divorce or redundancy. People need time and space to make sense of their pain, and come to terms with loss. ECT seems inappropriate in such situations, unless the person has become morbidly preoccupied with the traumatic event, and buried in depression that looks unlikely to lift.

Antidepressant drugs
People have very varied responses to medication. But there are different types of antidepressant available, and you may need to try several before finding one that works. Information about all of the different antidepressants currently prescribed in the UK is available in Making Sense of Antidepressants .

Talking treatments
Your GP is a good starting point for exploring psychotherapy and counselling, which can help you to deal with the problems underlying and surrounding your depression. The treatment works by providing an opportunity for you to talk, in a way that assists you to understand yourself better. It can then help you to work out a more positive and constructive way of living. Increasing numbers of GPs are employing counsellors in their practices, but if not, they should be able to refer you to other sources of psychotherapy or counselling. Your local Mind associations may offer free, or low-cost, talking treatments.

Cognitive behaviour therapy (CBT) is a practical, short-term aid to helping someone to cope with depression. A person's thoughts have a powerful impact on their feelings and behaviour, and it's possible for someone to think themselves into a state of extreme distress. But it's also possible to do the opposite, and challenge negative thought patterns that feed depression.

If you think you might be interested in CBT, talk to your GP about getting a referral to a clinical psychologist. (See Mind's booklets, Understanding Talking Treatments , Understanding Depression  and Making Sense of Cognitive Behaviour Therapy )

Arts therapies
Therapies using art, music, drama, dance or creative writing may be very powerful in helping to lift depression. Even someone who is so profoundly depressed they can't speak may be moved by music or poetry, which then begins a process of recovery. These therapies are available in some psychiatric units and community mental health facilities. (See Useful organisations.)

Complementary therapies
Complementary and alternative therapies have proved to be particularly helpful when people are experiencing stress-related symptoms, anxiety and depression. They can help people relax and feel better. Complementary therapists stress the connection between mind and body, and are not concerned with merely treating symptoms. There are many different therapies, including homeopathy, herbal medicine, acupuncture, aromatherapy, meditation, reflexology, neurolinguistic programming, and various types of massage. (For further information, see Further reading.)

Physical activity
Physical activity has proved to be very beneficial when tackling problems like depression. It works by changing levels of chemicals in the body that influence mood. (For more information, see The Mind Guide to Physical Activity .)

Self-help groups
Many people experiencing emotional distress find it helpful to share their feelings with others going through similar difficulties. There are self-help organisations for people suffering from depression. (See Mind's booklet Understanding Depression , and Useful organisations. Or ask at your local Mind group.)

Transcranial magnetic stimulation (TMS)
In the last 10 to 15 years, interest has grown in this new technique. Neurologists have been using TMS as a research tool for some time, and it seems clear that it may be useful for treating depression. Some researchers feel that it may be an alternative to ECT.

It involves creating magnetic fields through an insulated coil conducting an electric current, which is placed on the surface of the scalp. Rapidly changing magnetic fields cause electrical currents to flow within the brain. This affects the nerve function, without causing an epileptic fit. The technique has been investigated in various ways, by using different positions of the coil, by stimulating different areas of the brain, and by changing the signal frequencies, for example.

The first trials of TMS for depression used only small, selected groups of patients, with no control group for comparison. As a result, it was not clear whether this was really an effective treatment for depression. More recent research continues to suggest that it may become an alternative to ECT.

It is considered to be a safe procedure. The most important safety concern is the risk of seizures, but no seizures have been reported since the introduction of guidelines for safe use of the technique. This may seem a strange concern, given that ECT is considered to have failed if it does not cause a seizure. But, if similar results can be achieved without seizure, it would be a great advantage. There may be some local scalp pain or headache at the time of treatment, but there have been no reports of harmful effects.

The technique is still being researched, and is not yet available as a treatment.

Vagus nerve stimulation (VNS)
VNS was initially developed for treating epilepsy, but has been tried for depression in the last few years. It involves placing an electronic device under the skin in the left chest wall, with an electrode connecting it to the left vagus nerve in the neck. Putting the device in place takes about an hour. Once working, it sends mild, electrical pulses to the nerve, at intervals.

Side effects can occur, but usually only when the stimulation is on. They include voice alteration, shortness of breath, neck discomfort, and coughing, all of which apparently diminish over time. It's reported to lift depression, and is available in various centres throughout Europe, including the UK.

What are the pros and cons of ECT?
People's experience of ECT varies enormously. It's a short-term treatment, which can't directly address underlying despair or practical problems, and does not prevent future depression. Memory problems are widely reported, though for some people they are only temporary. Some people also feel violated by ECT.

However, ECT can lift depression, and the speed of response may be an important consideration, for instance in preventing kidney failure in someone who is not eating or drinking. ECT may help people enough for them to begin looking for a different solution. Some people feel that after ECT they are better able to make use of other forms of treatment and support.

One service user, who has commented favourably on his ECT treatment, makes the point that ECT, on its own, is not enough: 'On more than one occasion in my life, the intervention of ECT has been beneficial and not damaging. The initial help given, it's been all the more possible to gain from the skills and the patience of a clinical psychologist. It is true that ECT should not be used to excess, and it is also true that usually more than ECT is needed. But the different therapies and treatments can, and should, be seen as complementary, rather than in competition.'

Questions to ask your doctor
If ECT is recommended, you should ask the following questions:

What is the reason for suggesting ECT?
What are the risks associated with ECT?
How could ECT help me?
What are the side effects?
Are there any long-term effects?
Has every alternative treatment been tried, including different drug treatments, or talking treatments?
What treatment will be offered in addition to, and after, ECT?
What is the risk of physical deterioration or suicide?
How many treatments are proposed?
Is unilateral or bilateral ECT proposed?
How will the dosage be decided?

Useful organisations

Massage

What is massage?

The essential element across all kinds of massage is touch, a basic way of making contact with others, which we all need. For a baby, nurturing touch is essential for growth and development. If a child falls over, we instinctively rub it better. Massage uses touch in a sensitive and respectful way, with the intention of promoting a sense of wellbeing in the receiver.

This means the therapist takes account not just of your physical symptoms, but of your mental, emotional and spiritual being, and the circumstances under which you live your life. For instance, if you have no housing and are unemployed, this could affect your physical and mental health. Understanding the context in which problems develop is as important as looking for the symptoms.

A holistic approach is often seen as being the very opposite of conventional medicine, but not all complementary therapists work holistically, and conventional medicine can be practised in a holistic way.

Massage therapies are often described as being complementary or alternative. Complementary means a therapy that can be used in addition to, or alongside, conventional medicine. Alternative means a therapy that claims to be a complete system, which can be used instead of orthodox medicine. In practice, all forms of massage can be, and are, used on their own or alongside Western medical treatments. For the future, there are moves towards integrated medicine, including the best of both worlds.

Complementary and alternative approaches share a belief in the bodys ability to heal itself. Treatments are non-invasive, without unpleasant side effects, and the practitioner commits more time to the client than a GP is usually able to do. The quality of the relationship between therapist and client is important. Its a relationship based on trust, and is about being with rather than doing something to the client.

Massage practitioners are sometimes called bodyworkers. Western science tends to foster a split between body and mind, but complementary therapists often try to reunite them as one, with the concept of a bodymind. Practitioners believe that we are creatures whose mind and emotions are embodied in our physical existence. It follows that our memories and personal histories are also in our bodies, which is one reason why touch, in massage, can be both powerful and helpful.

What different kinds of massage are there?

Massage with oils
This is sometimes called Swedish massage. Various techniques such as stroking, friction and percussion are used to knead and stretch the soft tissues of the body.

Aromatherapy massage
This is usually a gentle massage, using essential oils from plants, because they have specific therapeutic purposes. Essential oils are chemically complex and very concentrated. For massage, they are usually diluted with a nut or vegetable oil, such as almond.

Shiatsu
Coming from Japan, this traditional massage works, like acupuncture, by stimulating and balancing the bodys energy flow along 'meridians' or energy pathways. The practitioner uses techniques such as holding, pressing, and stretching, to balance Ki or Qi (energy) in the body.

Thai yoga
Another traditional massage, this time based on Indian and Thai forms. It consists of a flowing sequence of stretching and pressing on energy pathways in the body, using hand, arm, thumb and foot pressure. The treatment includes passive yoga stretches.

Reflexology
Reflexology is based on the principles of zone therapy (similar to the meridians or energy pathways) and the theory that every organ and system of the body has a counterpart in reflex points in the feet and hands. Practitioners work largely on the feet.

On-site massage
A quick treatment, typically given in offices, which focuses on muscles and acupressure points on the back, arms, neck and head. Wearing normal clothes, you would usually sit leaning forward on a special chair, which supports you comfortably.

These are the most common types, but you may also hear of Indian head massage, Bowen, Hellerwork, Rolfing, Trager, biodynamic massage, pulsing and sports or remedial massage, among others. Practitioners may combine different types.

Your choice of massage will probably depend on convenience, cost and friends recommendations. And you may need to try several kinds before you find a type of massage and a practitioner that suit you.

Will I have to undress?

For massage with oils, including aromatherapy, you will need to take off some clothes. How much depends on what feels comfortable for you. Your privacy should always be respected. The practitioner will usually leave the room while you undress, and should give you a large towel to drape around your body. During the massage, you will be covered with towels, except for the part being massaged. Normally, to have a massage with oils, you would lie on a massage table or couch. You can ask to have only your neck and shoulders, or back massaged if you want to try out how massage feels.

You dont have to undress for reflexology, but you need to have bare feet. You will be treated while on a massage table, or in a special chair. For Shiatsu and Thai massage, you wear loose clothes, and lie on a mat or futon on the floor.

What happens in a massage session?

Sessions can last for anything between 20 and 90 minutes, depending on the type of massage. One hour is typical. At your first appointment, the practitioner will ask about your current and past illnesses, accidents or surgery, and whether you are taking any medication. Such information is confidential.

Its part of the therapists job to make you comfortable, by using supports for your head or neck, or a cushion under your knees to help support your lower back. The room should also be kept warm.

If there are parts of your body where you prefer not to be touched, tell the practitioner. For instance, the belly is a sensitive area where many people feel vulnerable. A therapist should never touch the genital area, or a womans breasts. But the lower back, buttocks and thighs are normally included in a whole-body massage.

The therapist may have soft music playing in the treatment room. This helps some clients let go of worries or negative thoughts. Others find music distracting, so tell the practitioner if you dont want it.

The massage often starts with the practitioner gently placing their hands on your back, head or feet for a few moments. From this connection, an aware practitioner will gain information that will help them give you a treatment that is right for you.

For people who have had negative experiences of touch in the past, such as physical punishment or sexual abuse, a massage may stir up painful memories. You might start crying, or want to stop the massage. Clients who have been abused may find it difficult to ask the therapist to stop. If this applies to you, you could discuss with your therapist a pre-arranged signal, such as raising your hand or using a neutral word like tree, which will tell them that you want to stop the treatment. A good practitioner will help you through this process if it occurs. Knowing that you are in a safe place, with clear, professional boundaries, will make it easier to cope with your reactions.

The practitioner will often ask for feedback, such as, Hows the pressure? Is it too light, too strong, or about right? If you have massage regularly, your response to this question will vary, according to your state of health and energy levels. The practitioner may encourage you to take a more active part in the treatment, for instance by suggesting how you can breathe more slowly.

Its not necessary to chat during a session, and you are more likely to benefit if you can quietly focus on your breathing and bodily sensations. You may find it more relaxing with your eyes shut, but if you are troubled by upsetting thoughts, having your eyes open may be a kind of reality check to help root you.

Sometimes the therapist will touch an area that feels sore, but also feels as if it needs to be held or pressed. This is sometimes called nice pain, or good pain. Before you get up, take time to notice how you are feeling and what feels different.

What are the benefits of massage? How does it help?

Having a treatment can be part of how you look after yourself, and can help you discover what deep relaxation feels like. A common effect is a balancing one. If you are feeling agitated, it will help to calm you. If you are tired and lethargic, it will make you feel lighter and more energetic. If you are in severe distress, massage can help you feel more in your body and grounded.

Emotionally, massage enables you to feel nurtured and cared for, and can help you feel more positive about your body. For those who lack physical touch in their daily lives, for instance many elderly people, massage can be affirming and nourishing. If you find talking about yourself difficult, bodywork is another way that could help you explore how you are feeling.

On a physical level, massage actively promotes the circulation of blood and lymph through the body, aids digestion, and alleviates chronic muscle tension. It helps with the symptoms of anxiety and panic, such as palpitations, a tight chest, and shallow breathing.

It may also relieve some of the side effects of medication. Massage is good at times when orthodox medicine has little to offer, for example for relieving headaches, backache and other chronic pain.

Shiatsu and Thai massage are especially good for loosening stiff joints, such as shoulders and hips, because treatments include passive stretches and joint rotations.

When will I start to feel the benefits?

Because the treatment is individually tailored to your needs at the time, massage helps bring you into a more balanced, tranquil state. It can be both calming and stimulating, so that you may notice sluggish areas feel more active, and busy areas quieter. Many people report sleeping better after a treatment.

After a massage, while toxins are shifting out of your system, you may experience mild flu-like symptoms or aches. This is a healing reaction, and wont last long. Drinking plenty of water after a treatment will help to cleanse your system.

The longer-term benefits of regular treatments include becoming more aware of your own body and its needs. You can learn to notice the signs of stress in your body sooner, and find new ways of coping with, or preventing illness. Massage can help you build up your self-esteem through recognising that you deserve to receive something good for yourself. Your therapist may suggest self-help exercises to improve your posture or relieve back pain.

How often should I have a massage?

This will depend on each persons particular circumstances, their health, and their finances. Even a one-off or occasional massage can be helpful, and may put you in touch with your own body in a way that could lead you towards other activities, such as meditation, yoga or tai chi. A massage once a month is good, if you can afford it.

Is massage always helpful?

If you are generally healthy, massage can help maintain good physical and mental health. If there are times when you are unwell, massage may or may not be a good idea.

Many people who have used mental health services recognise their own early signs of illness or crisis. At this stage, its important to seek known sources of support, which could include massage, especially if you have benefited from it before. If you are in mental health crisis, for instance feeling suicidal, wanting to self-harm, or hearing voices, whether massage can help will depend partly on your personal situation. Are you in a place where you feel safe and supported? This could be a residential project or a day centre, or at home with a good level of support from people you trust. If so, massage may be helpful. If youre not sure, or if you live alone and are in distress, without much support, its better to wait until you are through the acute phase of your crisis.

If you are physically ill, it may not be wise to have a massage. If you have a fracture, sprain or bruises, its fine as long as you avoid the site of the injury. If in doubt, ask your practitioner or GP.

Massage in pregnancy is unlikely to be harmful, though many practitioners will not treat women in the first 13 weeks of pregnancy, because of the risk of miscarriage. In later pregnancy, massage can relieve back pain, sciatica and general tiredness.

How do I find a practitioner?

A good way is by word of mouth. Ask your friends or colleagues if they can recommend someone. You could approach a therapist and ask to speak to an existing client. Or you could ask a friend to go with you the first time, or meet you afterwards.

Remember that massage is an unregulated profession, so you need to be aware of safety issues. Unfortunately, there have been cases of clients being exploited, sexually and emotionally, by therapists. Making a complaint is usually a long process, and may not achieve the redress the abused client seeks.

When making contact with a therapist, trust your gut instinct, or share your doubts with a friend. If it doesnt feel right, take your custom elsewhere. Recent governments have encouraged massage schools to develop their own self-regulation, and this is happening, although its a slow process. Organisations such as the British Complementary Medicine Association will give out names to enquirers.

Practitioners should have completed a training of at least a year. They should have insurance, and should, preferably, be registered with a body that has a code of ethics and a complaints procedure. Its fine to ask about any of these, and a reputable therapist will be glad to answer your questions. Its also fine to ask if a practitioner has specialist experience, for instance in working with people who have disabilities, or mental health needs.

A good practitioner will be aware of the limits of her or his competence, and should refer you on elsewhere, if they are unable to help you. Beware of any massage therapist claiming in a leaflet, for example, to cure psychological or medical problems. Such claims cant be backed up and are not ethical.

How much will it cost?

A private practitioner will charge ?30 to ?40. Thai massage appointments are often for one-and-a-half hours; expect to pay ?40 to ?50. On-site massage takes around 20 minutes, costing ?15 to ?20. Some therapists offer concessionary rates, or a reduction, if you book a series of treatments.

Access to massage within NHS mental health services is rare. Its available in a few day hospitals, inpatient wards and residential crisis projects.

Many NHS trusts are now listening, more than in the past, to the views of service users. While managers will often say there is no funding available, the more users ask for treatments like massage, the more likely it is that funding will eventually be found.

Many voluntary sector projects offer massage in day centres. Some are free, but some make a charge. Its worth checking in your area for massage or shiatsu training schools, which often have a student clinic. This has two advantages: much lower prices, and the fact that students are working under the supervision of their trainers.

Can I learn to do it myself?

You can massage most parts of your body, except the middle part of your back, which is hard to reach. One of the best things about receiving massage is that someone else is doing the work. With self-massage you have to make a certain effort, but it does have advantages. You can give yourself a quick neck and shoulder massage, while sitting at your desk at work, and you know exactly how much pressure is right for you.

Applying the techniques
The basic skills are not difficult. There are many short and introductory courses, from one day, to six or ten weeks, at adult education colleges. Courses are sometimes advertised as, Massage for friends and family. The idea is that you enrol with a friend or partner, and you learn to massage each other.

Massage is good to give as well as receive, as long as you remember a few tips:

Keep your shoulders loose and relaxed.
Use the weight of your body to create pressure, rather than just your hands.
Dont be afraid to use firm pressure.
Ask your partner for feedback. Pressure that is too light may make him or her feel uncomfortable.
Remember that long slow strokes are relaxing, while faster energetic ones, such as percussion or friction strokes, are stimulating.
Always make sure the room is warm.
There are many books on massage, including self-massage, available at public libraries and in bookshops.

Baby massage
Baby massage is a great way of spending quality time with your baby. Most children appreciate a massage at bedtime, to help them settle. Many GP practices and health centres have baby massage groups, where you meet other mothers with babies and learn simple massage techniques.

Useful Organisations

Yoga

What is yoga?

The word yoga tends to conjure up images of bodies in contorted positions, or semi-naked men sitting cross-legged, with rolled-up eyes, in a deep trance. These are powerful images, which persist in our imagination - but they are only part of a very diverse tradition, which originated in India about three thousand years ago. Less extreme forms of yoga have been widely practised in the West for at least thirty years.

Yoga is a hard word to define, because it covers a very wide range of practices. In its most general sense, it is a spiritual practice designed to increase awareness and self-knowledge, so that a person can be freed from old behaviour patterns and exercise more choice in his or her life. The exercises can lead to greater physical and mental freedom, and to greater control over the body and thought processes.

Yoga stems from the Hindu religion, but it doesnt mean that people have to share this belief to do yoga. Within it is a deep understanding of human psychology, of the link between mind and body and of the way that both mind and body work. This understanding, born of practice and experience, is universal and can be a means of health and wellbeing when adapted for use in the West.

What are the benefits of practising yoga?

Yoga can give you a sense of being grounded, balanced and centred. It can help you to relax and tackle lifes problems creatively, rather than feeling like a victim of them. As tension gets released, you will feel more energetic. It will also open up a general sense of wellbeing and optimism, improving your self-esteem and bringing greater enjoyment of your body, as it becomes more supple and fluid in its movements. You will learn to be present with your attention and to get more pleasure out of life, as you feel both more relaxed and more vital.

When you take part in a yoga class, the teacher helps you to focus awareness on your body and its relationship to the ground and the surrounding space. You will be invited to sense and to feel things, as much as to do things. So, when you make movements and assume positions, you will not be trying to make your body conform to an external shape (as in dance or gymnastics, for example). You will not be trying to impose anything on the body. Instead, you will be using the movements to explore your body from the inside, to find out where the tensions are. Gradually and patiently you will be able to release them, so that you can find a different way of moving and of being in your body, one that is more effective, more beautiful and more pleasurable. You are working from the inside out, as it were.

The very act of listening to your body and breathing, of bringing body and mind together, is deeply relaxing and energising. It is a kind of meditation. While creating more space in the body, you also create space inside the mind. The normal, constant flow of thoughts is interrupted. Even a few minutes of changing your attention level can give you a feeling of rest and renewal.

Someone who has never practised yoga in this way may find these claims surprising. But if you reflect on your daily life, you may realise just how rarely, if ever, you do anything with such integrated awareness. When busy mentally, you may well ignore your body altogether, unaware of tensions until aches and pains alert you. When physically active, you may let your mind wander  or use will power to make your body meet the demands you are making of it. This is more "mind over matter", rather than bringing mind and body together and respecting the bodys intelligence.

What is the best way to learn yoga? Yoga is best learned from a teacher. It is almost impossible to gain a good grounding from a book, because it's about developing an internal body awareness, rather than making the body conform to certain positions. But reading books can certainly help. You can enrol in one of the many classes now available, privately, or at adult education institutes and leisure centres. The advantage of joining a class is that you can learn from watching other people, and benefit from the social contact with fellow students and the atmosphere of concentration that comes from a group of people working together. However, many teachers offer one-to-one lessons. This is particularly effective, because learning yoga is such an individual process and the teacher can then give more direct, "hands-on" help. If you want to arrange personal lessons, it might be a good idea to attend a class first, to make sure you like the teacher. Beware of teachers who do not watch their students carefully or give any individual attention, or who allow beginners to try advanced postures, such as a headstand, unsupervised.

What's involved in going to classes?

Most yoga classes will include a variety of postures  lying, standing, sitting and inverted. It will also involve sometimes sitting quietly, paying attention to your breathing or some other simple meditation method, and a few minutes, at least, of total relaxation lying on the floor.

All you need to get started are some loose, comfortable clothes, such as leggings or tracksuit trousers and a t-shirt. It is very important to work with bare feet and to have nothing constricting you around the waist and pelvis. For practice at home, it can be useful to have a non-slip mat.

Ideally, you should go to a class once or twice a week, to begin with. Gradually, as you get into a routine of practice at home, you may not feel that you need to go so often. But, it's important to have guidance from a teacher on a regular basis, for some years, if you are applying yourself seriously to yoga.

How do I choose between the different types of yoga?
There are various forms of yoga taught in England and Wales. Some put more emphasis on sitting meditation, others on physical postures. Those that follow a particular teacher or guru tend to have a more traditional Indian flavour and may have a devotional nature. Some of the main schools of yoga in Britain are the British Wheel of Yoga, Iyengar yoga, Sivananda yoga, Vini yoga and an approach based on the teaching of Vanda Scaravelli.

The British Wheel is an umbrella organisation, which fosters the development of various kinds of yoga and organises events and teacher-training, nationally.
Iyengar yoga follows the very precise technique of the Indian teacher B. K. S. Iyengar. It is a fairly strenuous physical practice, combined with breathing exercises and relaxation.
Sivananda yoga, also named after its founder, teaches the classical postures and meditation practice.
Vini yoga is based on the teaching of Desikachar, the son of Krishnamacharya (Iyengars teacher). It is not unlike Iyengar yoga, coming from the same tradition, but it places more emphasis on the breath and adapting yoga practice to the individual.
Vanda Scaravelli was inspired by Iyengar and Desikachar and developed a way of working using the pull of gravity and the breath to undo tension and awaken the spine. This is still evolving, and is now continued by her students.
There are many other forms of yoga, described by many different names. Hatha yoga simply means any form of physical yoga, not a particular school of yoga. Astanga yoga - also known as power yoga - has become very popular recently, particularly with the young and fit. It combines traditional elements with a more gymnastic approach and is very strenuous, designed to build up body heat. It is for people who are already very fit.

Kundalini yoga is based in tantric tradition and aims for enlightenment through the release of energy around the spine. It also makes fairly extreme physical demands.

Whatever kind of yoga you decide to try, it is important to find a teacher you like and who seems to embody qualities you would like to find in yourself. Its also vital to trust your own instincts and judgment (particularly when you are just starting yoga) and not to continue with anything that makes you feel uncomfortable, either physically or mentally. If it makes you feel jarred, or on edge  or if it hurts you  stop.

Is doing yoga something that needs a lot of will-power?

You may need will power to go to your first class and to establish your own practice routine. After that, when you practise yoga, you should be aiming to give up the mindset of 'doing' and achieving goals that is characteristic of our education system (and our culture).

Patrick McDonald, teacher of the Alexander technique, talks of the "terrible urge to do, which nullifies sensory awareness". This applies to psychological awareness, as well. The urge "to do" comes from the ego (the sense of self) and when a person is permanently in that mode, he or she may become imprisoned and isolated in themselves, bodily and mentally. When you begin to refine the quality of your attention, letting go of the will to do, you can start to become aware of dimensions beyond the ego, within and outside of yourself. You may then feel connected to something beyond the ego, within which you can rest and from which you can draw nourishment. It is as if you are placing yourself in a wider context.

The quotation that opens this booklet is from a yoga student who was a long-term sufferer of severe ME, and eloquent about her experience of being helped by yoga. She went on to say:
"Although I was still 'only' lying down as I did the rest of the time, I inhabited my body in such a way that I no longer felt confined: imprisoned within the four walls of a room, or caged inside a body that had disowned me. I felt expanded beyond the boundaries of my body; to the elements around me  cradled by the earth below and nourished by the air above me. Simply inhaling and exhaling gave me the sense of an exchange with life, rather than feeling I had been forgotten in its darkest corner. And I felt connected to other bodies on mats around me, instead of feeling socially isolated. Normally, an ill or disabled person is defined in the negative: by not working or not doing. By non-connection to others, the 'normal' world of friends, acquaintances and colleagues is drastically reduced. But doing yoga I no longer felt a non-person. The universe began to open up within me like a great still reservoir, soothing my aching sense of smallness."

Can everyone benefit from doing yoga?

Even very stiff or unfit people can start doing yoga  and have all the more reason to do so! Because yoga is not about performance or achieving goals, every body can respond in its own time, letting go of tension, changing habits and awakening a new kind of intelligence. Even supple and fit people do not usually have access to this intelligence, initially. This is a process that takes time for everyone and is a very personal journey.

On a physical level, yoga undoes tension in the muscles. There is an immediate effect as the days tensions drop away.

Over time, the tension that has built up inside  tension you may not even be aware of, at first  also begins to dissolve. The quality of muscle tone changes, becoming softer. The muscles lengthen and become more elastic, changing the bodys shape, in a subtle yet noticeable way. The face becomes brighter and more relaxed. Many students report that practising yoga helps them to sleep better. Beginners who attend one class a week often notice that they sleep better the night after the class than they do during the rest of the week.

On the mental level, turning your attention onto your body, in the light yet precise way that yoga teaches, can disperse obsessive and repetitive thoughts. The mind can expand pleasurably, just as the body does, freeing you to see things from a different perspective. Because you are not trying "to do" but rather "to undo", you may become less judgemental of yourself and others. This can have a profoundly healing effect, psychologically.

Can yoga help me get fit?

Practising yoga wont enable you to run a mile or perform other athletic feats. But it can contribute to your aerobic fitness by improving the elasticity of your muscles, deepening your breathing and improving your circulation. Yoga complements other forms of exercise, so you may do them more easily and more efficiently.

Some people worry that doing yoga will mean losing their muscle tone. You will lose only the rigid muscle tone that prevents freedom of movement at the joints. It does not make you flabby! Your muscles will become softer to the touch and more elastic, sliding more easily over the bones, rather like a healthy animal.

Regular yoga practice can make you strong, but it is not exactly the kind of strength gained by pushing weights and training at the gym. While the large locomotive muscles of the body become softer and more elastic, deeper-lying muscles are invited to work more actively. These include the muscles close to the spine (such as the deep postural and breathing muscles). A person can then develop a sense of being strong and alive in the core of their body, and relaxed in the outer body. A healthier balance is achieved as the whole body becomes more integrated. People also engage the force of gravity and borrow strength from outside, using their muscles in a much less tiring way that feels almost boundless.

When will I start feeling the effects?

Most people feel benefits after a single session. They usually leave a class feeling better than when they arrived, sometimes dramatically so, because fatigue, backache and headaches can vanish. However, permanent changes in the body take place gradually.

Naturally, the more often you practise, the more quickly you see improvement. Most people who attend one class a week notice positive changes in the way they look and feel in their everyday life, after a few months. It is important to remember that the process cannot be hurried through will power and determination. It is about learning to be in the present, rather than striving towards a future goal. Keep practise sessions regular, short and intense; dont let them become erratic, prolonged and mechanical.

Is there anything I can practise safely on my own?

There is a very simple relaxation exercise that will refresh you and start the process of developing deeper bodily awareness. It can also greatly ease back pain.

Lie flat on the floor on a comfortable, warm surface, with your knees bent up and your feet flat on the floor. Alternatively, rest your lower legs on a bed or sofa. Make sure your body is straight.
Take hold of your head with both hands and give it a slight tug to release your neck and help your chin to drop. If your chin pokes up in the air, place a book under the back of your head (not a cushion). Cover yourself with a blanket, if you like.
Rest your hands palms down on your abdomen or, if you prefer, rest your arms on the floor a little away from your body, with palms turned upwards. Close your eyes and let them rest towards the back of your head. Relax your jaw muscles and your mouth and your tongue.
Feel your whole body letting go into the floor, as if it is spreading wider. Feel your muscles softening, as if letting go of their grip on the bones. Become aware of the rhythmical, slight rise and fall of your abdomen and solar plexus, as the breath comes in and goes out. Keep your thighs, abdominal muscles, hips and shoulders completely soft. Let the back of your waist widen and drop towards the floor, in its own time.
Rest your attention on the sensation of the breath and become familiar with its pulse, as though watching small waves breaking and receding on the beach. Stay like this for five minutes, or more, then open your eyes and roll on to your side before getting up.

Useful organisations

Eye Movement Desensitization and Reprocessing

What is EMDR?

Eye Movement Desensitization and Reprocessing (EMDR) is a psychotherapy treatment that was originally designed to alleviate the distress associated with traumatic memories (Shapiro, 1989a, 1989b). Shapiros (2001) Adaptive Information Processing model posits that EMDR facilitates the accessing and processing of traumatic memories to bring these to an adaptive resolution. After successful treatment with EMDR, affective distress is relieved, negative beliefs are reformulated, and physiological arousal is reduced. During EMDR the client attends to emotionally disturbing material in brief sequential doses while simultaneously focusing on an external stimulus. Therapist directed lateral eye movements are the most commonly used external stimulus but a variety of other stimuli including hand-tapping and audio stimulation are often used (Shapiro, 1991). Shapiro (1995) hypothesizes that EMDR facilitates the accessing of the traumatic memory network, so that information processing is enhanced, with new associations forged between the traumatic memory and more adaptive memories or information. These new associations are thought to result in complete information processing, new learning, elimination of emotional distress, and development of cognitive insights. EMDR uses a three pronged protocol: (1) the past events that have laid the groundwork for dysfunction are processed, forging new associative links with adaptive information; (2) the current circumstances that elicit distress are targeted, and internal and external triggers are desensitized; (3) imaginal templates of future events are incorporated, to assist the client in acquiring the skills needed for adaptive functioning.

What is the theoretical basis for EMDR?

Shapiro (1995) developed the Accelerated Information Processing model to describe and predict EMDRs effect. More recently, Shapiro (2001) expanded this into the Adaptive Information Processing (AIP) model to broaden its applicability. She hypothesizes that humans have an inherent information processing system that generally processes the multiple elements of experiences to an adaptive state where learning takes place. She conceptualizes memory as being stored in linked networks that are organized around the earliest related event and its associated affect. Memory networks are understood to contain related thoughts, images, emotions, and sensations. The AIP model hypothesizes that if the information related to a distressing or traumatic experience is not fully processed, the initial perceptions, emotions, and distorted thoughts will be stored as they were experienced at the time of the event. Shapiro argues that such unprocessed experiences become the basis of current dysfunctional reactions and are the cause of many mental disorders. She proposes that EMDR successfully alleviates mental disorders by processing the components of the distressing memory. These effects are thought to occur when the targeted memory is linked with other more adaptive information. When this occurs, learning takes place, and the experience is stored with appropriate emotions able to guide the person in the future.

Suggested Research. Research is needed to test predictions made by the AIP model. The hypothesis that treating etiological events will resolve core pathology could be evaluated with outcome measures evaluating personality, interpersonal qualities, affect control, and sense of identity. The hypothesis that EMDR enhances information processing can be tested by process research evaluating the in session elicitation of new material, and determining if and how this new material predicts resolution of the targeted memories.

Is EMDR a one-session cure?

No. When Shapiro (1989a) first introduced EMDR into the professional literature, she included the following caveat: It must be emphasized that the EMD procedure, as presented here, serves to desensitize the anxiety related to traumatic memories, not to eliminate all PTSD-symptomology and complications, nor to provide coping strategies to victims (p 221). In this first study, the focus was on one memory, with effects measured by changes in the Subjective Units of Disturbance (SUD) scale. The literature consistently reports similar effects for EMDR with SUD measures of in-session anxiety. Since that time, EMDR has evolved into an integrative approach that addresses the full clinical picture. Two studies (Lee, Gavriel, Drummond, Richards, & Greenwald, 2002; Rothbaum, 1997) have indicated an elimination of diagnosis of posttraumatic stress disorder (PTSD) in 83-90% of civilian participants after four to seven sessions. Other studies using participants with PTSD (e.g. Ironson, Freund, Strauss, & Williams, 2002; Scheck, Schaeffer, & Gillette, 1998; S. A. Wilson, Becker, & Tinker, 1995) have found significant decreases in a wide range of symptoms after three-four sessions. The only study (Carlson, Chemtob, Rusnak, Hedlund, & Muraoka, 1998) of combat veterans to address the multiple traumas of this population reported that 12 sessions of treatment resulted in a 77% elimination of PTSD. Clients with multiple traumas and/or complex histories of childhood abuse, neglect, and poor attachment may require more extensive therapy, including substantial preparatory work in phase two of EMDR (Korn & Leeds, 2002; Maxfield & Hyer, 2002; Shapiro, 2001).

Suggested research. It is recommended that outcome studies compare EMDR to other PTSD treatments using the complete three pronged protocol (described above) and 12 or more sessions, with a session by session evaluation of recovery patterns. A wide range of psychometrics should be used to evaluate the process of change in overt symptoms, quality of life, and personal development parameters. An evaluation of client factors, such as trauma history, should be analyzed to determine their possible effect on treatment length and course.

Is EMDR an efficacious treatment for PTSD?

Yes. EMDR is the most researched psychotherapeutic treatment for PTSD. Twenty controlled outcome studies have investigated the efficacy of EMDR in PTSD treatment. Sixteen of these have been published, and the preliminary findings of four have been presented at conferences. Studies using waitlist controls found EMDR superior; six studies compared EMDR to treatments such as biofeedback relaxation (Carlson et al., 1998), active listening (Scheck et al., 1998), standard care (group therapy) in a VA hospital (Boudewyns & Hyer, 1996), and standard care (various forms of individual therapy) in a Kaiser HMO facility (Marcus, Marquis, & Sakai, 1997). These studies all found EMDR superior to the control condition on measures of posttraumatic stress.

Seven randomized clinical trials have compared EMDR to exposure therapies (Ironson et al., 2002; McFarlane, 2000; Rothbaum, 2001; Thordarson et al., 2001; Vaughan et al., 1994) and to cognitive therapies plus exposure (Lee et al., 2002; Power et al., 2002). These studies have found EMDR and the cognitive/behavioral (CBT) control to be relatively equivalent, with a superiority in two studies for EMDR on measures of PTSD intrusive symptoms, and for CBT in the study by Taylor and colleagues Taylor, Thordarson, and Maxfield (2002) on PTSD symptoms of intrusion and avoidance. There were two controlled studies without randomization; one (Devilly & Spence, 1999) found the CBT condition superior to EMDR and the other (Sprang, 2001) found EMDR superior to the CBT control on multiple measures.
Two studies found EMDR to be more efficient than the CBT control condition, with EMDR using fewer treatment sessions to achieve effects (Ironson et al., 2002; Power et al., 2002). Two studies that compared treatment response on a session-by-session basis (Thordarson et al., 2001) and at mid-point (Rothbaum, 2001), reported that EMDR did not result in more rapid treatment effects than exposure. However, in both these studies the exposure treatment sessions were supplemented with one hour of daily homework, while the EMDR condition was implemented without homework. The only study to control for the ancillary effects of homework (Ironson et al., 2002) supplemented both exposure and EMDR treatments with the same number of hours of exposure homework (see above). Most studies noted that because EMDR has minimal homework requirements the overall treatment time was much shorter for EMDR (e.g., Lee et al., 2002; Vaughan et al., 1994). Treatment effects have generally been well maintained (see below).

The efficacy of EMDR in the treatment of PTSD is now well recognized. In 1998, independent reviewers (Chambless et al., 1998) for the APA Division of Clinical Psychology placed EMDR, exposure therapy, and stress inoculation therapy on a list of empirically supported treatments, as probably efficacious ; no other therapies for any form of PTSD were judged to be empirically supported by controlled research. In 2000, after the examination of additional published controlled studies, the treatment guidelines of the International Society for Traumatic Stress Studies gave EMDR an A/B rating (Chemtob, Tolin, van der Kolk, & Pitman, 2000) and EMDR was found efficacious for PTSD. The United Kingdom Department of Health (2001) has also listed EMDR as an efficacious treatment for PTSD.

Foa, Riggs, Massie, and Yarczower (1995) suggested that exposure therapy may not be very effective with clients whose prominent affect is anger, guilt, or shame. Reports by clinicians treating combat veterans (e.g., Lipke,1999; Silver & Rogers, 2002) indicate that EMDR may be effective with such PTSD presentations. A preliminary study found that EMDR reduced symptoms of guilt in combat-related PTSD (Cerone, 2000). Taylor et al. (2002) reported equivalent and significant effects for exposure therapy and EMDR on reducing symptoms of anger and guilt.

Suggested research. Although EMDR and CBT treatments are relatively equivalent in the treatment of PTSD symptoms, comparisons of both clinical and client factors are recommended. This includes the comprehensive evaluation of clinical factors such as length of treatment, attrition, maintenance, and generalization of effects, and the assessment of client factors such as symptom severity, affective presentation, comorbid disorders, and the presence of complex PTSD. Additional research in actual field settings are suggested to increase external validity. Specific attention should be paid to the client compliance (Scott & Stradling, 1997) and the effects of various treatments on the therapists (see Marks et al., 1998). It is also recommended that a wide range of psychometrics evaluating more than simple symptom reduction be included.

Are treatment effects maintained over time?

Twelve studies with PTSD populations assessed treatment maintenance by analyzing differences in outcome between post-treatment and follow-up. Follow-up times have varied and include periods of 3, 4, 9, 15 months, and 5 years after treatment. Treatment effects were maintained in eight of the nine studies with civilian participants; one study (Devilly & Spence, 1999) reported a trend for deterioration. Of the three studies with combat veteran participants only one (Carlson et al., 1998) provided a full course of treatment (12 sessions). This study found that treatment effects were maintained at 9 months. The other two studies provided limited treatment: Devilly, Spence and Rapee (1998) provided two sessions and moderate effects at post-test were not maintained at follow-up. Pitman et al. (1996) treated only two of multiple traumatic memories, and treatment effects were not maintained at 5 year follow-up (Macklin et al., 2000). It appears that the provision of limited treatment may be inadequate to fully treat the disorder, resulting in remission of the partial effects originally achieved.

Suggested research. Future research should investigate whether any client factor (e.g., symptom severity, affective presentation, comorbid disorders, complex PTSD) predicts sustained effects. An assessment of treatment factors (e.g., length of preparation, length of treatment, treatment compliance, treatment response, symptom reduction) would also assist in the evaluation of the maintenance of effects. It is further recommended that studies use longer follow-up periods to better ascertain the long-term effects of treatment.

Is EMDR effective in the treatment of phobias, panic disorder, or agoraphobia?

There is much anecdotal information that EMDR is effective in the treatment of specific phobias. Unfortunately, the research that has investigated EMDR treatment of phobias, panic disorder, and agoraphobia has failed to find strong empirical support for such applications. Although these results are due in part to methodological limitations in the various studies, it is also possible that EMDR may not be consistently effective with these disorders. De Jongh, Ten Broeke, and Renssen (1999) suggest that since EMDR is a treatment for distressing memories and related pathologies, it may be most effective in treating anxiety disorders which follow a traumatic experience (e.g., dog phobia after a dog bite), and less effective for those of unknown onset (e.g., snake phobia).

There have been several randomized clinical trials assessing EMDR treatment of spider phobia (Muris & Merckelbach, 1997; Muris, Merckelbach, van Haaften, & Nayer, 1997; Muris, Merkelbach, Holdrinet, & Sijsenaar, 1998). These studies indicated that EMDR was less effective than in vivo exposure therapy in eliminating the phobia. Methodological limitations of these studies include failure to use the full EMDR treatment protocol (see Shapiro, 1999) and confounding of effects, by using the exposure treatment protocol as the post-treatment assessment. When the full EMDR phobia protocol was used in case studies with medical and dental phobias (De Jongh et al., 1999; De Jongh, van den Oord, & Ten Broeke, 2002), good results were achieved.

Clinical utility is an important consideration in treatment selection. The application of in vivo exposure may be impractical for clinicians who do not have easy access to feared objects (e.g., spiders) in their office settings; some phobias are limited to specific events (e.g., thunderstorms) or places (e.g., bridges). EMDR may be a more practical treatment than in vivo exposure, and the in vivo aspect can often be added as homework (De Jongh et al., 1999).

There have been three studies that investigated EMDR treatment of panic disorder with/out agoraphobia. The first two studies were preliminary (Feske & Goldstein, 1997;Goldstein & Feske, 1994) and provided a short course (six sessions) of treatment for panic disorder. The results were promising, but limited by the short course of treatment. Feske and Goldstein write, Even 10 to 16 sessions of the most powerful treatments rarely result in a normalization of panic symptoms, especially when these are complicated by agoraphobia (p. 1034). The EMDR effects were generally maintained at follow-up. A third study (Goldstein et al., 2000) was conducted to assess the benefits of a longer treatment course. This study however changed the target population and treated agoraphobic patients. Participants suffering from Panic Disorder with Agoraphobia did not respond well to EMDR. Goldstein (quoted in Shapiro, 2001) suggests that these participants needed more extensive preparation, than was provided in the study, to develop anxiety tolerance. The authors suggest that EMDR may not be as effective as CBT in the treatment of panic disorder with/out agoraphobia; however no direct comparison studies have yet been conducted.

Suggested research. Studies are needed to make direct comparisons of EMDR and CBT in the treatment of panic disorder with/out agoraphobia. It is recommended that randomized clinical trials evaluate EMDRs efficacy in the treatment of traumatic phobias. Future studies could determine if there are any phobia populations for which EMDR treatment is inappropriate. The possibility that a combination of EMDR and in vivo exposure together may be more effective than either alone, should be investigated, with regards to outcome, efficiency, and attrition. In the treatment of agoraphobia, future research could examine the utility of developing anxiety tolerance prior to EMDR treatment. Appropriate fidelity should be assessed to include procedural adherence and the incorporation of the full phobia protocol (Shapiro, 2001).

Is EMDR applied to every clinical disorder?

No. EMDR was developed as a treatment for traumatic memories and research has demonstrated its effectiveness in the treatment of PTSD (see Is EMDR an efficacious treatment for PTSD?). Shapiro (2001) states that it should be helpful in reducing or eliminating other disorders that originate following a distressing experience. For example, Brown, McGoldrick, and Buchanan (1997) found successful remission in five of seven consecutive cases of Body Dysmorphic Disorder cases after 1-3 EMDR sessions that processed the etiological memory. Similarly there have been reports of elimination of phantom limb pain following EMDR treatment of the etiological memory and the pain sensations (Vanderlaan, 2000; Wilensky, 2000; S. A. Wilson, Tinker, Becker, Hofmann, & Cole, 2000). It is not anticipated that EMDR will be able to alleviate fully the symptoms arising from physiologically based disorders, such as schizophrenia or bipolar disorder. However, experiential contributors may play a major role in some symptoms, and there are anecdotal reports of persons with such disorders being treated successfully with EMDR for distress related to traumatic events.

In addition to studies assessing the effectiveness of EMDR in the treatment of PTSD, phobias, and panic disorders (see Is EMDR an effective treatment of phobias, panic disorder, and agoraphobia?), some preliminary investigations have indicated that EMDR might be helpful with other disorders. These include dissociative disorders (e.g, Fine & Berkowitz, 2001; Lazrove & Fine, 1996; Paulsen, 1995); performance anxiety (Foster & Lendl, 1996; Maxfield & Melnyk, 2000); body dysmorphic disorder (Brown et al., 1997); pain disorder (Grant & Threlfo, 2002); and personality disorders (e.g., Korn & Leeds, 2002; Manfield, 1998). These findings are preliminary and further research is required before any conclusions can be drawn. In Shapiro, 2002, applications of EMDR are described for complaints such as depression (Shapiro, 2002), attachment disorder (Siegel, 2002), social phobia (Smyth, & Poole, 2002), anger dyscontrol (Young, Zangwill, & Behary , 2002), generalized anxiety disorder (Lazarus, & Lazarus , 2002), distress related to infertility (Bohart & Greenberg, 2002), body image disturbance (Brown, 2002), marital discord (Kaslow, Nurse, & Thompson, 2002), and existential angst (Krystal, Prendergast, Krystal, Fenner, Shapiro, Shapiro, 2002); all such applications should be considered in need of controlled research for comprehensive examination.

Suggested research. It is recommended that research evaluate the effectiveness of the standard EMDR protocol with such clinical complaints, prior to, or in addition to, testing any modification of the protocol. This will determine whether or not adjustments in preparation, targets, or process are useful.

Can EMDR's effects be attributed to placebo or non-specific effects?

No. A number of studies have found EMDR superior in outcome to placebo treatments, and to treatments not specifically validated for PTSD. EMDR has outperformed active listening (Scheck et al., 1998), standard outpatient care consisting of individual cognitive, psychodynamic, or behavioural therapy in a Kaiser Permanente Hospital (Marcus et al., 1997), relaxation training with biofeedback (Carlson et al., 1998). EMDR has been found to be relatively equivalent to CBT therapies in seven randomized clinical trials that compared the two approaches. Because the treatment effects are large and clinically meaningful, it can be concluded that EMDR is not a placebo treatment. For example, in a meta-analysis of PTSD treatments, Van Etten and Taylor (1998), calculated the mean effect sizes on self-report measures for placebo and control conditions as 0. 43, for EMDR as 1.24, and for CBT as 1.27 (p. 135). Several studies (e.g., Thordarson et al., 2001) have measured the credibility of the treatments being provided, as a way to determine if EMDR elicited more confidence from clients, thereby producing larger effects; no study found EMDR more or less credible. Because EMDR is not more credible than these other therapies, it appears that the effects cannot be attributed to suggestion or a heightened placebo effect.

Suggested research. Assessments of credibility should be standard practice in all treatment outcome studies

What have meta-analyses revealed about EMDR?

There have been three meta-analyses that evaluated EMDR outcomes. Van Etten and Taylor (1998) examined responses to psychotherapeutic and pharmacological treatments of PTSD. They reported that EMDR and exposure therapies achieved similar outcomes, and were superior to other psychotherapeutic treatments. In their analysis they noted that the EMDR studies had used fewer sessions (4.3) to achieve the same level of results produced by more exposure sessions (10.4). They concluded that their results suggest that EMDR is effective for PTSD, and that it is more efficient than other treatments (p. 140). However, direct comparisons of efficiency are better made within a single study with the same population, by analysis of session-to-session response.

The Davidson and Parker (2001) meta-analysis evaluated outcomes in 34 different EMDR studies. This was a thorough and comprehensive meta-analysis, although some studies were overlooked. They concluded that EMDR was superior to no-treatment and non-specific treatment controls, and equivalent in outcome to exposure and cognitive behavioural therapies. As reported previously in this Appendix, such findings are consistent with those in the EMDR literature. Unfortunately in their investigation of the eye movement component, Davidson and Parker did not distinguish between clinical dismantling studies and component action studies (see below). In addition, they did not distinguish between analogue studies which used partial EMDR done for 15 minutes with normal students and dismantling studies with multiple sessions for persons with chronic PTSD. This lack of distinction created large variability in the meta-analysis, and made it difficult to find effects. However, they noted that their data indicated that the comparison effect size between EMDR-with-EMS and EMDR-without-EMs, was marginally significant if one examines only clinical populations satisfying [DSM] diagnostic criteria (p. 311). Even this evaluation, however, failed to evaluate whether the length of treatment offered to the various PTSD populations was clinically adequate to reveal differential main effects.

There is much variability in the outcomes of EMDR studies, with a range of outcomes reported, and with the efficacy of EMDR varying across studies. In a meta-analysis, Maxfield and Hyer (2002), sought to determine if differences in outcome were related to methodological differences. All published PTSD treatment outcome studies were reviewed to identify methodological strengths and weaknesses and rated using the Gold Standard (GS) Scale (adapted from Foa & Meadows, 1997). Then the relationship between methodological rigor and effect sizes in these studies was examined. Results indicated a significant relationship between scores on the GS Scale and effect size, with more rigorous studies reporting larger effect sizes. It appeared that methodological rigor removes noise and thereby decreases error measurement, allowing for the more accurate detection of true treatment effects. It should be noted that the association between methodology and outcome is purely correlational, and may actually be the effect of some unknown third variable. However, it can be argued that, when considering the aggregate evidence for the efficacy of EMDR, greater weight may be given to those studies with better methodology as these appear more likely to reveal accurate outcomes.

Suggested research. Future research can use meta-analyses to assess potential predictors of treatment outcome. Factors that could be examined include number of sessions, client characteristics, chronicity and severity of symptoms, type of diagnosis, and comorbidity. A meta-analysis of the eye movement component research is needed that will address the different types of research to determine if there is a differential outcome according to study type. This might assist in developing a more complete understanding of the role of dual attention in EMDR.

Is fidelity to treatment important?

Yes. Treatment fidelity is considered one of the gold standards of clinical research (Foa & Meadows, 1997). Clearly, if the treatment being tested does not adhere to the standard protocol, then the treatment being examined is not the standard treatment; the study will have poor internal validity and the results may not be informative about the actual treatment. Treatment fidelity has been a subject of much controversy (Greenwald, 1996; Rosen, 1999). There is evidence that EMDR is a robust treatment, not affected by some changes to protocol; for example, variations in the eye movement or stimulus component do not appear to interfere with outcome (Renfrey & Spates, 1994). On the other hand, there is evidence that truncating the procedure may result in poor outcomes; for example, an analysis (Shapiro, 1999) of the procedures used in the EMDR phobia studies found that those omitting more than half of the EMDR phases, achieved poor outcomes compared to those using the full protocol. In a methodological meta-analysis, Maxfield and Hyer (2002) found a significant positive correlation between pre-post effect size and assessments of fidelity. Specifically those studies with fidelity that was assessed as adequate, tended to have larger effects than those with fidelity that was assessed as variable or poor, or not assessed.

Suggested research. A measure of treatment fidelity needs to be developed with good inter-rater reliability. Then the relationship between ratings on this measure and ratings of treatment effect can the be specifically examined. Further, scores can be developed for the integrity of treatment received by each client, and this variable can be entered into analyses to determine the extent to which fidelity contributed to treatment outcome.

What elements of EMDR contribute to its effectiveness?

EMDR is a complex therapeutic approach that integrates elements of many traditional psychological orientations and combines these in structured protocols. These include psychodynamic (Fensterheim, 1996; Solomon & Neborsky, 2001; Wachtel, 2002), cognitive behavioural (Smyth & Poole, 2002; Wolpe, 1990; Young, Zangwill, & Behary, 2002), experiential (e.g., Bohart & Greenberg, 2002), physiological (Siegel, 2002; van der Kolk, 2002), and interactional therapies (Kaslow, Nurse, &Thompson, 2002). Consequently EMDR contains many effective components, all of which are thought to contribute to treatment outcome.

Marks, Lovell, Noshirvani, Livanou, & Thrasher (1998) propose that emotion can be conceptualised as a skein of responses, viewed as loosely linked reactions of many physiological, behavioural, and cognitive kinds (p. 324). They suggest that different types of treatment will weaken different strands within the skein of responses and that some treatments may act on several strands simultaneously (p. 324). EMDR is a multi-component approach that works with strands of imagery, cognition, affect, somatic sensation, and related memories. This complexity makes it difficult to isolate and measure the contribution of any single component, especially as different clients with the same diagnosis may respond differently to different elements.

Shapiros (2001) AIP model conceptualizes EMDR as working directly with cognitive, affective, and somatic components of memory to forge new associative links with more adaptive material. A number of treatment elements are formulated to enhance the processing and assimilation needed for adaptive resolution. These include: (1) Linking of memory components The clients simultaneous focus on the image of the event, the associated negative belief, and the attendant physical sensations, may serve to forge initial connections among various elements of the traumatic memory, thus initiating information processing. (2) Mindfulness. Mindfulness is encouraged by instructing clients to just notice and to let whatever happens, happen. This cultivation of a stabilized observer stance in EMDR appears similar to processes advocated by Teasdale (1999) as facilitating emotional processing. (3) Free association. During processing, clients are asked to report on any new insights, associations, emotions, sensations, images, that emerge into consciousness. This non-directive free association method may create associative links between the original targeted trauma and other related experiences and information, thus contributing to processing of the traumatic material (see Rogers & Silver, 2002). (4) Repeated access and dismissal of traumatic imagery. The brief exposures of EMDR provide clients with repeated practice in controlling and dismissing disturbing internal stimuli. This may provide clients with a sense of mastery, contributing to treatment effects by increasing their ability to reduce or manage negative interpretations and ruminations. (5) Eye movements and other dual attention stimuli. There are many theories about how and why eye movements may contribute to information processing, and these are discussed in detail below.

Suggested research. In order to determine the contribution of the relevant components, it is recommended that future dismantling studies employ more rigorous methodology (Maxfield & Hyer, 2002), a sample large enough to provide adequate power, and control conditions that are distinct from eye movements and theoretically meaningful. To date, no randomized clinical dismantling study has provided a full course of treatment to a large sample of clinically diagnosed subjects.

Is EMDR an exposure therapy?

A standard treatment for anxiety disorders involves exposing clients to anxiety eliciting stimuli. It has sometimes been assumed that EMDR uses exposure in this traditional manner and that this accounts for EMDRs effectiveness. Some reviewers have stated, Had EMDR been put forth simply as another variant of extant treatments, we suspect that much of the controversy over its efficacy and mechanisms of action could have been avoided (Lohr, Lilienfeld, Tolin, & Herbert, 1999, p. 201). However such a perspective ignores important elements of the EMDR procedure that are antithetical to exposure theories; in other words, the theories predict that if these EMDR elements were used in exposure therapy, a diminished outcome would result (Rogers & Silver, 2002). These elements include frequent brief exposures, interrupted exposure, and free association. (1) Exposure theorists Foa and McNally (1996) write: "Because habituation is a gradual process, it is assumed that exposure must be prolonged to be effective. Prolonged exposure produces better outcome than does brief exposure, regardless of diagnosis (p. 334). EMDR however uses extremely brief repeated exposures (i.e., 20-50 seconds). (2) Other theorists (Marks et al., 1998) state that exposure should be continual and uninterrupted: "Continuous stimulation in neurons and immune and endocrine cells tends to dampen responses, and intermittent stimulation tends to increase them (p 324). EMDR, on the other hand, interrupts the internal attention repeatedly to ask What do you get now? (3) Exposure therapy is structured to inhibit avoidance (Lyons & Keane, 1989), and specifically prohibits the patient from reducing his anxiety by changing the scene or moving it ahead quickly in time to skim over the most traumatic point (p. 146) in order to achieve extinction of the anxiety. However, free association to whatever enters the persons consciousness is an integral part of the EMDR process. Differences such as these have prompted exposure researchers to state: "In strict exposure therapy the use of many of ['a host of EMDR-essential treatment components'] is considered contrary to theory. Previous information also found that therapists and patients prefer this procedure over the more direct exposure procedure" (Boudewyn and Hyer, 1996, p.192) A one session direct process analysis of the two therapies found significant differences in practices and subjective response (Rogers et al., 1999).

Clearly theories explicating exposure therapy fail to explain the treatment effects of EMDR, with its brief, interrupted exposures, and its elicitation of free association. In addition there appears to be a difference in treatment process. During exposure therapy clients generally experience long periods of high anxiety (Foa & McNally, 1996), while EMDR clients generally experience rapid reductions in SUD levels early in the session (Rogers et al., 1999). This difference suggests the possibility that EMDRs use of repeated short focused attention may invoke a different mechanism of action that that of exposure therapy with its continual long exposure.

Are eye movements considered essential to EMDR?

Although eye movements are often considered its most distinctive element, EMDR is not a simple procedure dominated by the use of eye movements. It is a complex psychotherapy, containing numerous components that are considered to contribute to treatment effects. Eye movements are used to engage the clients attention to an external stimulus, while the client is simultaneously focusing on internal distressing material. Shapiro describes eye movements as dual attention stimuli, to identify the process in which the client attends to both external and internal stimuli. Therapist directed eye movements are the most commonly used dual attention stimulus but a variety of other stimuli including hand-tapping and auditory stimulation are often used. The use of such alternate stimuli has been an integral part of the EMDR protocol for more than 10 years (Shapiro 1991, 1993).

What has research determined about EMDR's eye movement component?

In 1989, Francine Shapiro (1995) noticed that the emotional distress accompanying disturbing thoughts disappeared as her eyes moved spontaneously and rapidly. She began experimenting with this effect and determined that when others moved their eyes, their distressing emotions also dissipated. She conducted a case study (1989b) and controlled study (1989a), and her hypothesis that eye movements (EMs) were related to desensitization of traumatic memories was supported. The role of eye movement had been previously documented in connection to cognitive processing mechanisms. A series of systematic experiments (Antrobus, 1973; Antrobus, Antrobus, & Singer, 1964) revealed that spontaneous EMs were associated with unpleasant emotions and cognitive changes.

There have been 20 published studies that investigated the role of EMs in EMDR. Studies have typically compared EMDR-with-EMs to a control condition in which the EM component was modified (e.g., EMDR-with-eyes-focused-and-unmoving). There have been four different types of studies: (1) case studies, (2) dismantling studies using clinical participants (3) dismantling studies using nonclinical analogue participants, and (4) component action studies in which eye movements are examined in isolation.

Case studies. Four case studies evaluated the effects of adding EMs to the treatment process, and three demonstrated an effect for EMs. Montgomery and Ayllon (1994) found eye movements to be necessary for EMDR treatment effects in five of six civilian PTSD patients. They wrote that the addition of the eye movement component resulted in the significant decreases in self-reports of distress previously addressed. These findings are reflected by decreases in psycho-physiological arousal (Montgomery & Ayllon, 1994, p. 228). Lohr, Tolin, and Kleinknecht (1995) reported that the addition of the eye movement component appeared to have a distinct effect in reducing the level of [SUD] ratings (p. 149). When Lohr, Tolin and Kleinknecht (1996) treated two claustrophobic subjects, substantial changes in disturbance ratings were achieved only after EMs were added to an imagery exposure procedure that used the brief frequent exposures of EMDR. The fourth study (Acierno, Tremont, Last, & Montgomery, 1994) did not use standard EMDR protocol for phobias, nor the standard procedures for accessing the image, formulating the negative belief, or eliciting new associations. In addition, the client was instructed to relax between sets of EMs until the SUD rating was reduced to baseline, a procedure not used in EMDR. The procedures used in this study did not eliminate the phobia and no effect was found for the EM condition.

Clinical dismantling studies with diagnosed participants. There have been four controlled dismantling studies with PTSD participants, and two studies where participants were diagnosed with other anxiety disorders. These studies have tended to show that EMDR-with-EMs was slightly better than EMDR-with-modification; however such comparisons have not usually been statistically significant, and results are equivocal. For example, Devilly et al. (1998) reported rates of reliable change of 67% for the EM condition, compared to 42% of the non-EM condition; Renfrey and Spates (1994) reported a decrease in PTSD diagnosis of 85% for EM conditions and 57% for the non-EM group. These studies unfortunately are limited by severe methodological problems, including inadequate statistical power. For example, there were seven or eight persons per condition in the Renfrey and Spates (1994) PTSD study. The participants in the other three PTSD (Boudeywns & Hyer, 1996; Devilly et al., 1998; Pitman et al., 1996) studies were combat veterans, who received only two sessions or treatment of only one traumatic memories. Such an inadequate course of treatment produced only moderate effect sizes; therefore a large sample would be required to provide adequate statistical power for the detection of any possible differences between groups. There has yet to be a single rigorous dismantling study with a sample adequate to assess treatment effects.

Clinical dismantling studies with analogue participants. The controlled studies that used analogue participants with nonclinical anxiety found no effect for EMs. There are many problems with these analogue studies, which typically used normal college student participants. The EMDR protocol was often truncated (e.g., Carrigan & Levis, 1999; Sanderson & Carpenter, 1992), resulting in poor construct validity and making interpretation of results problematic. It is also unlikely that the responses of analogue participants can be generalized to persons with chronic PTSD, a disorder that appears resistant to placebo effects (Solomon, Gerrity, & Muff, 1992; Van Etten & Taylor, 1998). Analogue participants responded well to EMDR-without-EMs, a procedure which contains a number of active components. The minimal distress of the analogue participants was relieved with minimal treatment, and the assessment of differences between the EM and nonEM conditions was limited by a floor effect. Consequently it may not have been possible to detect differences between conditions.

Component action studies. Component action studies test EMs in isolation. These studies typically provide brief sets of EMs (not EMDR) to examine their effects on memory, affect, cognition, or physiology. The purpose is to investigate the effects of moving the eyes (not EMDR), and EMs are compared to control conditions such as imaging and tapping. For example, a participant might be asked to visualize a memory image, then to move their eyes for a brief period ,and then to rate the vividness of the image. This permits a pure test of the specific effects of EMs and non-EMs without the added effects of the active ingredients of the other EMDR procedures. The studies have generally used nonclinical participants and a within-subject design, that compares the differences in each individuals responses to the various conditions. This reduces the variance of subjective responding, and eliminates possible floor effects.

Findings from these studies suggest that EMs may have an effect on physiology, decreasing arousal (e.g., Barrowcliff et al., in press; D. Wilson et al., 1996) on attentional flexaility (Kuiken, Bears, Miall & Smitth (2001-2001) and on memory processes, enhancing semantic recall (Christman et al., in press). Four studies (Andrade, Kavanagh, & Baddeley, 1997; Kavanaugh, Freese, Andrade, & May, 2001; Sharpley et al., 1996; van den Hout, Muris, Salemink, & Kindt, 2001) have demonstrated that EMs decrease the vividness of memory images and the associated emotion. No (or minimal) effect has been found for tapping conditions. These studies suggest that EMs may make a contribution to treatment by decreasing the salience of the memory and its associated affect. (See discussion below on mechanisms of action).

Do eye movements contribute to outcome in EMDR?

Much confusion tends to result when the outcomes of the three types of component studies (see What has research determined about EMDR's eye movement component) are combined. Because these studies differ substantially in design, purpose, participants, and outcome measures, they have produced a wide range of results: (1) In dismantling studies with analogue participants, EMs do not contribute to outcome, possibly because of a floor effect. (2) In clinical dismantling studies with diagnosed participants, there has been a consistent nonsignificant trend for a treatment effect. (3) In the component action studies a consistent significant effect for EMs in isolation was found in reducing the vividness of, and affect associated with, autobiographical memories; it is possible that such effects may contribute to treatment outcome. In the Davidson and Parker (2001) meta-analysis, no effects were found for EMDR-with-EMs compared to EMDR-without-EMS, when all types of studies were included. However, when the results of the clinical dismantling studies were examined, EMDR-with-EMs was significantly superior to EMDR-without-EMs.

What are the side effects?

As with any form of psychotherapy, there may be a temporary increase in distress.
distressing and unresolved memories may emerge
some clients may experience reactions during a treatment session that neither they nor the administering clinician may have anticipated, including a high level of emotion or physical sensations
subsequent to the treatment session, the processing of incidents/material may continue, and other dreams, memories feelings, etc., may emerge.

What can I expect with EMDR, ie.,..what should/could happen?

Each case is unique, but there is a standard eight phase approach that each clinician should follow. This includes taking a complete history, preparing the client, identifying targets and their components, actively processing the past, present and future aspects, and on-going evaluation. The processing of a target includes the use of dual stimulation (eye movements, taps, tones) while the client concentrates on various aspects. After each set of movements the client briefly describes to the clinician what s/he experienced. At the end of each session, the client should use the techniques s/he has been taught by the clinician in order to leave the session feeling in control and empowered. At the end of EMDR therapy, previously disturbing memories and present situations should no longer be problematic, and new healthy responses should be the norm.

How many sessions will it take?

The number of sessions depends upon the specific problem and client history. However, repeated controlled studies have shown that a single trauma can be processed within 3 sessions in 80-90% of the participants. While every disturbing event need not be processed, the amount of therapy will depend upon the complexity of the history. In a controlled study, 80% of multiple civilian trauma victims no longer had PTSD after approximately 6 hours of treatment. A study of combat veterans reported that after 12 sessions 77% no longer had post traumatic stress disorder.

How many sessions with the therapist BEFORE (s)he begins EMDR?

This depends upon the client's ability to "self-soothe" and use a variety of self-control techniques to decrease potential disturbance. The clinician should teach the client these techniques during the preparation phase. The amount of preparation needed will vary from client to client. In the majority of instances the active processing of memories should begin after one or two sessions.

Is EMDR effective with Schizophrenia?

There is currently no research on EMDR's use with schizophrenia. However, individuals with schizophrenia may have experienced distressing life experiences or traumas that exacerbate their symptoms. Using EMDR to process memories of such events may be helpful in alleviating stress and reducing symptoms. In such cases, it would be assumed that treatment would be provided only after appropriate stabilization, and in the hands of an expert in this specialty area. Anecdotal reports have given preliminary support for this. However, research needs to be conducted.

What questions should be asked to find out if clincians are qualified and if they have expertise using EMDR with my problem/disorder?

Ask:
Have they received both levels of training;
Was the training approved by EMDRIA;
Have they kept informed of the latest protocols and developments;
How many cases have they treated with your particular problem/disorder;
What is their success rate.

Is EMDR the same as hypnosis..what are the differences/similarities?

The American Journal of Hypnosis published a special issue on the use of EMDR and hypnosis. An introductory article by the editor and past president of the American Association of Clinical Hypnosis directly addressed the issue: "While it has been argued against categorizing hypnosis as a specific type of treatment method (e.g., Fischolz, 1995; 1997a; 1997b; 2000; Fischholz & Spiegel, 1983), this is not the case for EMDR. Like psychoanalysis, EMDR is both an evolving theory about how information is perceived, stored and retrieved in the human brain and a specific treatment method based on this theory (Shapiro, 1995, 2001). In fact, EMDR is a very unique treatment method, which like other types of treatment/methods/techniques (e.g. psychoanalytic/psychodynamic therapy, behavior, cognitive-behavioral therapy, ego-state therapy) can also be incorportated with hypnosis (Hammond, 1990).

We note there are some distinctive differences between hypnosis and EMDR, which we would like to briefly highlight. First, one of the major uses of hypnosis among clinical practitioners is to deliberately begin by inducing in the patient an altered state of mental relaxation. In contrast, when beginning EMDR mental relaxation is not typically attempted. In fact, deliberate attempts are often actually made to connect with an anxious (i.e. an emotionally disturbing as opposed to relaxed) mental state.

Second, therapists often use hypnosis to help a patient develop a single, highly focused state of aroused receptivity (Spiegel & Spiegel, 1978). In contrast, with EMDR attempts are made to maintain a duality of focus on both positive and negative currently held self-referencing beliefs, as well as the emotional arousal brought about by imaging the worst part of a disturbing memory. However, in this sense, EMDR does have a similarity to Spiegel's (Spiegel & Spiegel, 1978) split-screen cognitive restructuring technique.

Third, one of the proposed effects of hypnotizing a person is that they will have a decrease in their generalized reality orientation (GRO: Shor, 1979). This induced decrease in a person's GRO is often utilized in order to promote an increase in fantasy and imagination, perhaps by capitalizing on an increase in trance logic (Orne, 1977). In contrast, in EMDR attempts are made towards repeatedly grounding the patient by referencing current feelings and body sensations to prevent the patient from drifting away from reality. Specific encouragement/inducement is made towards rejecting previously irrational/self-blaming beliefs in favor of a newly, reframed positive belief with an increase in subjective conviction about that belief. Shapiro and Forrest (1997) and Nicosia (1995) have also noted additional differences between hypnosis and EMDR.

How do I know EMDR would work for me/work for my anxiety/problems, etc.? Am I a candidate for EMDR?

EMDR has been extensively researched as effective for problems based on earlier traumas. In addition, reports from clinicians over the past ten years have indicated that EMDR can be extremely effective when there are experiential contributors that need to be addressed. Read the book EMDR The Breakthrough Therapy for Overcoming Anxiety, Stress and Trauma by Shapiro & Forrest and see if any of your problems are covered in the cases. Interview at least 3 clinicians to ask them what experience they have using EMDR with your particular problem.

What are the adverse effects?

As with any form of psychotherapy, there may be a temporary increase in distress.
distressing and unresolved memories may emerge
some clients may experience reactions during a treatment session that neither they nor the administrating clinician may have anticipated, including a high level of emotion or physical sensation
subsequent to the treatment session, the processing of incidents/material may continue, and other dreams, memories, feelings, etc., may emerge.

Reiki

What is it?

Reiki is a Japanese technique for stress reduction and relaxation that also promotes healing. It is administered by "laying on hands" and is based on the idea that an unseen "life force energy" flows through us and is what causes us to be alive. If one's "life force energy" is low, then we are more likely to get sick or feel stress, and if it is high, we are more capable of being happy and healthy.

The word Reiki is made of two Japanese words - Rei which means "God's Wisdom or the Higher Power" and Ki which is "life force energy". So Reiki is actually "spiritually guided life force energy."

A treatment feels like a wonderful glowing radiance that flows through and around you. Reiki treats the whole person including body, emotions, mind and spirit creating many beneficial effects that include relaxation and feelings of peace, security and wellbeing. Many have reported miraculous results.

Reiki is a simple, natural and safe method of spiritual healing and self-improvement that everyone can use. It has been effective in helping virtually every known illness and malady and always creates a beneficial effect. It also works in conjunction with all other medical or therapeutic techniques to relieve side effects and promote recovery.

An amazingly simple technique to learn, the ability to use Reiki is not taught in the usual sense, but is transferred to the student during a Reiki class. This ability is passed on during an "attunement" given by a Reiki master and allows the student to tap into an unlimited supply of "life force energy" to improve one's health and enhance the quality of life.

Its use is not dependent on one's intellectual capacity or spiritual development and therefore is available to everyone. It has been successfully taught to thousands of people of all ages and backgrounds.

While Reiki is spiritual in nature, it is not a religion. It has no dogma, and there is nothing you must believe in order to learn and use Reiki. In fact, Reiki is not dependent on belief at all and will work whether you believe in it or not. Because Reiki comes from God, many people find that using Reiki puts them more in touch with the experience of their religion rather than having only an intellectual concept of it.

While Reiki is not a religion, it is still important to live and act in a way that promotes harmony with others. Dr. Mikao Usui, the founder of the Reiki system of natural healing, recommended that one practice certain simple ethical ideals to promote peace and harmony, which are nearly universal across all cultures.

During a meditation several years after developing Reiki, Dr. Usui decided to add the Reiki Ideals to the practice of Reiki. The Ideals came in part from the five prinicples of the Meiji emperor of Japan whom Dr. Usui admired. The Ideals were developed to add spiritual balance to Usui Reiki. Their purpose is to help people realize that healing the spirit by consciously deciding to improve oneself is a necessary part of the Reiki healing experience. In order for the Reiki healing energies to have lasting results, the client must accept responsibility for her or his healing and take an active part in it. Therefore, the Usui system of Reiki is more than the use of the Reiki energy. It must also include an active commitment to improve oneself in order for it to be a complete system. The ideals are both guidelines for living a gracious life and virtues worthy of practice for their inherent value.

How does it work?

We are alive because life force is flowing through us. Life force flows within the physical body though pathways called chakras, meridians and nadis. It also flows around us in a field of energy called the aura. Life force nourishes the organs and cells of the body, supporting them in their vital functions. When this flow of life force is disrupted, it causes diminished function in one or more of the organs and tissues of the physical body.

The life force is responsive to thoughts and feelings. It becomes disrupted when we accept, either consciously or unconsciously, negative thoughts or feelings about ourselves. These negative thoughts and feelings attach themselves to the energy field and cause a disruption in the flow of life force. This diminishes the vital function of the organs and cells of the physical body.

Reiki heals by flowing through the affected parts of the energy field and charging them with positive energy. It raises the vibratory level of the energy field in and around the physical body where the negative thoughts and feelings are attached. This causes the negative energy to break apart and fall away. In so doing, Reiki clears, straightens and heals the energy pathways, thus allowing the life force to flow in a healthy and natural way.

Reiki Energy, What is it? How does it heal?

The word Reiki is composed of two Japanese words - Rei and Ki. When translating Japanese into English we must keep in mind that an exact translation is difficult. The Japanese language has many levels of meaning. Therefore the context the word is being used in must be kept in mind when attempting to communicate its essence. Because these words are used in a spiritual healing context, a Japanese/English dictionary does not provide the depth of meaning we seek, as its definitions are based on common everyday Japanese. As an example, Rei is often defined as ghost and Ki as vapor and while these words vaguely point in the direction of meaning we seek, they fall far short of the understanding that is needed.

When seeking a definition from a more spiritual context, we find that Rei can be defined as the Higher Intelligence that guides the creation and functioning of the universe. Rei is a subtle wisdom that permeates everything, both animate and inanimate. This subtle wisdom guides the evolution of all creation ranging from the unfolding of galaxies to the development of life. On a human level, it is available to help us in times of need and to act as a source of guidance in our lives. Because of its infinite nature, it is all knowing. Rei is also called God and has many other names depending on the culture that has named it.

Ki is the non-physical energy that animates all living things. Ki is flowing in everything that is alive including plants, animals and humans. When a person's Ki is high, they will feel strong, confident, and ready to enjoy life and take on it's challenges. When it is low, they will feel weak and are more likely to get sick. We receive Ki from the air we breath, from food, sunshine, and from sleep. It is also possible to increase our Ki by using breathing exercises and meditation. When a person dies, their Ki leaves the physical body. Ki is also the Chi of China, the prana of India, the Ti or Ki of the Hawaiians, and has also been called odic force, orgone, bioplasma and life force.

With the above information in mind, Reiki can be defined as a non-physical healing energy made up of life force energy that is guided by the Higher Intelligence, or spiritually guided life force energy. This is a functional definition as it closely parallels the experience of those who practice Reiki in that Reiki energy seems to have an intelligence of its own flowing where it is needed in the client and creating the healing conditions necessary for the individuals needs. It cannot be guided by the mind, therefore it is not limited by the experience or ability of the practitioner. Nether can it be misused as it always creates a healing effect. ( It must be kept in mind that Reiki is not the same as simple life force energy as life force energy by itself can be influenced by the mind and because of this, can create benefit as well as cause problems including ill health.)

The source or cause of health comes from the Ki that flows through and around the individual rather than from the functional condition of the physical organs and tissues. It is Ki that animates the physical organs and tissues as it flows through them and therefore is responsible for creating a healthy condition. If the flow of Ki is disrupted, the physical organs and tissues will be adversely affected. Therefore, it is a disruption in the flow of Ki that is the main cause of illness.

An important attribute of Ki is that it responds to ones thoughts and feelings. Ki will flow more strongly or be weakened in its action depending on the quality of ones thoughts and feelings. It is our negative thoughts and feelings that are the main cause of restriction in the flow of Ki. All negative or dis-harmonious thoughts or feelings will cause a disruption in the flow of Ki. Even Western medicine recognizes the role played by the mind in creating illness and some Western doctors state that as much as 98% of illness is caused directly or indirectly by the mind.

It must be understood that the mind exists not only in the brain, but also through-out the body. The nervous system extends to every organ and tissue in the body and so the mind exists here also. It is also known that the mind even extends outside the body in a subtle energy field 2 to 3 feet thick called the aura. Because of this, it is more appropriate to call our mind a mind/body as the mind and body are so closely linked.

Therefore, our negative thoughts are not just in the brain, but also collect in various locations through-out the body and in the aura. The places where negative thoughts and feelings collect is where Ki is restricted in its flow. The physical organs that exist at these locations are restricted in their functioning. If the negative thoughts and feelings are not eliminated quickly, illness results.

The negative thoughts and feelings that are lodged in the unconscious mind/body are the greatest problem as we are not aware of them and therefore, are we are greatly hampered in changing or eliminating them.

The great value of Reiki is that because it is guided by the Higher Intelligence, it knows exactly where to go and how to respond to restrictions in the flow of Ki. It can work directly in the unconscious parts of the mind/body which contain negative Ki-inhibiting thoughts and feelings and eliminate them. As Reiki flows through a sick or unhealthy area, it breaks up and washes away any negative thoughts or feelings lodged in the unconscious mind/body thus allowing a normal healthy flow of Ki to resume. As this happens, the unhealthy physical organs and tissues become properly nourished with Ki and begin functioning in a balanced healthy way thus replacing illness with health.

This non-invasive, completely benign healing technique is becoming more and more popular. As western medicine continues to explore alternative methods of healing, Reiki is destined to play an important role as an accepted and valued healing practice.

Exposure Therapy

Exposure therapy is a type of behavior therapy in which the patient confronts a feared situation, object, thought, or memory. Sometimes, exposure therapy involves reliving a traumatic experience in a controlled, therapeutic environment. The goal of exposure therapy is to reduce the distress, physical or emotional, felt in certain situations. Exposure therapy may be used in dealing with anxiety, phobias, and post-traumatic stress.

During exposure therapy treatment, a therapist helps the patient remember a disturbing thought, traumatic situation, or feared object. The therapist also helps the patient deal with the unpleasant emotions or physical symptoms that may arise from this exposure. Through confronting the situations and thoughts that cause stress, patients are often able to learn coping skills, eventually reducing or even eliminating symptoms.

Patients are usually encouraged to talk about their feelings during exposure therapy and to learn ways to face fears and stressful emotions. They are also encouraged to learn news ways of viewing fears and distressing situations. Hypnosis is sometimes used as part of this type of therapy. Even virtual reality techniques are used at times.

Sometimes, relaxation techniques are taught as part of exposure therapy. These techniques may be very helpful in dealing with both physical and emotional distress. They are intended to help the patient maintain control, even when faced with the situation, object, or thought that causes fear or distress. Often, breathing exercises can be effective interventions taught in conjunction with exposure therapy.

Exposure therapy is sometimes compared to desensitization. Unlike desensitization, however, exposure therapy produces anxiety in the patient on purpose. Desensitization, on the other hand, combines relaxation with gradual introduction to the anxiety-producing object, thought, or situation. Furthermore, exposure therapy involves exposing the patient to the most distressing thought or situation first, while systematic desensitization begins with that which causes the least fear.

Exposure therapy may include flooding or graduated techniques. When flooding techniques are used, the patient may be exposed to the frightening or distressing thought, situation, or object for as much as two hours at a time. Graduated techniques are considered gentler because the patient may face the distressing stimuli in shorter chunks of time and have more control over the duration of the exposure.
 

How to do Exposure Therapy

Some of the rules for constructing a good program of Exposure Therapy are:

The subject should have a final goal which should represent non-phobic behavior. This might be (for example) to hold a large snake and rub it against their cheek for several minutes.
They should also have in mind a series of intermediate steps such that once they have partially habituated to one step the next is close enough to it that they can readily move on. Such a sequence is called a hierarchy. It may be explicit, in the form of a list of increasingly challenging tasks, or implicit, in the form of a set of principles for escalating the exposure. The therapist will decide which of these will be more useful for the subject. (A useful way of constructing such a hierarchy is the Method of Factors.
At every stage the subjects self-exposure should be completely voluntary - a criterion that may be derived from the theory of cognitive dissonance. One important corollary of this principle is that, at every moment, the subject must have an easy way of terminating the exposure. By choosing not to escape - and therefore practising a competing response - the subject thereby weakens the arousal-escape connection.
The arousal experienced at any point should be the maximum that the subject is prepared to accept (this is the main difference between Exposure Therapy and Systematic desensitization). It's useful if at each stage the subject asks themselves "is there anything more I could do?" By considering which factors they can manipulate they should be able to keep moving smoothly up their hierarchy.
Research by Marks and Rachmann[citation needed] demonstrated that optimum results are obtained with daily practice lasting at least an hour; and that the daily session should be ended by allowing the level of arousal to fall off to around half its peak value. For this reason it's useful for the subject to keep a note of their arousal level on a 0-8 scale (where 0=no arousal and 8=intolerable arousal). Before this fall-off phase the level of arousal should be maintained at an uncomfortable but tolerable level.

Exposure therapy is essential if you are to overcome your anxiety, ie you must put yourself in the social situations you are worried about. Although this sounds frightening, your therapist will give you the tools to cope with confronting your fears (e.g. rational thinking, slow breathing & isometric relaxation)

The exposure sessions must be

graded

repeated and regular

prolonged

Graded:
Your therapist will work with you to determine what would be an appropriate first step; it should be difficult enough to provoke some anxiety but easy enough for you to be fairly confident you can do it. Once you can cope with Step 1 confidently, then you can move onto a more difficult situation and gradually work up your most feared scenarios.

It is important not to confront a feared situation that is far too difficult for you, as if you tackle something too stressful, without sufficient preparation, you may become extremely anxious or even have a panic attack. Such a negative experience would only strengthen the association between fear and the setting.

Repeated:
You need to confront your feared situations frequently and regularly if you are going to overcome your anxiety. If your exposures are too far apart your fear will have risen again by the next time you do it.

Prolonged:
Generally, it is advised that you stay in the feared situation until your anxiety starts to decrease. Anxious people often approach or attempt a feared situation but then choose to escape from the feared social or performance situation. When you avoid or leave feared situations your fear of them increases because the decrease in anxiety which follows escape gives you the idea that avoidance was a helpful strategy. However, if you stayed in the feared situation your anxiety would eventually decrease and the next time you confronted the situation you would be less anxious.

Therefore, it is important to your recovery that you stay in the situation you are attempting. Try not to panic or flee if the anxiety becomes severe. If your anxiety is high, you may feel you temporarily need time out from your feared activity, e.g. if you were attending a house party you might go to the bathroom or sit outside in the garden, do some slow breathing, develop some rational thoughts and wait for the fear to decrease for going back into the party.

Remember exposure is necessary for your recovery.

Emotional Freedom Technique

Emotional Freedom Techniques (EFT) is a psychotherapeutic tool based on a theory that negative emotions are caused by disturbances in the body's energy field and that tapping on the meridians while thinking of a negative emotion alters the body's energy field, restoring it to "balance." There are two studies which appear to show positive outcomes from use of the technique, but another study has suggested that it is indistinguishable from the placebo effect. Critics have described the theory behind EFT as pseudoscientific and have suggested that its utility stems from its more traditional cognitive components, such as distraction from negative thoughts, rather than from manipulation of energy meridians.

EFT was created by Gary Craig in the mid 1990s, and is meant to be a simplification and improvement of Roger Callahan's Thought Field Therapy techniques. Craig trained with Callahan in the early 1990s. In 1993, Craig was the first person Callahan trained in his most advanced procedure, a proprietary procedure known as Voice Technology. Craig found through his experience that the sequence of tapping points did not matter and that special proprietary procedures were therefore unnecessary, so by the mid 1990s he had simplified Callahan's procedures.

Proponents of EFT claim it relieves many psychological and physical conditions, including depression, anxiety, post-traumatic stress disorder, general stress, addictions and phobias. More extreme claims have been made for multiple sclerosis and one proponent claims that "you can also use it for everything from the common cold to cancer. The basic EFT technique involves holding a disturbing memory or emotion in mind and simultaneously using the fingers to tap on a series of 12 specific points on the body that correspond to meridians used in Chinese medicine. The theory behind EFT is that negative emotions are caused by disturbances in the body's energy field and that tapping on the meridians while thinking of a negative emotion alters the body's energy field, restoring it to "balance."

The theory states that negative emotions are built in the following stages: A negative experience occurs; negative emotions are felt in response to this negative experience, leading to inappropriate programming inside the body; and then the body's energy system gets disrupted due to these negative emotions. The contention of EFT is that in order to remove the negative responses, tackling the negative experience is not enough, because doing so cannot correct the energy imbalance. Rather, the energy imbalance must be restored along with curing the negative emotions.

The main difference between EFT and TFT lies not in principles, but in application. In TFT, a specific sequence of tapping points (known as an algorithm) is used for a particular problem. This sequence is determined using muscle testing, a procedure also used by applied kinesiology.

In EFT, the order and sequence of tapping points is deemed to be unimportant, and therefore there are no individual algorithms for different problems. Instead, a comprehensive algorithm is used for all problems, and no diagnosis or muscle testing is required.

Neuro-Linguistic Programming

Neuro-Linguistic Programming is a powerful body of information about how the human mind works built up since the 1970`s and continuing to evolve through new research. You are likely to find many different descriptions of NLP.

At the heart of NLP is a wide range of methods and models it offers for understanding how people think, behave and change. It offers a flexible approach which brings about positive, fast change in individuals and organisations and empowers them to adapt to an ever-shifting world.

NLP training provides the skills to define and achieve your outcomes or goals and a heightened awareness of your five senses, allowing you to remain flexible, on track and maintain rapport with those around you.

NLP has a wide range of practical applications in business (e.g. management, personnel, sales, consulting), training and development, education, dyslexia, the helping professions, health, relationships, writing and the arts, sports, parenting, hobbies and personal development - anywhere communicating and excelling are important.

The more you are interested in communication, personal effectiveness and development - the more NLP has to offer.

How does it work?

Have you ever done something so elegantly and effectively that it took your breath away? Have you had times where you were delighted at what you did and wondered how you did it?

NLP shows you how to understand and model your own successes, so that you can reproduce them. It is a way of discovering and unfolding your personal genius, a way of bringing out the best in yourself and others.

NLP is the study of excellence. It is the study of both the conscious and unconscious processes that combine to enable people to do what they do. The key to success is often unknown at a conscious level. Using NLP you can elicit these unknown pieces.

You may want to improve your relationships, or eliminate an anxiety, or become more competitive in the market place. The key pieces are not found in the muscles, but in your inner thoughts, like words or pictures, or feelings or even beliefs. Once you know these unknown pieces you can change them. NLP exercises are like thought experiments, mental exercises or a game. The laboratory is your mind.

How did NLP develop?

Neuro-Linguistic Programming was first defined by Dr Richard Bandler (a Mathematician) and John Grinder (an Associate Professor of Linguistics) working together at the University of California , Santa Cruz , in the early l970s at a time of rapid development in the humanities field.

They asked the important question "What is it that makes the difference between somebody who is merely competent and someone who excels at the same skill?" and decided to model various people i order to discover the answers. It just so happens that three people they chose to model were the outstanding therapists, Fritz Perls (Gestalt Therapy), Virginia Satir (Family Therapy) and Milton Erickson (world renowned psychiatrist who gave his name to a form of hypnosis). They could just as easily have modelled outstanding businessmen or scientists.

Richard Bandler and John Grinder modelled their language, physiology and mental processes and then identified patterns (rather than theories) which could be explicitly taught. NLP also drew on many existing fields of study including the work of Chomsky in linguistics, of Korsybski in general semantics, Ashby in systems thinking and many, many others.

Bright Light Therapy

Phototherapy or bright light therapy has been shown to suppress the brain's secretion of melatonin. Treatment consists of sitting in front of a full-spectrum light for about four hours per day, preferably in the mornings. This is a substitute for bright natural sunlight, the lack of which seems to cause a particular form of depression.

Dr. Normal E. Rosenthal's seminal 1985 paper defining Seasonal Affective Disorder (SAD) was the first to describe application of bright artificial light in the treatment of winter depression. Rosenthal's hypothesis was that lengthening the daily photoperiod (in effect mimicking summer day length in the northern latitudes) would effect a remission of winter depressive symptoms.

Treatment sessions can last from 15 minutes to three hours, once or twice a day, depending on individual needs and equipment used. The average length of a session for a system delivering 10,000 lux illumination is, for example, much shorter than for 2,500 lux (30 minutes vs. two hours). In clinical trials at our institute, with over 100 SAD patients who used a 10,000 lux system with UV-filtered light diffusion and angular tilt, for 30 minutes each day, about 3/4 showed major improvement of depressive symptoms. In another experiment, we found that 30 minutes was an unnecessarily long exposure for some patients (who responded fully at 15 minutes), while several required 1-hour exposures to show the effect.

Light Therapy using light box
Light treatment should be used daily in Winter (and dull periods in summer) starting in early Autumn when the first symptoms appear. It consists of sitting two to three feet away from a specially designed light box, usually on a table, allowing the light to shine directly through the eyes.

The user can carry out normal activity such as reading, working, eating and knitting while stationary in front of the box. It is not necessary to stare at the light although it has been proved safe.

Treatment is usually effective within three or four days and the effect continues provided it is used every day. Tinted lenses, or any device that blocks the light to the retina of the eye, should not be worn.

Light Therapy for Seasonal Affective Disorder
Light Therapy found to be effective in cases of seasonal affective disorder (SAD). Dramatic improvement can be seen within a week or two.

Spending an hour outside each day can often produce beneficial results in some individuals. However, one cannot get early morning outside light in the winter. Not everyone's job will allow for an hour-long outside walk. Only highly motivated people will continue their daily walk when it the rains or snows.

This is not a treatment that is widely available on the National Health services in the UK, but it is possible to buy your own lamp to use at home. However, it is best to be sure that the depression from which you suffer is SAD. It is also possible that if you become a member of the SAD Association they may allow you to hire a light for a trial period to see if it might help you.

Other Benefits of Bright Light Therapy
Increasingly, light therapy is being used to reset our body clocks - sometimes along with melatonin and sometimes on its own-no matter how or why they've been put off track. Scientists are discovering that light therapy may have potential for treatment of several other disorders in addition to that of SAD. Another area where bright light therapy has proven itself beneficial is in the area of sleep disorders. Advanced sleep phase syndrome (ASPS) is characterized by premature sleep onset and early morning awakening. Future applications of bright light therapy may well include any area where a disease or syndrome recurs seasonally, shows winter exacerbation, or plausibly is related to insufficient or ill-timed outdoor light exposure regardless of the season.

Early Morning Insomnia
Night-owl insomnia
Jet Lag
Productivity Enhancement
Bulimia
Late-shift drowsiness
Nonseasonal depression
Prolonged menstrual cycles

Nutrition Therapy for Anxiety Disorders

It is well known that certain foods and substances tend to create additional stress and anxiety, while others promote a calmer and steadier mood. Certain natural substances have a direct calming effect and others are known to have an antidepressant effect.

Stimulants
Caffeine  coffee, tea, alcohol, coke stimulate an adrenal response in your body, which can provoke anxiety, nervousness and insomnia to name a few side effects. They also deplete the body of necessary vitamins and minerals that help balance our mood and nervous system. Recommended dosage  less than 100mg per day (one cup of percolated coffee or two diet cola beverages per day. Less than 50mg per day is preferable.

Nicotine  this is as strong as caffeine  it stimulates increased physiological arousal, vasoconstriction and makes your heart work harder. Smokers tend to be more anxious than non-smokers and tend to sleep less well than non-smokers.

Stimulant Drugs  beware of prescription drugs that contain caffeine and amphetamines, and recreational drugs such as cocaine that increase levels of anxiety and panic attacks in people using them.

Salt
Salt depletes the body of potassium, a mineral important to the proper functioning of the nervous system. Salt raises blood pressure that in turn puts a strain on the heart and arteries and hastens arteriolosclerosis. Recommended dosage  do not excess 1gm of salt per day.

Preservatives
There are over 5000 chemical additives in commercial food processing. Our bodies are not equipped to handle these, and little is known about long term biological effects. Try and eat whole unprocessed foods as much as possible. Try to purchase vegetables and fruit that havent been treated with pesticides (organically grown).

Hormones in Meat
Most commercially forms of meat have been fed hormones to promote fast weight gain and growth. One hormone diethylstilbestrol (DES) has been implicated in the development of breast cancer and fibroid tumors. Try to replace red meat, pork and poultry with organically raised beef, poultry and fish such as cod, salmon, snapper, sole, trout.

Sweet, refined foods
Reduce intake of sweet refined foods as these affect the blood sugar that can lead to anxiety and mood swings while also affecting how the brain functions.

MSG
MSG from Chinese takeaway should be avoided as it can have a major irritating effect on the nervous system producing the following: headaches, tingling, numbness and chest pains.

Drink Soda Water
Soda water increases the levels of carbon dioxide that helps the body to become balanced when someone is hyperventilating. Soda water also decreases smooth muscle contractions and dilates blood vessels, which allows blood to flow easily around the body.

Food Allergies
Be aware to check for food allergies as they can be one of the main causes of many emotional problems.

Food to eat to reduce anxiety and maintain calm state
Wholegrain cereals
Asparagus
Garlic
Eggs
Fish
Molasses
 Wheat germ
Brewers yeast
Carrots
Onions
Beetroot
 Spinach
Paw paw
Celery
Stone fruit
Avocado
 

Stressful Eating Habits
Stress and anxiety can be aggravated not only by what you eat, but the way you eat. Any of the following habits can aggravate your daily level of stress:

Eating too fast or on the run
Not chewing food at least 15-20 times per mouthful
Eating too much to the point of feeling stuffed or bloated
Drinking too much fluid with a meal which can dilute stomach acid and digestive enzymes (one cup with a meal is sufficient)
These behaviours put strain on your stomach and intestines in their attempt to properly digest and assimilate food. This increases stress in two ways:

Directly through indigestion, bloating, and cramping
Indirectly through malabsorption of essential nutrients
Nutrients
There are specific nutrients which can decrease anxiety. These include:

Magnesium  aids with muscle relaxation, maintenance of the heart muscle, neuromuscular transmission and widening of the blood vessels. A deficiency of magnesium can cause:

Agitation
Anxiety
Behavioral disturbances
Confusion
Cold hands and feet
Depression
Insomnia
Restlessness

B Complex Vitamins  these are the spark plugs for our body. They help provide energy by acting with enzymes to convert major nutrients such as carbohydrates to energy forms. They are important for the normal function of the nervous system and are helpful in bringing relaxation or energy to individuals who are stressed or fatigued. A deficiency of certain B vitamins will cause:

Fatigue
Irritability
Nervousness
Depression
Insomnia
Loss of appetite
Calcium  works with maintenance of electrolyte balance, muscle contractions, nerve transmission, regulation of cell division, hormone secretion and bone and teeth formation. A deficiency can cause:

Agitation
Depression
Heart palpitations
Insomnia
Irritability

Relaxation Therapy for Anxiety Disorders

To overcome anxiety, phobias, or panic attacks it is of paramount importance to learn how to relax. It is impossible to feel relaxed and tense at the same time. People who live with high levels of anxiety often do not know how to relax or to release the tension stored in their muscles that is contributing to the experience of anxiety.

Regular, daily practice of relaxation techniques will assist you in relieving muscle tension, greatly improve your overall feeling of wellbeing and reduce your anxiety. Deep relaxation involves a number of physiological changes including:

Decreases in heart rate
Decrease in respiration rate
Decrease in blood pressure
Decreases in skeletal muscle tension
Decrease in metabolic rate and oxygen consumption
Decrease in analytical thinking
Increase in skin resistance
Regular practice of deep relaxation for 20  30 minutes on a daily basis can produce, over time, a general feeling of relaxation and wellbeing that benefits every area of your life. When you feel relaxed and at ease you are less likely to turn on the anxiety response and will find that you feel more in control most of the time.

Other benefits of deep relaxation include:
Reduction of generalized anxiety
Reduction of frequency and severity of panic attacks
Prevention of stress becoming cumulative
Increased energy and productivity.
Improved concentration and memory
Increase in ability to focus
Reduction of insomnia and fatigue
Deeper and sounder sleep
Prevention and or reduction of psychosomatic disorders such as hypertension, migraines, headaches, asthma, ulcers etc.
Increased self confidence and reduced self blame
Increased availability of feelings. Muscle tension is one of the chief impediments to an awareness of your feelings.

How do you achieve a state of deep relaxation?
Correct abdominal breathing
Progressive muscle relaxation techniques
Meditation

Progressive Muscle Relaxation Technique
Progressive Muscle Relaxation is a technique for achieving a deep state of relaxation. Tensing a muscle and holding it for a few seconds, then releasing that tension will produce a deep sense of relaxation, and will rid the body of the built up tension from living with high levels of anxiety on a daily basis.

Guidelines
Practice for at least 20 minutes per day
Find a quiet location free from distraction
Ensure the room temperature is comfortable - not too hot, and not too cold
Practice at regular times  on awakening or before retiring or before meals
Assume a comfortable position  your entire body needs to be supported
Loosen any tight clothing and take off shoes
Make a decision not to worry about anything - if you have any other thought come into your mind, just let them go and bring your attention back to your relaxation
Assume a passive, detached attitude

Technique
Progressive muscle relaxation is a technique where you tense and relax one at a time, all the major muscle groups of the body. The idea is to tense each muscle group hard for about 10 seconds, and then to let go of it suddenly. You then give yourself 15  20 seconds to relax and become aware of the contrast between the feeling of relaxation to how it felt when tensed. You then move onto the next muscle group until you have worked your way through your whole body. Often it is helpful to have some quiet, gentle music in the background.

Alternative Approaches To Mental Health Care

An alternative approach to mental health care that emphasizes the interrelationship between mind, body, and spirit can play an important role in recovery and healing. Although some people with mental health problems recover using alternative methods alone, most people combine them with other, more traditional treatments such as therapy and, perhaps, medication. It is crucial, however, to consult with your health care providers about the approaches you are using to achieve mental wellness.

Although some alternative approaches have a long history, many remain controversial. The National Center for Complementary and Alternative Medicine at the National Institutes of Health was created in 1992 to help evaluate alternative methods of treatment and to integrate those that are effective into mainstream health care practice.

SELF-HELP
Once considered a fringe approach to managing the symptoms of various illnesses, self-help has become an integral part of treatment for mental health problems. Many people with mental illnesses find that self-help groups are an invaluable resource for recovery and for empowerment. Self-help generally refers to groups or meetings that:

Involve people who have similar needs
Are facilitated by a consumer, survivor, or other layperson;
Assist people to deal with a "life-disrupting" event, such as a death, abuse, serious accident, addiction, or diagnosis of a physical, emotional, or mental disability, for oneself or a relative;
Are operated on an informal, free-of-charge, and nonprofit basis;
Provide support and education; and
Are voluntary, anonymous, and confidential.

DIET AND NUTRITION
Adjusting both diet and nutrition may help some people with mental illnesses manage their symptoms and promote recovery. For example, research suggests that eliminating milk and wheat products can reduce the severity of symptoms for some people who have schizophrenia and some children with autism. Similarly, some holistic/natural physicians use herbal treatments, B-complex vitamins, riboflavin, magnesium, and thiamine to treat anxiety, autism, depression, drug-induced psychoses, and hyperactivity.

PASTORAL COUNSELING
Some people prefer to seek help for mental health problems from their pastor, rabbi, or priest, rather than from therapists who are not affiliated with a religious community. Counselors working within traditional faith communities increasingly are recognizing the need to incorporate psychotherapy and/or medication, along with prayer and spirituality, to effectively help some people with mental disorders.

ANIMAL ASSISTED THERAPIES
Working with an animal (or animals) under the guidance of a health care professional may benefit some people with mental illness by facilitating positive changes, such as increased empathy and enhanced socialization skills. Animals can be used as part of group therapy programs to encourage communication and increase the ability to focus. Developing self-esteem and reducing loneliness and anxiety are just some potential benefits of individual-animal therapy (Delta Society, 2002).

EXPRESSIVE THERAPIES
Art Therapy: Drawing, painting, and sculpting help many people to reconcile inner conflicts, release deeply repressed emotions, and foster self-awareness, as well as personal growth. Some mental health providers use art therapy as both a diagnostic tool and as a way to help treat disorders such as depression, abuse-related trauma, and schizophrenia. You may be able to find a therapist in your area who has received special training and certification in art therapy.

Dance/Movement Therapy: Some people find that their spirits soar when they let their feet fly. Others-particularly those who prefer more structure or who feel they have "two left feet"-gain the same sense of release and inner peace from the Eastern martial arts, such as Aikido and Tai Chi. Those who are recovering from physical, sexual, or emotional abuse may find these techniques especially helpful for gaining a sense of ease with their own bodies. The underlying premise to dance/movement therapy is that it can help a person integrate the emotional, physical, and cognitive facets of "self."

Music/Sound Therapy: It is no coincidence that many people turn on soothing music to relax or snazzy tunes to help feel upbeat. Research suggests that music stimulates the body's natural "feel good" chemicals (opiates and endorphins). This stimulation results in improved blood flow, blood pressure, pulse rate, breathing, and posture changes. Music or sound therapy has been used to treat disorders such as stress, grief, depression, schizophrenia, and autism in children, and to diagnose mental health needs.

CULTURALLY BASED HEALING ARTS
Traditional Oriental medicine (such as acupuncture, shiatsu, and reiki), Indian systems of health care (such as Ayurveda and yoga), and Native American healing practices (such as the Sweat Lodge and Talking Circles) all incorporate the beliefs that:

Wellness is a state of balance between the spiritual, physical, and mental/emotional "selves."
An imbalance of forces within the body is the cause of illness.
Herbal/natural remedies, combined with sound nutrition, exercise, and meditation/prayer, will correct this imbalance.
Acupuncture: The Chinese practice of inserting needles into the body at specific points manipulates the body's flow of energy to balance the endocrine system. This manipulation regulates functions such as heart rate, body temperature, and respiration, as well as sleep patterns and emotional changes. Acupuncture has been used in clinics to assist people with substance abuse disorders through detoxification; to relieve stress and anxiety; to treat attention deficit and hyperactivity disorder in children; to reduce symptoms of depression; and to help people with physical ailments.

Ayurveda: Ayurvedic medicine is described as "knowledge of how to live." It incorporates an individualized regimensuch as diet, meditation, herbal preparations, or other techniquesto treat a variety of conditions, including depression, to facilitate lifestyle changes, and to teach people how to release stress and tension through yoga or transcendental meditation.

Yoga/meditation: Practitioners of this ancient Indian system of health care use breathing exercises, posture, stretches, and meditation to balance the body's energy centers. Yoga is used in combination with other treatment for depression, anxiety, and stress-related disorders.

Native American traditional practices: Ceremonial dances, chants, and cleansing rituals are part of Indian Health Service programs to heal depression, stress, trauma (including those related to physical and sexual abuse), and substance abuse.

Cuentos: Based on folktales, this form of therapy originated in Puerto Rico. The stories used contain healing themes and models of behavior such as self-transformation and endurance through adversity. Cuentos is used primarily to help Hispanic children recover from depression and other mental health problems related to leaving one's homeland and living in a foreign culture.

RELAXATION AND STRESS REDUCTION TECHNIQUES
Biofeedback: Learning to control muscle tension and "involuntary" body functioning, such as heart rate and skin temperature, can be a path to mastering one's fears. It is used in combination with, or as an alternative to, medication to treat disorders such as anxiety, panic, and phobias. For example, a person can learn to "retrain" his or her breathing habits in stressful situations to induce relaxation and decrease hyperventilation. Some preliminary research indicates it may offer an additional tool for treating schizophrenia and depression.

Guided Imagery or Visualization: This process involves going into a state of deep relaxation and creating a mental image of recovery and wellness. Physicians, nurses, and mental health providers occasionally use this approach to treat alcohol and drug addictions, depression, panic disorders, phobias, and stress

Massage therapy: The underlying principle of this approach is that rubbing, kneading, brushing, and tapping a person's muscles can help release tension and pent emotions. It has been used to treat trauma-related depression and stress. A highly unregulated industry, certification for massage therapy varies widely from State to State. Some States have strict guidelines, while others have none.

TECHNOLOGY-BASED APPLICATIONS
The boom in electronic tools at home and in the office makes access to mental health information just a telephone call or a "mouse click" away. Technology is also making treatment more widely available in once-isolated areas.

Telemedicine: Plugging into video and computer technology is a relatively new innovation in health care. It allows both consumers and providers in remote or rural areas to gain access to mental health or specialty expertise. Telemedicine can enable consulting providers to speak to and observe patients directly. It also can be used in education and training programs for generalist clinicians.

Telephone counseling: Active listening skills are a hallmark of telephone counselors. These also provide information and referral to interested callers. For many people telephone counseling often is a first step to receiving in-depth mental health care. Research shows that such counseling from specially trained mental health providers reaches many people who otherwise might not get the help they need. Before calling, be sure to check the telephone number for service fees; a 900 area code means you will be billed for the call, an 800 or 888 area code means the call is toll-free.

Electronic communications: Technologies such as the Internet, bulletin boards, and electronic mail lists provide access directly to consumers and the public on a wide range of information. On-line consumer groups can exchange information, experiences, and views on mental health, treatment systems, alternative medicine, and other related topics.

Radio psychiatry: Another relative newcomer to therapy, radio psychiatry was first introduced in the United States in 1976. Radio psychiatrists and psychologists provide advice, information, and referrals in response to a variety of mental health questions from callers. The American Psychiatric Association and the American Psychological Association have issued ethical guidelines for the role of psychiatrists and psychologists on radio shows.

RESOURCES

American Art Therapy Association, Inc.
1202 Allanson Road
Mundelein, IL 60060-3808
Telephone: 847-949-6064/888-290-0878
Fax: 847-566-4580
E-mail: arttherapy@ntr.net
www.arttherapy.org

American Association of Pastoral Counselors
9504-A Lee Highway
Fairfax, VA 22031-2303
Telephone: 703-385-6967
Fax: 703-352-7725
E-mail: info@aapc.org
www.aapc.org

American Chiropractic Association
1701 Clarendon Boulevard
Arlington, VA 22209
Telephone: 800-986-4636
Fax: 703-243-2593
www.amerchiro.org

American Dance Therapy Association
2000 Century Plaza, Suite 108
10632 Little Patuxent Parkway
Columbia, MD 21044
Telephone: 410-997-4040
Fax: 410-997-4048
E-mail: info@adta.org
www.adta.org

American Music Therapy Association
8455 Colesville Rd, Suite 1000
Silver Spring, MD 20910
Telephone: 301-589-3300
Fax: 301-589-5175
E-mail: info@musictherapy.org
www.musictherapy.org

American Association of Oriental Medicine
5530 Wisconsin Avenue, Suite 1210
Chevy Chase, MD 20815
Telephone: 888-500-7999
Fax: 301-986-9313
E-mail: hq@aaom.org
www.aaom.org

The Delta Society
580 Naches Avenue SW, Suite 101
Renton, WA 98055-2297
Telephone: 425-226-7357
Fax: 425-235-1076
E-mail: info@deltasociety.org
www.deltasociety.org

National Empowerment Center
599 Canal Street
Lawrence, MA 01840
Telephone: 800-769-3728
Fax: 508-681-6426
www.power2u.org

National Mental Health Consumers'
Self-Help Clearinghouse
1211 Chestnut Street, Suite 1207
Philadelphia, PA 19107
Telephone: 800-553-4539
Fax: 215-636-6312
E-mail: info@mhselfhelp.org
www.mhselfhelp.org

Herbal Remedies

Why do people choose herbal medicine?
People try herbal remedies for all sorts of reasons: because they hear from others that it has worked, because they feel it's natural and believe it's likely to have fewer side effects, or because they prefer its holistic approach. People also like the idea of having more control over their own treatment. Others turn to herbal remedies because conventional medicine has let them down, or because they want to relieve the side effects caused by the prescription medication they need to take.

The popularity of herbal medicines is clear now that herbs are much more widely available over the counter. Also on the increase is the number of qualified practitioners and those choosing plant medicines, in their many forms.

Herbal medicines can be used to treat health problems that are short-lived (acute) or firmly established (chronic), as part of a holistic approach to health. In other words, when looking at the person as a whole, and working out whether there are underlying medical, emotional or lifestyle factors that may be having some influence on the outbreak of symptoms. (See Useful organisations and Further reading for more information.)

How is it best to use herbs?
It's important to recognise, first of all, that herbs don't have a specific and limited purpose, in the way that conventional medicines do. Each person should have their individual needs identified, so that herbs prescribed specially for him or her, at the time, can address these. For example, not only are there different types of depression, but they can also vary in intensity. A person may go through a depression that is altogether different from their experience of depression on a previous occasion. It may also involve a whole range of physical symptoms - lethargy, stomach problems (constipation and diarrhoea) and headaches, to name just a few - that are individual to that person.

A herbalist will take into consideration the whole picture of someones symptoms, and use an individually tailored combination of plants to address those symtoms and to restore health. Combining two or more herbs can enhance the individual effects of each one. This is known as synergism. Herbs for the nervous system fall into a number of categories. They can be used to strengthen a system, to relax or sedate a system, or to stimulate it.

How should I take herbal remedies?
At home, the easiest way is to make a tea or 'infusion', by leaving the plant material in boiling water for 5-10 minutes, before straining and drinking it. Herbal remedies come in many other forms, however. They can be bought over the counter as:

fresh herbs (such as, garlic cloves or peppermint leaves)
capsules or tablets (powdered herbs)
extracts (a concentrated form that comes as liquid tinctures, solid pills or capsules)
tea
in foods
as essential oils (for external use)
as creams and ointments (for applying to the skin).
The potency and quality of all of these vary widely. The herbs need additives to make them into extracts, which come in a range of strengths. Tinctures are more readily absorbed and solid extracts (pills or capsules) are the most concentrated and perhaps the best value.

Some products are (or contain) 'standardised extract'. This means that the manufacturer guarantees that the product contains a certain amount of a particular ingredient, so that you know how much (by weight) of that ingredient is in each day's dose. Different manufacturers produce remedies in different strengths and to different qualities. Prices will vary, and may not necessarily reflect the quality of the product.

Herbalists themselves prefer to use herbs in their natural state, or as close to it as possible, with nothing added and nothing taken away. They prefer this 'full spectrum' to standardised extracts because they feel that preparations with added or boosted components influence the effectiveness and safety of plants, for no good reason.

How do I shop for them?
Remedies are now available in health food shops, chemists and supermarkets, and directly from herbalists. (Some can even be bought via mail order.) Supplements can be useful, but its always better to get an individual prescription rather than just guessing which herbs to use.

Herbal remedies aren't covered by a standard licensing procedure (although some do have product licences). They are either classed as food supplements, or come under section 12 of the Medicines Act, which makes them exempt from licensing. They don't have to undergo the same testing procedures as pharmaceutical drugs.

When buying herbs,

Choose remedies carefully - do a bit of research before you buy anything, and compare manufacturers as well as different forms of the herb. Don't choose on the basis of price alone.
Buy your herbs from a reputable supplier to ensure high quality.
Check the expiry date.
Choose single herbs, not combinations. (Remember that herbs act synergistically.)
Check the recommended dosage - different manufacturers have different recommendations.
Always read and follow the instructions on the label, carefully.
Dont overuse products. With all herbs, if you are self-prescribing, follow the instructions on the product, or the recommendations of a qualified herbalist. Start with the minimum dosage recommended.
Be aware of any side effects you experience. If you feel a herb does not suit you, stop taking it and seek advice from a qualified herbalist.
Many of the herbs available are user-friendly and have clear instructions. If you are self-prescribing but are unsure what to buy, contact a herbalist for advice.

Do herbs have side-effects?
A herb, like any other chemical compound, may have side effects. Being 'natural' doesn't make something automatically safe. But, on the whole, the side effects seem to be much milder and more infrequent than for pharmaceutical drugs. Most of the herbs that may have side effects in high doses arent readily available to buy over the counter. Where problems have been reported, this seems to have been caused by very poor-quality products or by extreme misuse.

Sometimes, people do take the wrong remedy for the wrong reason - mistakenly believing, perhaps, that taking a higher dose will make it work better. Not only might they do themselves harm, they also miss out on the real benefits of the remedy. That's why it's vital to know what you're taking and why you're taking it.

Is it safe to treat myself or my family using herbs?
Most people can safely treat themselves for problems that are normally fairly short-lived, but for any long-standing condition, or one that doesn't go away, you should consult a qualified herbalist, and make sure that another form of treatment isn't also necessary. With self-diagnosis, it's important to know if and when to consult a doctor.

If your child is under five or has a tendency to allergies, seek help from a qualified practitioner. Otherwise, using herbs for children is relatively straightforward, with chamomile perhaps being the mainstay of the first-aid cabinet. When giving children herbs, mix them in yogurt with a little honey or dilute fruit juice, to help them.

For safe and accurate treatment, follow these guidelines:

Don't overuse products. Use the minimum dosage for all herbs, if you are self-prescribing.
Be aware of any side effects you experience. If a herb doesnt suit you, stop using it.
The more severe the problem, the more cautious you should be about self-treatment, as a general rule.
Don't use herbal remedies if you are trying to have a baby, or if you are already pregnant or breastfeeding, without first consulting a qualified herbalist or your GP.
Never use herbs for babies or small children without seeking professional advice.
Don't take herbs alongside other prescribed drugs without consulting a qualified herbalist, because some herbs may strengthen the effects of drugs or make others less effective. With consultation, it may be possible to reduce your conventional medication.
Don't make the mistake of switching from your existing pharmaceutical drug to a herbal remedy without consultation. Herbs are medicines that work in complex and subtle ways and won't always have exactly the same effect.
If you have long-standing health problems, see a herbalist who can work with you in a holistic and effective way to treat the underlying causes and achieve the best outcome.
If you have a short-lived condition and the symptoms arent getting better within a few days, get professional advice.

In what way can a herbalist help me?
Herbalists see people of all ages, who are trying to cope with short- or long-term problems. People often ask for help when they havent been able to find relief from long-standing problems, or when they are taking prescription drugs, which have unwelcome side effects. Often, herbal remedies can help reduce these. Medical herbalists also see many children with common and ongoing conditions, such as eczema, asthma and problems sleeping or with digestion.

Herbalists treat symptoms affecting many systems of the body. Frequently, people have a batch of symptoms that can all be addressed by a trained practitioner. The same person could have a problem with their kidneys (recurrent cystitis), digestive system (irritable bowel syndrome or diverticulitis), heart and circulation (high blood-pressure), gynaecological problems (period pains or menopausal problems), nervous system (insomnia or nerve pain) and joints (arthritis).

What happens during a consultation?
Herbalists want to tackle the underlying causes of ill-health, as well as to relieve the symptoms that brought you to see them in the first place. So, a first consultation will take between an hour and an hour-and-a-half. It will cover, in detail, aspects of your medical, dietary, and emotional history and lifestyle, as well as getting a good account of your current state of health. He or she may do a physical examination, if that's necessary, and will usually check your blood pressure. This is especially useful if you havent been to see your GP for a long time. It's also important for a herbalist to decide whether you should see your doctor, or whether a different system of health-care could be helpful.

Herbalists don't dispense standard remedies for symptoms. Following a consultation, a herbalist may prescribe herbs for a period of two to three weeks. After this time, the prescription will be reviewed, depending on what the outcome has been.

Remedies can take time to work or may work quickly, depending on the symptom and health picture. A qualified herbalist will give you an indication of timescales in which to expect changes and improvements to your symptoms, and how this will be evaluated.

How do I find a good herbalist?
To be confident about someone treating you, you should check whether they are qualified members of a recognised, professional body, and find out details of their training and experience. For instance, members of the National Institute of Medical Herbalists (established in 1864) have undergone a rigorous, four-year training, including subjects such as Western medical sciences, pharmacy, nutrition, the therapeutic actions of plants, and therapeutics. They have a strict code of ethics and full professional insurance. The letter MNIMH or FNIMH after the name indicate that someone is a member of the Institute.

Most herbalists have a sliding scale of fees, which they can apply according to whether you are working or on a reduced income. Unfortunately, not everyone can afford herbal medicine. Many GPs are open to the idea of herbal remedies (some are even practising herbalists themselves). Although they have general guidelines for referring patients to complementary practitioners, they don't have standard criteria for doing so. In some areas, herbalists work within GP practice settings, alongside other health professionals who may work with complementary or conventional medicine.

What herbs are used for mental and emotional health?
Practitioners approaching mental or emotional problems frequently choose from a class of herbs that includes those known as the nervous trophorestoratives. In other words, these are herbs that feed and nourish a system. Herbs usually have a primary action, but may also have additional influences. It's therefore important to use herbs that synergise, or enhance each other's activities. Such herbs may include St John's wort, lemon balm, damiana, passionflower, hops, valerian and kava kava.

Herbalists need to take care that the herbs they use do not over-stimulate an individual. In the short-term, the herbalist may use additional prescriptions of regular doses of herbs throughout the day to regulate sleep or alleviate panic attacks, for instance. This will go on until the main prescription begins to make an impact. The time-scale will depend on the choice of treatment and individual needs.

Scientific research on the herbs St John's wort, kava kava and valerian has confirmed good results in treating, variously, depression, anxiety, insomnia, and memory problems. It has also provided much more information about side effects that might be associated with them.

There are other herbs traditionally used for emotional problems:

passionflower, reishi and hops, for anxiety and stress
sage, hyperzine and peony, for memory problems
chamomile, lemon balm and passionflower, for sleep.
Recently, theres been greater focus and interest in treating problems relating to sexual function. Here, herbs are seen as a safe option when compared to the medications frequently prescribed. Self-help is probably of limited value however, because problems of this kind can have so many origins. Its best to speak to a qualified practitioner about this, if possible.

St John's wort has been successful as a safe treatment for many people who have mild or moderate depression. But this has fuelled a mistaken idea that a particular herb can 'fix' a particular problem, and that all people need do is go and buy a bottle. This contradicts the core principles of herbal medicine, and creates false expectations. It's important to remember that what works for one person may not work for another, in just the same way that someone may try several conventional antidepressants before finding one that works.

Herbs that may be used for mental health

Although there have been tests on many herbs, there is often no conclusive information about what side effects may occur and how likely they are. However, in comparison to the majority of pharmaceuticals, herbs are well tolerated. Its worth remembering that herbal remedies have been used safely for a very long time.

Damiana
A herb, Damiana Turnera diffusa. ( Plant family: Turneraceae.) Comes as a leaf, powder, capsule, tincture or fluid extract.
What's it for?
A tonic herb to strengthen the reproductive and nervous systems. For mild to moderate depression and anxiety associated with fatigue. Also for lack of sexual desire.
Possible side effects
No reported side effects.
Caution
Turnera can be very stimulating, so, if you are self-prescribing, use the minimum dosage.

Gingko biloba
Extract from a Chinese tree. (Plant family: Gingkoaceae.) Comes as tablets, liquid or tea.
What's it for?
Memory and other age-related mental effects. Can be helpful for depression, and when an antidepressant reduces interest in sex. Gingko has a powerful influence on the circulatory system, and research has been undertaken into how it affects Alzheimers disease and dementia.
Possible side effects
Rare. Stomach upset, headache, allergic skin reactions, or slight dizziness, on occasion.

Kava kava
A shrub, Piper methysticum, a member of the pepper family. (Plant family: Piperaceae.) Comes as pills, capsules, liquids, tea, tincture or spray. Currently unavailable in the UK.
What's it for?
Anxiety and stress. May also be helpful for sleep, pain and depression. Used for chronic irritation of the urinary tract and for some arthritis.
Possible side effects
Generally well tolerated. Exceptionally, people have experienced stomach discomfort, headache, tiredness and wobbliness.
Caution
Consult your doctor if you are already taking sedatives.

Lavender
A herb, Lavendula officinalis. (Plant family: Labiatae.) Available as a tea, essential oil and in some over-the-counter preparations.
Whats it for?
A safe herb, generally used to influence the nervous system, digestive system, circulation and skin. Aids sluggish digestion and sleep, and relieves tension headaches. Also used by herbalists to help people with mild to moderate depression, and to ease pain.
Possible side effects
No reported side effects.

Lemon balm
A herb, Melissa officinalis. (Plant family: Labiatae.) Available as a tea and essential oil.
Whats it for?
Anxiety, irritability, insomnia, headaches and period pains.
Possible side effects
No reported side effects.

Peppermint
Mentha piperita. (Plant family: Labiatae.) Comes as herb, powder, capsule, essential oil, tincture and fluid extract.
What's it for?
Commonly used by sufferers of irritable bowel syndrome. Useful for those who experience nausea due to emotional disruption, for digestive spasm and pain, mild diarrhoea, headaches and migraine.
Caution
Do not use medicinally in children under five. Do not use during pregnancy or when breastfeeding.

St John's wort
A herb, Hypericum perforatum. (Plant family: Guttiferae.) Comes as tablets, capsules, liquid, tea, tincture, ointment and oil.
What's it for?
Depression. Clinical trials confirm its benefits for treating mild depression. May also be helpful for anxiety, sleep problems and seasonal affective disorder (SAD). It can influence the nervous system, the body's defences (the immune system) and the glands, and can be used, internally and externally, for a wide range of symptoms. Herbalists may use St Johns wort to influence a number of health problems, including nerve damage, menopausal symptoms and viral infections.
Possible side effects
Mild nausea, headaches, sleepiness, dry mouth, constipation, itchiness, restlessness, dizziness, mania (in manic depression) and sunburn. Has been shown in scientific trials to have fewer side effects than older antidepressants.
Caution
Do not use it if you are taking medication (including the contraceptive pill) without seeking professional advice. May thin the blood. The Medicines Control Agency suggests it should not be used with drugs such as Warfarin, anticonvulsants and certain antidepressants. Increases the skin's sensitivity to sun.

Valerian
A common plant, Valeriana officinalis. (Plant family: Valerianaceae.) Comes in capsules, pills, liquid extracts, tinctures, infusions, and tea.
What's it for?
Anxiety and stress. It may be helpful for depression and for sleep problems. Herbalists may use valerian in combination with other herbs for pain management and to influence a whole range of health problems that may be exacerbated by disruption of the nervous system.
Possible side effects
Mild headaches, feeling sick, nervousness, palpitations, grogginess on waking. Long-term use at large doses may increase the range and severity of side effects.

References
A combination of plant extracts in the treatment of outpatients with adjustment disorder with anxious mood M. Bourin, T. Bougerol, B. Guitton (Fundamental and clinical pharmacology 1997, 11)
The complete floral healer A. McIntyre (Gaia 1996)
Critical evaluation of the effects of valerian extract on sleep structure and sleep quality F. Donath, S. Quisipe et al. (Pharmacopsychiatry November 2000)
Double blind study of a valerian preparation O. Lindahl, L. Lindwall (Pharmacology biochemistry and behavior April 1998)
Effects of a fixed valerian-hop extract A. Fussel, A. Wolf, A Brattistrom, (European journal of medical research September 2000)
The effects of valerian, propanolol and their combination on activation, performance and mood in healthy volunteers under stress conditions R. Kohnen, W. D. Oswald (Pharmacopsychiatry 1988, 21)
Herbs for the mind J. R. T. Davidson, K. M. Connor (The Guilford Press 2000)
Herbal first aid A. Chevalier (Amberwood Publishing 1993)
Herbal remedies - a beginners: guide to making effective remedies in the kitchen C. Hedley, N. Shaw (Paragon 1997)
The new holistic herbal D. Hoffman (Element 1991)

Useful organisations

Deep muscle Therapy

Deep Muscle Therapy or Pfrimmer Deep muscle Therapy, is a very successful form of remedial massage that, as the name implies, works into the deeper levels of muscles.

When a person is ill or in pain, often friends will suggest a particular therapy that worked for them. They try the recommended therapy to no avail or they may receive minor relief. Perhaps they were fortunate enough to achieve the desired results.

Why are some therapies successful for one individual and not for another?

To answer this question we will not go into a long exposé of physiological processes within the body. The answers are simple...the basic principle of a healthy body is to have healthy blood, which can only be achieved by good circulation. If each and every cell of the body is well nourished and healthy then so too will the whole body be healthy. Our cells get sick and we get sick!

Surrounding each cell is Lymphatic fluid; obviously the purity of the lymph depends on the quality of the blood and the vigour of the circulation. The cleansing action of the lymph, being as important as the nourishing action.

To achieve Homeostasis (perfectly balanced body chemistry), the blood and the lymph must flow freely...rich in nutrients and oxygen and free from unwanted substances and toxins.
 

One of the major factors restricting the flow of the blood and lymph; is tight muscles.
 

When the muscles, particularly the deep layers, are in spasm there is a 'clamping' effect on the arteries which slows the circulation and inhibits the lymphatic flow. These spasms (and subsequent adhesions) may be present for many years, affecting every single organ and tissue in the body...the liver, heart, brain, etc.
 

Most therapies overlook the factor of releasing the deeper layers of the muscles as a priority to enhanced circulation.
 

We have a two-fold effect that takes place, once these deeper muscle layers are released. Not only are the arteries released but also overall circulation through the muscles is increased, building a stronger immune system; thus helping our bodies to cope with the pressures of life.
 

These are the basic principles, on which depends a successful therapy. With this in mind, we would like to introduce you to Deep Muscle Therapy. As the name implies, this therapy treats the deeper layers of the muscles, nerves and major vessels that have been constricted.
 

Deep Muscle therapy is not just another therapy that may help. THE FACT IS THAT IT WILL HELP and plays a major part in how fast the healing process can take place within the body. Let us explain this bold statement.

People become paralysed for two reasons:
 

1. The blood supply to their muscles has been diminished. Without fresh, oxygenated, Arterial blood, their muscles degenerate. They may become hardened, rubbery, stringy, woody, etc; and
 

2. The flow of lymph plasma to their muscles is restricted. This fluid is vital to the lubrication of the muscles as it prevents the muscles from adhering to one another. Without lymph, there is friction and different muscles adhere together. Regardless of the disease, the same basic muscle problems, effecting the circulation.

The only difference from case to case is that different parts of the muscles are involved. Depending on the case, it may be the beginning of the muscle (the origin), the middle (the belly), the end (the insertion), the coating (the sheath) or in the individual muscle fibres. Aside from this, the problems are the same. It is obvious that by softening hardened muscle fibres and releasing muscles that have adhered; lymph flow between the muscles will be restored and an improved circulation into the muscles; will result. It is apparent that working down the muscles will not open the fibres as required and working across the muscles does help, although, it is not completely successful. By working at different angles the treatment becomes very successful and this technique will help in many different conditions. By softening hardened muscle fibres and releasing the muscles that have become adhered; the lymph flow between the muscles would be restored and improved circulation into the muscles; will result.

When explaining the techniques of working angles; the most commonly asked question is "does it hurt." The answer to this question is both Yes and No.

An important thing to remember is that "Deep Muscle Therapy simply uncovers the pain that is already there". It also depends on the condition of the muscles...the tighter the muscles, the more pain will be felt. This may be minimized by the use of a natural analgesic cream. The first treatment is always the most intense. As muscles become free - pain decreases. Children don't usually suffer pain ... some discomfort only, is experienced.

Clients will often say that they don't feel that their muscles are tight...but as time goes by, and their muscles get tighter, they WILL feel pain.

To best explain this; imagine that there is a scale; - 0% representing a completely free muscle and 100% representing a totally locked muscle in severe spasm. On the scale we place another point at 75% and this represents the point where pain is actually felt.

Under 75% the body will usually tolerate muscle spasms, when the spasm increase above this point; pain will be felt. Many other treatments will bring the client below the 75% threshold, reducing the pain and the problem appears to be resolved. However, this is not so...
 

Being under 75% is not enough...the muscles must be completely released; or the problem will recur.

Often in this scenario the circulation will be constantly impaired and as previously explained...if the body does not have good circulation, the person cannot experience good health.

Deep Muscle Therapy is an essential ingredient to achieving optimum results by improving the circulation and therefore; maintaining good health.