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 people’s 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 who’s 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 Mind’s 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 don’t play the piano, organ or violin any more, as I can’t 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 can’t 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. That’s 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 Mind’s 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 Mind’s 2001 survey.

Death following ECT is relatively uncommon, but does happen. It’s 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. Mind’s 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 body’s 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. It’s 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 body’s 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 don’t 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.

It’s part of the therapist’s 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 woman’s 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 don’t 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, ‘How’s 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.

It’s 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 won’t 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 person’s 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, it’s 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 you’re not sure, or if you live alone and are in distress, without much support, it’s 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, it’s 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 doesn’t feel right, take your custom elsewhere. Recent governments have encouraged massage schools to develop their own self-regulation, and this is happening, although it’s 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. It’s fine to ask about any of these, and a reputable therapist will be glad to answer your questions. It’s 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 can’t 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. It’s 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. It’s 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.
Don’t 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 doesn’t 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 life’s 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 body’s 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 (Iyengar’s 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. It’s 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 day’s 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 body’s 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 won’t 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; don’t 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). Shapiro’s (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