Recent years have seen remarkable advances in our understanding of how the nervous system is wired and how it functions. Through a combination of accurate brain scanning, animal studies and other techniques, it has become possible to visualise which parts of the nervous system are involved in the execution of specific processes. For example, work by Joseph LeDoux1 correlates experience of distressing emotions, and especially fear, with activity in the amygdala, the hypothalamus and related structures in the brain (known collectively as the limbic system). This article will discuss the process of experiential psychotherapy with particular emphasis on a technique known as focusing. It will then offer a hypothesis for the neural correlates of this approach, with particular emphasis on the hypothesised role of the vagus nerves.

The technique of focusing
Focusing is an approach to introspection which was discovered 50 years ago, and despite robust evidence of its efficacy in psychotherapeutic settings, it has not enjoyed the recognition it deserves. Working in the 1960s, Professor Eugene Gendlin2 of the University of Chicago first discovered focusing when attempting to discover why psychotherapy was helpful for some people but not for others. Ann Weiser Cornell,3 who has worked with Gendlin since she first encountered focusing in 1972, describes his work and findings thus: ‘He and his colleagues studied tapes of hundreds of sessions… some clients were getting better, some were not… There was no significant difference in therapist behaviour… [but] there was a difference between the successful therapy clients and the unsuccessful ones… Whatever this was, it wasn’t something that [they] learned how to do because of therapy; it was something they were already doing, able to do, when they walked in the door… What [the researchers] heard was this: at some point in the session, the successful therapy clients would slow down their talk, become less articulate, and begin to grope for words to describe something that they were feeling at that moment… [They] had a vague hard-to-describe body awareness that they were directly sensing during the session. [The] unsuccessful clients stayed “up in their heads”.’

What Gendlin and colleagues had discovered was our natural ability to ‘focus’ on an odd kind of meaningful body sensation called a ‘felt sense’. As Weiser Cornell3 went on to write: ‘Focusing was a natural skill that was discovered, not invented… Focusing ability is the birthright of every person: we were born with the ability to know how we feel from moment to moment… [and] the experiences of hurt and alienation in our childhood and from our culture, have caused us to lose trust in our bodies and our feelings. We need to re-learn focusing.’ [Since writing her book Weiser Cornell has changed her view of the ‘felt sense’ and she no longer believes it is equivalent to ‘knowing how we feel from moment to moment’ (personal communication)]. Gendlin developed a six-step strategy to guide this learning, publishing it in 1978 in a book called Focusing.2

Focusing in practice
In my own practice, I have often found that shifting from this intellectual discussion of a problem to how it feels in the body can have a profound effect on the subject’s sense of it. Let us imagine a situation in which a client feels stuck with feelings about a situation and is struggling to understand it. Having exhausted the conversation about who said what and what it meant and so on, the client is invited to turn their attention away from their thinking, and to focus it instead on what they feel at that moment in the central areas of their body, from their throat to their chest and down into their abdomen. This will usually be strange at first, but with attentive listening from the therapist and a little guidance, the client may get in touch with what is called the ‘felt sense’ of the problem. Asked to get an overall feel of ‘all about this issue’, the client may report, for example, a ‘tightness across the chest’ or a feeling ‘like a big black sticky mass’ in the belly. The therapist’s role at this point is to echo verbatim what the client has just said: ‘a tightness across your chest’, ‘like a big black sticky mass’. This is important as the therapist needs to avoid putting his or her own interpretation on what is developing in the client’s core area.

The client may then be invited to simply say hello internally to this feeling. This is just to acknowledge the experience at this stage, as the client may not yet be able to process it further. The process can proceed in many ways from here. Therapist and client can wait for the felt sense to communicate further spontaneously, or a word, a phrase, an image, a simile or a metaphor can be offered, which might capture the essence of the feeling: ‘A kind of strangled feeling, yes, that’s it.’ In the beginning, the client will often prefer to switch back to their head, to come out of their body, and to retreat to the comfort of talking about the problem again. When this happens, a noticeable change in the client’s disposition occurs; there will be a switch from an inwardly focused state, often with eyes closed, to a more ‘back in the room, let’s talk about my problem’ state. The therapist may wish to guide the client back into the body, depending on the client’s readiness to face the felt sense.

Focusing can be a useful adjunct to the more usual modes of psychotherapy, with a shifting back and forth between, say, a cognitive approach and somatic (bodily) sensing. People suffering from anxiety often find it illuminating to discover that their fears are actually a complex web of sensations in the body, with an intellectual overlay of negative thoughts. This often gives them a new perspective on their difficulty. Focusing can open up a new inner relationship with the parts of oneself hitherto unknown. Weiser Cornell describes this process as ‘Inner Relationship Focusing’. Exploring the issue in these ways hopefully leads to a sense of resolution and completion, and when this occurs there will be a ‘felt shift’ in the bodily awareness. This may be felt as an ‘aha’ experience, or the sense of the issue no longer being a problem, or there may be a feeling of relaxation in the body.

Since focusing is an introspective skill, it can be broadened from psychotherapy to other areas of experience. For example, friends who learn to focus take turns at being the focuser and then the listener. Through the Focusing Institutes of Britain and the United States,5 a network of focusing friendships has developed, where people can meet, often by telephone, to share focusing conversations. Focusing has been used effectively in psychotherapy, business, marriage and friendship, and can be used alone. It can be used to face personal suffering effectively, when the physical experience of that suffering can be addressed directly and not side-stepped by the ruminating mind.

Focusing can also be used as a form of meditation. With a focusing-oriented meditation, the practitioner may choose to attend to the felt sense in the core area, and to observe how that sense develops. Many resources are available to help people learn focusing, both within a psychotherapeutic context and without. The respective institutes provide workshops and access to other focusers, as well as written and audio material.

The connection to neurophysiology
It is worth mentioning that Gendlin and others in the community are not entirely happy with the term ‘focusing’ [personal communication] as it conjures up an image of sustained and concentrated attention of the type one might use to ‘focus’ on one’s work or one’s children or to ‘focus attention’ on a candle flame or a football match. Neither is focusing mere introspection on the content of one’s thoughts and the cyclical pattern of habitual and often automatic thought forms. Nor is it simply watching one’s breathing, or the rise and fall of the abdomen, although these are not excluded as components of it. In my opinion, the spirit of focusing can be captured by the word ‘vague’. If one turns to the core area, there may be distinct sensations coming from tense muscles in the throat, chest or abdomen, giving rise to a sense of choking, constriction and so on. But there are more subtle sensations than these, sensations which are best described as ‘murky’ or ‘unclear’.

My hypothesis is that focusing is, at least partially, a visceral sense and that it marks the discovery of a sense modality which has been there all along, but hitherto unacknowledged. Moreover, I postulate that the principal neural transmitters of this visceral sense are the vagus nerves.

Overview of the nervous system
To orientate the reader, it is necessary to give an overview of the nervous system. The regulation of the body’s inner milieu is controlled by two main systems, each overlapping and interacting. One is the endocrine system, which comprises the hormone-secreting glands as well as the pituitary gland in the brain, where hormone messengers are conveyed around the body via the blood stream; the other is the nervous system.

The nervous system has two major components, the voluntary nervous system and the involuntary, or autonomic nervous system (ANS). The former controls the muscles and receives its sensory input from the muscles, the joints and the skin, as well as from the organs of balance in the inner ear. If one attends to the sensations coming from the limbs, for example, one has a more or less precise sensation of muscle tone, of position sense, of pressure and the effects of gravity, as well as a sense of warmth or cold, pain or itching, pressure and so on, from the skin.

The motor component exerts (usually) voluntary control over muscles, controlling movement, maintaining balance, and so on. These nerve pathways travel via the spinal cord, except for those relating to the head, which travel in paired nerves known as the cranial nerves. It is the ANS which exerts involuntary (automatic) control over the organism’s state of arousal, its readiness for action and over the vegetative functions of blood pressure control, digestion, elimination and so on. It has two divisions, the sympathetic and the parasympathetic. (Michael Gershon6 has pointed out, however, that a third division exists, the enteric nervous system, which operates more or less independently of the sympathetic and parasympathetic systems, and is replete with its own suite of neurotransmitters, of which serotonin is a major example – see table below). These are designed to work in a harmonious and complementary fashion. The sympathetic division prepares the organism for ‘fight or flight’.

Figure 1: Functions of the autonomic nervous system

Parasympathetic
o Rest and digest
o Decreases heart rate
o Decreases blood pressure (dilates blood vessels)
o Constricts airways
o Constricts pupils
o Stimulates salivation
o Opens sphincters (urination and defecation)
o Moves blood to gut (for digestion)
o Increases gut movement
o Inhibits sweating
o Stimulates tears

Sympathetic
o Fight and flight
o Increases heart rate
o Increases blood pressure (constricts blood vessels)
o Opens airways
o Dilates pupils
o Inhibits salivation
o Closes sphincters (inhibits bladder and bowel)
o Moves blood to muscles (for action)
o Inhibits gut movement
o Increases sweating
o Inhibits tears

The other divisions are the enteric (gut) nervous system and the cardiac nervous system.

Adrenaline and noradrenaline are its principal neurotransmitters and its neural circuits travel outside, but parallel, to the spinal cord. The parasympathetic division is energy conserving and controls the vegetative functions, sometimes referred to as ‘rest and digest’. It is this portion of the nervous system which is of most interest here. For an outline of the respective functions of the sympathetic and parasympathetic systems see the box, left. People who suffer from anxiety will often have an overactive sympathetic drive, with inadequate parasympathetic tone to balance it. The goal of anxiety management from a neurophysiological perspective is to balance and integrate the activities of both sympathetic and parasympathetic systems.

The major pathways for parasympathetic impulses in the body are the vagus nerves. These nerves are the tenth of 12 pairs of cranial nerves which arise within the brain. The first, second and eighth cranial nerves carry the senses of smell, sight and hearing respectively. The remaining pairs are principally involved with supplying motor function to and receiving sensory information from the head and neck. Most of these cranial nerves have their origins (known as the ‘cell nuclei’) in the brainstem, which links the spinal cord and the brain, and they are relatively short.

In contrast the vagus nerves are very long. Taking their name from the Latin for ‘wanderer’, the vagus nerves leave their origin in the brainstem and wander from the neck down into the chest and on into the abdomen. The vagus is composed of about 20 per cent motor fibres and 80 per cent sensory. Its motor component supplies some of the muscles in the throat and the voicebox. It also supplies motor fibres which influence the involuntary muscles and the glandular secretions of the oesophagus, stomach, liver, pancreas, gall bladder and most of the gut. The internal organs collectively are referred to as the viscera. The part of the vagus which supplies nerves to the heart and lungs operates to conserve energy (the opposite of fight and flight response) and slows the heart, drops blood pressure, constricts airways, and secretes mucus. The vagus also carries general visceral sensory information from the throat and voicebox, heart, lungs, oesophagus, stomach, liver, gall-bladder, pancreas and all of the gut except the last third of the large bowel and the rectum (this portion is supplied by nerves coming from the lower end of the spinal cord). It is this third part, the general visceral component, which is especially relevant here. It is now known that the gut has its own complex of 100 million nerve cells which developed independently of the central nervous system (CNS) and is of earlier evolutionary age. Its role is the integration of the digestive system and it is known as the enteric nervous system. This system receives input from the motor component of the vagus, but largely functions independently.

The majority of vagal sensory fibres transmit information from the enteric nervous system to the brainstem. Similarly, it has been discovered that the heart too has a complex of nerve cells (40,000 or so) which functions partly autonomously and which also interfaces with the CNS via the vagus. It is interesting that these two systems – placed in the gut and in the heart – produce their own neurotransmitters and hormones, such as serotonin and endorphins (which are understood to play a role in regulation of mood and a sense of wellbeing, respectively) and even oxytocin, the hormone involved in affectional bonding.7 Sensory information from these gut and heart complexes is conveyed to the brain via the vagus nerves. In addition to relaying and receiving information from the body, the cell nuclei of the vagus in the brainstem have been shown to relay to and from higher regions in the brain: to the hypothalamus and amygdala, which are involved in emotional responses, as well as to higher structures including the frontal lobes, which are believed to play a role in mediating our deepest awareness.

The vagus nerves are important when considering anxiety as, in conjunction with other cell nuclei in the brainstem, they play a central role in the regulation of breathing, acting with the other cell nuclei in a complex fashion to stimulate and end inhalation, initiate exhalation, stimulate the next inhalation, and so on. The vagus’ role seems to be specifically related to exhalation. In meditation, the expiratory phase of respiration is prolonged (typically to a ratio of 4:1 over inhalation); and it is proposed that this is a significant component of the relaxation response which meditation and breathing exercises evoke. A recent study8 has demonstrated an increase in cell numbers in the vagal brainstem nuclei of a group of experienced meditators. This capacity of the brain to change its anatomy and function in response to repeated practice is known as neuroplasticity. Long-term meditation, especially body-oriented practices, and/or breathing exercises appears to reduce the vulnerability to anxiety, at least partially by increasing vagal tone. Presumably, this relays upward to the higher centres and pacifies the activity of the amygdala and other limbic structures.

In a way similar to how the other cranial nerves relay information from the nose, eyes and ears, the vagus nerves relay information from inside the body. The eyes and ears are exteroceptive, which means they look outward. The vagus is interoceptive, which means it looks inward, to the viscera themselves; these nerves are like inner eyes. They pick up ‘gut feelings’, things that are ‘heart-felt’, feelings in our waters. This truly is a sixth sense, with the objects of perception being our own innards, supplementary brains in heart and gut, with their own feelings and wisdom. They won’t, of course, communicate verbally, which is why words don’t come when we attend here. Like all other skills, the more we ‘look inward’, the better we will become at it.

I propose that regular practice of focusing and allied body practices will also enhance vagal tone, and reduce unhealthy over-arousal of the limbic system. It is worth emphasising that the proposed neurophysiology may have some relevance in other body-oriented therapies such as the Alexander Technique, the Feldenkrais Method, and Rolfing, as well as to breath therapies. These practices, to varying degrees, involve paying attention to sensations arising from the musculoskeletal system, but there may be some sensory input from the heart, lungs and abdominal organs (the viscera), via the vagus nerves. Similarly, yoga and t’ai chi develop awareness of both voluntary and visceral sensations by promoting awareness of the body’s movement on the one hand and paying attention to the breath and the belly, on the other.

Looking at the evidence
What evidence is there that the vagus nerve is involved in somatic practices, including focusing? The evidence is patchy and sometimes circumstantial, but a number of strands are noteworthy. Antonio Damasio9 describes some emerging evidence that feelings and emotions are not only experienced in the body, but that without the body’s input, they do not occur. He describes the tragic condition known as ‘Locked-in Syndrome’, where a stroke in the brainstem leaves patients completely paralysed apart from the ability to blink, and with no sensory input whatsoever from the body. They can communicate by blinking via a word processor and remain fully conscious and capable of feeling joy and sadness, but not the anguish of fear and suffering. In contrast, people who suffer spinal cord damage suffer loss of the capacity to feel the body generally, but with the vagus nerve still intact, sensory input from the viscera remains, and they retain the capacity to feel fear and anguish. This is an over-simplification, as even complete severance of the cord high up still leaves the nerve supply to the head and neck intact, and we know that much emotion is generated in the feedback from the muscles of facial expression, and there is still argument over whether visceral inputs from the vagus are necessary for full feeling of emotion.

Another clue comes from the experience of people who receive Tubocurarine as a muscle relaxant in anaesthesia. Some such patients, if they are insufficiently anaesthetised, report memories of the total paralysis and accompanying terror, in contrast to the locked-in patients who do not feel such terror. The clue here is that Tubocurarine paralyses the skeletal muscle only and signals from the smooth muscle of the gut, via the vagus, continue.

Damasio’s final piece in the puzzle is the well-established fact that the laying down of memory is enhanced if there is an emotional charge accompanying the experience. We all remember emotionally charged events better than neutral ones. In contrast, rats whose vagus nerves have been cut do not learn (ie remember) as well as those with intact visceral input, implying a role for the vagus in emotion.

An interesting related phenomenon is known as ‘cardiac coherence’. Discovered in 1992 by physicist Dan Winter and now being developed further by Dr Alan Watkins,10 it refers to a natural variability of the heart rate with respiration. Sometimes the variability is chaotic, sometimes it is what is called coherent or rhythmical. It is proposed that the coherent form has an integrating and soothing effect on the CNS, increasing parasympathetic tone. Coherence can be promoted by a form of inward attention similar to focusing, and biofeedback machines have been developed to provide information on when it has been achieved by means of a pulse sensor linked to a computer programme. This appears to be mediated via the vagus nerve from the heart’s brain to the CNS.

Another area of research which is suggestive is a 1953 study11 of patients who underwent vagotomy. From the 1950s, until relatively recently, vagotomy, a severing of the vagus nerve below the diaphragm, was performed on people suffering from ulcer disease, then thought to be due to excess acid secretion by the stomach. This secretion is largely under vagal control. Most studies of the effects of vagotomy have concentrated on the effects of the procedure on gastrointestinal function. However, one study in the psychiatric literature compared 40 vagotomy patients with controls and reported that: ‘Twelve patients, despite improvement in ulcer symptoms, had increased difficulties in adjustment at home, at work, and in interpersonal relationships in general. In 10 patients, the affective changes and adjustment difficulties appeared to be due to the specific effects of vagotomy.’ This evidence suggests a role for the vagus nerve in the experience and integration of emotional life, and this is potentially a fruitful area for further study.

Stephen Porges12 has advanced a fascinating idea, which he calls polyvagal theory. It appears there are at least two major divisions of the vagus, one older and one which developed later. The older one, from an evolutionary perspective, is of reptilian or earlier origin, and innervates the organs below the diaphragm. The later one, most highly developed in mammals, innervates the heart and lungs and probably reflects the higher metabolic demands of warm-blooded creatures. As Porges13 explains: ‘[In the face of external threat], behavioural orienting in reptiles is characterised by a focusing of [smell, vision and hearing] and a freezing of gross motor activity. [Evolutionary] development not only illustrates changes in the neuroanatomy of the vagus, but also parallel changes in behaviour. One of these behavioural shifts is the addition of active or voluntary attention and complex emotions… The underpowered reptiles use [vagal impulses] to the heart to deal with specific challenges: to orient and freeze in response to predator or prey and to conserve oxygen while submerged for lengthy periods. In contrast, supercharged mammals use vagal [impulses] as a persistent brake to [rein them in]… Thus, in contrast to that observed in reptiles, in mammals, vagal tone is highest during unchallenged situations such as sleep, and vagal tone is actively withdrawn in response to external demands, including… exercise, stress, and information processing.’

As Porges goes on to write, the Polyvagal theory proposes that the development of special, vagal outputs changed the role of the vagus with the vagal pathways from the older vagus being part of a passive reflexive motor system associated with vegetative function and hence, a vegetative vagus. (Vegetative referring to control of blood pressure, digestion etc.) The special, newer vagal pathways, he propounds, create an active voluntary motor system associated with the conscious functions of attention, motion, emotion and communication, and thus, as Porges states, ‘a smart vagus’. This indicates that the mammalian vagus has a sophisticated role to play in autonomic regulation, which includes the social aspects of arousal and interaction. I propose that, because of the capacity for neuroplastic change, there is great potential to enhance vagal regulation of our arousal through body practices.

Finally, a technique known as vagus nerve stimulation (VNS)14 has been devised to treat uncontrolled epilepsy, and is now being used to treat depression, with some success. Electrodes, receiving electrical pulses at intervals, from a device inserted under the skin of the chest, are implanted in the left vagus nerve in the neck. The mode of action is poorly understood, but presumably it works by increasing the vagal tone, and its dampening effect on the higher structures. It is plausible that the body practices are a natural way of achieving the same effect.

Summary
When faced with threat, the most primitive response (and the only one available to reptiles) is for the organism to focus its special senses outward towards the environment and the perceived source of the threat. In addition to this capacity, mammals, partly because of a more sophisticated vagal system, have a greater repertoire of possible responses, including a capacity to assess the situation from a social perspective. They can evaluate whether to appease the attacker, or to dominate it, for example. Humans have the added ability to orient themselves internally to the inner landscape of the body itself, largely via the vagus nerves. This inner gaze is what constitutes the work of meditation, contemplative prayer and body-oriented practices such as breath-work, yoga, chi-gung and focusing. The physiological term for this body feeling is coenaesthesia. Webster15 defines it as ‘the totality of sensations arising from the bodily organs through which one sees his own body’.

The hypothesis presented here is that focusing and related practices are the voluntary turning of attention towards this vast unknown territory. The fruits of the sustained practice of such techniques will hopefully be a greater knowledge and experience of the body and its wisdom; integration and more efficient function of the ANS, enhancement of the capacity to experience equanimity, and reduced vulnerability to stress, anxiety and fear. Finally, and hopefully, it leads to the total liberation of the person from all fear, in the discovery known as ‘satori’ or ‘enlightenment’, when the potential of human life reaches its complete fulfilment.

In his short story, A Painful Case, James Joyce16 describes our universal predicament. In it, Mr Duffy ‘lived at a little distance from his body, regarding his own acts with doubtful side glances’. Repeated and sustained attention to the inner world of our body may help us to end this sense of separation, and ultimately sever the ties that bind us.
*

Dr Joseph Bray has been a consultant psychiatrist in private practice at Priory Hospital Southampton since 2007. Before that he practised as a consultant psychiatrist in the NHS for 13 years. He has a special interest in the treatment of anxiety and stress-related illness, and in the role of spiritual practice in human wellbeing and flourishing, and their neurophysiological correlates. He maintains a regular meditation practice.

Valuable feedback from Ann Weiser Cornell is gratefully acknowledged.

This article was first published in the January 2011 Healthcare Counselling and Psychotherapy Journal (HCPJ), the official journal of BACP Healthcare. For further details about joining the BACP Healthcare division, email julie.camfield@bacp.co.uk.

Counselling Madrid: dedicated to the expat community in Madrid, Spain.

By Joseph Maussen – 2009

good enough often is good enough

To read more about relaxation techniques please visit www.counsellingmadrid.org/publications

(Els runs a private practice in The Netherlands helping expats with counselling, couple therapy and mediation.)

Article:
My life has been interesting with lots of traveling and living in different countries, including many years in Japan. Whenever I returned to Tokyo International Airport from a trip outside the country, the choice for lining up at passport control was always: ALIEN or NATIVE. It did not take long to absorb the fact that to Japanese this was a distinction of importance – not something to joke about. So I learnt to choose my place (as outsider, foreigner) and avoid hassle, but some other foreigners kept complaining about the airport signs.

Initially, life in a new country and culture can be a wonderful experience you just love to tell the folks back home about, but sooner or later the thrill gets mixed with frustration or anger, and you may miss home and all it stands for. This reaction is not so strange if we consider the definition of culture: ideas, customs and social behaviour of a particular people or society or the attitudes and behaviour characteristic of a particular social group that are
• based on learned human behaviour
• passed on from generation to generation
• a coherent, dynamic complex of norms, values and behavioural codes
• shared by a group of people.

When we try and settle in another country, we bring our own ways of being and thinking with us, and find they/we are different, which often comes across as ‘wrong’. Trouble is that when people from different cultural backgrounds interact, each takes things for granted that the other often finds unfamiliar (and sometimes appalling). The more that something is taken as ‘simply a fact of life’ by one, the harder it may be for the other to deal with it.

People miscommunicate for a number of reasons:
 It is hard to communicate in any language, more so in a second or third one. Little misunderstandings add up and stereotypical thinking or assumptions distort what is said or heard. Even body-language (non-verbal communication) differs subtly or majorly between cultures.
 How people use space differs: a good distance for one can be uncomfortably close to another. Private space is much more important in one culture than in another. Trouble is, there tend to be unspoken ‘rules’ about these things.
 How people regard time differs, for example: punctuality, dividing work and free time or private and family time. When people from different cultures live or work together, this can create chaos – consider for example what happens when a linear thinker (time is a line: one thing at a time) tries to interact with a person who likes to shift quickly from one thing to another or rather do several things at once…..
 Cultural values tell us what is seen as good, bad, important or trivial. They can differ hugely as to: how men/women/children should be treated, what food to eat, how to behave… Using your partner’s bathrobe may be a sign of pleasing intimacy to you, but to the other absolutely ‘not done’. Whenever people make judgements, values come into play. It needs awareness of one’s own values and a fairly strong sense of self to accept the fact that others have different values, without feeling threatened.
 Decisionmaking can vary from a high-context model (all opinions must be taken into account and ethics are situational) to low-context (strong demand for quick top-down decisions). Having to work things out with someone from another background can be much more difficult because of this difference in approach, however when you live anywhere long enough, there will be important decisions to make about: home, beliefs, lifestyle, childrearing, managing finances/ time/ vacations, family interaction, etcetera.
 Also the way in which information is shared, varies. An ‘outsider’ may be expected to know all about ‘the system’ (be it: social/ medical/ company/ family) without a need to explain. Trouble is, if someone expects you to know, but you don’t even know you ought to know, miscommunication is sure to happen.

People’s personality and character play a role too – in fact each individual carries her/his own culture, worldview and experiences from way-back that go beyond the mere fact of nationality and family of origin…… Even travelling to the other side of the world, we carry our own ‘bagage’ with us and that gives us that uniqueness, that can be fascinating as well as singularly difficult. Because wherever one lives, there is a need to create and maintain relationships and to find a niche to be comfortable in as an individual as well.

In close relationships, problems arise sometimes because there are too many unresolved issues (like family of origin or childhood difficulties). People think they get involved with a certain kind of person and then may find themselves plunged into situations they are unprepared for.
Having given up a career or satisfying job to be with this partner or spouse and thereby feeling fairly strongly dependent initially, this is bound to create difficult and painful situations. Another source of difficulties is that often signals are missed or misread as to: how a person feels, what is important or trivial, what really liked or disliked, what wanted or needed. How to communicate these things clearly? Too often we expect lover or friend to understand or be sensitive enough to know those things that are dearest/most personal to us.

People can behave differently when they are abroad as compared to back home in familiar settings, and this too can be confusing or upsetting – it may be useful to distinguish here between more group-based cultures (like many Asian, African or rural/traditional) and more urban, individualistic, Western societies. Interestingly though, intercultural interaction between people from a fairly similar background, that expect to have a lot in common, may actually be full of difficulties, probably because of those unspoken assumptions and high expectations. Of course our thinking about people and culture should not be rigid – sterotypes never promote understanding and neither do misconceptions, mistaken self-views or biases.

But if life in one’s own tried and trusted environment is hardly ever easy, international and intercultural living tends to be even more of a ‘mixed bag’. In fact, it can be said that living in another country is a life-altering experience, in ways that you never expected or could have foreseen. Of course, it makes a difference whether you chose to be there, or if fate has somehow thrown you there – and whether you plan to stay for a while only, or ‘for life’ because commitment or circumstances make leaving unlikely. When, for whatever reason, you feel you don’t have much choice, the experience is likely to be more stressful. Being part of a couple requires deeper commitment – when things do not go so well, there may be a greater sense of loss of ‘what was or could have been’. Short-term expatriates can take refuge in social interaction with people of their own nationality exclusively (a bit of Why bother?), but those who plan to stay feel a need to succeed, to get to know their new country and its people; there is likely to be more pressure to learn about and adapt to the culture and customs, and that may bring marvel or joy, but also frustration, irritation or tension. Support and understanding from partners or in-laws is not always there – it may be hard for them to be that empathic.

Occasionally things really go wrong. When you keep questioning yourself: What in the world am I doing here? and when you are feeling down all the time, you may be experiencing culture shock. That can be defined as: a condition of emotional upset and tension that becomes chronic for a period of varying duration and is experienced by persons who, exposed to life in an unfamiliar setting, react with anxiety, irritation and frustration. It can happen to anyone who has had to leave home, with its familiar and manageable routines and social patterns, and feels confronted with life in a different social setting with a language and mores/values that are unfamiliar (and that may be repugnant to the person with culture shock). No wonder this happens, because to feel lonely, isolated, uncertain about proper procedures, unable to control life, does give a lot of stress and wears a person down.
Culture shock has:
1. a honeymoon phase when all is terribly new, exciting, unknown but charming…
2. an angry, upset phase when you can’t help thinking Why don’t they do things properly?
3. a coping phase with more resignation, trying to adapt without losing your sense of self
4. a more integrated phase, when you are comfortable most of the time with where you are and how things are going.
Actually these phases may come and go and even after a long time any of those moods can become more dominant in certain circumstances. It helps to be aware of them, to know that what is happening is not uncommon, and to try and get help for the middle phases, such as an empathic listener, encouragement, good tips or support, if need be professional help. Don’t wait too long because getting timely professional help can save a lot of heartache!

Human beings are creatures of habit and maybe a nomadic existence is only good for those who can carry their ‘home’ with them, who feel at home whereever they are. That takes quite a bit of inner strength and considerable flexibility of mind. Those people have little trouble finding their feet in a new environment, they often have a talent for languages and a high degree of curiosity about other cultures or other ways of life. Experience learns though that even the most experienced expats can get some culture shock when they finally do go home and find it/themselves somehow changed, difficult to fit in again. It should be noted all of this goes for kids and especially adolescents as well – they may have been comfortable in a particular environment, but feel uprooted when they have to go and live in their ‘own’ country and feel ‘different’.

Of course in all of this there are many positives to consider, as the following statement expresses: The international and intercultural experience can be an unparallelled opportunity for learning and developing, for personal and professional growth and for sharing with others a sense of the uniqueness of the individual, whilst celebrating the diversity and similarity of human beings here, there and everywhere…..

About the author:
Els Barkema-Sala, MPhil, MBACP
www.counsellinginternational.com

Els, thanks again for your contribution!
Joseph Maussen
Head of Counselling
Counselling Madrid

From the above view you may deduct that some people receiving Coaching, actually might benefit more from Counselling. For example, when someone´s performance is temporarily affected by issues such as relationship problems or work related stress, Counselling seems a more approprioate way to get someone back on track again. I would add to this that Counsellors have more in-depth knowledge about the underlying triggers that lead to stress, and therefore are better equipped to look at the source of stress, rather then trying to make the symptoms go away through the use of relaxation techniques (also an important part of counselling). However, there are also people, currently receiving Counselling, that might actually benefit more from Coaching. Obviously there is no such thing as a clear line drawing the line between “will probably benefit most from Coaching” and “will probably benefit most from Counselling”.

Issues such as costs and availability also play a key role: the availability of one service – coaching or counselling – might increase the likelyhood of someone using one of the two services where actually the non-available service might benefit this client most. Let us also not forget the companies, schools and universities that are more or less inclined to be pro-active when it comes to offering Counselling and Coaching services to their most valued Human Capital: employees and students.

Anxiety
Recommendations are made for both panic disorder and generalized anxiety disorder as follows:
Panic Disorder:
- CBT
- Self help in the form of bibliotherapy

Generalized Anxiety Disorder:
- CBT
- Self-help (bibliotherapy based on CBT principles

Attention deficit hyperactivity disorder (ADHD)
The ADHD guideline focuses on treatment for pre-schoolchildren, school-age children and adults:
- Group based parent-training/education programmes (CBT and/or social skills training)
- Individual based psrent training/education programmes
- Individual psychological interventions (CBT or social skills training)
- Group or individual CBT

Bipolar disorder
The guideline for bipolar disorder includes a number of recommendations for psychological therapies, including:
- Individual psychological therapy
- Structured psychological therapy
- Psychological treatment
- CBT
- Counselling (for women with unplanned pregnancy)
- Psychosocial intervention (psychoeducation and motivational enhancement)
- Self-help approaches (CCBT)
- Brief psychologival interventions
- Focused family interventions

Dementia
The guideline for dementia recommends:
- Psychological therapy (including CBT)
- Structured group cognitive stimulation programme
- Psychoeducation
- Genetic counselling

Depression
Psychological interventions feature in several of the key steps for the treatment of depression. Within step two, for the treatment of mild depression, the folowing treatments are recommended:
- Self-help based on CBT
- Brief psychological treatment – such as problem solving therapy, brief CBT and counselling.

In both mild and moderate depression, psychological treatment specifically focused on depression, such as problem-solving therapy, brief CBT and counselling, of six to eight sessions over ten to twelve weeks should be considered. Within step three, for moderate to severe depression, the folowing treatments are recommended:
- CBT (the guidelines states it should not be offered to patients with moderate or severe depression who do not take or who refuse antidepressant treatment)
- IPT if the patient expresses a preference for it or if, in the view of the healthcare professional, the patient may benefit from it. However, for moderate, severe and treatment-resistant depression, the treatment of coice is CBT
- Couple-focussed therapy for patients who have a regular partner and who have not benefited from a brief individual intervention
- Psychodynamic psychotherapy for the treatment of the complex comorbidities that may be present along with depression. In step four, CBT and mindfullness-based CBT are recommended.

Depression in children and young people

to be continued shortly

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Meditation can be very helpful living a life more mindful. However, there are many misconceptions about meditation:

Misconception #1: Meditation is just a relaxation technique
The bugaboo here is the word ‘just’. Relaxation is a key component of meditation, but Vipassana-style meditation aims at a much loftier goal. Nevertheless, the statement is essentially true for many other systems of meditation. All meditation procedures stress concentration of the mind, bringing the mind to rest on one item or one area of thought. Do it strongly and thoroughly enough, and you achieve a deep and blissful relaxation which is called Jhana. It is a state of such supreme tranquility that it amounts to rapture. It is a form of pleasure which lies above and beyond anything that can be experienced in the normal state of consciousness. Most systems stop right there. That is the goal, and when you attain that, you simply repeat the experience for the rest of your life. Not so with Vipassana meditation. Vipassana seeks another goal–awareness. Concentration and relaxation are considered necessary concomitants to awareness. They are required precursors, handy tools, and beneficial byproducts. But they are not the goal. The goal is insight. Vipassana meditation is a profound religious practice aimed at nothing less that the purification and transformation of your everyday life.

Misconception #2: Meditation means going into a trance
Here again the statement could be applied accurately to certain systems of meditation, but not to Vipassana. Insight meditation is not a form of hypnosis. You are not trying to black out your mind so as to become unconscious. You are not trying to turn yourself into an emotionless vegetable. If anything, the reverse is true. You will become more and more attuned to your own emotional changes. You will learn to know yourself with ever- greater clarity and precision. In learning this technique, certain states do occur which may appear trance-like to the observer. But they are really quite the opposite. In hypnotic trance, the subject is susceptible to control by another party, whereas in deep concentration the meditator remains very much under his own control. The similarity is superficial, and in any case the occurrence of these phenomena is not the point of Vipassana. As we have said, the deep concentration of Jhana is a tool or stepping stone on the route to heightened awareness. Vipassana by definition is the cultivation of mindfulness or awareness. If you find that you are becoming unconscious in meditation, then you aren’t meditating, according to the definition of the word as used in the Vipassana system. It is that simple.

Misconception #3: Meditation is a mysterious practice which cannot be understood
Here again, this is almost true, but not quite. Meditation deals with levels of consciousness which lie deeper than symbolic thought. Therefore, some of the data about meditation just won’t fit into words. That does not mean, however, that it cannot be understood. There are deeper ways to understand things than words. You understand how to walk. You probably can’t describe the exact order in which your nerve fibers and your muscles contract during that process. But you can do it. Meditation needs to be understood that same way, by doing it. It is not something that you can learn in abstract terms. It is to be experienced. Meditation is not some mindless formula which gives automatic and predictable results. You can never really predict exactly what will come up in any particular session. It is an investigation and experiment and an adventure every time. In fact, this is so true that when you do reach a feeling of predictability and sameness in your practice, you use that as an indicator. It means that you have gotten off the track somewhere and you are headed for stagnation. Learning to look at each second as if it were the first and only second in the universe is most essential in Vipassana meditation.

Joseph Maussen: By demystifying meditation, clients can be motivated to start relaxing themselves. This is often a first and necessary step to become more aware, more mindful, of our thoughts and emotions and how these thoughts and emotions are the result of certain specific situations or events. Increased mindfulness opens the door to respond to situations instead of reacting or acting out. Clients often experience more freedom as a result and more fulfilling interactions with others, either at home or at work, with family members or friends.

Source: Mindfulness in Plain English, by Ven. Henepola Gunaratana
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