We wanted to share with you a metaphor which is sometimes used in the beginning of therapy, particularly in third wave CBT, to set the context and the direction of work. It is adapted from the original by David Gillanders.

“Imagine that life were like sailing a small sailing boat. During your life, you have picked up the skills necessary to sail your boat and you have a sense of where you are taking this boat. At some point in your learning to sail, you have learned that from time to time, waves may wash over the bow and you will find yourself with wet feet. The usual response that people have learned is as follows: when you’ve water around your feet, use this bailer to bail out the water.

So you’ve learned about the bailer, but when its not been needed it has been put away in a locker, ready to be used if needed. And at some point along your journey you have had waves come over your boat and there is now water in the bottom of your boat. So you have started to do the thing that is sensible and logic to do: get rid of the water. You have been using that bailer a lot, sometimes bailing quickly, sometimes bailing carefully, sometimes baling wildly, sometimes baling desperately and: in your experience, have you managed to get rid of the water yet? And all this time that you have been bailing, what has been happening to the direction and progress your boat has been making? Is it fair to say that you have been bailing more than you have been sailing this boat?

Now; what if you were to one day really look at the bailer and to see that it was full of holes? What if it was a sieve? What would you have to do first?

(Most people will recognize that a sieve is not a good bailer and so will suggest using a different tool; a bucket or their hands)

Well; it may be that part of the work that we do together may be about investigating which tools are really useful to you, and some of those may well be more effective tools for bailing.

Even more that that, the implicit promise of bailing is this: once you get rid of the water – then we’ll get this boat back on track and start sailing it where you want it to go. What if our work could really be about that? About working together to let go of needing to get rid of the water, to begin to look up from the bailing and looking out in front of the boat and actually choosing a direction that you want to take this boat. What if our work could be about helping you to put a hand on the tiller and to choose to pull in the sails and getting the boat moving in whatever direction you choose? This could be very slowly at first, there is no speedometer in this work. Once we get the boat moving, then we might be able to investigate some other ways of bailing; if they prove to be useful strategies in helping you to take this boat where you want it to go.

The question to ask yourself might be something like this; if you could have this boat with only a little water in the bottom, but the boat is drifting, you are not choosing the direction you sail or the boat has water in the bottom, maybe sometimes so much water that you wonder how it is still afloat, but you are taking this boat, however slowly, in the direction that you would most want to take it….which would you choose?”

Best wishes
​Fernwood Clinic Team

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We were recently supporting a young client whose parents were in the process of going through a complex divorce. Initially, one of the parents brought the child to therapy and upon finding out about it, the other parent has written to us asking if the exact facts of the court case have been made available to the psychologist, so that she can accurately establish what events took place. 

Of course, we would never request any such documents, and in fact it does not actually matter to us what “really” happened, only the impact that it had on our client, how they feel about it and how they can move forward. 

It raises an interesting question of whether reality actually matters and what is reality anyway. We know that every person experiences events subjectively, perceiving them through a compex prism, impacted by their own background, values and a way of being in the world. Often we can live through the most harrowing ordeal and cope very well with it. And then someone’s throwaway comment in an office impacts us so much that we can’t stop thinking about it for weeks. 

Frequently we use the seemingly “objective” description of events to allow ourselves to feel a certain way about them. For example, a death of a loved one--naturally we expect to be in pieces. Stood up on a date--not so much. But there is no rule book about what should and should not touch us emotionally. Our feelings, emotions and reactions communicate valuable information to us about what matters, particularly if we can find some space to be mindful of them. 

Sometimes when clients come to us for the first time, they say things like “therapy is so indulgent”, “lots of people have it much worse” or “another person needs this slot more than me”. The question we ask is “are you suffering?” If the answer is yes, you have the right to have help.

Accepting our emotions without judging them, changing them or linking them to particular past “facts” is one of the themes of Acceptance and Commitment Therapy (ACT), which is sometimes called third-wave CBT, as it developed from the same theoretical orientation. There is a growing body of evidence for the effectiveness of ACT, particularly in improving psychological well-being, reducing stress and anxiety. 

We have found that ACT works really well for a lot of our clients, especially where other more traditional approaches have not been effective. One of our clients found it so useful that she has created a prototype app project to make the skills accessible to the wider audience.

You don’t need permission from anything or anyone to feel how you feel. Your truth is “the” truth. Nevertheless, acknowledging and respecting our own feelings, whatever these may be, does not need to paralyze us or stop us from taking committed action towards value-based life goals.

Best wishes
​Fernwood Clinic Team

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There has been a lot of debate recently, following the publication of Johann Hari’s new book, about what role medication plays in helping people recover from depression.

Few people would argue that a long-term dependency on antidepressants is a good thing. Numerous studies have shown that withdrawal symptoms can be very severe and become a major mental health risk factor in themselves. Our clients at Fernwood report that whilst antidepressants can provide a safety net during a particularly severe episode, in general they tend to numb us to the experiences of everyday life--both positive and negative.

So, if we accept that generally it would be preferable not to rely on antidepressants for too long, the next decision is when to take them and for what period.

To provide some context, it is important to understand how antidepressants are prescribed in the UK. Generally, antidepressants are prescribed by GPs, and in the minority of cases--by psychiatrists. In 2016, there was a record number of antidepressants prescribed through the NHS. From our experience of interacting with GPs from our local area, we have observed the following. GPs only have 10 minutes to see each patient. In that time they need to assess their concerns, develop an appropriate treatment plan, prescribe medication or provide a referral etc. It is a very limited time frame to properly assess risk level for someone presenting with low mood and, considering a long waiting list for NHS talking therapy, antidepressants are frequently the only practically available option. 

With this in mind, it would probably not be an overstatement to say that the majority of people who ask their GPs for antidepressants will get them, which makes it even more important that we try to make an informed choice.

Are antidepressants clinically effective? This is a very big question. It is probably best addressed in the context of “compared to what”. Compared to doing nothing? Yes. Compared to placebo? Yes (at least for short term acute depression in adults). Compared to talking therapy? And this is where it gets interesting. Most studies find no statistically significant difference in recovery for antidepressants versus talking therapy. However, these studies tend to measure recovery straight after treatment, rather than look at the longer-term outcomes, i.e. whether progress has actually been maintained. 

The NICE (National Institute of Clinical Excellence) recommendation is that both medication and talking therapy should be made available to clients with low mood and anxiety, and it is a personal choice which one you would prefer. However, the two approaches are very different. The way we address the problem is indicative of the way we view the problem. So if we take medication, naturally this means that we think the issue is the chemical imbalance in the brain. If we choose to talk, we acknowledge that our life’s context must be taken into account.

In our experience, our clients’ concerns tend to stem from external circumstances (whether past or present), combined with a way that they react and deal with those circumstances--the two often reinforcing each other through time. Each person has a unique and valuable story, which must be respected and untangled with great care to discover a way forward.

We hope our clients and readers feel empowered to make a mindful and informed choice when it comes to medication, therapy or both. 

Best wishes
Fernwood Clinic Team

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