Beginnings and premature endings: A therapist reflection on termination in therapy

The process of termination in therapy is often one fraught with intense emotions for both the client and the therapist. I find that this can become increasingly more intense when terminations are premature. As I therapist I feel incredibly guilty when I have to terminate with a client before we have done all the work together that we could have.

In the context in which I work where the majority of clients have experienced horrific losses and often feel unsupported, isolated and alone in their worlds, I always feel like I am playing into this dynamic and their sense of abandonment when the time for termination arises. But the reality is that as a therapist, we cannot be with our clients forever, we cannot assist our clients on their journey to healing to the extent that our minds and hopes desire. Nor do we have that control over things. But as a therapist, it is hard when I feel that I have not done what I could and that I am making their process of healing even more complicated. However, it is also all MY voice that feels that I am at the centre of the termination. As if I am letting the client down or that I am abandoning them. But the truth is that I am not the most important element of this process.

There are times when I have had to prematurely terminate with clients, but despite what I felt in the room, I allowed them to say they are fine and that they understand why this is happening and in doing so I facilitated their avoidance of what this ending may mean. This is particularly important based on how I work as a therapist within the context that I do. Due to all the contextual challenges clients face, we often sit in a space of crisis management and help in the avoidance of the difficult feelings and memories attached to traumatic events and the circumstances that have led them to therapy. Avoiding avoidance, so to say, is necessary to navigate the unfolding of the therapy process, which can lead to beautiful insights.  In doing this there is a relationship and trust that forms.

Furthermore, in the context of the work that I do where it can often be difficult to do pure therapeutic work, the foundation that I have worked from is trying to allow my clients to see that they can trust another human being. In doing that they can try and get the support they need to get through the difficulties and challenges they face. But trying to translate this into practices outside of the therapy room is a long process. So when I terminate before this point I feel like I have not finished what we started together.

And this is the position I find myself currently in. I have endured premature terminations before, but I have found that this time some of them are a lot more intense than previous ones. In reflecting on this, it is clear that it is the depth of where we have gone together in the therapeutic process, the level of trust created in the space together, the things that they have never explored with another before and those are the things I have taken and held but am handing back and leaving them with before they are entirely ready. So, in sitting with my feelings of guilt at having to tell my clients that we were ending and feeling the need to make it a pleasant and easy process for them, my supervisor pointed out something important: That through the process of therapy and in ending we cannot be the all good object but if the process of termination is handled properly I can hope to leave my clients with the ability to integrate good and bad in one object. That through this they will be able to hold onto the good parts after the termination and remember the things they need to when facing challenges. But that if I don’t and we don’t think and talk about the difficult parts then they will either shut that off and may see me as an entirely bad object and in doing so never access me (and the things done in therapy) for support in the future.

So in introducing the terminations this time around I was horribly aware of needing to do this for my clients. It was difficult sitting in the room being told I am ‘breaking a heart’, or that I am ‘loved and in leaving will create an emptiness’. The pain in this at times became almost unbearable and I wanted to run away, but sitting in it and tolerating it was what I needed to do. So for sessions we spoke about the imminent termination date and the difficulties related to it. But through this process we also spoke about the things that helped make sense of it and in speaking about it I could see the shifts in my clients. When my one incredibly emotionally avoidant client could articulate that he was sad about us ending I felt such happiness. Through difficult moments there can be moments of such intense beauty and growth.

I have reflected on this in relation to my own personal spaces, such as therapy and supervision, that have pushed me to spaces I have not wanted to go but places that I have needed to in order to grow. There is a sadness and beauty in ending something that has allowed a sharing of parts of you that are hidden to the rest of the world. What those spaces have shown me is that the hard, difficult and broken parts of me can be shared with and tolerated with another human being without them hurting me, judging me or running away. So a termination is like the end of a movie, there has been a story together and difficult choices made but that in the end the final decision is to leave and say good bye, the ending is inevitable. But in saying good bye, the memory does not leave. Through the difficulty of it there is a growth that occurs and there are parts of both of you that are changed forever.

Written by Jacqui Chowles

#MentalHealthMatters

1 in 3 South Africans will suffer from a mental illness in their lifetime (South African Depression and Anxiety Group)

Suicide is the second and “fastest growing” cause of death amongst 15-24 year olds (Mental Pressures can force youth into suicide-Karabo Ngoepe-Sunday Independent News).

Today marks World Mental Health Day, the theme for this year is ‘Young People and Mental Health in a changing world’. Reflecting on this theme, two thoughts come to mind: the increase of suicide rates amongst youth in universities across the country; and the stigma of mental health which continues to persist in our society. As a psychologist working with youth, depression is noted as a common feature, and as we hear more and more about youth suicides, there is a need to explore and understand the links between depression, youth and suicide in our society today.

Speaking to various mental health practitioners in the field working with youth, discussions have been around the societal pressures that youth face. The pressure to be smart, fabulous, a slay queen on social media, a real man, a successful academic. These pressures combined with financial pressures and limited social support structures has an impact on youth’s ability to navigate their social and personal world. Other practitioners have had conversations with youth, who have related their mental health struggles to issues of worth and purpose. As youth, feel they have no role to play in society today. In comparison to youth in the past that fought for Freedom. Highlighting an identity crisis where society cannot grasp what they are becoming or what is needed for them. They are referred to as the ‘millennials’, often thought of as lazy, not as robust as the generations before, having a sense of entitlement and lacking a hard work ethic. And the more connected they are through social media and other platforms of connection, the more isolated and disconnected they appear to be from their peers and even more so authority structures such as Universities, Government and even social support structures in society. Youth have found it hard to take their struggles to these platforms, feeling people don’t care, youth are seen as not doing enough, ‘the generation before did it why can’t you?’ And this often leaves them feeling alone and stuck. Reflecting on the incidents of suicide in this year amongst youth, many thoughts of why come to mind. Didn’t they have a friend to speak to? Someone to hear their cry? No one just decides to kill themselves, depression has a starting point and intervention can make a difference. So why is intervention happening too late or not at all.

The silence around mental illnesses is still a major problem in our society. And more so amongst our youth. As mental health issues in youth are often brushed aside (‘you will get over it’; it’s just a phase’), misunderstood and not received empathetically. As youth report that they are seen as weak if they are not coping, or pretending to cope. So they suffer in silence, attempt to manage their difficulties on their own and are not accessing support structures available to them. Raising awareness to decrease stigma is important and a starting point to get people to talk about mental illness. The more it’s talked about, the more it can be normalized and a part of conversation in society. Not seen as something that has to be kept a secret  and that if people do find out, will think you ‘crazy’, incompetent, not strong enough. How do we go about doing this? How to raise awareness and acknowledge mental health and illness as a part of the human experience and not something alien to us that has to be hidden, shunned and ignored?

I think it starts with each one of us, taking the time to educate ourselves, to understand mental illnesses and each other and not judge. To create safe spaces amongst ourselves, peers, families and communities to acknowledge the experiences of each, whatever that may be and engage with it, with empathy.

Today marks World Mental Health Day, this month marks World Mental Health Month, but the importance of mental health on us as individuals, families and communities is ongoing and requires ongoing attention, advocacy and support.

There is no health without mental health (World Health Organisation)

Written by: Sumaiya Mohamed

Not all pain is physical-Not all wounds are visible-Mental Illness is real

Growing up in South Africa, Swartruggens in the North West Province, my understanding of mental health was vague, I knew it related to the medical sphere and that medication could be used to treat it but I didn’t fully grasp the complex nature of its causes, symptoms and impact on mental health patients, their families and communities. I think this relates to a common stigma in our societies around mental health, where mental health patients are viewed or labelled as ‘ditsenwa’ in my language, which loosely translated means crazy. I feel this stigma comes from a lack of understanding of mental health. Physical illness is better understood. It is seen, it can be bandaged, and the healing process is visible. Whereas, mental illness is felt primarily by the mental health patient, it takes medication and something intangible like therapy to start the healing process. Thus, what has been a problem in many different societies is that there is limited knowledge on mental health and its detrimental effects on one’s functioning, health, wellbeing and increased stigma in seeking help.

In society today we are constantly see a lack of understanding and empathy with regards to mental illness itself through the gruesome events and human rights violations of the mentally ill, noted at Life Health Care Esidimeni. Facilities that are available are either not well equipped, service providers lack the knowledge in health care related to the field or just deliberately ignoring people’s rights to health care. We really need to re-evaluate ourselves as a nation because such neglect clearly shows the lack of respect for human life and the effects of that neglect on the vulnerable in our society such as mental health patients and their families.

October is mental health month and the aim of this month is to raise awareness on mental health in the country and to reduce the stigma attached to it. According to the South African Depression and Anxiety Group mental illness is on the rise countrywide with adults ranging from 16.5 % and children in the Western Cape alone ranging from 17% (SADAG, 2018). One in five people will suffer or are suffering from mental illness and the problem in the country is access to facilities that can assist in the treatment of mental disorders such as depression, anxiety, substance abuse and socio-economic stressors (SADAG, 2018).

A while back, I was listening to a radio program and the topic was based on an individual who had committed suicide due to debt, high stress levels and inability to cope. While listening to the show, the views on the person’s suicide caught the ear of many locals and everyone had a similar opinion that people who end up committing suicide are just lazy, not thankful for the life they have and they lack a “back bone” to face life. The assumption is that one is weak if they commit suicide, stress is not seen as something as important as physical illness. And many people lack the knowledge on what mental illness is, similarly to the concept of depression.

Coming to university in 2015, mental health was a topic from the first day of orientation. In their description of mental health they summed it up as one’s general wellbeing. Being well and balanced in the body, the mind and the spirit and in achieving this one has to understand and practice self-care. Students are one of the populations that are faced with mental breakdowns and mental health issues and as a result this has led to many students either using harmful substances as a coping mechanism or committing suicide.

I have proposed a question to my fellow colleagues and lecturers on how does one practice self-care and maintain balance when there are no support systems to guide them in that process? In my personal experience I’ve had to talk myself out of dropping out of school countless times, feeling like I do not belong in this prestigious university. I have had suicidal thoughts. Every time I was going through those phases and feelings I would wish for support from my family, and some sort of understanding from the University. I spent days explaining to my mother and siblings the importance of them checking on me. The importance of just sending an encouraging message or a message of love and care because countless times I felt alone in University and contact from them was what I needed to just get through the day.

We are all members of some system or another and the most primary of all is the family and the school environment and both of these systems are important as support systems. However the family systems in some communities or societies have the assumption that support is financial, neglecting the emotional aspect of it which is vital to one’s mental wellbeing.

The school is another primary system of socialisation where mental illness such as depression is prevalent. In South African schools, specifically with reference to public schools, I have recognised that there are limited support systems such as counselling services which are important to assist learners with the different issues they are facing in their developmental years. Anger is one emotion that they are unable to control, bullying is on the rise and many of our learners resort to violence or to committing suicide as a solution. There needs to be interventions to assist, educate and support learners, a place where they can feel free to talk about their issues without judgement.

We are seeing devastating news in institutions of learning daily. Learners are killing each other and their teachers, there are high rates of teenage pregnancy and substance use and school drop outs. In the University of the Witwatersrand this year alone there are more than two cases of suicide with the most recent occurring on the 19^th of September 2018. Many social issues need intervention from the government but there is neglect on children and the youth’s mental health and wellbeing because of the assumption that children are unable to feel stressed or overwhelmed or affected by any issues. Interventions have to be done from grass roots level from as early as primary school because depression is real, it is on the rise amongst our youth and taking from us on a daily basis.

At the same time we should not neglect that the workplace is another systems that people are a part of. There needs to be awareness and the need to understand that the workplace is one area or system that affects mental health as well. Companies have to provide wellbeing or wellness programs aimed at ensuring that people are functioning well because work can be stressful and at the same time employees do not exist in isolation, there are family related stressors that employees need to understand and be aware of, to empathise and provide services that will aid employees. A healthy and happy employee is a productive employee and therefore the company or business or any working environment will benefit also in ensuring good mental health for their employees.

It should be recognised that a month alone to raise awareness on such an important issue as mental health is not enough. Discussions and policies that will be implemented have to take place as a way forward and funding has to go into organisations that can assist not only in urban areas but in rural areas, villages, townships etc., that will focus on helping people country wide. We need to build a society that cares for the wellbeing of its people so that growth and development can occur.

Written by Julia Makganye (Social Work Intern at The Centre for the Study of Violence and Reconciliation)

Reference

South Afrcan Depression and Anxiety Group. (n.d.). Retrieved from A South African Depression and Anxiety Group web site: http://www.SADAG.org.za

 

Who has the right to fight for gender equality vs Who should fight for gender equality?

With the beginning of August came the beginning of women’s month in South Africa. As the month came closer one found oneself having more and more conversations, both personally and in work spaces, about the inequality that exists for women, particularly in our country. This year was also slightly different in that to initiate the start of the month there was the #totalshutdown march that aimed to highlight the challenges faced by women and gender non-conforming individuals and call an end to it. In relation to this there are two main elements that I have been thinking about,  the state of feminism in the country and across the globe, as well as the separation in both calling an end to and perpetuating the cycles of violence against minority groups.

I am a self-identified feminist (but by no means a theoretical expert on the topic) but in various ways have been told that I am not. I was told that what I actually am is an equalitarian and that I do not dress the part because of the fact that I wear feminine clothing, like the colour pink and shave my legs. This made me search further into the definition and understanding of feminism and if perhaps I was wrong and that perhaps it is not what I am. What it did highlight is how differently people understand the term and how many feminist schools of thought there are. Truly, as an introduction to this, the talk that resonated a lot with me in relation to how I make sense of it in my day to day life was Chimamanda Ngozi Adichies’ ted talk “We should all be feminists”. (https://www.ted.com/talks/chimamanda_ngozi_adichie_we_should_all_be_feminists/transcript?language=en)

But through all the discussions of what is feminism and how we define it, what is also particularly noticeable is the separation it creates. Because the very basic definition of it is, “The advocacy of women’s rights on the ground of the equality of the sexes.” But somehow we determined that men cannot be feminists and that they are very often excluded from the conversations around gender inequality and gender based violence.

This starts then perpetuating a hierarchical structure as to who is allowed to be part of the conversations and whose opinions in it matter more. As a privileged female, the assumption is that I face less/different challenges related to gender equality than someone from a different social class or sexual orientation. And based on this my contributions are limited and perhaps seen in a specific light. So even though I am a feminist, I am not as much of a feminist as another. What I would like to relate this to is what Eckhart Tolle[1] writes about as the current state of insanity of humanity and the elements that contribute to the perpetuation of violence within the world today. There are various factors that he speaks about in relation to this, but one is the need for us to create power dynamics and make ourselves feel superior by making someone else feel inferior. Furthermore, that if I feel inferior I will attempt to find something to make myself superior to another in order to feed my ego and feel a sense of power.

So how do we consider this in relation to gender equality and those involved for the fight for it? We exclude normative men from the conversation and tell them that it is something they have no right to speak about because as women this allows us to regain some sense of power that inherently we don’t have based on the patriarchal structures of society. Then within the remainder of us that are allowed to discuss it, we perpetuate this pattern by claiming, that as a certain group contributing to the movement, our challenges and contributions are worth more than another’s. So that even within an overarching movement that is fighting for equal rights we create separation and exclusion to find ways of regaining our power. I do not say this in a blasé manner that is aimed at taking away or diminishing the different experiences that individuals have experienced, but as a means of highlighting the separatism that we perpetuate to the exclusion of many whose involvement may be imperative in shifting the discourses and behaviours related to gender equality. I do not believe that by solely empowering women or minority groups we will end gender inequality. For women to gain power men also need to relinquish some of their power. They also need to be a part of the change so that the power differentials disappear and we can be equal. Because the other side is that it is determined that the only way of gaining this power from men is to take it by force, which then ultimately contributes to a further perpetuation of violence.

For me this separation was also highlighted in relation to the people in my life and society that participated in the #totalshutdown. My friends that work in corporate South Africa did not know about it until I told them about it nor did their companies support their participation in the march or requested activities of the day. This is challenging in that there is the growing awareness and attention to the  high levels of gender inequality, sexual harassment and perpetuate patriarchy in the work place across numerous sectors. They need to be involved in the change that is needed.

So the question I raise is, how does everyone become part of the change that is required to create a gender equal society?

Written by Jacqui Chowles

[1] Eckhart Tolle A New Earth

She’s too small to think

A common phrase I hear working with parents is, ‘she’s too small to think’, ‘they’re too small to understand what’s happening’, don’t worry about them, they don’t understand’. And because they don’t understand and are perceived as lacking the ability to think and understand what is happening around them, they are fine and we don’t need to worry about them. We don’t need to worry about the time I was attacked in our home and they sat by screaming for my attacker to leave me alone. We don’t have to worry about the time they walked in on me trying to commit suicide. We don’t have to worry because they too small to think and they will be fine. This often takes me back to the way I was raised, whereby “children should be seen and not heard”. These are the ways of thinking that I carry with me based on my upbringing and they only started shifting and changing as I studied psychology and got to understand more about the internal world of a child and their development. How so much of what happens in early life shapes and forms that child’s adult life.

Over the past 3 years the CSVR Trauma Clinic has evolved to include family interventions into the work that we do, based on the impact of the trauma on families and children specifically. Witnessing the impact of trauma and poverty on a parent’s ability to be emotionally available for their child, the ability to create a holding environment for a child: one in which they can be understood, emotionally nurtured and psychologically held has become more and more of a challenge in today’s times, which has further broadened my understanding of development especially in relation to the context in which children are raised.

So now as a therapist sitting with a parent and their 2, 3,4,5,6 year old child in a room. I see curiosity in the eyes of the child as mum talks, a glance towards mum as her voice softens and a caressing of mums face as tears fall. And I wonder, what is she thinking? What are the messages she is receiving from her world and how are they understood? When her ability to think, comprehend, have a mind and the impact of her context on that mind is questioned. And how do I try and translate my understanding, that what is happening around the child is having an impact on them, especially when the parents are sitting with numerous contextual challenges and their own traumas?

Looking at the current situation beyond the family, whereby immigrant children are detained in South Africa and the United States, it seems that this lack of concern for a mind of a child, a child as a being, is not only one that is held by families that are traumatized but by societies that are traumatized and is something that fits in with the historical legacy and societal norms of how we have thought about children that continue to be perpetuated. Holding in mind the importance of early childhood development, the nurture versus nature debate comes to mind. Reflecting on our current societies, and the processes of socialization that children are being exposed to at a very young age (detained migrant children, sexually abused children, cyber bullying, violence in the home and outside the home), as well as the limited parental and societal understandings of the impact of this on the child.

So when we have parents, societies and countries that unable to hold and contain children, how does the un-held, un-contained and wounded child develop? And what impact does that have on them in their adolescent and adult life and the ways in which they can contribute to society?

And this becomes the crux of the matter. Research done by CSVR on the drivers of violence which include structural and community level factors (socio economic inequality, gender and masculinity, lack of social cohesion, alcohol and firearms) helps make sense of the reason why providing an emotionally nurturing environment for children is a challenge. These ‘drivers’ which are predominantly evident amongst the most vulnerable and marginalized of our society, have an impact on family relationships, infant development and parenting. Thus, contributing to the cyclical nature of violence. As families in poverty, have mouths to feed, basic needs to meet and emotional bonding, psychological holding, nurturance through acknowledgement has to wait. There is no choice. We have undergone trainings, workshops and sat with many perspectives in relation to family interventions and one thing that stood out was, Attachment is Everything! Early attachment can be seen as the key to understanding many of the individual, familial and societal challenges we experience today and this links strongly to the continuous perpetuation of cycles of violence.

This was further highlighted in a talk by Dr. Clinton Van Der Walt, titled, ‘Formulating violence as a response to dysregulated and distressed mental states’ at EPASSA (Educational Psychology Association of South Africa) annual conference this year, where he highlighted the importance of attachment disruptions and trauma as major contributing factors to the development of violence, as he states that, ‘dysregulated children become dysregulated adults haunted by the ghosts in the nursery’. So as generations to come are exposed to violent, un-held and uncontained environments will they continue to express violence as an appropriate response to levels of despair, inequality and disempowerment? Reflecting on our youth, we find a generation riddled with feelings of hopelessness, helplessness and despair steered to crime and interpersonal and self-violence. And a society who looks upon this generation with judgement and vitriol, further othering them and entrenching their feelings of worthlessness and inferiority. Contributing unconsciously to the cyclical process of transgenerational trauma, poverty, mental health challenges and violence.

Taking this into consideration, I ask, is enough being done at an early intervention level to prevent violence?

These concepts are spoken in length about at academic and elite levels, yet are only trickling down in small ways to a grass roots level. Why? A lot of good work is being done in the field of early child development. Non-governmental organisations such as Ububele and Seven Passes Initiative, whom work with children, families and communities highlight the importance of attachment relationships with primary caregivers as the key to emotional development and provide this through various interventions. There are prenatal and post-natal classes offered to pregnant women. However, these early methods of intervention are only accessible to the minority of the population. Therefore, with some amazing interventions out there that have been shown to help and create the change that is needed in our current society, why are there still so many challenges to implementation on a larger scale? Why is this something that has not been prioritised by government?

So no, I don’t think enough is being done at an early intervention level in relation to the prevention of violence. Why are we not investing in our youth? Why are we not investing in our children? Helping them to create a violent free society by helping them to manage their own emotions and make sense of them.

Healthy individuals contribute to health families which contribute to health societies.

Written by: Sumaiya Mohamed, Jacqui Chowles and Celeste Matross