This blog is no longer being updated. However, the Therapy Place Blog has moved to join directly with my website. New posts appear regularly on a wide range of therapy issues including: ADHD; compulsive sexual issues; couples and relationship therapy; and much more.
I hope to see you on the new site soon. Happy therapy reading.
Duncan
(This blog article was originally posted as on Attention Allies: Therapists for ADHD in December 2024.)
Attention Allies founder and specialist couples therapist Duncan E. Stafford offers some introductory insight to how SDT can be a strong, flexible and empowering framework to help support those living in mixed ADHD/neurotypical relationships.
Couples therapy involving one partner who has an ADHD neurotype requires a compassionate and structured approach to foster success. Traditional therapy models often unintentionally frame the work as an ADHD partner needing to be “fixed” or that they must be taught or learn “how to conform” to a neurotypical concept of relationships. This framing tends to alienate ADHDers and can exacerbate relational tensions rather than help to address them.
Many couples who seek help at my practice report that previous therapists had struggled to balance the needs of both partners, often overlooking or underestimating the distinct challenges and strengths associated with ADHD. Without proper recognition of these issues, therapy risks becoming another source of frustration for the mixed-neurotype couple, leaving them feeling unseen and unsupported.
From my 25 years of professional experience and 37 years in a successful, loving mixed-neurotype marriage, I’ve found that the core principles of Self-Determination Theory (SDT) – autonomy, competence and relatedness – provide a robust framework for fostering resilience, empathy and growth in couples therapy. These principles allow partners to navigate conflicts constructively and create a supportive, thriving relationship.
For individuals with ADHD, the often-reported challenges such as disorganisation, impulsivity and difficulties with emotional regulation can strain communication and mutual understanding in romantic relationships. If not addressed, these issues may lead to misaligned expectations, frustration and feelings of disconnect.
Introducing the SDT framework for couples work
SDT was developed by psychologists Edward Deci and Richard Ryan and was first comprehensively outlined in their 1985 book Intrinsic Motivation and Self-Determination in Human Behavior. Focused on understanding the factors that enhance or undermine motivation, SDT identifies three essential psychological needs:
Autonomy – the need to feel self-directed and in control of your own actions
Competence – the need to feel effective and capable
Relatedness – the need to feel connected, valued and have a sense of belonging.
An SDT-based approach to couples work will help both partners identify and meet their psychological needs while simultaneously promoting mutual respect and empathy within the couple. By empowering an ADHD partner to develop tailored strategies for managing their challenges, therapy can increase autonomy. The building of confidence through therapeutic work helps to develop abilities (competence), and enhancing emotional connection and understanding in couples work increases relatedness.
Therapy can transform recurring conflicts into opportunities for deeper connection and shared growth. This approach acknowledges the ADHD dynamics in the relationship – creating a pathway to sustainable harmony and partnership.
ADHDers often experience unique challenges in romantic relationships, and the common issues ADHD can bring often strain the communication systems and understanding of a couple. Using SDT in couples work provides a structured framework for addressing the issues and challenges that are especially prevalent in mixed-neurotype relationships.
When I first met Jess (diagnosed with ADHD) and Mo (neurotypical), their relationship was mired in daily conflict and palpable frustration. Sessions often began with a seemingly minor disagreement that quickly escalated. On one occasion, Mo was deeply frustrated because Jess had once again missed a deadline for paying a household bill. Despite repeated “requests” to “do it right next time,” Mo felt nothing ever changed, leaving her to shoulder most of the family responsibilities.
What I observed was a deeper pattern: Mo’s attempts to manage Jess’s behaviour were experienced by Jess as micromanagement, which undermined her competence (confidence in her ability to handle responsibilities) and autonomy (freedom to self-direct). For Jess, this dynamic triggered overwhelm and defensiveness.
The core issue lay in miscommunication of their individual needs and understanding of the other. As a neurotypical individual, Mo prioritised structure and predictability. Meanwhile, Jess’s ADHD presented challenges with timing and task prioritisation. These differing approaches turned relatively small issues into significant conflicts.
Autonomy: Jess was encouraged to handle tasks in a way that worked for her. Mo’s request was for Jess to simply set up an automated payment, but this triggered Jess’s childhood memories of being seen as incompetent. Instead, Jess set about designing a visual task board that included a wider set of financial goals and accounts. With the use of colour and an impressively artistic hand-drawn financial flow chart, Jess successfully navigated the challenge and was able to stick to, and increase, her financial responsibilities for the family.
Competence: Therapy focused on building Jess’s skills without criticism, which helped her to feel more effective in managing responsibilities. Mo’s competence increased once she realised it wasn’t her responsibility to do things it had been mutually agreed Jess would do. Mo took pride in her new skill of “sitting back”.
Relatedness: Mo learned to express concerns empathetically, removing frustrated responses and replacing them with expressive dialogue like “I feel anxious when bills are late”. Jess was encouraged to share how constant reminders and micromanagement felt overwhelming, fostering mutual understanding.
By applying SDT models, the conflict between Jess and Mo began to reduce. This allowed them to build further trust in one another, transforming challenges into opportunities for growth.
This article provides an introduction to how SDT can begin to reshape ingrained patterns in mixed ADHD/NT relationships. Visit us again for future articles on applying SDT in therapy.
Note: Jess and Mo are composite characters, inspired by a mix of consensually shared and fictionalised examples.
References
Deci, Edward L. and Richard M. Ryan. 1985. Intrinsic Motivation and Self-Determination in Human Behavior.
Click the link if you’d like to visit Duncan’s couples therapy website
All rights reserved © Copyright Duncan E. Stafford 2024. Unauthorised use and/or duplication of this material without express and written permission from the author of this post is strictly prohibited. Author contact via website Contact page.
Website version and image © Copyright Attention Allies 2024.
(This blog article was originally posted as Can autonomy, competence and relatedness be the ADHDers’ defence against RSD? on Attention Allies: Therapists for ADHD in Nov 2024.)
RSD (Rejection Sensitive Dysphoria) is an overwhelming challenge for many ADHDers. However, I suggest that by focusing on autonomy, competence and relatedness (the three basic psychological needs outlined in self-determination theory (SDT)) we can begin to build ADHDers resilience against the intense emotional pain of RSD.
If you live with ADHD, you may have experienced the intense, sometimes overwhelming, set of emotions known as RSD (Rejection Sensitive Dysphoria). Although RSD doesn’t yet constitute a formal diagnosis, it’s a term that resonates deeply within the ADHD community.
RSD is generally understood as an extremely intense emotional reaction to perceived or actual rejection, criticism or failure. The emotional pain can be overwhelming, leading people to avoid social situations, withdraw from relationships or, in some cases, express explosive anger. These reactions can deeply affect an individual’s psychological needs, leaving life feeling like a series of high-stakes emotional hurdles.
Sam’s rejections
Sam, who was diagnosed with ADHD aged 38, describes her past experience with RSD as feeling like an “internal ticking bomb”. In her words:
I was hypersensitive to anything that might feel like rejection. When I was in that headspace, neutral or sometimes even supportive comments would feel like attacks.
This hypersensitivity undermined her sense of competence and her belief in her own ability to handle life’s ups and downs effectively. During times of real and perceived rejection, Sam’s confidence would plummet – being replaced by self-doubt and a sense of deep failure.
Before Sam entered coaching and therapy (where she developed skills that helped her to “step back from herself”) she strongly believed the classical thinking about ADHD: that she lacked control because of impaired executive function. Coaching and therapy that used SDT principles began to support and develop her sense of autonomy (our ability to regulate our own responses and manage the emotional world), helping her to become engaged and invested in personal change that no longer felt out of reach:
I went from feeling like my reactions had a life of their own to having a stepped framework to understand I could be autonomous and competent. The intense RSD feelings – the after effects of which could last for a few days – became something I began to deal with as soon as I was aware I’d been triggered.
Therapy helped Sam to recognise specific triggers that tended to precede these emotional surges, gradually supporting and developing her sense of autonomy. By becoming more aware of these triggers, she could manage her emotions before they spiralled out of control.
Connection amid emotional pain
RSD often chips away at our sense of connection to others (relatedness). When minor misunderstandings or perceived slights can feel like intense rejection it’s easy to question whether we’re genuinely accepted or valued by others. For Sam, this played out in her relationships with friends, family and colleagues. A seemingly casual comment, for example, could be misinterpreted as criticism, threatening her sense of security and belonging.
Our need for relatedness runs deep, but when RSD undermines our connections it can lead to social withdrawal or frustrated outbursts. Sam found that coaching and therapy helped to strengthen her communication skills so she could be clearer about her needs, feelings and boundaries, in turn easing the impact of RSD in her relationships.
Feeling with meaning
Many ADHD researchers suggest that emotional regulation issues stem partly from impulsivity and challenges with executive functioning. Yet for those with ADHD, emotional control often aligns with how competent, related and autonomous they feel. For example, when a task feels meaningful and we feel capable, emotional regulation is easier. When an ADHDer feels disconnected or the task lacks value and interest, managing emotions becomes considerably harder.
Ali, another person with ADHD, describes how, “when I’m feeling overwhelmed, it doesn’t take much to set me off. A crowded store or a car cutting me up in a queue would feel very personal, like an attack.” Ali found that his RSD was often connected to previous experiences of times when he’d felt invisible or unimportant leading him to spiral into feelings of rejection – even when he logically knew that wasn’t the case. Through therapy, Ali worked on recognising his emotional triggers and particularly developing his sense of competence. He additionally developed greater autonomy in handling his emotions, further reducing the power of RSD episodes over his life.
Recognition
Being able to recognise situations and people who challenge our fundamental experience of autonomy, competence and relatedness can help us to begin to gain control over RSD. Recognising triggers can begin the process of developing our autonomy, empowering us to manage our emotional responses. Techniques learned through therapy or coaching can help us to release pent-up emotions, fostering a sense of competence and self-efficacy. By nurturing supportive relationships, we can reinforce our relatedness, creating a safety net for times when RSD feels especially intense.
Sam’s journey through therapy highlighted the importance of strengthening all three of these psychological needs. When she learned how to identify her triggers, she gained autonomy; when she practised emotional regulation techniques, she built her competence and when she improved her communication with friends and family, she was able to see and develop her relatedness. Each of these shifts contributed to her ability to better manage RSD, improving her emotional health and overall wellbeing.
Understanding how RSD impacts our core needs of autonomy, competence and relatedness can offer those with ADHD a new way to navigate life’s challenges, build stronger connections and feel more secure within themself.
You can read more about adult ADHD on Attention Allies blog site.
All character-based realisations contained in this post are either of a fictional nature or have been derived from heavily disguised, consensually given information.
All rights reserved © Copyright Duncan E. Stafford 2024. Unauthorised use and/or duplication of this material without express and written permission from the author of this post is strictly prohibited. Author contact via website Contact page.
Website version and image © Copyright Attention Allies 2024.
(This post was originally posted on Attention Allies: Therapists for ADHD in August 2024)
Psychotherapist, counsellor and ADHD coach Duncan E. Stafford hopes you “don’t feel normal”. Why is this and how can it help ADHDers to create useful tools for self-development?
The subject of “normal” in connection with adult ADHD is one that comes up regularly in my consulting room. Any quick search online for information about adult ADHD will support the persistent nature of questions like this, returning results such as:
This fascinates me because the concept of the “normal” human being is both subjective and perhaps, surprisingly, a relatively new concept.
The word “normal” – from the Latin root normalis, meaning something made according to a carpenter’s square – hadn’t been applied to human beings before the nineteenth century, when Adolphe Quetelet published “On Man and the Development of His Faculties, or Essay on Social Physics”.
In the years before 1835, “normal” was a term used only in mathematics and related disciplines, including astronomy. Quetelet took the astronomer’s error curve or, as it became known, the “normal distribution curve” and applied it to measuring humans. And the rest, as they say, is history.
A subjective term
“Normal” in relation to people is a subjective term. When used as a description, it implies a thing that should be aimed for or agreed upon. Being “normal” in human terms suggests the acceptable boundaries of what a person is or should aim to be. “Normal” is applied to the body through size, weight, shape, strength and so on; it’s applied to the mind in terms of aspects such as cognitive ability, sanity, reasoning and perceptual speed, among other measures. If we look at the term historically, it has often been used to reinforce white, Western and middle-class people’s definitions and standards of humanity. And so, you might see why I have a problem with ADHDers asking if they are “normal”. I might even suggest: “Who wants to be ‘normal’?”
Our development since childhood has been measured against created “normal goals”. In school, our abilities are tested to see if we reach at least the minimum, “normal” or “average” of others in a range of things thought to be the most useful.
Hyperkinetic to ADHD
When I was at the end of my school education, the term ADD (1980)** had hardly begun to be used, and ADHD (1987)*** hadn’t yet been created. In my own school era (and perhaps even today), students with ADHD were likely to be castigated for their internal motor-driven impulses and told to sit down, behave, stop being careless, stop making silly mistakes and stop being naughty, disruptive or “stupid” rather than receiving positive comments about themselves. Nothing on the preceding list was valued as good “normal” behaviours in classrooms. But the balancing behaviours often seen in the hyperkinetic child – as pre-1980s psychiatry, developmental psychology and education then termed ADHDers – weren’t valued in such children. It was, and perhaps still is, almost invisible to many the ultra-inquisitiveness, robust enthusiasm, unusual or eccentric creativity, sweeping spontaneity, fantastical imagination, and lively conversational skills and personality that the ADHDer brings.
When an ADHDer asks me “Am I/Is it normal?”, I tend to answer “I hope not!”. I suggest that we replace “normal” with “typical” in terms of feelings and behaviour. From there we can often see what someone’s real question and/or concern about themself is: “Are there other people like me?” If that inquisitiveness (typical of many ADHDers) can be engaged with, it may allow the inquisitor to feel calmer, less alone and, importantly, able to ask more questions of themself and what I call “the soup” we were brought up in and live in. In creating an interest not in normality, but in similarity, we potentially lead to the prerequisite for the creation of vital personal tools for self-development. As a therapist, I can help ADHDers engage and support self-actualisation and self-determination.
Back to the curve?
So, are you tempted to plot all of this on a standard deviation curve? I’m not. To do so is to limit our creative engagement with understanding ourselves in an attempt to reach mythical, societally created norms.
I like to know what others do and why they think they do things, but I like to help ADHD people understand that living your life by comparison to created norms tends, on the whole, to make an ADHDer feel claustrophobic, tense and constricted at minimum. ADHDers don’t need more restriction or created failures; they need freedom to be, and for that they need flexibility.
Footnotes
* Retrieved from Google search 10 August 2024.
** The American Psychiatric Association released a third edition of the Diagnostic and Statistical Manual (DSM-III) in 1980 in which it renamed Hyperkinetic Reaction of Childhood to Attention Deficit Disorder (ADD). Two categories were outlined: with – and without – hyperactivity.
*** The American Psychiatric Association released a revised third edition of the Diagnostic and Statistical Manual (DSM-III-R) in 1987, in which it renamed ADD as Attention Deficit and Hyperactivity Disorder (ADHD).
You can read more blog about ADHD on the Attention Allies blog pages.
All rights reserved © Copyright Duncan E. Stafford 2024. Unauthorised use and/or duplication of this material without express and written permission from the author of this post is strictly prohibited. Author contact via website Contact page.
Website version and image © Copyright Attention Allies 2024.
I know I’ve left it late in the session – but I’ve got to start working on this dream with you …
Patient: … it’s definitely part of the sequence.
Therapist: We can always make a start. It’s important to capture the energy while it’s fresher; we can come back to it then.
[The therapist’s eyes close to listen.]
P: I walk into this huge organic building. It’s like it’s made of pushed-up earth but it towers above me – not like a skyscraper – although it’s tall. I get this strange essence that it is alive. It has a heavy ring towards the top – like some form of viewing platform or an escape route. Before I enter the building I’m in a clearing. I don’t know if it’s some sort of jungle that I’ve walked through? Tall, overpowering grasses sway in the perfect temperature.
T: Perfect temperature?
P: Yeah, sunny but not hot; cool, not cold. Like those wonderful spring days when the world hints at what summer will bring. That first day when you slip off your winter clothes. You feel the world on your skin after all that insulation.
T: Le Sacre du printemps?
P: Sacred spring?
T: Yes.
P: There’s an air of real danger outside. I can hear an old woman’s voice that carries across the clearing. She is singing a song I know. I can’t sing it though; I know that I mustn’t sing the words.
T: What might happen if you did?
P: I don’t know … but, as always, there’s something very dangerous about stepping into the building. I can see the vestibule is open. It’s not very big. I’m a bit concerned I could get stuck if I start to walk in. It’s like that claustrophobic feeling I had when I went caving as a teenager. Then I realise something bad will only happen if I step in knowing the words. I try not to hear the song; I cover my ears. I try not to sing the words in my head. I know the song foretells the future and the future that waits in the building could change my life in big ways. My heart’s beating really heavily; I feel drenched in sweat. I’m just about to turn back as a group of young women flock around me and push me through the entranceway. The instant I’m inside the building, the women fall to the floor.
[There is a long silence. The therapist doesn’t move. The sound of water being gulped and swallowed invades the space.]
T: Are the women dressed or naked this time?
P: Bound in cheesecloth. Full-length dresses. Like they’re in some sort of shroud. I run my hand over one of them expecting warmth, a subtle smoothness beneath the material, but I realise she’s made of sand or perhaps salt. I can’t swallow.
[A glass chinks just before the gulping sound enters the room again.]
P: I look round the white inner space. All the people have divided into two separate groups.
T: Are they doing anything? Saying anything?
P: They form up a procession that leads out of the space. They pass some sort of holy metal object or relic along the line and I’m forced to follow it right out of the building.
T: Atmosphere?
P: It’s incredibly powerful … spiritual. I’m laid to the ground by the procession. I feel very free. When I look up there is a sage woman looking at me. She rests her hands on my head and then, with an opening of hands, I’m thrown high into the air, floating on a passage of energy.
T: Any other signs or symbols from the dream series?
P: Just those obvious recurring ones …
[The patient pauses.]
P: When I look down the young women have begun to draw circles on the ground. I can see one particular fire-haired woman. She gets lost in the action and is suddenly abandoned in the main circle.
T: Do you know what’s about to happen at that point when you’re in the dream?
P: I do. I know exactly what’s going to happen next. But I wake up before she starts to dance.
T: You want to see it?
P: No, I don’t want to see her die this time.
T: Not even for the elements – the soil, the flame, the drops of water or the breeze?
P: No, not to appease the gods. It’s changing. For once, in the dream, I realise I want my life. I don’t want to be reborn a young woman, no renaissance life. I want to be anima rising. To use my life.
[Her eyes move towards the clock. He smiles at her warmly.]
T: Well, the outline’s told. I think we can pick up on it next session. Perhaps we can reflect on the sand/salt women and the change to the sacrificial dance?
Duncan suggests …
Reading Man and His Symbols by C G Jung, since knowing when things are a sign and when they are a symbol of something else is one of the most important things we can learn.
All rights reserved © Copyright Duncan E. Stafford 2022. Unauthorized use and/or duplication of this material without express and written permission from the author of this post is strictly prohibited. (This article was originally published in 2020 as part of the Three Men with a Blog project.)
All character-based realisations contained in this post are either of a fictional nature or have been derived from heavily disguised, consensually given information.
The thought is in my head: I’m a cheat, a liar. No, worse than that, I’m a phoney and a fraud …
The thoughts come fast because, in the moment, I know the conflict between my human self and my professional role is in play. I’m also in trouble because I’m quite sure congruence has deserted me.
Although the thoughts are challenging ones to be throwing at myself, if you knew what I was thinking about the person sat looking at me through the screen you might agree with my self-assessment. The difficulty is not just that I’m suffering a lack of congruence but that I’m deeply caught in negative countertransference and so my empathic response has taken absence without leave.
Without being able to reach for empathy, the therapist’s chair feels a lonely and dangerous place.
It’s difficult to hear things from him that make me consider him in a new, negative light. My inner human self is ranting at him: What did you expect to happen? Could you not see your own stupidity, your own selfishness?
My supervisee isn’t giving me time to gather my professional thoughts; a set of words about how responsible he feels has just collided with his own self-loathing about the choices he made. But his split doesn’t mirror my own internal human/professional dust-up.
The space that the two of us have relied on in all our years of working together feels closed off. I’m still wrestling with these thoughts as he starts to emote deeply. He looks disorientated and his face has become red and mottled as if he were an alcoholic sitting on a park bench, complete with bottle of Bucky wrapped in a brown paper bag. As I hear his intake of breath and moan of grief, the tears and snot that were hanging off the end of his nose drip out of the lense’s gaze.
Unlike many of my colleagues who, perhaps erroneously, only think of in-room work as ‘face to face’, the 371 miles between Alastair and myself has never seemed a vast distance. Indeed, how much more face to face can you be than the 40 centimetres between face and screen on each side. I can see the threads of blood in the whites of his eyes.
Over the years we’ve worked collaboratively, I’ve watched him deal with some dire moments as a therapist and a human being. When his sister was killed in a road traffic collision we worked so carefully and trustingly together on his departure from, and return to, his case load. The loss of a long-term patient to motor-neurone disease was another moment when my admiration for his care and thoughtful practice grew. His attention to that patient seemed to make so much difference to the end of her life. He felt pain and I shared some of it with him in the supervision space.
I’m working really hard for the supervisory couple. I’m fighting for us. I feel the need to converse with my own therapist. He may have died years ago but he’s often with me in the room as an internal supervisor. We talk in the shadow, considering how, in the collective unconscious, there are some serious waves of communication going on between Alistair and me. And then my old clinical supervisor is sitting on my shoulder, asking me – no, interrogating me – about my lack of tolerance in the room.
I’m monitoring my breathing pattern. My body is just engaging with the kinesthetic memory of deep relaxation. And I’m back. I’m in my professional-self.
This is better. Feel the space! The walls have moved far away. Some of my other consultants over the years flow to the space – from therapeutic and supervision engagements. It’s quite a team to have on my side.
Spaces in the therapeutic profession are very considered and complex things. There are the outer ones, the room, the being together in a space and then there are myriad ever-changing inner ones. I know what I have to say, with congruence reintegrated; I know it will feel risky but we have always worked with honesty and I will have to let him judge me as I might still be judging him.
I begin to talk, my professional risking forward what I hope will be considered a balanced tone – something my inner human had temporarily been without. ‘I’m hearing in all this that you feel, somehow, it was definitively you who brought Covid into the family. That you contracted the coronavirus from your in-room work and that made you responsible. Now, you’re heartbroken. It’s not only the loss in your family – it’s also because you aren’t in a place where you can support your patients with the trouble they’re experiencing in life while you are stuck in your own guilt and grief. Perhaps, given that you know I’m only working online during the pandemic, you’re also wondering if I’m looking down on you from a point of judgment?’
There is a pause.
He breathes deeply …
Duncan cogitates …
The above raises what can be a deeply uncomfortable reality: the binary split between human-self and professional-self in an encounter.
All rights reserved © Copyright Duncan E. Stafford 2022. Unauthorized use and/or duplication of this material without express and written permission from the author of this post is strictly prohibited. (This article was originally published in 2021 as part of the Three Men with a Blog project.)
All character-based realisations contained in this post are either of a fictional nature or have been derived from heavily disguised, consensually given information.
I think I first noticed the man because he looked uncannily like a school teacher I’d had a positive relationship with. It didn’t seem to matter how many times I went to the supermarket, the man was always there. I’d say inside my head, ‘Good morning “Mr Collingwood”’ in that distinct rhythm we are all taught to address teachers by as school children.
Sometimes I’d meet ‘Mr Collingwood’ in one of the aisles; on other visits I’d see him, almost hunkered down, in the far corner of the car park, close to the railway line – my favourite parking spot.
When someone looks familiar, I think we signal something to the other person – perhaps we radiate a connection in the unconscious that they respond to.
Over the warm summer months it felt comfortable striking up a non-verbal, nodding acquaintance. When you see someone often enough on a regular route or passage, you begin to notice things about them. What I observed about ‘Mr Collingwood’ was that despite his slender frame he was always eating, but there were only ever two things he consumed: a large baguette pulled straight from the bread rack, cellophane wrapper rolled a little way down as he consumed it; or a family size bag of salt and vinegar chipsticks. Both the baguette and the chipsticks were eaten in a very similar manner – thumbs to the back of the packaging and fingers to the front. He would tilt his head down to a fixed position and then the packaging was raised close to his mouth as the food from within was consumed. It took a few observations before I was certain, but it became clear that bread was eaten inside the supermarket yet the salt and vinegar snacks were only ever eaten outside. In fact, the more often I saw him with the savoury snacks, the more I noticed he ate the sticks in a manner reminiscent of a horse with a nose bag, munching up the hay.
I’m not that certain how many times I actually saw ‘Mr Collingwood’ and I’m not sure how quickly I realised he had mental health issues, but we were exchanging a few words by the time the clocks went back in autumn. We never went beyond an ‘It’s warm today …’, ‘For the time of year …’ type of conversation, but it seemed appropriate, safe, friendly – respectful, even.
Shortly before Christmas, on my journey to the supermarket I was overtaken by a police car. At the roundabout, which is the entry road to the store, I could see, close to my parking spot, another police car. The traffic quickly began to back up at the railway crossing and it was clear that a late middle age man, stripped to the waist, was in major distress in the middle of the track. Those with mental health problems need to be treated sensitively and it is incumbent upon police officers to respond in such a manner. Being the first at a scene like this you’d hope the officers had extensive training in how to calm a situation and deal with the distress. But how can this really be expected of a service that was created for very different purposes? I took a look at the officers. They were young and I’m certain trying to do their best, but watching the scene from the car park it was apparent that every time a uniformed figure approached and shouted out to the half-naked figure, a wave of distress racked the figure’s body. He repeatedly raised his hand then smashed his fists on his body like a man boxing an internal shadow he was trying to rid himself of. I looked around for ‘Mr Collingwood’ and my heart leapt; for a moment I didn’t catch my breath and then a tear pricked my eye. It was poor ‘Mr Collingwood’ who was on the railway line. I pushed myself forward for a few metres and talked to the female officer closest to me.
‘I wonder if I can help?’ I asked.
‘No sir, we have to keep you back this side of the line,’ she replied.
‘I know this man a little; I’m a psychotherapist.’
What the hell am I saying!! This isn’t my line of work anymore. I’ve not worked in a hospital department since 2004.
‘We have called for an appropriate medical professional sir, if you could just stand back please.’ And I watched as three other officers tried to herd ‘Mr Collingwood’ like a farm animal.
I’ve not seen him since at the supermarket; I miss our nods and acknowledgements of the simple things we’ve noticed of the day. I hope you are well ‘Mr Collingwood’, I hope you are well.
All rights reserved © Copyright Duncan E. Stafford 2022. Unauthorized use and/or duplication of this material without express and written permission from the author of this post is strictly prohibited. (This article was originally published in 2019 as part of the Three Men with a Blog project.)
This year, and for the first time, the anniversary of my father’s death some years ago passed by without me remembering …
It had been a short drive to the nursing home my father had moved to eight days previously. My wife and I had been his primary carers for close to a decade but when, fourteen weeks earlier, he had fallen and broken his hip, his move away from his home and into the healthcare system sparked in him a serious decline. There was also a touch of guilt at the freedoms his move was affording to us.
As we neared the care home, an ambulance on an emergency call passed us. A minute later we drew up behind it and a paramedic vehicle already parked at the home. My wife said to me, ‘It’s for your father.’ I winced; I felt her to be right.
As we strode down the corridor of the second floor suite in which my father had taken residency, a member of staff addressed us: ‘Are you here to see Brian?’
‘Yes,’ we both smiled.
There was already a temporal shift occurring – odd, I thought, no one has addressed us in such a way before. A nurse blocked our path to my father’s room: ‘You’re Brian’s relatives?’ Somehow, in a moment, we were all in her office. My wife looked pale: ‘You’d better sit down Mrs Stafford.’ But there was a dreadful tension and confusion in the space. With my psychotherapist’s hat on I honed in on the emotion – there was huge anxiety being broadcast from this experienced nurse. After a few words she left us saying, ‘I’ll just check on your father’s condition.’ It hit my wife and me at the same moment and we rushed along the corridor.
Bundling into my father’s room we saw a paramedic ‘shouting’ at the prone and half naked figure: ‘Come on Brian … stay with us.’ My father’s chest heaved in physical distress as a bag covered his mouth and another medic prepared to shock him. His skin had the waxy hue and paleness I’d seen on my mother as she passed away.
In the small living space that had become my father’s whole world the paraphernalia of modern emergency support was strewn all around. My wife was first to enunciate her horror: ‘What are you doing this for?!’
For several weeks in three separate medical establishments my father, despite his communication difficulties caused by a stroke some years earlier, had made himself understood – he wanted to die. For the long years before he broke his hip my wife and I had cared for my father, it had been difficult to watch his almost daily decline; he had been a proud, principled and independent man, a teacher and an artist. At eighty, long overdue, he become a published poet. Difficult as it was to watch, we respected that this was a man fading out at his own request. And yet here we were, thrust into the most terrible of moments – a man who wanted to die being forced back into a world he no longer had an interest in. Our protestations that my father be allowed to pass away brought yet more tension into the room. The ‘shouting’ stopped, but our fourteen weeks of frustrations at the NHS care system were too much for me and my wife.
In counterpoint we made our cases aloud to the six medics about respect and civilised treatment. But apparently, my father’s DNR (do not resuscitate) wishes had not been recorded in the requisite manner. Procedure and regulation were in the way of care and welfare, and overrode my father’s desires.
For his entire adult life, my father voted for a system that respected people, treated them well; a welfare state, a national health service, free at the point of need – one of the marks of a civilised and mature society. Those entrusted to administer NHS continuing healthcare had already attempted piracy with his rights and, now, these paramedics were clearly having to apply procedure rather than the human care they so obviously wished to dispense.
My father was being denied his wish to die peacefully and with respect. This was a system seeking to revive him so that it might take him back to a hospital he had already refused to be taken to, in order that he could ‘die’ once more, probably on a trolly in a corridor in A&E.
Before all was lost, the senior paramedic took control and through several different stages and conversations that involved myself and my father’s GP the paramedics were allowed to ‘withdraw’. And then the room was quiet and my father once more calm. His beloved radio could be heard in the corner of his room and death once more began to claim his body. Peacefully and with us as comforters for his passage he was able to complete his life, with respect and dignity.
All rights reserved © Copyright Duncan E. Stafford 2022. Unauthorized use and/or duplication of this material without express and written permission from the author of this post is strictly prohibited. (This article was originally published on Three men with a blog in 2018.)
Moving forward under our own steam on two legs is, in itself, an expressive thing. Look around as you move through the city or the country and you will see people doing it – using their bodies and expressing something about their actions, their direction – the stroller ambling along, the I’m late, I’m late followed by, or bumping into, the smart phone addict head down in a separate world, still checking social media on the way from one meeting to the next. But what’s happening with the inner voice? What past directions and journeys are being played in the inner self?
When I take people for a walk-and-talk session they are curious about how it might work. They are often stuck in life, distressed with it or perhaps bereaved. Inner symbols reveal as you walk: things we pass trigger memories, and the pace and openness of not being trapped within four walls help some very difficult thoughts to make their way out of the unconscious into the conscious realm. And, of course, nature and the environment makes itself very much part of the work. This might make sense as to why therapists so often use tree imagery on their websites. Sometimes a rabbit really is a symbol – vitality and rebirth are never far when you take therapy for a walk …
Read on for some of my free verse triggered by the walking therapy I offer.
Pace: on walking with distress
Walking, walking, walking. Pacing things through. We are in the world right now.
Talking, listening, watching. Right at the very edge of life. ‘I remember how my father laughed at me as we drove down the hill. I was about to shit my pants and he was laughing, crying with pleasure … at my distress.’
Concrete, gravel, turf, tarmac, the water at our side. ‘If you add the negative moments up and you add the neutral and the positive, you don’t get what you expect.’
Walking, marching, ambling, pausing, listening, watching. ‘The whole marriage is lost.’ Loving and losing, kissing and hating. Steps pass by as seconds rotate in time. [Again] ‘Were more of them good than bad?’
A courting couple in the back of a car cuts like a knife. Pace, control and then, then, there is just loss. ‘An intense toothache. Everyone knows toothache. Through the whole body, the mind, to quiddity.’
Walking, walking, walking, talking, talking, talking, listening, listening, listening. ‘We finally managed to break down the door but he was already dead, squashed against the back of it.’
If we looked over the bridge once, what would happen? Twice? Would a third time make the pain greater or lessen it? ‘Would you jump?’ How much would I remember of my story?
Moving, moving, now always moving. ‘It helps with the pain; it stops that claustrophobic tightness in my head.’ ‘Are these things in your head or are they in your body?’ The sensation of the cradle rocking, the soft, soft murmuring song before I fell asleep.
Pain, pain, pain, stabbing at the pith. Not needing to let go today, not quite rocked, not stepping away just yet. Step, mirror, step, mirror, step, walking, talking, listening, ‘expressing?’.
What does the body say? ‘A question? What does the body say?’ ‘Feel?’ ‘Say!’ ‘Oh look, a rabbit! Lots of them.’ ‘And the body?’ [Slowly] ‘L-o-o-k, t-h-e-r-e-’s a r-a-b-b-i-t-?’ ‘Yes.’ ‘Yes.’
Walking, walking, walking, talking, talking, talking, listening, hearing, feeling, hearing?
‘Yes.’ Feeling? ‘Oh, look, another rabbit!’
***
I highly recommend taking therapy beyond the four walls of the consulting room out into the real world and seeing what happens for you. NB this idea makes many therapists anxious about controlling the situation and the space – but they can get help with that.
All rights reserved © Copyright Duncan E. Stafford 2022. Unauthorized use and/or duplication of this material without express and written permission from the author of this post is strictly prohibited. (This article was originally published in 2019 at part of the Three Men with a Blog project.)
It’s been a little while since I blogged about men and therapy. So, at the start of the year, when many people decide to put things in order and turn to psychotherapy and counselling for some clarity about their lives, I thought I’d write something that might help men take a therapeutic step.
It’s a sad fact that, according to the latest 2016 release from the UK Office for National Statistics, men still make up around three-quarters of deaths by suicide and yet are only reported to make up just over one-third of referrals to NHS talking therapies. So, if that sobering statistic makes you think, read on …
Access to therapy isn’t about men vs. women. It’s much more about why, as men, we might find barriers to getting help.
The continued high suicide figures for men by comparison to women suggest there is definitely something going wrong for us men – but taking your life by your own hand is just the start of the male distress story. It’s also true that around three-quarters of adults who choose to ‘go missing’ from home are men, and close to 90 percent of rough sleepers are men. It’s men who are three times more likely to become dependent on alcohol and three times more likely to report frequent drug use. Men also make up two-thirds of drug deaths, 95 per cent of the prison population, and commit more than 85 per cent of violent crimes. Additionally, they are twice as likely as women to be victims of violent crime. Sadly, men have lower access than women to social support networks, and are 50 per cent more likely than women to be detained and compulsorily treated as psychiatric inpatients.
If we look at boys, then we see they perform less well than girls at all levels of education and that close to 80 per cent of children who are excluded permanently from schools are – you guessed it – boys.
While there might be a number of reasons that these gender differences exist, what’s really important to perceive is that, for a large number of men, life is difficult.
When it comes to depression we already know from practitioners’ reports and some academic research that the commonly recognised and described symptoms of depression – being tearful, withdrawn, lacking in motivation and energy – are a more typically female presentation of the issue. Men will actually often express symptoms in an externalized way that we call ‘acting out’. This might be through uncontrolled anger, addictive behaviours that are used as a cover up for the felt distress, or the use of physical aggression. And, of course, if you express your depression in these sorts of ways it tends to compound difficulties in the social world, and will often make family, friends and professional helpers less sympathetic in their response.
Data drawn from population level studies suggest that men who are in psychological distress are more likely than women to choose coping strategies that don’t help them adjust adequately or appropriately to the environment or situation. A popular strategy might be to self-medicate through alcohol, drugs, or porn and/or sexual addictions. Of course, generalised data about gender is just that: general! And so it doesn’t tell us about any one individual. But my experience since joining this profession at the beginning of the 21st century certainly adds up with the data.
This blog hasn’t sought to offer a quick fix or a set of tools to use. What it has done is outline to anyone who reads it that we might need to approach men and their problems in a different way. Men need a space that will reflect their male nature in a positive frame. Sometimes that means that a male therapist can be a good starting point – although it is suggested by some research that as long as the space takes a ‘male positive’ stance men make better progress. For other men it might be the environment in which they access their therapy that helps them to make progress – for example, men can thrive during online sessions or walk-and-talk sessions where the therapist is alongside them rather than sitting face-to-face.
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In my own practice, I see more men than women (excluding couples work) and I offer face-to-face sessions as well as online video-based counselling, psychotherapy and coaching through FaceTime or What’sApp. I also provide single-session therapy and one-off walk-and-talk therapy sessions (on particular days throughout the year) in Cambridge, Bath and Bristol. And, of course, a one-off session can become a gateway to deeper ongoing work …
Statistics for this blog were drawn from sources reporting between 2014 and 2016, including those from the Office for National Statistics.
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