And it's the final early morning of this four day residential group.  I wrote yesterday about sunshine along the wall outside - and it's here again today, bright & fresh.  Sunday morning.  I can be a very organized person - lovely though to let my hair down at times here (what hair I've got left).  Yesterday evening we sang around a bonfire.  Fantastic stars.  The stream.  Wine.  Singing together.  Happiness.  Not to bed till well after midnight.

The day had begun writing in this little side sitting room here in the old converted watermill.  People emerging.  A dip in the stream.  Less a torrent now, but still wake-uppingly cold.  Breakfast and into our small support groups.  Checking in, and from brief conversations at breakfast I'd had a sense that some challenging issues might well be raised that I would be involved with in the full group.  And having the chance to begin feeling, thinking, speaking them through in this little support group of four people.  So lovely this chance to get to know these people better ... and be "seen" more by them.  An hour and a quarter or so in the small group.  Coffee and into the full group.  I had been a little concerned that because we are mostly such old friends coming together for this "20 year reunion", we might stay very much in "good time" mode.  Absolutely special and appropriate celebrating our friendship, but a chance to work psychologically on more difficult issues is also a precious, important aspect of these groups.  I'd wondered whether this kind of tricky stuff might be avoided a bit here.  But no.  Happily, at times bruisingly, we have regularly worked right into true feelings, even when they have been very challenging.

And themes of safety, loss, boundaries, grief, anger bubbling and criss-crossing.  Being given space.  Held.  Kindness, experience, enquiry, expression, working through.  Gosh so many crucial things can be raised here ... and mostly, again and again, they're processed very helpfully.  Not always, but frequently enough to make this one of the most special, in some ways "sacred" aspects of these meetings.  And we do have a lot of experience, insight, courage here.  There's no formal leader.  The richness of strong, honest, wise people sharing together.  I love it.  Scary at times ... and I love it.  Alive and learning.  Giving.  Receiving.

Lunch.  Speaking afterwards as two couples with old friends.  We've been on holiday breaks with them.  Crossed the country to be at each other's major celebrations & anniversaries.  Even run workshops together at times in the past.  Friendship.

And then one-to-one, walking with an old, old friend.  We've been here together so many times in Cumbria.  And not surprisingly, we agreed to explore a walk we'd never been on before ... even after more than 20 years of coming here.  Fresh, beautiful day.  Talking deeply.  The curlew calls bubbling and dancing over the fields.  Checking in with our lives as we've done for well over a decade now - the post "Friendship: science, art & gratitude" looked more fully at these relationships.  And as I wrote then "The blog post "Strong relationships improve survival as much as quitting smoking" discussed a major recent meta-analysis highlighting how key the benefits of relationships can be. As the meta-analysis's linked editorial stated "The researchers reported that stronger social relationships were associated with a 50% increased chance of survival over the course of the studies, on average. The effect was similar for both "functional" (e.g., the receipt or perception of receipt of support within a social relationship) and "structural" measures of relationships (e.g., being married, living alone, size of social networks). Quite remarkably, the degree of mortality risk associated with lack of social relationships is similar to that which exists for more widely publicized risk factors, such as smoking. Arguably, such a level of risk deserves attention at the highest possible level in determination of health policy."

So good relationships are literally a life & death issue. They are also a happiness & wellbeing issue. As I wrote in the post "Friendship: a three day workshop" - "But it's not just about physical health & mortality - relationships are also so strongly connected with happiness & wellbeing. Csikszentmihalyi & Hunter's "Happiness in everyday life: the uses of experience sampling" found highest levels of reported happiness when people were with friends. Diener & Seligman's study on "Very happy people" reported how social happy people are. And it's not just sociability, it's depth too. Demir et al found that friendship variables (number, quality, personality, conflict) accounted for nearly 60% of variance in happiness, with friendship "quality" being of particular importance. Similarly Reis et al's "Daily well-being: the role of autonomy, competence, and relatedness" reported that to satisfy relationship needs "The best predictors were meaningful talk and feeling understood and appreciated by interaction partners". And in a study done this year - "Eavesdropping on happiness" - Mehl & colleagues used digital audio recorders to track real world behaviour and found that 'The happy life is social rather than solitary, and conversationally deep rather than superficial'".

And back from the walk.  Tea.  Again into a bit of a cauldron of feelings.  Where else could we do this?  Extraordinary.  People touching down to profound emotions.  Sharing here what is so immensely hard to feel down to in the busy-ness of our day-to-day lives, let alone to have the time & courage to express and be heard so openly & caringly.

And the supper.  Another feast.  But not drinking alcohol, so we could go to the bonfire and initially use it for a ceremony involving what we want to burn, leave behind and what we want to take forward from these magic days.  And then bringing in the wine, harmonica, singing on into the night!  And now the morning is speeding up.  People clearing, cleaning, looking again at the photos that go back over the last two decades.  Time to head out into this last morning of the group.  

More to follow ...

The start of the second full day here.  In yesterday's post I wrote about the first full day.  We've had so much rain over the last couple of days, it's a blessing to see the bright early sunlight splashed along the wall outside the window as I sit here writing.  I sneaked away to bed with Catero my wife a bit early yesterday evening.  It had been a long special day and now I'm up this morning feeling fresh.

After breakfast yesterday we began in small "support" groups of four.  The groups had been picked out of a hat, with a little subsequent swapping around as some couples decided they would prefer to be in separate support groups.  There's a very real sense in which these four day residentials are like the weather.  As long as we stay true, honest, open, caring ... it brings up so much "stuff".  So on the first full day, as you'd expect ... with a bunch of dear friends getting together again ... there was lots of celebration ending with the wild, hugely fun, dancing in the evening.  More exuberant, more unselfconscious, more friendly than pretty much anywhere else that I've ever danced.

But yesterday morning, the psychological storm clouds had begun to gather.  It's fine.  Working with what comes up is so much what these groups are about.  In our small support group, someone talked about strains in their marriage.  A sense that there was nowhere else as potentially helpful that they felt they could bring this.  Speaking about it.  Opening it up.  Trying to feel in, to understand.  Good.  And after coffee, the full group and the couple working on these blocks.  Love and commitment and the difficulties that probably every couple faces at times in their marriage.  Of course problems will come up in long term relationships.  The small stuff it's usually best to let go by, with patience and generosity.  But bigger stuff it's typically important to address - see, for example, the sequence of posts that includes "Conflict: not too much, not too little - the importance of assertiveness in close relationships".  Hard.  Just because we have had so many experiences over the years in these groups of difficult, painful knots untying and easing when we work kindly and truly with them, it doesn't mean anyone is likely to approach these kind of turbulent, heart-hurting rapids casually or without anxiety.  The stakes are bloody high when couples and families are involved.  And so heart-warming and healing to go down this tricky, bumpy section of the river together.  So much experience here.  Humility too.  Pretty much all of us here have sometimes been through hard times in our marriages and personally.  Sometimes it's rainy weather.  Not trying to "pull the canoes out onto the bank".  Going down the rapids with courage and open-heartedness.  At times in groups this size with so much psychological knowledge/experience around, "too many cooks can spoil the broth".  However when multiple input works well, it too can be quite extraordinary.  We know each other well.  We're deeply concerned about the struggle in our friends' marriage.  People want to come in with insights, comments, suggestions, interventions.  Like a challenging section of free jazz, how do we play this so the couple don't get caught in the cross-fire of too many suggestions, too many options.  Working with feelings.  Beautiful to see them coming through, out into clearer, calmer water.  Fantastic.  Just this piece of psychological work on its own would make the whole residential worthwhile. 

And an old friend, who I haven't seen a lot for a while, coming up to me afterwards to say he would like to spend some time with me in the "break" after lunch to talk through a distance he was feeling in our relationship.  And sitting together.  Saying as honestly as we can how we're feeling with each other.  And this doesn't always work ... and it did so well here.  So easy when someone challenges me with quite confronting statements to slip up into my head, into defence, into all the many explanations & reasons.  And this is all true and may also be worth touching on, but I find it's often even more helpful to go down inside too to speak out what feelings are coming up.  And this starts with not knowing for me.  What is it that I'm feeling in my gut, in my body when this person says these things to me.  Going inside to find out.  Having the ability to tease out the confusing mix of inner responses.  To put them into language in a way that stays open, that doesn't do the easy and almost certainly unhelpful hitting back, hitting out.  And of course it's a million times easier when one is talking with someone who has "emotional intelligence", where there is underlying goodwill, where we go into the heat because we want to come through again to somewhere better, where we go into it assuming that "it takes two to tango", that both of us have almost certainly contributed to the difficulty and that both of us have important, potentially helpful things to learn from the exploring and openness. And then walking together afterwards.  Catching up with each other's lives.  Friendship blossoming again. 

And into small group time again ... but a different mix.  Talking about the planet, climate change, transition towns.  And then sitting by the stream in the drizzle with my wife and an old friend catching up with each other.  The second full group of the day.  Fathers.  Talking about fathers and someone especially speaking about their relationship with their long-dead father.  And that spinning on into speaking about aging, our own aging, death, being with dying parents, our own children's reactions to our aging.  And supper.  These meals all seem to be feasts.  People taking turns to prepare the food.  I'd end up spherical if I was fed such banquets all the time.  Talking again at supper.  I love the way the "in-between" conversations take on such richness in these groups.  The conversations over meals, during walks.  They can be so good too.

And it's getting close to 8.00am.  Some of us meeting to meditate together and then my morning ritual of dipping into the mill stream.  And this morning it will be in the sunshine, not my experience of holding onto a rock to stop myself being washed downstream in the rain splashed torrent of the last two days.

And see tomorrow's post for a description of our third & last full day here.

Still before breakfast - at the start of the second full day now.  Yesterday I wrote about "arriving".  The noise of the mill stream just outside provides a constant back drop while we're here.  When we arrived on Wednesday evening it was flowing so quietly, the water level almost as low as I've seen it.  Then the rain came and it turned into a torrent.  Roaring.  In a way a bit of a parallel for our group.  We've got going fast.  So many of us know each other well.  Familiar place.  Familiar to be in one of these residential groups together again.  And new.  Extraordinary to "age" alongside these people.  We've brought photographs from earlier groups going back over twenty years.  Poignant, funny, endearing, happy-sad.

Breakfast is pretty much always such a good meal in the big communal eating area.  Lovely.  Meeting, hugging, greeting.  Very tender.  Heart-warming.  And then to the first full group meeting.  Finding our way in; feeling our way in.  Everyone - all sixteen of us now - "checking in".  How are we feeling being here?  What are our hopes for these four days?  How would we like to structure our time?   Someone talked about wanting to look at how they used their "power".  I commented that coming to these groups over a couple of decades has probably been the best lesson in interpersonal power that I've experienced.  I sometimes think of it as trying to ride a big horse down the centre of a track.  The horse is the power.  The track is responding to what emerges ... responding to, serving, the needs of the moment.  On one side of the track is the ditch of being too loud, insensitive, oppressive of others.  I don't mean typically in any kind of "big", obvious way.  I mean more subtly than that ... for example with the little puffing ups of "aren't-I-a-fine-fellow" syndrome.  And the ditch on the other side is inhibiting myself too much.  Not allowing what wants validly to express to come out.  Kind of semi-castrating myself.  Authenticity, empathy & compassion.  The jazz trio metaphor.

And the age range is so fascinating here too.  Some "youngsters" in their 40's, right up to people around 70.  The interplay of energy.  The different stages of life.  Extraordinary ... and very "ordinary" too.  And after a coffee break and speaking again, we ended with a kind of shaking ourselves out dance.  Sometimes good to use other methods than just words.

Lunch, and I then met with some people who wanted to talk more about the rescue I'd experienced in Skye two weeks ago. 

going up onto the ruined wall ... playing the recording ...

Small groups ... I really appreciate the randomness ...

Full group again ... a little stuttery for me ... as I would expect ... time, melting ... and the maybe-too-early gratitude pairs ... my comment about authenticity ... and for me it worked ... softening, connecting more deeply.  Wonderful.  And intense conversations, catching up at supper ... and then dancing, prancing, moving, laughing ... fun ... and to bed.  We've kicked fast into this group.  Parts of me are still trying to catch up.

More to follow ...

See tomorrow's post for a description of the second full day.

First morning of the "Mixed Group".  We have been meeting like this - in an old converted watermill in Cumbria - nearly every year since the start of the 90's.  This year's residential is a bit different.  For many it's a 20 year reunion (or thereabouts).  Sixteen old friends!  Sounds a little like "The big chill" or "Peter's friends" or any of a whole series of other films and stories looking at  "reunions".  I've written a lot about these residential groups in this blog - see, for example, the group work links in "Update on website traffic: my own favourite top 15 ... ".  Some - both Scottish & UK wide - are Mixed Groups, and some are Men's Groups.  There are Women's Groups too in this loose network, but I don't get to go to these!  The Cumbrian Spring groups are Mixed.     

I've said in the past "I find a four part understanding of why people come to these peer groups quite helpful.  The four parts are friendship, personal growth work, retreat/holiday, and outreach.  I think for different people these four components carry different weights ... and their relative importance for individuals are likely to change too over time.  So, for example, I might first come out of curiosity, a wish to work on myself (and how I relate with other people), and for a break/retreat/holiday.  Later, reconnecting with friends may become the most important reason for coming.  And for others, outreach, generativity, sharing and passing on becomes increasingly relevant." 

We arrived bit by bit last night.  Five couples and four not in a couple sat down for supper.  Hopefully a sixth couple got here safely after most of us had gone to bed.  Our full complement should be sixteen.  Sitting here early this morning, I feel a bit disconnected from it all.  I guess this is partly "parachuting in" from living such a busy goal-directed life back up in Scotland.  I know from of old that it can take me a bit of time to "arrive" psychologically into this four day "community".  I guess the same is going to be true, more or less, for pretty much all of us.  Making home & work arrangements for while we're away, for many of us sorting childcare, the longish journey to Cumbria itself by car or train.  It is quite "magical" in a sense, this suddenly "appearing" to each other after months or, in some cases, years without meeting. 

In some ways, I feel a little shy, a little "stand-offish".  Still arriving.  Almost as if my body is only slowly waking up, beginning to remember what it is to spend intense, "intimate" time with a big group of friends.  Because of the "20 year reunion" tag to this group, we're a bit more homogenous than these annual peer groups often are.  There are no "newcomers" this year.  There's more of a feel for me, that friendship is a particular focus.  How are these dear people doing now and in their lives?  How am I doing now and in my life?  And, in ways I don't really understand, I feel that my "brush with death" on Skye two weeks ago also colours my experience here in this group.  Two weeks ago I was getting up after a very blowy, noisy, tent-flapping night in Sligachan campsite.  Making breakfast in the well-known environment of my two-man tent before heading up into the Cuillin and trouble.  So very precious to be here now.  To be with dear friends.  To be aging together rather than broken or dead at the bottom of a cliff.  Time to go to do some yoga, walk maybe, sit to meditate, dip in the stream. 

See tomorrow's post for a description of our first full day.

Still less than three days since the most intense, prolonged, potentially catastrophic experience of my life.  What have I learned ... both personally and as a therapist?  Gratitude ... of course.  Gratitude to the mountain rescue service, gratitude to my wife & family & friends, gratitude for my health, for the extraordinary beauty of this world, for being able to walk, to breath, to smile.  And gratitude can even help me process what happened better. 

And what else?  The day after I was helicoptered off the mountain, I drove home.  It's nearly a five hour journey and I stopped by the shore of Loch Cluanie in Kintail.  I walked for two hours up to the gentle summit of Carn Ghluasaid.  A very different day.  Clouds well above the tops.  Classic Highland hill walking.  A stalkers' path, ridges, snow, sunshine rippling on the loch down below, hills away into the distance, beautiful.  Nobody in sight over the whole landscape except a delightful little lizard on the track that I stopped to chat to!  Then sort of surreal ... as I walked over the plateau at the top of the mountain, I saw a man ... roughly my age ... sitting, legs outstretched, with his back against the summit cairn.  Here we were, meeting, kind of "in the middle of nowhere".  Very simple.  The camaraderie of hill walkers.  I sat down beside him and we ate lunch together.  I told him the story of my rescue ... less than 24 hours before.  And yes I was beating myself up a bit about my bad decision making.  He was experienced on the hills ... had climbed nearly all of the 283 currently listed Munros (compared with my more modest 100 or so).  Quietly he said "If you keep walking for long enough, something a bit like this happens to all of us."  Healing, warm, accepting, somebody who knows.  I thanked him, wished him very well, and walked back down the hill.

And what are the lessons I've learned ... without beating up on myself too hard?  Well, maybe four things to learn and four things to celebrate.  First, of course, the huge "Don't commit to going down or up a route with no clear exit unless I'm very clear that (if it goes wrong) I will be able to get back out again."  Secondly, become even more skilful with my equipment.  I'm a bit clumsy with mobile phones as, because I work from home and my age, I nearly always use landlines.  I plan to switch to making more of my personal/domestic calls by mobile and to using it more routinely.  Mobiles are great technology and I want to master them better.  And the same with my walking GPS.  I'm OK with it, but mostly I use map & compass.  The GPS is a back up which I look at occasionally to confirm that I'm where I think I am on the map.  I want to be able to use it better to pinpoint and read the precise grid reference for my location.  Of course there's the thorny question of ice axe & crampons.  I had both ... they were in the car.  Would having them in my pack have made a difference?  Probably not, but they should have been there.  And what about involvement of others?  As a pretty regular solo walker, I let people know where I'm going and I usually also leave a printout on the dashboard of my car showing my planned route.  It's not enough.  I would quite likely have been dead and cold before rescuers got to me, if I had had to wait until my wife raised the alarm after I failed to check in by phone at our agreed time of 8.00 that evening.  Hence the value of the personal location beacon (PLB) which can raise the alert rapidly even when I'm out of mobile range.  My wife & son would then be rung as my recorded next of kin.  What I need to ask them to do next is to ring the Mountain Rescue who are involved to tell them what route I planned to take ... the PLB may not be broadcasting accurate information if I'm down a gully. 

And a fourth lesson?  This is more for me as a therapist.  I always remember a delightful comment on "management by wandering about" in Peters' & Austin's classic book "A passion for excellence".  It's a long time since I read it, but they said something like "The good manager creeps about until he catches somebody doing something right, and then he praises him."  The gender bias rather dates the remark, but the point is that a variety of friends have responded to hearing what I've been through.  It's so interesting the variety of their reactions.  I notice how affirming it is to be validated.  I made a life-threatening mistake and then recovered from it.  Some friends particularly pointed out and praised the recovery.  As a therapist, I want to notice this.  I don't think I do this as fully as I could ... really feel into how my client, my patient, has come through their traumatic challenging experiences.  Look for what I can praise & validate about how they have survived and make sure I let them know.  They're likely to be battered and self-doubting enough as it is; they probably could do with the nourishment of being affirmed.  As pretty much always, of course, it's likely to be worth checking how they experience what I've said.

And four celebrations?  So much!  I celebrate keeping my 62 year old body fit and strong.  I celebrate finding that I could think clearly and act decisively when I was looking at potential death pretty close up.  I vastly celebrate my relationships, my dear darling wife and children, my friends.  And I celebrate that when I saw a possible rapid end to my life, I didn't have regrets, just gratitude & love.  I tear up thinking of these things.  Who knows where my mind would have got to if I'd been stuck on that steep, cold slope for four or five hours, not just two.  I was unlucky and then I got lucky.  And it's a weird privilege to face my death like this and come away unscathed and, I pray, wiser.   

So there are many lessons and as Garnefski & Kraaij found in their research using the "Cognitive emotion regulation questionnaire (CERQ)", "positive reappraisal" with challenging experiences is so routinely associated with better outcomes.  Look for affirmative answers to the four questions "I think I can learn something from the situation", "I think that I can become a stronger person as a result of what has happened", "I think that the situation also has its positive sides" and "I look for the positive sides to the matter".  Watch out too for how I could easily beat myself up for my life-threatening mistake on the hillside.  Of course I must learn from it, but that doesn't have to come through sackcloth & ashes.  It ties in with the importance of self-compassion - see, for example, Leary et al's "Self-compassion and reactions to unpleasant self-relevant events: the implications of treating oneself kindly" and Neff et al's "Self-compassion, achievement goals, and coping with academic failure", although specific self-compassion interventions following trauma are still in their infancy - see this year's paper "‘Being kinder to myself ': A prospective comparative study, exploring post-trauma therapy outcome measures, for two groups of clients, receiving either cognitive behaviour therapy or cognitive behaviour therapy and compassionate mind training".  For me, as often happens for our clients too, a key "intervention" to reduce excessive self-blame wasn't from any "sophisticated therapist" colleague so much as from the kind, fellow hill walker on the top of Carn Ghluasaid who said "If you keep walking for long enough, something a bit like this happens to all of us." 

And what about so-called "posttraumatic growth"?  It's early days, but this currently stands out for me (with my very fortunate outcome) much more than any "posttraumatic stress".  I've written about this area before, for example in the blog posts "Writing (& speaking) for resilience & wellbeing: personal growth" and "An intriguing and encouraging development in therapeutic writing".  In the first of these posts I said "Richard Tedeschi and Lawrence Calhoun at the University of North Carolina have been particularly active in researching this area of possible posttraumatic growth (Tedeschi and Calhoun 2004; Calhoun and Tedeschi 2004). They highlight: "Most of us, when we face very difficult losses or great suffering, will have a variety of highly distressing psychological reactions. Just because individuals experience growth does not mean that they will not suffer. Distress is typical when we face traumatic events. We most definitely are not implying that traumatic events are good - they are not. But for many of us, life crises are inevitable and we are not given the choice between suffering and growth on the one hand, and no suffering and no change, on the other. Posttraumatic growth is not universal. It is not uncommon, but neither does everybody who faces a traumatic event experience growth. Our hope is that you never face a major loss or crisis, but most of us eventually do, and perhaps you may also experience an encounter with posttraumatic growth."

They also explain: "what is posttraumatic growth? It is positive change experienced as a result of the struggle with a major life crisis or a traumatic event. Although we coined the term posttraumatic growth, the idea that human beings can be changed by their encounters with life challenges, sometimes in radically positive ways, is not new. The theme is present in ancient spiritual and religious traditions, literature, and philosophy. What is reasonably new is the systematic study of this phenomenon by psychologists, social workers, counselors, and scholars in other traditions of clinical practice and scientific investigation. what forms does posttraumatic growth take? Posttraumatic growth tends to occur in five general areas. Sometimes people who must face major life crises develop a sense that new opportunities have emerged from the struggle, opening up possibilities that were not present before. A second area is a change in relationships with others. Some people experience closer relationships with some specific people, and they can also experience an increased sense of connection to others who suffer. A third area of possible change is an increased sense of one's own strength - "if I lived through that, I can face anything". A fourth aspect of posttraumatic growth experienced by some people is a greater appreciation for life in general. The fifth area involves the spiritual or religious domain. Some individuals experience a deepening of their spiritual lives, however, this deepening can also involve a significant change in one's belief system."

This is thought-provoking and potentially wise territory. New possibilities, deepening of relationships, an increased sense of strength, appreciation of life, existential and spiritual change. Tedeschi and Calhoun developed the "Posttraumatic growth inventory" as a questionnaire to explore these possibilities. They write that they are happy for the scale to be employed for research purposes as long as financial gain does not occur from its use. See their website at UNC Charlotte for more information and freely downloadable research papers. Clearly it is important to employ this measure sensitively and only when it seems it might be indicated e.g. if the client themself seems open to looking at possible posttraumatic growth. This might occur after they have already written and/or talked more directly about what happened and shared the emotions and thoughts associated with the trauma.   I can certainly see how the "Posttraumatic growth inventory" is very much relevant for me here.

It's really early, and paradoxically I should be sleeping beautifully because I'm in a comfortable room at the Sligachan Hotel on the Isle of Skye.  However I'm not too fussed - acute sleep deprivation may well affect memory consolidation and reduce the risk of posttraumatic stress disorder (PTSD) following trauma.  And why the possible PTSD?  Well coming down the mountain, yesterday's walk went quite badly wrong.  I'd taken over four hours to climb Bruach na Frithe when the Scottish Mountaineering Club's book "The Munros" estimates it's likely to take a little over three hours.  I usually walk as fast or faster than their estimates, so it had been a tough climb.  Highish wind, snow & ice.  Maybe the strain of the climb, maybe not stopping to eat or drink before trying to get back down below the snow line, maybe not having been hill walking much over the last eighteen months ... anyway I made a bad decision on my way down. 

Getting down the mountain was pretty slippy-slidey.  Iced rocks and snow.  Biggish falls threatening.  I bum-shuffled a fair amount, slipping down on my backside and using both hands & both boots to keep myself safe.  It was going fine and I was feeling quietly exhilarated.  On the way up, I'd detoured down off the West of the crest on a series of occasions to avoid the iced up ridge in the high wind.  It had gone fine.  Coming down I repeated this manoeuvre a few times.  Trying to stay close to the crest but taking what looked like tracks to either side when they seemed sensible.  I came to an option of going down a snowed up route on the East of the crest.  It looked OK and I was making good progress with my bum-shuffle and kicking steps into the snow with the heels of my boots.  I came to a drop down over a steeper section of rock as the gully narrowed & deepened.  I managed to negotiate it and then repeated the process a couple more times.  Bad mistake.  Coming down was difficult, but going back up would be next to impossible for me.  I wasn't thinking clearly enough and then my gut turned as I realised the snow chute disappeared ahead of me over a cliff.  I dislodged a piece of snow.  It bounced down the steep slope over the edge and was immediately blown back vertically upwards in the wind.  Damn ... I was in serious trouble.  I knew it would be very hard indeed to climb back up the gully and I didn't have any leeway for making a mistake.  If I slipped I would be likely to toboggan down the steep snow and out over the cliff.  From what I could see, and I didn't fancy going down too close to the edge, I had very little chance of going forward.  I can feel my body tightening & going cold with the memory.  The exit down at the end of the snow chute looked pretty terrifying and I was resting with my back against the snow slope and my heels kicked in making a small ledge.  Damn ... not at all good and I could feel myself chilling in the wind.

Maybe I'd been a little unlucky, but mostly I'd just been plain stupid.  Bad decisions in these conditions can certainly kill you and I felt I was looking down the barrel myself.  Now, thank heavens, I got lucky and I started to make some better decisions.  The first one was that I didn't wait.  It was quarter past two with plenty of daylight left.  Pulling stuff out of the haversack was a little tricky as losing my footing wasn't really an option, but I dug out my mobile phone.  Now here was luck.  I had reception and happily I'd prepared properly and had a full battery too.  A lot of the time in the Scottish hills, I go out of mobile reception.  Quite probably being able to call saved my life or at least saved me from pretty serious damage.  "999" ... that's the way to mountain rescue ... but Jeeze, dealing with the "Fire, police or ambulance?" rigmarole tried my patience when I was getting colder by the minute and already beginning to work out just how many hours I might have to try to stay with my heels dug into the steep snow slope.  The exit over the cliff looked pretty vicious, a bit like a mouth waiting for me down below. 

Eventually I was put through to the Inverness police and it seemed like mountain rescue was going to be alerted.  Managing the phone, gloves & glasses with my head encased in a woolen hat & hood, holding onto my haversack and balancing, it felt scary.  I'm not sure how much it was at my end, but throughout all this time on the hillside I kept losing reception.  And here's another lesson of the several I take away from this.  I work from home and only occasionally use my mobile.  I don't remember the number.  Fairly tough when, for some reason, they couldn't pick up what number I was and I was trying to juggle my phone to work it out.  Learn it or put it on a label in big numbers on the back.  The Dutch researchers Garnefski & Kraaij talk about the importance of learning from difficult experiences, however they also talk about the importance of avoiding rumination/worry, catastrophising, and self-blame.  Well I could save the self-blame till later.  It was hard not to catastrophise.  By the time the mountain rescue was alerted and got up the hillside to my level, it would take what ... three hours?  I wouldn't be at all easy to locate either.  Maybe close to four hours before they found me?  Not good.  I was chilling.  My legs started to get bouts of intermittent strong shivering.  Probably fear & a bit of shock as well as cold, but I wasn't sure how well I'd manage waiting four hours perched a bit precariously, legs going into shakes, and my hands were numbing too.

Problem solve.  When in the sh*t, don't ruminate & worry, bloody well problem solve.  I was carrying a personal location beacon (PLB) and I'd activated it early in this whole process.  It was sitting in a little snow ledge I'd gouged out, bleeping up to the satellites, broadcasting my position.  The problem was (and I found out later that this was exactly the case) the steep sides of the gully I was in (and possibly too Skye's famous magnetic rock) meant that the PLB wasn't able to transmit accurate information.  If anything it possibly sent my rescuers off on a bit of a wild goose chase.  I hauled some food out of my sack, drank a bit too.  It could be a long wait.  I pulled out a bit of extra clothing and worked it in under my bum so I wasn't so snow exposed.  I even had an extra pair of gloves.  Could I hang on?  I'm an inveterate optimist.  Mostly I did believe I had a good chance of coming through, but there was a real risk I wouldn't or that I would end up badly injured.  Weirdly my dear son rang me.  The PLB goes to the coastguards who then contact a couple of emergency numbers you leave with them when you register the radio beacon.  I didn't want to stay on the line to him as the rescue people had said they would be trying to contact me and that I should try to preserve the phone battery.  I was able to say to Kieran that I was uninjured and that mountain rescue had been alerted and ... knowing the PLB people & the police might also have got through to my wife ... he said he would ring her to say I was still OK.  I hadn't wanted to contact her, as there was nothing further she could do and I thought it would be a serious nightmare knowing your husband was perched on a snow chute above a cliff with absolutely nothing you could do to help.  I did have a dictaphone with me though (as one does!).  I reckoned that if I slipped over the cliff, there was a pretty good chance the dictaphone might come through better than I did.  I recorded a message to her describing my situation and saying "Hopefully I will be able to play it back to you and we can laugh together about it, and if by chance that doesn't happen, what do I want to say to you?"  And I told her how much I loved her and how good our life together had been.  I talked a little about the kids and her life if I didn't make it.  I tear up listening to it.  A kind of a privilege to hear what you end up saying when you think maybe you could die within the next few hours.  Actually listening to this recording, with the wind buffeting in the background, is what churns me up most when I remember the whole experience.

And now I got lucky again.  Maybe I wouldn't have to wait nearly four hours.  I thought I heard the sound of a helicopter.  Then it faded again.  I listened carefully, but maybe it was all just the wind?  And then after a while the noise became unmistakable.  A large red helicopter.  Oh, how good that felt.  But not for very long.  It circled and hovered.  Deep in my gully, I waved and waved ... and then it flew away.  Later I found out that the location beacon was transmitting confusing information and they were distracted by other possible places the beacon suggested I might be ... apparently the messed up transmission indicated two widely divergent options, neither of which were correct.  Sinking feeling.  Maybe no helicopter after all.  Then the blessing of the mobile again.  Contact from Mountain Rescue base down at Sligachan.  I could tell them the helicopter had come and gone.  A confusion of phone calls, even talking to someone on the 'copter.  Reception coming and going.  They got me to put on my head torch.  Again, something I did right, the batteries were fresh, strong and changed at the start of this trip.  They asked me to turn the torch to flashing mode.  Eventually after several fruitless passes, the helicopter slid back over the West of the ridge and saw me.  Phone contact with someone on the 'copter.  Blessings.  I wasn't sure what would happen next.  I knew I'd been seen, but then the helicopter flew back out of sight.  I managed to phone the Mountain Rescue Sligachan base again and heard that three men had been winched down onto the ridge.  Wait.  Shout occasionally.  Quite a while before they found me. 

Then two hours after getting trapped, a lump of snow came tumbling down the slope to hit me in the back.  Then another.  Keep my footing, look back, a man on a rope coming down the snow chute.  I shouted my thanks and my apologies.  "You'll need to come higher up the slope" he yelled.  "The rope's not long enough."  I didn't fancy it.  I was numb, shaky and acutely aware of where I'd end up if I lost my footing.  Not a lot of choice though.  Start back up the snow slope.  Kick in toehold by toehold.  Slice into the snow to get some purchase with my hands.  I made it.  He could throw down a sling to put over my head and under my arms.  Shouted instructions about tying on.  I'm no mountaineer, but we cobbled something together with a knot and a carabineer.  Then it was back up the snow chute.  God I'm glad I didn't try it without a rope.  It was damn hard and if I'd tried to climb out on my own, I think it's a hundred to one that I would either have had to give up or that I would have slipped with all that was likely to imply.  It's impressive what you can do with the help of a rope though.  At the worst point I could get no purchase at all with my feet on the icy vertical rock.  Thank heavens I keep my arms strong.  Fist in a crack, fingers onto a ledge, haul up.  When we got to the top, my kind mountaineering rescuer complimented me on my climbing as a hill walker!  He commented to his colleague something like "That was bloody hard.  Definitely a grade four climb."  To which his mate replied "You're not going to claim it as a new route are you?"  Then down.  Slipping , sliding, helped by these three supportive, expert rescuers.  Blessings.  And the helicopter came in.  A slightly flatter place was chosen where we could stand.  Down came the looped harness.  Well!  Is there no end to this adventure?  "Shove it over your head and under your arms."  I was told.  "When they haul you up, keep your arms by your sides even if it's painful.  If you lift them up you could just slide out of the loop and fall."  Mm ... a good incentive to keep my arms very firmly by my sides.  And up.  In a strange way it reminded me of bungee jumping, but in reverse.  Hauled into the coastguard helicopter.  Joined by the three guys from mountain rescue and then down the hill a whole lot more easily than with the long trudge up about seven hours earlier.

We landed on a flat patch of land close to the Sligachan Mountain Rescue headquarters.  They must have helicoptered in a lot of damaged or dead people in their time.  These hills are serious.  Gratitude for how expert the whole operation had been.  Probably because the Cuillin are the most challenging hills in the UK, the mountain rescue service are very experienced.  Kind too.  "Getting caught in a snow gully happens all the time." they said.  "Don't blame yourself."  Of course I blame myself.  I made a stupid decision.  I don't think I'm going to develop much of a posttraumatic stress reaction, but I certainly intend to learn some important lessons.  "Really pay attention and don't go up or down a route with no clear exit, unless you know you can retrace your steps" seems pretty good for starters.  "Even if you don't use your mobile much, either memorise the number and/or write it on a label stuck to the back of the phone" is worth noting too.  "Find out how to contact and thank the mountain rescue people ... and whether it's possible to make a donation towards their work."  I believe that, in the UK, having your life saved like this is a free service!  "Listen to the recording I left my dearest wife, when I thought I might die.  Profoundly appreciate the precious, precious life I have" makes damn good sense too. 

And as far as PTSD is concerned, both the fact that I have great social support and also that I feel OK about how I managed the crisis once I was in it probably make it less likely that I'm vulnerable to posttraumatic effects.  Panic-associated derealization and disorganized memory of the worst moments of the trauma can be potent paths into later PTSD, so fascinatingly writing this blog post is also likely to help.  There's a nice research study - "Intensive care diaries reduce new onset post traumatic stress disorder following critical illness" - where giving patients a staff-kept diary of what happened to them during their time in intensive care reduced development of subsequent PTSD from 13% to 5%. 

For more on processing trauma & reducing risk of PTSD, see the next post "Walking in Skye & Kintail: lessons, self-compassion & posttraumatic growth".

In yesterday's post, I introduced the jazz trio metaphor ... head (observation/knowledge), heart (warmth/compassion) and gut (emotion/authenticity) ... and discussed both heart and, to some extent, head.  Continuing this exploration of head "observation & knowledge".  It's clear that cognitive empathy & perspective taking can be very helpful, but we need to be cautious about slipping into something quite cold-blooded and potentially manipulative. Recent research reported "Physicians down-regulate their pain empathy response: An event-related brain potential study" and we know the power differential between helper & helped can produce distance - "Power, distress, and compassion: turning a blind eye to the suffering of others". Yes, it's important that helpers don't drown in distress triggered by their responses to the suffering of those they're trying to help, however loss of compassion & emotional connection can be just as or more damaging - and this cuts both ways. So the classic Ambady et al study - "Surgeons' tone of voice: a clue to malpractice history" - where short recordings of doctor voices in routine consultations showed clear links between an uncaring, dominant tone and the chance of the doctor being sued. And also reduced empathy appears to be associated with an increased tendency to make medical errors & physically damage patients - "Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study".

So how does this all relate to the jazz trio metaphor? Well in the triad of head, heart and gut, head, for me, represents knowledge & research findings as well as perspective taking & cognitive empathy. It can be out of balance either dominating the picture - too cool, too manipulative - or not present enough as illustrated in the old saying "It's important to keep an open mind, but not so open that your brains fall out". The cerebral "head work", I feel, needs to be balanced by a connection that's much more emotional, more felt in my body. In a paper published earlier this year - "Social cognitive neuroscience of empathy: Concepts, circuits, and genes" - the author writes "This article reviews concepts of, as well as neurocognitive and genetic studies on, empathy. Whereas cognitive empathy can be equated with affective theory of mind, that is, with mentalizing the emotions of others, affective empathy is about sharing emotions with others. The neural circuits underlying different forms of empathy do overlap but also involve rather specific brain areas for cognitive (ventromedial prefrontal cortex) and affective (anterior insula, midcingulate cortex, and possibly inferior frontal gyrus) empathy."

I find this helpful, the notion that there is cognitive empathy and an overlapping but distinct affective empathy - in the jazz metaphor, I see affective empathy as "the gut". In another of this year's papers - "Empathy for the social suffering of friends and strangers recruits distinct patterns of brain activation" - this cognitive/affective distinction is enlarged on: "Humans observe various peoples' social suffering throughout their lives, but it is unknown whether the same brain mechanisms respond to people we are close to and strangers' social suffering. To address this question, we had participant's complete functional magnetic resonance imaging (fMRI) while observing a friend and stranger experience social exclusion. Observing a friend's exclusion activated affective pain regions associated with the direct (i.e. firsthand) experience of exclusion [dorsal anterior cingulate cortex (dACC) and insula], and this activation correlated with self-reported self-other overlap with the friend. Alternatively, observing a stranger's exclusion activated regions associated with thinking about the traits, mental states and intentions of others ['mentalizing'; dorsal medial prefrontal cortex (DMPFC), precuneus, and temporal pole]. Comparing activation from observing friend's vs stranger's exclusion showed increased activation in brain regions associated with the firsthand experience of exclusion (dACC and anterior insula) and with thinking about the self [medial prefrontal cortex (MPFC)]. Finally, functional connectivity analyses demonstrated that MPFC and affective pain regions activated in concert during empathy for friends, but not strangers. These results suggest empathy for friends' social suffering relies on emotion sharing and self-processing mechanisms, whereas empathy for strangers' social suffering may rely more heavily on mentalizing systems."

Emotion - such an important ingredient in psychotherapy - and in life. In the post "The importance of processing 'hot' cognitions & feelings" I said: In his paper "Emotional processes in psychotherapy: evidence across therapeutic modalities", Whelton wrote "At the present time there is an interest in emotion research in therapy that cuts across all therapeutic modalities. Emotional processing and depth of experiencing, two heavily-researched emotion process categories of the behaviourists and humanists respectively, have been shown to have a robust association with outcome. There is accumulating evidence that both the in-session activation of specific, relevant emotions and the cognitive exploration and elaboration of the significance and meaning of these emotions are important for therapeutic change".

Nearly twenty years ago, in his seminal paper "Emotion and two kinds of meaning: cognitive therapy and applied cognitive science", the great CBT researcher John Teasdale wrote "The clinical cognitive approach assumes that emotional reactions are mediated through the meanings given to events. Cognitive therapy aims to change emotion by changing meanings. It focuses on specific level meanings, evaluating the truth value of particular beliefs ... This focus on meaning at a specific level causes problems, e.g. the contrasts between 'intellectual' and 'emotional' belief, between 'cold' and 'hot' cognition, and between explicit and intuitive knowledge ... the Interacting Cognitive Subsystems (ICS) approach ... suggests a therapeutic focus on holistic rather than specific meanings, a role for 'non-evidential' interventions, such as guided imagery, and a rational basis for certain experiential therapies." There is a danger that cognitive therapists can find themselves all too easily working at the level of "cold" rather than "hot" cognitions. In their fascinating paper "Clients' emotional processing in psychotherapy: a comparison between cognitive-behavioral and process-experiential therapies", Jeanne Watson & Danielle Bedard wrote "The authors compared clients' emotional processing in good and bad outcome cases in cognitive behavioral therapy (CBT) and process-experiential therapy (PET) ... Twenty minutes from each of 3 sessions from 40 clients were rated on the Experiencing Scale. A 2 x 2 x 3 analysis of variance showed a significant difference between outcome and therapy groups, with clients in the good outcome and PET groups showing significantly higher levels of emotional processing than those in the poor outcome and CBT groups, respectively ... The results indicate that CBT clients are more distant and disengaged from their emotional experience than clients in PET." And I would emphasise, even just comparing clients in the CBT group, a deeper level of emotional processing - working more with "hot" cognitions - was associated with better clinical outcome. I find it valuable to keep a rough notion of what level we are on the "Experiencing scale" (PDF here) when I'm working with clients. And there's fascinating work suggesting that "the therapist's depth of experiential focus influences client's depth of experiencing, and this relates to outcome".

Gut stuff. Authentic gut stuff. As psychotherapists we can be surprisingly poor at navigating these internal emotional waters. This might be no surprise in cognitive-behaviourists, but my experience over the years is that it's not unusual for therapists of all persuasions to be daunted by moving deeply into feelings ... see, for example, "A quiet rant to group facilitators" and various posts discussing catharsis in peer group work. Much of the work on conflict is relevant here too as is "Is interpersonal group work better than sitting meditation for training mindfulness?"

The jazz trio. Head (observation/knowledge), heart (warmth/compassion) and gut (emotion/authenticity). I hope this exploration triggers off useful thoughts for you, the reader. What internal charts/reminders do you use ... especially when interpersonal interactions become more deeply emotional?

Working as a psychotherapist or counsellor, practising as a doctor, participating in interpersonal groupwork, and at the heart of relating deeply with another human being - I have internal reminders, charts, ways of helping myself be present in as constructive a way as I can.  One inner chart or internal reminder is the jazz trio metaphor.  A bit like a musician revisiting and making fresh again their playing of a well known classical work, the jazz trio metaphor takes another look at the key, so often explored territory of the therapeutic relationship - which overlaps to a huge extent with the more universal territory of how to be profoundly present in any deep relationship with another human being. 

Carl Rogers' core conditions are empathy, authenticity & "unconditional positive regard".  I talk sometimes of these qualities as a three-legged stool that we want to keep in balance.  Mick Cooper has reworked these conditions into a dynamic dyadic model for meeting at "relational depth":
And as Tim Anderson has shown in his research on "Facilitative interpersonal skills", this ability to navigate deeper connection with a client (especially when the going gets bumpy) is at the heart of what it takes to be a really helpful psychotherapist and, I believe, at the heart of what it takes to be a really helpful human being when relating at depth with others.

So in the powerful flow of a strong interaction with another person, what is the jazz trio metaphor and how is it useful?  The trio is made up of head, heart & gut - observation/knowledge, warmth/compassion & emotion/authenticity.  To do this well is like being a fine musician ... or a fine jazz trio!  It can be fantastically challenging and a deeply rewarding flow activity.  At the centre is the heart.  It's a dedication, a vocation.  I'm not formally religious, but pretty much every working day I will internally "pray" for the clients that I'm going to be seeing.  Pray?  Well, channel them goodwill ... think of who I'm due to be seeing and internally, deeply wish them well.  This isn't just some empty ritual.  Research shows that this kind of practice can help to orientate and open us ... like a warm-up exercise before playing sport!  And returning physically, internally to a sense of my heart area and a physical feeling of connection with the other person ... maybe using the breath to help this ... maybe relaxing, releasing into a sense of letting the other person in, of connecting with them.  These are "cookery tips", ways of working that aren't typically discussed in psychotherapy training, but they can be so at the centre of one's work. 

And at the same time there's the paying attention.  What is this person saying?  How are they saying it?  How do they look?  How do they sit?  How does the problem they're bringing relate to the huge amount of research and knowledge that is relevant to their situation.  After decades of work, reading thousands of research studies, having worked with such huge numbers of clients, how can I access information that's truly useful to this unique person in front of me.  How can I link with truly helpful information while honouring this particular person's never-before-seen history & characteristics?  There's a joy in knowing, in understanding ways that this suffering human being can ease the pain they're experiencing.  It's one of the most rewarding things I can experience.  A deep pleasure.  "As we explore this together, can we come up with a different way of understanding what you're struggling with.  What you're experiencing makes huge sense and it's possible, very possible to move forward from where you currently feel so trapped.  Here is a way that so many others in your situation have been able to free themselves."  A guide in a mountain landscape.  Knowing, from so many years of experience, how it may help to move forward while being aware as well that this person is a once-off.  Listening, monitoring, getting feedback, checking.  Is this right for them?  Is it helping them get to where they want to be? 

Teaching medical students to try to see things from their patients' point of view certainly seems to increase patient satisfaction - see "Does perspective-taking increase patient satisfaction in medical encounters?" I get a little nervous though that this cool cognitive stance can become manipulative. So in their paper "Why it pays to get inside the head of your opponent: the differential effects of perspective taking and empathy in negotiations", Galinksy & colleagues wrote "The current research explored whether two related yet distinct social competencies - perspective taking (the cognitive capacity to consider the world from another individual's viewpoint) and empathy (the ability to connect emotionally with another individual) - have differential effects in negotiations. Across three studies, using both individual difference measures and experimental manipulations, we found that perspective taking increased individuals' ability to discover hidden agreements and to both create and claim resources at the bargaining table. However, empathy did not prove nearly as advantageous and at times was detrimental to discovering a possible deal and achieving individual profit. These results held regardless of whether the interaction was a negotiation in which a prima facie solution was not possible or a multiple-issue negotiation that required discovering mutually beneficial trade-offs. Although empathy is an essential tool in many aspects of social life, perspective taking appears to be a particularly critical ability in negotiations."

See tomorrow's post for an extension of this discussion of head (observation/knowledge), heart (warmth/compassion) & gut (emotion/authenticity).

(A handout of the key points in this blog post is downloadable both as a Word doc and as a PDF file)

I have written a series of blog posts on Nick Grey's expert workshop on CBT treatment of posttraumatic stress disorder.  The day's focus was particularly on treatment approaches involving the trauma memory itself.  Nick highlighted four interlinked memory-focused methods - exposure & reliving, written narrative, site visit, and discrimination of triggers.  This post is the text of a client handout I subsequently put together discussing how best to go about the written narrative.  

Introductory comments: Traumatic experience can be like a wound that has been bandaged up, but that still causes real difficulties in one's life.  It is as though the wound has never been fully cleaned, has never had a chance to mend properly.  Typically one did the best one knew at the time to move on from what happened, but in many ways one continues to be powerfully affected by these past experiences.  The wound is now a bit like an abscess.  It can still be badly stirred up, producing very real distress and interfering with fully living one's current life.  This "cleaning out an old wound" meta-phor is one way of understanding the importance of emotional processing for many old traumas.  Another useful model is the "Factory metaphor" (see the associated handout).  Restacking a badly packed cupboard or filling in an only partly completed jigsaw puzzle are other potentially helpful ways of seeing this type of processing work.  The trauma may have been a single dreadful experience, or a series, or whole periods of one's life.  In all these situations it may be important and very helpful to go back and re-process what happened, take the bandage off for a bit, clean the wound out better, and allow fuller healing.  In cognitive therapy for posttraumatic stress disorder, this re-processing of trauma memories may well involve four components - retelling what happened, writing about it (the subject of this suggestions sheet), visiting/viewing where it happened, and discriminating between the original trauma warnings and current non-traumatic triggers.  This handout gives more information about the writing part of this healing process.         

From when to when & present or past tense?: If one is writing about a single dreadful traumatic experience, it's likely to be best to begin the description from just before things started to go wrong, and then to continue through to where one has emerged from the trauma and largely come out the other side.  There isn't a cut-and-dried, right-or-wrong way of deciding exactly what period of time to include in one's writing but, for single traumas, it's typically from before things became unsafe to after one has emerged and the worst has passed.  Similarly there isn't a definite right-or-wrong about writing in the present tense or in the past tense.  Sometimes describing the trauma in the present tense - as if one is going through the experience as one writes - may help in making the description fuller and more vivid.  This is likely to be helpful therapeutically.  The main thing though is writing a full, detailed and emotional account of what happened, and it's OK to do this writing in the past tense if this is what feels best for you.  If in doubt, first try writing in the present tense.  For multiple traumas, it may be best to write a separate description for each of the most important events.  For whole periods of one's life, sometimes it's useful to get an overview by filling in charts like the companion "Life review" sheets, or drawing out a time line on a piece of paper with marks to show when one's situation was particularly bad and maybe too, marks to show periods of time that were a bit easier.  One can then write as for multiple traumas, with separate descriptions for a few of the very worst experiences.  Every trauma episode that occurred over an extended period of one's life doesn't have to be written about.  Typically working with the worst experiences will help too with not-quite-so-bad experiences, so one doesn't need  to write about these as well.

By hand or using a computer?: Both writing by hand and using a computer can be fine.  Sometimes writing in longhand allows people to be more expressive, more spontaneous and more able to get in touch with important emotions.  If you do decide to write by hand, please leave plenty of space to go back and add more information later.  To do this, some people only write on every third line, or leave very wide margins, or leave large spaces between paragraphs.  If you're going to write by hand, work out beforehand how you'll make sure you can go back and add in more detail and under-standing later on.  Remember though - whether you're writing by hand or using a word processor - this is not about spelling, punctuation, or keeping things tidy.  Far from it, this is about a healing process so as long as you can understand what you've written, please don't try to make it some kind of "literary work".  Just go for it. 

Writing using a computer can be good too, especially if you're familiar with using a word processor so the actual practicalities of typing don't get in the way of you really being able to engage with the writing as fully and honestly as you can.  A potential big advantage of using a computer is that it's so easy to add further material later on.  This additional information often comes from one's own memory.  Once one has started writing and/or talking about what happened, more detail may well pop into one's mind both when one tries to remember further and also spontaneously - when thinking about other things or even in dreams.  Some people may get more information too - more pieces of the jigsaw - from other sources and conversations.  It's sometimes helpful to use different text colours or other distinguishing styles.  For example one could use a different colour or font or put inside brackets or other method when one adds new information that one had initially forgotten or simply not known about.  Some people may also use different text colours/styles/insertions when they add in new emotional responses and new understandings - particularly facts or perspectives that they didn't have access to at the time of the trauma.

What happened, what I felt, what it meant to me: When we write it can be helpful to see that there are at least three "lenses", three overlapping aspects that it's important to cover.  One lens involves describing the external facts - what happened, who was there, what did it look like, what was said - all the details picked up through our senses.  A second lens focuses on internal facts - what did we feel, what mix of emotions were there, in what order, what feelings were most intense?  It's so important that we dig down deeply and honestly into our emotions.  In many ways, re-contacting the feelings helps to "melt" our frozen responses and allows them to reform in updated and more healing ways.  And this is the third lens - how did we understand what happened, what sense, what meaning, what explanations did we come up with?  And crucially, now, with the greater understanding that we have, what meaning, what explanation can we now develop?  Questionnaires like the "Posttraumatic cognitions inventory (PCTI)" and the "Postraumatic growth inventory" may be useful here. 

Piecing together & letting light into the "worst moments": It's likely that successful treatment for posttraumatic reactions helps through at least two overlapping mechanisms.  One is to organise & transform the memory so that it can be "packed away" and no longer keeps affecting us so badly.  In a typical severe trauma there are likely to be several "hot spots" of particularly intense emotion.  These hot spots are crucial therapeutic targets  as they are often sections of memory that are most disorganized and that are key sources of self-damaging misunderstanding.  Challenging & updating these "misunderstandings" or only "partial understandings" is a second major mechanism of effective & helpful treatment.

Concluding comments: Persisting distress after deeply upsetting experiences is very common.  "Emotional processing" of these traumas - unpacking/clarifying/organizing the memories and challenging & updating the meanings we have given to them - can be tremendously helpful in easing sufferering and helping us reclaim & move on with our lives.  Writing about what happened is often an important aspect of the cluster of methods used to make therapy for such problems as effective as possible.  It can feel a daunting prospect to write in this way, but it can be immensely helpful & healing.    

I plan to write further posts about Nick Grey's workshop and trauma-focused CBT for PTSD next month.

This is the third in a series of posts triggered by Nick Grey's workshop on memory-focused approaches in CBT for adults with PTSD.  In the second post yesterday, I wrote about " ... treatment structure".  In today's post I want to step back for a moment and get a broader perspective.  These trauma-focused treatments have much wider applicability than just for DSM-IV-TR congruent, single episode traumas, and its this wider applicability that's a major reason for me doing this workshop.

The question of appropriate client assessment and monitoring can open a bit of a can of worms here, or a cornucopia of possibilities if you'd prefer a more upbeat spin. I can think of at least three types of therapeutic situation where I might want to be using adaptations of trauma-focused cognitive therapy, but where assessment might best look more broadly than just using straightforward type I trauma questionnaires like the IES-R. So one such situation is with PTSD symptoms that are triggered by life events that don't typically qualify for a PTSD diagnosis - usually this would mean that they don't fit with criterion A which states the sufferer should have been "exposed to a traumatic event in which both of the following were present: 1.) experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. 2.) the person's response involved intense fear, helplessness, or horror (in children, this may be expressed instead by disorganized or agitated behaviour)."  Fascinatingly, PTSD symptoms in the community often don't require this kind of initiator - see the classic Gold et al paper "Is life stress more traumatic than traumatic stress?" with its abstract reading "This study explored the definition of a traumatic stressor, as it currently stands in the DSM-IV-TR, and the relationship between this definition and psychological symptomatology. Four hundred and fifty-four college undergraduates completed measures assessing psychopathology and exposure to trauma. Individuals were then divided into two groups, those who reported a traumatic event that was consistent with the DSM Criterion A1 definition and those who reported a traumatic event that was inconsistent with the definition. Surprisingly, the latter group reported significantly greater severity of PTSD symptomatology than those who reported a Criterion A1 PTSD event. In addition, significantly more people in the DSM trauma-incongruent group met criteria for PTSD than those in the DSM trauma-congruent group. Nearly two-thirds of the DSM trauma-incongruent group identified the death or illness of a loved one as their traumatic experience. The results are discussed within the context of the ongoing controversy over PTSD Criterion A1." Mol, Arntz et al showed a similar picture in a large adult population, see "Symptoms of post-traumatic stress disorder after non-traumatic events: evidence from an open population study." It might be absolutely appropriate to use a measure like the IES-R in this common trauma-incongruent PTSD, but - where death of a loved one is the trigger - it may well be that it would be more helpful to conceptualise the symptoms as traumatic grief and use a more appropriate scale like Prigerson et al's questionnaire described in their paper "Inventory of Complicated Grief: a scale to measure maladaptive symptoms of loss." A copy of the "Traumatic grief inventory" is downloadable from further down the "Relationships in general" page of this website. Grief is a huge subject area in its own right and the overlap with PTSD is widely appreciated - see, for example, Anke Ehlers' paper "Understanding and treating complicated grief: What can we learn from posttraumatic stress disorder?"

A second type of therapeutic situation where I might want to use an adaptation of trauma-focused cognitive therapy is with the surprisingly common finding that other Axis I disorders (for example social anxiety, panic disorder, depressive disorder, etc) may have been triggered initially by "traumatic" life experiences.  Often there is some kind of underlying vulnerability, but this might never have sprouted into a full blown disorder without the specific event trigger.    

More to follow ... in completing this post soon, in the next post "BABCP Spring meeting: Nick Grey on memory-focused approaches ... writing suggestions (4th post) , and next month.