Wednesday, 24 May 2017

Catastrophisation

I first came across the term “catastrophisation” many years ago in a conversation with a clinical psychologist at Southampton General Hospital. I understood that it is a concept often explored in CBT client work.

Basically, it is making mountains out of molehills. Not an entirely uncommon thing to happen, but it is something that can prove to be rather problematic. Of course, some of these molehills can themselves be rather problematic in the first place, but the process of catastrophisation is rarely helpful on top of this.

In “The Rainbow Machine…” I gave an example in the chapter on Right Man Syndrome of the father who told his son that he had “ruined his life” simply for getting a tattoo. 

The 19-year-son hadn’t really ruined his life; he’d simply got himself tattooed. 

Now, had he got a swastika tattooed on his forehead, shaved his head and joined the local Nazi cabal, then possibly his father may have had a point. But of course, the fellow Nazi’s may not agree with that at all. Some things are just a matter of perspective.

The level of catastrophisation is undoubtedly proportional to the intensity of the feeling the offended party. The stronger the offended party feels about the issue, the greater the level of catastrophe.
Catastrophisation is also a pattern that can be applied to self. 

A while ago I had a client say to me, “I might as well die if I do not pass this exam.” That's a pretty catastrophic reaction she had planned there – fail exam, then die (or apply its nearest equivalent).

She is not alone. I often hear similar phrases uttered by clients, such as:
  • “It’s the end of the world….”
  • “My world came to an end that day.”
  • “Everything collapsed around me.”
  • “My life is a complete shambles.”
  • “My sex life is a disaster.”
  • “It kills me to see her this way.”
  • “It’s destroying everything.”

    And so on.
Much of this phraseology is an expression of the level of emotional intensity the person feels, but I often wonder how much of this emotional intensity is in part due to the story the person is telling themselves about the relevant events.

Now personally, I’ve seen genuine catastrophes. I know what they look like. I am reminded of the horror that was a full laden bus falling off a road and down an incredibly steep and deep ravine in Nepal. Knowing that we were helpless to offer aid to any unlikely survivors and knowing that formal rescue would be several hours away the situation was as bad as it can get. 

Curiously, one of the distressed onlookers uttered out loud, “Why does this always happen to me?” I couldn’t help but think that nothing had actually happened to her, it had happened to those other poor souls lying broken, dead and dying at the bottom of the ravine.

But this wasn’t the story as she experienced it. She evidently was measuring the situation by her emotional reaction to it, and given her choice of word I’m guessing she was no stranger to such events. I did make a mental note not to get back onto the same mini-bus as her though. No point in tempting providence, I say.
 
I also remember the daily personal catastrophes that I saw when working in Accident and Emergency. 

Most of those people brought into us never expected their day to end the way it did. Fortunately, most people survive and recover, but some die and others live on, but in such a radically changed way that things are never the same for them again. 

I’m thinking here of some of the burns victims, people who lost large portions of their body, serious genital injury, serious facial disfigurement and of course irreversible brain damage. Some are the sole survivor of their family or friends; others survive knowing or believing that they were the cause of their deaths. 

Things change and not always for the better, and some, but not all, never recover any form of meaningful existence or happiness following the catastrophic event, despite all the hope and help and treatment on offer. Their remaining life is one of suffering and their death is one of merciful release. It can be grim, very grim indeed.

I’ve personally seen people living in the slums in India and Africa, foraging as best they can on the municipal rubbish dumps, or selling their bodies on the streets, or finding themselves owned and exploited by gangmasters and organised crime. For so many people, life is an unremitting daily horror.

Helpless to do anything about any of this, the best comfort I offer myself is that at least this is not happening to me; it is happening to someone else. Not an entirely Christian outlook, I must confess, but I do what I can. Which, admittedly, isn’t very much at all.

It is with all this in mind then that I receive the news from some clients that their life is some kind of personal catastrophe when in fact all that is really happening for so many of them is that they don’t feel all that great. The fact that the story they tell is one of catastrophe usually implies helplessness and the need for rescue.

One psychiatric client of mine, a middle-aged lady, had recently embarked on an all new anorexic adventure. Previously she has tried alcoholism, but that hadn't really agreed with her, she'd also tried out self-harm in the form of cutting, but found that much too painful. A subsequent skin infection leading to a dose of cellulitis put an end to that nonsense.

She sat down opposite me and appeared keen to impress me with how ill she was. Thus began the catastrophisation, “What you need to understand,” she told, “is that the anorexia is destroying everyone around me.” 

I nearly choked on my tea as I declared, “Everyone?! Holy shit! Do I need to be afraid?”

She laughed at this and told me that she didn't mean everyone. She meant her family. I started to break this down further.

Why exactly do I need to understand this?” I asked her, which was met with a rather blank look. “You see, you began this by saying, 'What you need to understand is that the anorexia is destroying everyone around you.' Why me?”

The blank look continued.

And you also refer to the anorexia like it is some kind of creature. And I must I say, I have just got to tell you this. The fact that you are not eating very much isn't likely to be destroying anyone at all. Well, you might be getting a bit thinner and saving money on food bills and stuff, but really, destroying people? Give me a break!”

And before she could protest I ushered her back out of the door.

In working with patterns of catastrophisation, a reality check may well be in order. But I have noticed that therapists often catastrophise too. I have lost count of how many inexperienced therapists ask me the classic question, “What if that client went and killed herself?”

I must get asked this question at least once a workshop and also once a month by email. I even had a psychiatrist email me once, who, having read my book emailed me to intimate that she thought that I probably left a trail of corpses everywhere I went.

I think I might have noticed if this was the case. It did leave me wondering what it must be like being a patient in her hospital ward. Tightly bound in cotton wool, “ward policies” and straitjacketed sufficiently with neuroleptics to remove all sense and reason? In some places, no-one flees the cuckoo's nest - too many rules preventing such an action.

When therapists catastrophise, there are two main patterns at play.

1. They significantly overestimate the level of influence they can exert upon people
2. They tend to view people as woefully fragile and rather dependent upon therapy for any form of mental functioning and future.

This leads to an interesting game: Delusions of grandeur. Delusions of grandeur are often thought of as being in the positive, i.e. the person may believe he is the king of the world, a grand duke, Jesus, or some God-like figure and so on. But delusions of grandeur can also be negative, i.e. the depressive who believes, “everything is my fault!”, “everyone hates me”, “they are all out to get me” and so on. It is rather grandiose to assume that people care all that much about them.

Victims often think this way too. It is quite understandable of course. The victim may well be quite preoccupied with morbid thoughts of their aggressor, and of course, assume that their aggressor is equally as pre-occupied with thoughts of the victim. But of course, this isn't always the case.

Many therapists think the same way about their clients and patients. Yet so many clients and patients don't give their therapist a second thought in between sessions. “But I never hear from them again,” is a lament I hear so often from therapists when discussing client follow up. 

I have a particular problem when clients call me up on the phone for follow up. I often have to frantically type in their details to pull up the summary to remind me who they are. I have often thought about asking clients to send me a recent photo of themselves along with the assessment form to make my life easier, but think this might be seen as a bit odd. I know I would if I were a potential client.

Here's the game of Delusions of Grandeur. Just do a google search to see it played out on the internet.

Clients/Patients:
  • My whole life is ruined
  • I might as well be dead
  • I'd be better off dead
  • My whole world has collapsed
  • I've reached the end of the road
  • I've wasted my life
  • I have no future
...and so on.

Therapists:
  • Get the life you want
  • You can have unlimited freedom
  • Be the best you can be
  • Apply the law of attraction to change your world
  • Make a world of difference
  • Set yourself free and live the life you choose
  • Have unlimited power
...and so on.

And somewhere in the middle of no-man's land the place I so often find myself in my line of work, I hope there is some reality that I can actually work with.

1 comment:

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