Priska Imberti left her native Argentina 20 years ago in search of a better life in America. Here she tells her story of loss and transformation and explains why immigrants living in a hostile social and legal climate need a therapeutic space where they can heal and reconcile the different parts of themselves

It was towards the end of 1988 – summer in Argentina – when a friend suggested over supper that my husband and I take our preschool children and emigrate to the United States. The economic situation in our country seemed truly hopeless: radically unstable currency and terrible inflation, disappearing consumer goods, and increasing poverty. Our friend, a medical doctor in Argentina, had recently married a US-born woman and immigrated to New York. In the US he couldn’t work as a physician. But within a few months, he was employed making deliveries for a catering service, and – in spite of the presumed drop in status – had discovered the benefits of getting paid on time in a stable currency that allowed him to afford his rent every month without sacrificing other essentials, like food, clothes, and transportation.

My husband was in law school and I was approaching graduation in a university psychology programme, but we had few prospects in Argentina. Higher education was and is free there, so anyone without a job or much income can pursue professional studies. This produces a surfeit of professionals in a sinking economy. In Cordoba, for example, where we attended the university, there was a lawyer for every five people, a medical doctor for every 10. The middle class in Argentina was disappearing. Simply getting shoes for our children, books for our graduate studies, and rent money every month had turned into a nightmare that didn’t seem likely to end anytime soon.

That same night, we made the decision. There was no time to evaluate pros and cons, no time for contemplation of family ties, and no fears or doubts. Here was our opportunity and we had to seize it. We did not think much about the risks – nothing in a remote country, we thought, could possibly be worse than the reality in our own. A couple of months later, my husband arrived in New York, and 11 months after, our children and I followed.

As children of first- and second-generation immigrants ourselves, growing up in a country where most of the population has at least one Italian, Spanish, German, Turkish, or Japanese grandparent, we did not find it difficult to think of migration as a means of improving our lives. Once in the United States, my husband worked a series of jobs – dishwasher, delivery person, cook, driver – seven days a week, sometimes for 14 to 16 hours a day for a minimum wage. Seven years after coming here, he was driving a limousine for an affluent businessman. But even before this stroke of luck, what might sound like meagre employment represented a significant financial improvement for us. Even with a budget that allowed for no luxuries, we could pay our rent and other bills, buy food and clothing, and still send money to our relatives back home.

Yet there were immediate problems. I spoke little English, and my immigration status was uncertain – we had only temporary visas, and the possibility of obtaining permanent residence status was remote. This meant that I could not continue my education. We were raising our children without the support of the extended network of family, friends, and neighbours that is the norm in Latin American countries, while navigating a new culture with multiple new systems – education, housing, employment, community, shopping, transportation – all the while trying to ‘fit in’ and not make waves. During those early years I stayed home and took care of my children because we didn’t know anybody we could trust to take care of them. Besides, we thought that being in a foreign country among unfamiliar people speaking an unknown language was hard enough for them without putting them in the care of strangers.

Looking back, I think I was lonely. I did have one friend, who had come with us from Argentina, but she was busy most of the time, so I saw little of her and spent a lot of time by myself while my children were in school. I even stopped smoking cigarettes, which I had always associated with social life in Argentina. During that time I did so much walking! I never took a dictionary with me when I ventured out, so I would memorise words I read on street signs and stores and then look them up at home. I visited local libraries and analysed everything I saw, trying to understand the culture I was embedding myself in. I watched three TV news channels every night, finally understanding something of what I was hearing by the time I got to the third. My brain was like a sponge – I tried to learn everything that crossed my path. I do not think I will ever again have that kind of energy and voracious curiosity. The worst part was being an adult (I was 25 when we came) and feeling so infantilised when I lacked the words to express myself.

The sacrifices of immigration
Immigrants come with a store of knowledge, experiences, and family history that have both delineated their position in the home society and given them their sense of personal identity. Often much of this familiar identity is lost in the new country, particularly when they must sacrifice their old social and professional status to survive. For example, one lawyer I know from Colombia works as a teacher’s assistant in a New York suburban high school. Clients who are professional engineers in South America work as construction labourers here. A psychology student in her native Bolivia is cleaning houses in New York City.

Finding work was not easy for me. At first, I taught Spanish language and Latin American culture on Saturdays in the independent school my children attended so they would stay connected with our cultural roots. Then on 26 January 1996 everything changed. In an effort to get my family’s legal status resolved, I visited a nonprofit immigrant agency led by Don Gomez, a prominent community organiser from Colombia, to get information. I left with a job as an immigration consultant in his agency.

At this agency I began working closely with people like me who faced legal problems related to unresolved immigration status, as well as the pain of family separation, financial vicissitudes, the challenges of adjusting to their new environment, and the emotional upheavals resulting from all these difficulties. Most of these clients had arrived here in the late 1980s and early 1990s undocumented, but had found a way to legalise their status, either by marriage, long-standing work-related visas, or relatives’ petitions.

Many of the people talking to me were sharing their immigration experiences with another person for the first time since their arrival, and their revelations – often revealed with grief and tears – clearly brought them great relief. Some of their stories were deeply traumatic and have stayed with me.

Magdalena, for example, was 14 years old when she left her native Venezuela with her aunt. From Mexico, she continued alone on the journey to the US to reunite with her mother, whom she had never met. On her way here, walking across the desert – probably with smugglers – she was raped twice and escaped a third attempt by running away and jumping over a cliff. She told me that she had decided she would rather die in her leap than face another attack. Instead, she stood up and continued walking until she finally made it to her mother’s home. But the emotional cost was terrible. ‘I wish I could look back and be able to erase parts of my life,’ she told me. ‘I found my mother, but lost my childhood. I feel I lost myself in the voyage.’

Jorgito, a six-year-old boy from Honduras, came to the US to meet his parents who had left him under the care of his grandparents as a three-month-old baby and were now financially able to reunite the family. Somehow, on his way to the States, he was lost, nobody knew where or how. After a month his parents in New York City traced him: he had been found at Chicago International Airport and placed in a foster home by social services. Even though he finally made it home to his parents, the terror and loneliness of the episode left him speechless. Three years later, he still could not talk.

Pedro, a middle-aged father of six, travelled from Ecuador to the US, partly in a small boat with nearly 30 other people, but no food, water, or toilet, before making the rest of the journey by foot. He was picked up and sent back by the border patrol several times, but always managed to return. Now, many years later, he’s an engineer in this country, who has managed to send enough money home to put several of his children through school and college.

Listening to these clients and hearing their appreciation for whatever help I could give them convinced me that if I completed my education and became a psychotherapist, I could help them even more, while contributing something to the country that had embraced me. It also became clearer that we immigrants need help in creating a space within ourselves for incorporating the transforming experiences we undergo, for understanding and accepting our losses, and for acknowledging our achievements. It can be very hard to find a balance between acknowledging and accepting the very real losses (immigrants often work at not thinking about what they have lost) and embracing our accomplishments and victories. Pauline Boss’s concept of ‘ambiguous loss’1 fits the immigrant’s situation well. You know that you are no longer who you were or who you wanted to be, but somebody else. This ‘somebody else’ may be better than the person you would have become had you not immigrated to a new country, but there is still a bittersweet sense of loss.

As a therapist today I can see the beginning of my journey reflected in the narratives of the immigrants I see in my practice. With empty hands, but full of energy and plenty of dreams, many of us arrive in the US hoping for better times, but the journey does not stop upon arrival: it continues throughout our stay.

A ‘temporary’ life
Immigrant families I work with tend not to explore many of the possibilities offered by their new country – in education, economic and financial opportunities, labour rights, social life and recreation – partly because they are dealing with basic survival. They seem to have the sense that everything is temporary. They often feel that they can never get ahead enough to settle down, become truly at home, and begin seeking some personal fulfillment.

For some, their perpetually ‘temporary’ state here means that they never can abandon the dream of returning home one day and getting old in their native lands, even though there is no realistic possibility that they will ever do so. Other immigrants do not dream about going home as much as have nightmares of being forced out of the US. Some face impending deportation procedures and live not knowing where they might wake up the next day – at home, in custody, or even back in their home country. I can vividly remember the bad dreams I used to have in which I was being forced to return to my country and arrived back there without work, without status, without a future. In the therapy room my clients recall those nightmares, too.

For people who are afraid of what the future holds, living purely in the present moment keeps them from falling apart. Detaching themselves from their emotions and not thinking too much about what they have been through or what they have left behind allows them to get through each day. What keeps them going is the thought that they are helping their distant families now and that someday there will be enough money to bring them here. They also dream that one day a general amnesty will allow them to stay here legally, to get some recognition and entitlements, and to be appreciated and respected for the hard work they perform.

Dealing with feelings of loss
In my experience, we immigrants suffer four basic losses: a loss of mastery over surroundings, a concrete loss of family networks, a critical loss of language, and an erosive loss of the everyday life. These losses give our existence a chronic sense of never quite belonging anywhere.

Take loss of mastery. Mercedes, a Salvadorian single mother of four, attended a parent-teacher conference requested by her daughter’s high school teacher because the girl was not doing well in school. I interpreted the meeting for Mercedes, who speaks little English. During the course of the meeting she pleaded with her daughter to apply herself and improve her performance. ‘My child,’ she said, ‘you know English and can defend yourself. You can express your feelings and thoughts. Look at me: it has been my experience that most of the time, I cannot say what I feel, and it stays within me. I feel it stays inside me forever! It is very painful, it happens to me all the time, even today.’ Mercedes’ words convey a sense of intangible loss. Unlike tangible losses – social class, family, income – loss of mastery causes a silent, persistent grief in a society that consistently devalues those who are different or do not measure up to mainstream standards of language or cultural proficiency. Loss of mastery creates an internal shame, which often silences the real self and renders the person essentially powerless and voiceless.

Loss of family networks, the second major loss, can have profound and unexpected consequences, even when immigrants struggle to maintain old ties. Emilia and Estela are sisters, 19 and 18, who came here three years ago from Central America. After their mother had left for this country, 16 years ago, they were raised by their grandparents. While in the US, their mother got married and had two other children, now 14 and seven.

Like many immigrants, she lived a life oriented toward bare survival, focusing almost entirely on work while minimising and suppressing her own pain and suffering. Even though she visited Emilia and Estela a few times, their relationship was held together by phone conversations, monetary support, and the dream that they would be reunited.

Emilia and Estela are now in high school here, struggling with the language and cultural differences that at times make them regret having come at all. Emilia spoke about their painful realisation that time and distance have distorted their mother-daughter relationship: ‘The woman we knew in Nicaragua was a different one,’ she explained. ‘She visited us from the US two or three times, and we saw her happy and loving. The woman we encountered here is another one – we don’t know her. She treats us with no love, she blames us for her problems, and she regrets having brought us here and wants us to pay for that. She makes a big difference between us and her other children who were born here. Now, we think she did not see us growing up and that is why she does not feel for us what she feels for the other two she raised.’ As is the case with many other immigrants, Emilia and Estela’s experience has been deeply affected by the time and space fragmenting their family and interrupting its normal life cycle.

A third major loss – loss of language – promotes a sense of insecurity, inadequacy, and low self esteem, and can have far reaching negative psychological effects. During a school counselling session, Carla, an 18-year old Guatemalan girl, was asked about her experience so far in a US high school. She became suddenly emotional and disclosed how painful every day of her life had become since she entered the school after her arrival here. ‘First of all, one is being looked at as garbage! That is how I feel sometimes,’ she said. ‘It is hard, very hard. I try my best to understand, and I surprise myself how much I try, but it is never enough. I feel my classmates look at me badly. It is like they are saying “What is wrong with her?” I feel they get frustrated with me because I do not speak well, like I do not know what I am talking about.’

Loss of the normal patterns of existence that comprise daily life in the old world, a fourth type of loss, can be a desolating reminder of all that is gone forever. Cristian and Evangelina are two middle school students from a small town in Peru where wild flowers, warm-water rivers, and high mountains were their everyday landscape. During group sessions of the school counselling I do, they always drew coloured pictures of those landscapes and talked about their life in their hometown. ‘Every day after school I rode my bicycle to the river and swam for hours before going home to my grandmother,’ Cristian remembered. ‘Here, I take the bus home to no one because my mom works until late, eat something, do homework, and watch TV.’ Evangelina recalled, ‘I used to spend a lot of time with my friends because we did a lot of walking to and from school every day. We would walk for an hour and play outside. It was a lot of fun. I don’t really have many friends here. Besides, we all live blocks away from each other and my parents say it is dangerous to play in the street.’ Differences in lifestyles, foods, climate, after-school activities, geography, child care, social networks, and support are, indeed, the parts of the everyday life that provide us with a sense of belonging. Without them, we become foreigners in a foreign land.

A nation of immigrants at odds with itself
Because of my experiences growing up in a different world and taking the risk of following my dreams, I began to believe that what allowed me to persevere was not to allow myself to be slowed down or defeated by self-limiting attitudes arising from practical difficulties (language, work adjustments, immigration status). I refused to say, ‘I cannot,’ or ‘This is impossible for me because I do not speak English,’ or ‘I will not ever be able to pursue professional studies,’ or allow myself to be intimidated: by other people, by the systems I had to deal with (Immigration Services, for example), by the thought of writing an academic paper in a foreign language or the prospect of treating English-speaking clients. In fact, I think the experiences of immigration have given me a sense of selfrealisation that I might not have acquired otherwise. Becoming familiar with a new culture and now knowing two worlds, learning a new language and becoming bilingual, finding mentors in the United States who have helped me – all this has allowed me to find pride and joy in my own transformation.

Yet at times I have experienced, as have so many of the immigrants and clients I know, particularly those whose immigration status is ambiguous or undocumented, a chronic state of hypervigilance, an alertness to danger and possible catastrophe that can be debilitating. My clients above all live in this chronically hypervigilant state, often due to the real fear that ‘la migra’ – slang for immigration authorities – can alter their lives completely at a moment’s notice.

For some the immigration journey gradually brings about the realisation that there is a vast disconnect between the fantasy of a better future and the reality of being an alien in an unwelcoming land. And yet immigrants stay in spite of their disappointments. Often, they have no choice. It may be too late to turn back – they have severed too many ties. Religious, political, and social persecution might also rule out the possibility of returning.

Sadly, in a society abounding with immigrants, there is a subtle (and at times obvious) sense that being foreign born, speaking a different language, and adhering to different cultural values are negative characteristics, which need to be altered or ignored, but rarely celebrated. Our way of speaking sounds unfamiliar and is often perceived as unattractive and flawed. The common expression, that we speak ‘broken English’, and classes offering ‘accent correction’ can make us feel that we are somehow ‘broken’ and need repair. Those of us who speak accented English are always being questioned about our origins, as if because of our accents we do not quite make sense as human beings. For the last 18 years, 365 days a year, I have found myself responding to the same question – ‘You have an accent. Where do you come from?’ – making me feel that I must explain myself every time I meet someone.

The healing work: self-reconciliation
Today therapists are much more likely than they were decades ago to take into consideration the ways that race, class, gender, and culture powerfully affect individual psychology and family relationships. However, we still tend to neglect exploring the various immigration experiences to discover how they have transformed the inner world of our immigrant clients. Only by understanding their aspirations and validating the difficulties of their journey can we help them find a healing place from which they can begin to look at what they have achieved. As much or more than any other client population, immigrants – living in this hostile social and legal climate – need a therapeutic breathing space for reconciling the different parts of themselves and healing.

Meeting with Emilia and Estela’s mother – who the two girls felt was rejecting them in the United States in favour of the two daughters she had born here – helped me understand how she could be so emotionally connected to her daughters when she visited them in Nicaragua and so apparently disconnected from them in this country. When she lost her family network, she not only lost her relationships directly, she lost the part of herself that was valued as a mother and as a member of her close-knit family and community. In her journey of transformation, she had felt compelled to suppress this pain to devote herself completely to working in the US on behalf of the family she had left behind. In the process, she gained status and pride within herself by being a hard worker and provider, and for having succeeded in her epic effort to bring her Nicaraguan-born children here.

I gently invited her to access the place within herself where she still kept hidden the pain of separating from her firstborn children and, at the same time, acknowledge the joy of having been able to reunite with them. The therapeutic work involved helping her connect with these aspects of her journey – the loss and the gain, the trauma of the separation and the victory of the reunion: the power of her accomplishments.

For Mercedes (the mother who could not advocate for her child because of her inadequate English) and Cristian and Evangelina (who longed for their beautiful rural Peruvian landscape of flowers and warm rivers), it was necessary to work through their grief at having lost their sense of belonging to a community and a culture, as well as having lost the old sense of mastery over their surroundings. To ground themselves in their new unfamiliar terrain, they needed to develop a new kind of compass for measuring personal mastery and self-worth.

In my personal and professional experience as an immigrant, I know that in our new world we need to create room to hold the two realities – what has been lost and what has been gained. It isn’t that the accomplishments replace the losses – they don’t – but the two go hand in hand and, considered together, help make the immigrant feel more whole.

As for me, looking back always brings mixed feelings. Once I left Argentina, I never saw my mother again. I can’t spend a lot of quality time with family and friends whom I love who live in my home country: phone conversations don’t make up for physical absence. Yet I see myself writing this paper in my second language and feel accomplished. Recently, after visiting Argentina, my 25-year-old daughter said how much she now appreciates our decision to leave 20 years ago. She told me that the trip made her realise all the opportunities she had here compared with the emptiness she sensed in Argentina among young people her age. ‘Seeing how my life is now and knowing how it could have been if we’d stayed makes me appreciate how hard you struggled and how much I’ve taken for granted.’ Her words were deeply satisfying to me.

I know that my journey does not end here. There will be more transitions and adjustments, more ‘immigrant’ experiences I will have to absorb. My grandchildren, for instance, will not speak Spanish naturally as their mother tongue – we will have to take pains to instill it in them. This is no tragedy, but it brings me a little pang of sadness nonetheless. Meanwhile, they – with their nativeborn Argentine grandparents and parents – still continue the journey and live in two worlds, though the worlds are not as far apart as the two my husband and I had to bring into a single orbit.

The journey of the immigrant never ends. It begins with a dream – a dream of a better life for us, a better future for our children. Along the way, there will be trauma and loss that transform our lives and reorganise our world, which will need to be explored and healed if we are to reconcile the divided parts of ourselves and thrive. Creating a space for stories of loss, suffering, and survival in the therapy room gives meaning to the journey. Embracing the story and exploring the dichotomy between the cultural self (who one is in one’s native land) and the everyday social self (who one is or becomes in the new land) are critical to helping immigrants bridge the great divide in their lives.
Priska Imberti, a bilingual and bicultural psychotherapist, is the cofounder of Integral Enrichment Services in New York City and Long Island, NY, a group practice that provides holistic and culturally sensitive psychotherapy and psychoeducational services to individuals, families and organisations. She has written articles and workshop presentations on issues relating to immigration. Contact prixgus@optonline.net This article was first published in the May/June 2008 Psychotherapy Networker (www.psychotherapynetwor ker.org ) and is reproduced here with the kind permission of Psychotherapy Networker and the author.

References:
1. Boss P. Ambiguous Loss: Learning to live with unresolved grief. Harvard University Press; 1999.

“Resentment is like drinking poison and then hoping it will kill your enemies.”

Once we see the truth of this thought we realize that resentment only hurts the one who walks around with resentment. And it doesnt change anything really. It’s actaully the opposite: resentment is unhealthy when experienced for an extended period of time. So what can we do when we feel resentment in our daily lives because of negative live experiences? What does it take to get over feelings of resentment?

One of the big thruths out there is “People are not against you, they are merely for themselves.” This insight allows us to see that people who hurt us in the past did not do so intentionally. They did not hurt us beacuse they wanted. They just decided to do something they believed was right for them at a given moment in time. Once we get to this new perspective we open the door to new (and healthier) interpretations of past experiences. This will allow us to distance ourselves from resentment. Resentment that can be replaced by forgiveness. Why forgiveness? Because forgiveness takes away the weight of resentment. Why forgiveness? Because its good (healthy) for the one who forgives as it transforms feelings of resentment into healthier feelings like a felt sense of peace with oneself and ones past.

Obviously forgiving is not a short-cut to living happier and healthier. It’s a process where we will find ourselves over and over again with feelings of resentment, but instead of feeling stuck like we did in the past, we now can re-interpret this experience using new, and healthier, insights such as “He was not against me, he was merely for himself.”

Joseph Maussen – Head of Counselling Services @ Counselling Madrid

The other day I received a card in the post from a friend. A rotund middle-aged male circus performer is pinned to a board by a number of knives, including a mean-looking double-edged axe that just misses his head. Beside him stands his buxom, aging assistant – or perhaps it’s his wife. She holds a second double-edged axe and looks menacingly at him. The caption reads, ‘Frank wondered how long the menopause would last.’ For me, the card sums up the general mocking attitude towards the menopause in Western society. When a woman reaches a certain age, she turns mean and ends up being impossible to live with. Speaking as a psychotherapist who has been through it, and as the author of Sex, Meaning and the Menopause (a book for both men and women, tackling the lived, felt experience of the menopause), this momentous life transition deserves much more respect and understanding in society and in the therapeutic space.

One third of women in the UK are currently going through the menopause, with numbers set to rise as the population ages. The average age for the menopause is 51. However, most women entering their 50s are completely unprepared for the physical, mental and emotional changes they will experience as their periods cease, reflecting the massive drop in oestrogen levels that comes at this time. Distressing and sometimes debilitating symptoms such as hot flushes, anxiety, night sweats, mood swings and sexual changes affect almost 70 per cent of women, and often begin well before the menopause itself happens. Nevertheless, a 2010 YouGov survey, carried out on behalf of Phyto Soya, reports that the menopause remains a taboo subject, often leaving women feeling isolated and reluctant or too embarrassed to talk about it with their partners. Many also said their doctors failed to understand what they were going through, which compounded their distress.

When it comes to women at work, it’s an even bleaker picture. A recent study carried out by Nottingham University on behalf of the British Occupational Health Research Foundation reported that over 50 per cent of the female workforce of menopausal age (who represent almost 50 per cent of the UK workforce) were struggling to cope with their symptoms, and experiencing difficulties at home and at work. Many who took part in the study believed that the menopause had a negative impact on their managers’ and colleagues’ perceptions of their competence. When they took a day off because of menopausal symptoms, over half did not tell their line managers the real reason for their absenteeism.

Menopause is rarely, if ever, addressed in counselling or psychotherapy training. It certainly was never mentioned in my own training – with the result, as I address in more detail below, that therapists can fail to make important connections between a woman reaching menopausal age and the emotional difficulties she is – or they themselves might be – experiencing.

My own menopause
Personally, I was fortunate with my menopause. I had very few physical symptoms. However, I did experience a massive drop in my libido, which began to cause issues in my marriage. When I searched for information about this, I became increasingly annoyed at the way the menopause is presented primarily as a medical dysfunction in need of treatment, which can be ‘fixed’ by taking hormone replacement therapy (HRT). I didn’t want to take HRT to boost my sex drive. I wanted to go through the menopause naturally.

As the months passed, I felt increasingly guilty about my lack of interest in sex, at the same time as staring into the mirror every morning, mortified at how quickly the young, attractive woman I used to be was disappearing. I tried to find information about the emotional impact of going through the menopause. Was I unusual? How did other women deal with the loss of their fertility, looks and sexuality? Most books and websites had much to say about managing hot flushes and mood swings, but little, if anything at all, about what I was going through. Rather, there was the one-dimensional message that a woman is post-menopausal once her periods have ceased for 12 months. This to me, by the way, was the same as saying an adolescent instantly becomes an adult when they reach 18 years old.
I began to talk to friends in their 50s about how they were experiencing the menopause. Their responses amazed me. Most had never spoken in any depth about it before, and found it a relief to talk to someone who was genuinely interested, rather than cracking droll jokes about it. These friends passed on other friends and I found myself interviewing more than 60 women about how they were negotiating their way through this emotional minefield. It’s impossible to cover in this article all the issues that I explored in my subsequent book, but here are the main themes I suggest we will all meet in our therapy practice. This article does not cover men’s transition into older age; that deserves a piece of its own.

Emotional chaos
Many women were experiencing emotional overwhelm and they found that frightening. One woman summed up her menopause with the comment: ‘Everything is out of proportion. From being even-tempered, pretty cheerful and easy going I have become completely unpredictable. I swing between irritability and being in floods of tears. I alternate between feeling nothing and drowning in empathy. I feel I’ve lost the person I was and find myself asking, “Was I always like this?” or “How long have I been like this?”’

Loss of youth and fertility
Some, like me, were finding it very hard to come to terms with the loss of their looks. ‘I went out the other night, and it was horrible to realise something had gone,’ a woman told me. ‘That was very obvious when a man tapped me on the shoulder. I turned round, but he said, “Sorry” and walked away. It threw me into a downward spiral. Who am I when my looks have gone?’

Others were grieving the loss of their fertility. One woman burst into tears as she said, ‘There is a grieving process that flickers in and out of my life. I look at a baby and know I can’t have another one. You never know when it’s going to be too late to have that choice. Then one day you have to face the fact it’s not here any more.’

Mother/daughter issues
Several women told me about the complexity of being forced to confront their aging process at the same time as their daughters were turning into attractive young women. ‘It used to be me who got the whistles – now it’s my daughter,’ one woman said with great sorrow. ‘No one tells us what it will feel like when we reach this time of life.’ Others were having different parental experiences. For example, one mother of a pubescent daughter said through clenched teeth, ‘A menopausal woman living with a hormonal daughter is nothing less than the work of the devil!’

Grief and bereavement
Many menopausal women also make up the ‘sandwich generation’, caught between the needs of their children and grandchildren and caring for elderly parents. But it’s not just about being a carer. The 50s are the time when parents and friends begin to die, and other pressures build up. One woman spoke of ‘having a miserable couple of years’ as she entered the menopause. Following the death of her mother, who she adored, she had to support a father who was virtually unable to function. He died two years later, followed closely by her mother-in-law and then two good friends, both in their 50s. On top of this, her husband took early redundancy from his well-paid but high-pressured job because he couldn’t cope any more. He’s still recovering from the aftermath of years of working in a stressful occupation, while she is just about keeping her head above water.

Sex and the menopause
Sex and the menopause is a vast and sensitive subject. So again, let me just outline the major issues that came out of my interviews. Few women had spoken to anyone else about their experiences of sex and menopause. Most were completely unprepared for the sexual changes they were experiencing but either found it too embarrassing or too difficult to admit that these sexual changes meant they were aging. Talking to these women, I discovered that sexual changes fall into six broad categories. A small proportion of women experience a surge in sexual desire, but this tends to dwindle with time. A significant number continue to enjoy sex just as much as before the menopause. However, the following four categories fall into the clinical diagnosis of ‘sexual dysfunction’, although I find this diagnosis offensive. Sexual changes during the menopause are not a dysfunction. This is what can naturally happen as hormone levels drop.
These categories include women who are capable of having sex, but not really bothered any more, or who have sex to keep their partners happy. Then there are women – many more than you would think – who experience the sudden death of sexual desire. Some find sex horribly painful, while the last group of women are enormously relieved it’s all over, with no desire to have sex again.

I want to return to painful sex, or vaginal atrophy. One in two women develop vaginal atrophy as they go through the menopause. This is an intensely intimate and embarrassing condition, which few women want to talk about, particularly as it makes penetration all but impossible. The loss of sexual desire coupled with vaginal atrophy can have a devastating effect on relationships. Men are even less informed about this than women, and husbands have to rely on partners and wives to explain what is happening to them. Since many women are often too ashamed to talk about their sexual changes, this can lead to serious difficulties in communication.

Therefore the menopause can be a critical time for relationships, and it’s interesting to note that ‘Saga divorces’ – couples separating after 30 and 40 years of marriage – have risen by 19 per cent in recent years. The relationship counselling organisation Relate says that women now initiate seven out of 10 of the Saga divorces. While men tend to leave marriage for another woman, women leave because they want independence.

Early menopause
Another important area for therapists to be aware of is early menopause, which affects around one per cent of women under 40, and a smaller minority under the age of 30. Research also suggests that increasing numbers of women in the UK are having early menopause brought about by stress. Other factors, such as lack of exercise, poor diet, too much alcohol, birth control pills, even pollution and toxins from food packaging that we ingest every day, can affect this.

As therapists it’s important to recognise that peri-menopause symptoms – the years in the run-up to menopause when hormone imbalance and fluctuations increase – are similar to those of stress. For example, a client in her early to mid-40s presenting with depression may complain about headaches, low sex drive, weight gain, hair loss, and mood swings. It usually does not occur to her or her therapist that she might be experiencing peri-menopausal warning signs. ‘I am far too young for that,’ is the usual lament. But she might not be, particularly if she is holding down a taxing job, juggling the demands of motherhood, her marriage is under strain or she’s a struggling single mother.

These days I always look for other signs. For example, when a 46-year-old client began to experience panic attacks, I asked her if she was experiencing hot flushes. ‘Lots,’ she replied. I explained how the menopause can be the cause of such symptoms and suggested she saw her GP to check her hormone levels. Although mortified that she might indeed be peri-menopausal, she was also relieved to know that she wasn’t going mad.

Early menopause can also happen to younger women who have a hysterectomy or are prescribed anti-cancer drugs. This can be profoundly distressing, especially when these women have to face the knowledge that they will never be able to conceive. Loss of fertility can severely affect their self-esteem, self-image and the way they see themselves as a sexual partner. The consequences can be debilitating with prolonged feelings of fear, anxiety and sorrow.

Meaning and purpose
As with any life crisis, the menopause gives women the opportunity to learn more about themselves. Bonnie Horrigan, author of the wonderful Red Moon Passage (highly recommended for anyone going through the menopause or working with menopausal clients) believes that the change of life is a time of spiritual transition for women. She says that this is an opportunity for us to find our inner treasure, to know who we are, and to recognise personal truths. This enables us to find our calling and develop distinctive gifts that we can use in the world.

Many women I spoke to agreed with Horrigan. One interviewee told me she experienced a feeling of ‘coming home’ as she went through the menopause. Another said, ‘We all have to go through it; it’s part of the deal of becoming an older woman. My spiritual beliefs have deepened and helped to put life into perspective. It allows me to let go and watch things unfold in their own time – life is bigger than me and I need to remember that.’

In whatever way we experience the menopause, meaning and purpose will change. For some it can be a slow growing awareness. For others it can be much more dramatic. Accepting these changes is an important part of our psychological and spiritual wellbeing as we enter later life.

For me, it felt as if a deepening had taken place, a sinking into who I really was. Becoming an older woman has also helped me in my psychotherapy practice. I do feel wiser and I am more able to help clients identify the broader picture when they feel trapped by their immediate fears.

Therapists need to be much more aware
Researching my book, I ran workshops for therapists to explore how they worked with the menopause. Sadly, although it seems to be the norm for most continuing professional development workshops I’ve attended, there were no male therapists present. I was amazed how few therapists considered the menopause to be a major factor in the way older women feel about themselves. Younger female therapists were particularly ignorant of this, and were astonished that the psychological changes brought about by the menopause continued over many years. None had taken on board how a woman enters her 50s usually still menstruating, but ends the decade in a completely different post-menopausal state. Nor – and this was perhaps my most important finding – had they realised that the menopause is a profound existential journey which forces a woman, whether she is ready or not, to confront her aging process, and how this makes her re-evaluate everything in her life.

Most therapists were not aware of the range of sexual changes a woman can experience during the menopause. They were surprised that many wives and partners continue to have sex essentially just to keep the peace in their relationship, and often harbour resentment about this. They were also unaware that many clients may feel too ashamed to talk about sex, especially when they don’t want it any more. Men may be reluctant in therapy to admit to their wives’ sexual changes being a major contributing factor to their relationship problems. One therapist said it had never crossed her mind to ask a male client in his 50s if his wife was going through the menopause, and how that might be affecting his life. Another said that she had never thought that sexual changes during the menopause might be the cause of marital breakdown.

At the end of the workshop, several therapists said they would look with fresh eyes at their work with older women and men, especially regarding how sexual changes impact on relationships. One, a relationship counsellor, said she now realised how important it was to bring the menopause into the room when she was working with older couples. Some of the younger therapists said they felt nervous about entering their own menopause, but were grateful to have had the opportunity to learn about it. Knowing about it helped them to feel more confident about working with older clients.

Helping clients to embrace the menopause
To conclude, the breadth of emotional and psychological issues that can arise during the menopause is complex, profound and multifaceted. I hope I have outlined the importance for therapists to recognise that the menopause is a major – indeed the major – life transition for a woman. We also need to be aware that a client may very well not recognise or accept that she is entering the menopause. However, in whatever way our clients experience the menopause, it’s our job to help them embrace this transition so they can find their way through to the other side as post-menopausal women. As I know myself, learning to put aside that double-edged axe means that I – and my husband – can enjoy life again.

Sue Brayne is a psychotherapist and writer who enjoys tackling taboos about sex, aging and death. Sue originally trained as a nurse, and has an MA in the Rhetoric and Rituals of Death. Her book, The D-Word: Talking about Dying was published in 2010, and she was interviewed recently on BBC Radio 4’s Woman’s Hour about it. Sex, Meaning and the Menopause featured in the Femail section of the Daily Mail in the article, ‘Will your marriage survive the menopause?’ Sue blogs regularly about issues to do with menopause, death and dying, and the aging process.

I think I understand the problem but I wonder about the size of it. Do you know what proportion of British children attend boarding schools? What are the typical ages for attendance and what is the breakdown of single-sex and mixed schools?

The problem is both a psychological one (what’s the effect of sending children away from their families on the adults they become?) and a political one. Here the numbers – which I’ll come to – are not the significant issue, but the fact that ex-boarders make up what Toynbee called a ‘dominant minority’ in British life. The two collide when we realise that, to survive their exile, children have to become masters of splitting. Witness the smooth duplicity in which David Cameron presented himself as an ordinary guy in the recent election. According to the Boarding School Association’s figures, nine per cent of just over eight million UK schoolchildren attend fee-paying schools – euphemistically known as the ‘independent sector’ – of which 13.25 per cent board. The usual entry age to ‘prep’ schools is seven or eight – although we regularly have contact from adults who were sent away as young as four. ‘Public school’ starts at 13. I don’t have figures for mixed schools, but the norm is single-sex, though over the past 20 years many boys’ public schools have admitted small numbers of girls to present co-ed status. Anecdotally, we hear that this is not an easy situation for the girls.

I think it’s been well known, or suspected for some time, that the negative phenomena and effects of public school boarding are as you say they are – the emergence of a defensive personality and ‘disowned self’, fagging/bullying, abuse, hot-housing, distortion of sexuality, sense of separateness and entitlement, lack of empathy for others, and so on. How much is this all still in the realm of suspicion, speculation and clinical observation rather than hard empirical evidence?

Well, you frame your question as if you find it hard to imagine that children who don’t grow up in families are going to be affected, and it needs to be ‘scientifically proven’! This is a typically British approach to the subject which our European neighbours find rather shocking. Actually, we have data from the earliest days of psychology in this country: First World War psychiatrist WHR Rivers’ work on shell shock revealed that the common reaction of mutism amongst enlisted men was not replicated by officers who had, he said, already learned not only to repress expression of fear, but to dissociate from emotion entirely at their public schools. And it is all over our literature. But such has been the reluctance to pathologise the boarding school habit in Britain that it is only in the last few years that we are beginning to acknowledge the problem. ‘Evidence’ is now building as people are writing dissertations and doing bits of research, and there are some excellent new records such us Vyvyen Brendon’s Prep School Children. Personally, I have had thousands of letters from members of the public since first writing about the issue in The Independent in 1990, mostly thanking me for speaking out about it. I suggest in my current article that many therapists have complex attitudes to the problem, and interestingly my book The Making of Them was never reviewed by Therapy Today, whereas it was by the BMJ, and was taken very seriously by the Royal College of Nursing. Besides, the whole notion of pitting clinical evidence against dedicated research findings begs many questions.

I wonder if there is a lack of concern for such people as adults precisely because so many of them seem to have the privileges that the rest of us envy – confidence, high level social skills, advantageous networks and wealth? Some of us must be thinking – why all the therapeutic attention for these people who already have so many privileges, and who are probably in the best position to afford their own private therapy that others can’t afford?

You put your finger right on it here, Colin. It is exactly the shame/fear of envy about the privilege that torments many boarding schools survivors and prevents them from speaking about their unhappiness while blinding the public because of those obvious advantages you mention. This all keeps the denial going. Boarding school children learn it’s better not to complain; most ex-boarder adults fail to recognise their intimacy avoidance and other habits, which only emerge in private settings, as anything but normal – to the utter dismay of their partners. Omitting for now those who didn’t survive very well, due to bullying or sexual abuse in the 24-hour institutions they grew up in, their confidence has a tendency to be a brittle shell, since the built-in expectations that the ex-boarder should end up chairman of the board or prime minister creates additional shame. Actually, these issues rarely get therapeutic attention, so I suggest that your phrase all the therapeutic attention is misplaced. I think British society would be better if our profession was more critical about sending children away from families, as social workers are. Then we might concentrate on raising educational opportunities for all our children rather than losing the wealthiest parents from local PTAs.

Are there perhaps sometimes some mitigating factors such as the contrast between home environment and public school, the size and ethos of the school (some are very traditional and academically high-pressured, others are smaller and more ‘humanistic’, some are full-time and others part-time), and the individual personalities concerned (ie some students may thrive in such environments while others suffer)?

Look, one really good teacher can save a child’s soul, and some families are ghastly. Some kids arrive at school broken already and some feel loved enough to bounce through. This is all academic. In the hands of those who want to sanitise the practice of sending children away it’s a dangerous argument to suggest that there will always be those weaker children who won’t take to boarding – a reinforcer of the internal shaming. You have to remember how small a seven or eight year old is to put this in its rightful context. Have a look at Colin Luke’s film The Making of Them following boarders in the first few weeks of prep school and watch the wee children putting on their false selves right in front of your eyes – it’s now up on YouTube for all to see. The only built-in mitigation I can see would be weekly boarding, where at least the child comes home at weekends and has more of a chance to maintain family relationships.

I suspect that there is a spectrum of educational experiences here – traditional all-male public boarding schools may cause most harm, followed by all-male non-residential schools, then all-female boarding schools, followed by mixed boarding, … through typical comprehensives to small-scale alternative schools and home schooling. And let’s not forget some punitive faith schools. Doesn’t all compulsory schooling have damaging effects that we still don’t recognise?

I don’t know. And I don’t know on what basis you make girls’ experience secondary. British boarding schools are based on the values of self-reliance and keeping busy, on competition and other hyper-masculine principles; for girls to be subjected to this can be annihilating for their natural feminine selves. I’m interested in what happens to people who have been institutionalised and brought up amongst other frightened children over three-month terms, 24-hours a day. It is that timetable and that degree of self-reliance that is noxious. It is especially hard to reverse in later life, which is when the effects emerge.

I agree that some barely recognised or denied institutional mechanism is responsible for a great deal of human suffering but aren’t public boarding schools just one small example of this institutional ‘evil’? In other words, can’t we see dehumanising trends in the home, workplace, in patriarchal politics, in religion, and in the institutions of psychotherapy too?

It is not a small example because of the effect that boarding/public schools have on the life of the whole nation. Those who go to these schools, as well as those who wish to pass as if they did, tend to be our leaders, lawmakers and upholders of a divided class-ridden society which bears no resemblance – despite our enviable civil liberties – to the socially advanced places like Scandinavia, The Netherlands and Germany that we could be like, let alone the emotionally warmer climes of southern Europe. From these vantage points Britain looks anachronistically feudal, and people wonder, why do we want to have children if we send them away?

Nick Duffell boarded both in Europe and in England. In 1990 Nick Duffell began running workshops for Boarding School Survivors, as he provocatively named ex-boarders, and the programme continues. Nick has consulted on boarding issues to the Royal College of Nursing, a House of Commons Select Committee and to the Australian Boarding Colloquium.

Recent years have seen remarkable advances in our understanding of how the nervous system is wired and how it functions. Through a combination of accurate brain scanning, animal studies and other techniques, it has become possible to visualise which parts of the nervous system are involved in the execution of specific processes. For example, work by Joseph LeDoux1 correlates experience of distressing emotions, and especially fear, with activity in the amygdala, the hypothalamus and related structures in the brain (known collectively as the limbic system). This article will discuss the process of experiential psychotherapy with particular emphasis on a technique known as focusing. It will then offer a hypothesis for the neural correlates of this approach, with particular emphasis on the hypothesised role of the vagus nerves.

The technique of focusing
Focusing is an approach to introspection which was discovered 50 years ago, and despite robust evidence of its efficacy in psychotherapeutic settings, it has not enjoyed the recognition it deserves. Working in the 1960s, Professor Eugene Gendlin2 of the University of Chicago first discovered focusing when attempting to discover why psychotherapy was helpful for some people but not for others. Ann Weiser Cornell,3 who has worked with Gendlin since she first encountered focusing in 1972, describes his work and findings thus: ‘He and his colleagues studied tapes of hundreds of sessions… some clients were getting better, some were not… There was no significant difference in therapist behaviour… [but] there was a difference between the successful therapy clients and the unsuccessful ones… Whatever this was, it wasn’t something that [they] learned how to do because of therapy; it was something they were already doing, able to do, when they walked in the door… What [the researchers] heard was this: at some point in the session, the successful therapy clients would slow down their talk, become less articulate, and begin to grope for words to describe something that they were feeling at that moment… [They] had a vague hard-to-describe body awareness that they were directly sensing during the session. [The] unsuccessful clients stayed “up in their heads”.’

What Gendlin and colleagues had discovered was our natural ability to ‘focus’ on an odd kind of meaningful body sensation called a ‘felt sense’. As Weiser Cornell3 went on to write: ‘Focusing was a natural skill that was discovered, not invented… Focusing ability is the birthright of every person: we were born with the ability to know how we feel from moment to moment… [and] the experiences of hurt and alienation in our childhood and from our culture, have caused us to lose trust in our bodies and our feelings. We need to re-learn focusing.’ [Since writing her book Weiser Cornell has changed her view of the ‘felt sense’ and she no longer believes it is equivalent to ‘knowing how we feel from moment to moment’ (personal communication)]. Gendlin developed a six-step strategy to guide this learning, publishing it in 1978 in a book called Focusing.2

Focusing in practice
In my own practice, I have often found that shifting from this intellectual discussion of a problem to how it feels in the body can have a profound effect on the subject’s sense of it. Let us imagine a situation in which a client feels stuck with feelings about a situation and is struggling to understand it. Having exhausted the conversation about who said what and what it meant and so on, the client is invited to turn their attention away from their thinking, and to focus it instead on what they feel at that moment in the central areas of their body, from their throat to their chest and down into their abdomen. This will usually be strange at first, but with attentive listening from the therapist and a little guidance, the client may get in touch with what is called the ‘felt sense’ of the problem. Asked to get an overall feel of ‘all about this issue’, the client may report, for example, a ‘tightness across the chest’ or a feeling ‘like a big black sticky mass’ in the belly. The therapist’s role at this point is to echo verbatim what the client has just said: ‘a tightness across your chest’, ‘like a big black sticky mass’. This is important as the therapist needs to avoid putting his or her own interpretation on what is developing in the client’s core area.

The client may then be invited to simply say hello internally to this feeling. This is just to acknowledge the experience at this stage, as the client may not yet be able to process it further. The process can proceed in many ways from here. Therapist and client can wait for the felt sense to communicate further spontaneously, or a word, a phrase, an image, a simile or a metaphor can be offered, which might capture the essence of the feeling: ‘A kind of strangled feeling, yes, that’s it.’ In the beginning, the client will often prefer to switch back to their head, to come out of their body, and to retreat to the comfort of talking about the problem again. When this happens, a noticeable change in the client’s disposition occurs; there will be a switch from an inwardly focused state, often with eyes closed, to a more ‘back in the room, let’s talk about my problem’ state. The therapist may wish to guide the client back into the body, depending on the client’s readiness to face the felt sense.

Focusing can be a useful adjunct to the more usual modes of psychotherapy, with a shifting back and forth between, say, a cognitive approach and somatic (bodily) sensing. People suffering from anxiety often find it illuminating to discover that their fears are actually a complex web of sensations in the body, with an intellectual overlay of negative thoughts. This often gives them a new perspective on their difficulty. Focusing can open up a new inner relationship with the parts of oneself hitherto unknown. Weiser Cornell describes this process as ‘Inner Relationship Focusing’. Exploring the issue in these ways hopefully leads to a sense of resolution and completion, and when this occurs there will be a ‘felt shift’ in the bodily awareness. This may be felt as an ‘aha’ experience, or the sense of the issue no longer being a problem, or there may be a feeling of relaxation in the body.

Since focusing is an introspective skill, it can be broadened from psychotherapy to other areas of experience. For example, friends who learn to focus take turns at being the focuser and then the listener. Through the Focusing Institutes of Britain and the United States,5 a network of focusing friendships has developed, where people can meet, often by telephone, to share focusing conversations. Focusing has been used effectively in psychotherapy, business, marriage and friendship, and can be used alone. It can be used to face personal suffering effectively, when the physical experience of that suffering can be addressed directly and not side-stepped by the ruminating mind.

Focusing can also be used as a form of meditation. With a focusing-oriented meditation, the practitioner may choose to attend to the felt sense in the core area, and to observe how that sense develops. Many resources are available to help people learn focusing, both within a psychotherapeutic context and without. The respective institutes provide workshops and access to other focusers, as well as written and audio material.

The connection to neurophysiology
It is worth mentioning that Gendlin and others in the community are not entirely happy with the term ‘focusing’ [personal communication] as it conjures up an image of sustained and concentrated attention of the type one might use to ‘focus’ on one’s work or one’s children or to ‘focus attention’ on a candle flame or a football match. Neither is focusing mere introspection on the content of one’s thoughts and the cyclical pattern of habitual and often automatic thought forms. Nor is it simply watching one’s breathing, or the rise and fall of the abdomen, although these are not excluded as components of it. In my opinion, the spirit of focusing can be captured by the word ‘vague’. If one turns to the core area, there may be distinct sensations coming from tense muscles in the throat, chest or abdomen, giving rise to a sense of choking, constriction and so on. But there are more subtle sensations than these, sensations which are best described as ‘murky’ or ‘unclear’.

My hypothesis is that focusing is, at least partially, a visceral sense and that it marks the discovery of a sense modality which has been there all along, but hitherto unacknowledged. Moreover, I postulate that the principal neural transmitters of this visceral sense are the vagus nerves.

Overview of the nervous system
To orientate the reader, it is necessary to give an overview of the nervous system. The regulation of the body’s inner milieu is controlled by two main systems, each overlapping and interacting. One is the endocrine system, which comprises the hormone-secreting glands as well as the pituitary gland in the brain, where hormone messengers are conveyed around the body via the blood stream; the other is the nervous system.

The nervous system has two major components, the voluntary nervous system and the involuntary, or autonomic nervous system (ANS). The former controls the muscles and receives its sensory input from the muscles, the joints and the skin, as well as from the organs of balance in the inner ear. If one attends to the sensations coming from the limbs, for example, one has a more or less precise sensation of muscle tone, of position sense, of pressure and the effects of gravity, as well as a sense of warmth or cold, pain or itching, pressure and so on, from the skin.

The motor component exerts (usually) voluntary control over muscles, controlling movement, maintaining balance, and so on. These nerve pathways travel via the spinal cord, except for those relating to the head, which travel in paired nerves known as the cranial nerves. It is the ANS which exerts involuntary (automatic) control over the organism’s state of arousal, its readiness for action and over the vegetative functions of blood pressure control, digestion, elimination and so on. It has two divisions, the sympathetic and the parasympathetic. (Michael Gershon6 has pointed out, however, that a third division exists, the enteric nervous system, which operates more or less independently of the sympathetic and parasympathetic systems, and is replete with its own suite of neurotransmitters, of which serotonin is a major example – see table below). These are designed to work in a harmonious and complementary fashion. The sympathetic division prepares the organism for ‘fight or flight’.

Figure 1: Functions of the autonomic nervous system

Parasympathetic
o Rest and digest
o Decreases heart rate
o Decreases blood pressure (dilates blood vessels)
o Constricts airways
o Constricts pupils
o Stimulates salivation
o Opens sphincters (urination and defecation)
o Moves blood to gut (for digestion)
o Increases gut movement
o Inhibits sweating
o Stimulates tears

Sympathetic
o Fight and flight
o Increases heart rate
o Increases blood pressure (constricts blood vessels)
o Opens airways
o Dilates pupils
o Inhibits salivation
o Closes sphincters (inhibits bladder and bowel)
o Moves blood to muscles (for action)
o Inhibits gut movement
o Increases sweating
o Inhibits tears

The other divisions are the enteric (gut) nervous system and the cardiac nervous system.

Adrenaline and noradrenaline are its principal neurotransmitters and its neural circuits travel outside, but parallel, to the spinal cord. The parasympathetic division is energy conserving and controls the vegetative functions, sometimes referred to as ‘rest and digest’. It is this portion of the nervous system which is of most interest here. For an outline of the respective functions of the sympathetic and parasympathetic systems see the box, left. People who suffer from anxiety will often have an overactive sympathetic drive, with inadequate parasympathetic tone to balance it. The goal of anxiety management from a neurophysiological perspective is to balance and integrate the activities of both sympathetic and parasympathetic systems.

The major pathways for parasympathetic impulses in the body are the vagus nerves. These nerves are the tenth of 12 pairs of cranial nerves which arise within the brain. The first, second and eighth cranial nerves carry the senses of smell, sight and hearing respectively. The remaining pairs are principally involved with supplying motor function to and receiving sensory information from the head and neck. Most of these cranial nerves have their origins (known as the ‘cell nuclei’) in the brainstem, which links the spinal cord and the brain, and they are relatively short.

In contrast the vagus nerves are very long. Taking their name from the Latin for ‘wanderer’, the vagus nerves leave their origin in the brainstem and wander from the neck down into the chest and on into the abdomen. The vagus is composed of about 20 per cent motor fibres and 80 per cent sensory. Its motor component supplies some of the muscles in the throat and the voicebox. It also supplies motor fibres which influence the involuntary muscles and the glandular secretions of the oesophagus, stomach, liver, pancreas, gall bladder and most of the gut. The internal organs collectively are referred to as the viscera. The part of the vagus which supplies nerves to the heart and lungs operates to conserve energy (the opposite of fight and flight response) and slows the heart, drops blood pressure, constricts airways, and secretes mucus. The vagus also carries general visceral sensory information from the throat and voicebox, heart, lungs, oesophagus, stomach, liver, gall-bladder, pancreas and all of the gut except the last third of the large bowel and the rectum (this portion is supplied by nerves coming from the lower end of the spinal cord). It is this third part, the general visceral component, which is especially relevant here. It is now known that the gut has its own complex of 100 million nerve cells which developed independently of the central nervous system (CNS) and is of earlier evolutionary age. Its role is the integration of the digestive system and it is known as the enteric nervous system. This system receives input from the motor component of the vagus, but largely functions independently.

The majority of vagal sensory fibres transmit information from the enteric nervous system to the brainstem. Similarly, it has been discovered that the heart too has a complex of nerve cells (40,000 or so) which functions partly autonomously and which also interfaces with the CNS via the vagus. It is interesting that these two systems – placed in the gut and in the heart – produce their own neurotransmitters and hormones, such as serotonin and endorphins (which are understood to play a role in regulation of mood and a sense of wellbeing, respectively) and even oxytocin, the hormone involved in affectional bonding.7 Sensory information from these gut and heart complexes is conveyed to the brain via the vagus nerves. In addition to relaying and receiving information from the body, the cell nuclei of the vagus in the brainstem have been shown to relay to and from higher regions in the brain: to the hypothalamus and amygdala, which are involved in emotional responses, as well as to higher structures including the frontal lobes, which are believed to play a role in mediating our deepest awareness.

The vagus nerves are important when considering anxiety as, in conjunction with other cell nuclei in the brainstem, they play a central role in the regulation of breathing, acting with the other cell nuclei in a complex fashion to stimulate and end inhalation, initiate exhalation, stimulate the next inhalation, and so on. The vagus’ role seems to be specifically related to exhalation. In meditation, the expiratory phase of respiration is prolonged (typically to a ratio of 4:1 over inhalation); and it is proposed that this is a significant component of the relaxation response which meditation and breathing exercises evoke. A recent study8 has demonstrated an increase in cell numbers in the vagal brainstem nuclei of a group of experienced meditators. This capacity of the brain to change its anatomy and function in response to repeated practice is known as neuroplasticity. Long-term meditation, especially body-oriented practices, and/or breathing exercises appears to reduce the vulnerability to anxiety, at least partially by increasing vagal tone. Presumably, this relays upward to the higher centres and pacifies the activity of the amygdala and other limbic structures.

In a way similar to how the other cranial nerves relay information from the nose, eyes and ears, the vagus nerves relay information from inside the body. The eyes and ears are exteroceptive, which means they look outward. The vagus is interoceptive, which means it looks inward, to the viscera themselves; these nerves are like inner eyes. They pick up ‘gut feelings’, things that are ‘heart-felt’, feelings in our waters. This truly is a sixth sense, with the objects of perception being our own innards, supplementary brains in heart and gut, with their own feelings and wisdom. They won’t, of course, communicate verbally, which is why words don’t come when we attend here. Like all other skills, the more we ‘look inward’, the better we will become at it.

I propose that regular practice of focusing and allied body practices will also enhance vagal tone, and reduce unhealthy over-arousal of the limbic system. It is worth emphasising that the proposed neurophysiology may have some relevance in other body-oriented therapies such as the Alexander Technique, the Feldenkrais Method, and Rolfing, as well as to breath therapies. These practices, to varying degrees, involve paying attention to sensations arising from the musculoskeletal system, but there may be some sensory input from the heart, lungs and abdominal organs (the viscera), via the vagus nerves. Similarly, yoga and t’ai chi develop awareness of both voluntary and visceral sensations by promoting awareness of the body’s movement on the one hand and paying attention to the breath and the belly, on the other.

Looking at the evidence
What evidence is there that the vagus nerve is involved in somatic practices, including focusing? The evidence is patchy and sometimes circumstantial, but a number of strands are noteworthy. Antonio Damasio9 describes some emerging evidence that feelings and emotions are not only experienced in the body, but that without the body’s input, they do not occur. He describes the tragic condition known as ‘Locked-in Syndrome’, where a stroke in the brainstem leaves patients completely paralysed apart from the ability to blink, and with no sensory input whatsoever from the body. They can communicate by blinking via a word processor and remain fully conscious and capable of feeling joy and sadness, but not the anguish of fear and suffering. In contrast, people who suffer spinal cord damage suffer loss of the capacity to feel the body generally, but with the vagus nerve still intact, sensory input from the viscera remains, and they retain the capacity to feel fear and anguish. This is an over-simplification, as even complete severance of the cord high up still leaves the nerve supply to the head and neck intact, and we know that much emotion is generated in the feedback from the muscles of facial expression, and there is still argument over whether visceral inputs from the vagus are necessary for full feeling of emotion.

Another clue comes from the experience of people who receive Tubocurarine as a muscle relaxant in anaesthesia. Some such patients, if they are insufficiently anaesthetised, report memories of the total paralysis and accompanying terror, in contrast to the locked-in patients who do not feel such terror. The clue here is that Tubocurarine paralyses the skeletal muscle only and signals from the smooth muscle of the gut, via the vagus, continue.

Damasio’s final piece in the puzzle is the well-established fact that the laying down of memory is enhanced if there is an emotional charge accompanying the experience. We all remember emotionally charged events better than neutral ones. In contrast, rats whose vagus nerves have been cut do not learn (ie remember) as well as those with intact visceral input, implying a role for the vagus in emotion.

An interesting related phenomenon is known as ‘cardiac coherence’. Discovered in 1992 by physicist Dan Winter and now being developed further by Dr Alan Watkins,10 it refers to a natural variability of the heart rate with respiration. Sometimes the variability is chaotic, sometimes it is what is called coherent or rhythmical. It is proposed that the coherent form has an integrating and soothing effect on the CNS, increasing parasympathetic tone. Coherence can be promoted by a form of inward attention similar to focusing, and biofeedback machines have been developed to provide information on when it has been achieved by means of a pulse sensor linked to a computer programme. This appears to be mediated via the vagus nerve from the heart’s brain to the CNS.

Another area of research which is suggestive is a 1953 study11 of patients who underwent vagotomy. From the 1950s, until relatively recently, vagotomy, a severing of the vagus nerve below the diaphragm, was performed on people suffering from ulcer disease, then thought to be due to excess acid secretion by the stomach. This secretion is largely under vagal control. Most studies of the effects of vagotomy have concentrated on the effects of the procedure on gastrointestinal function. However, one study in the psychiatric literature compared 40 vagotomy patients with controls and reported that: ‘Twelve patients, despite improvement in ulcer symptoms, had increased difficulties in adjustment at home, at work, and in interpersonal relationships in general. In 10 patients, the affective changes and adjustment difficulties appeared to be due to the specific effects of vagotomy.’ This evidence suggests a role for the vagus nerve in the experience and integration of emotional life, and this is potentially a fruitful area for further study.

Stephen Porges12 has advanced a fascinating idea, which he calls polyvagal theory. It appears there are at least two major divisions of the vagus, one older and one which developed later. The older one, from an evolutionary perspective, is of reptilian or earlier origin, and innervates the organs below the diaphragm. The later one, most highly developed in mammals, innervates the heart and lungs and probably reflects the higher metabolic demands of warm-blooded creatures. As Porges13 explains: ‘[In the face of external threat], behavioural orienting in reptiles is characterised by a focusing of [smell, vision and hearing] and a freezing of gross motor activity. [Evolutionary] development not only illustrates changes in the neuroanatomy of the vagus, but also parallel changes in behaviour. One of these behavioural shifts is the addition of active or voluntary attention and complex emotions… The underpowered reptiles use [vagal impulses] to the heart to deal with specific challenges: to orient and freeze in response to predator or prey and to conserve oxygen while submerged for lengthy periods. In contrast, supercharged mammals use vagal [impulses] as a persistent brake to [rein them in]… Thus, in contrast to that observed in reptiles, in mammals, vagal tone is highest during unchallenged situations such as sleep, and vagal tone is actively withdrawn in response to external demands, including… exercise, stress, and information processing.’

As Porges goes on to write, the Polyvagal theory proposes that the development of special, vagal outputs changed the role of the vagus with the vagal pathways from the older vagus being part of a passive reflexive motor system associated with vegetative function and hence, a vegetative vagus. (Vegetative referring to control of blood pressure, digestion etc.) The special, newer vagal pathways, he propounds, create an active voluntary motor system associated with the conscious functions of attention, motion, emotion and communication, and thus, as Porges states, ‘a smart vagus’. This indicates that the mammalian vagus has a sophisticated role to play in autonomic regulation, which includes the social aspects of arousal and interaction. I propose that, because of the capacity for neuroplastic change, there is great potential to enhance vagal regulation of our arousal through body practices.

Finally, a technique known as vagus nerve stimulation (VNS)14 has been devised to treat uncontrolled epilepsy, and is now being used to treat depression, with some success. Electrodes, receiving electrical pulses at intervals, from a device inserted under the skin of the chest, are implanted in the left vagus nerve in the neck. The mode of action is poorly understood, but presumably it works by increasing the vagal tone, and its dampening effect on the higher structures. It is plausible that the body practices are a natural way of achieving the same effect.

Summary
When faced with threat, the most primitive response (and the only one available to reptiles) is for the organism to focus its special senses outward towards the environment and the perceived source of the threat. In addition to this capacity, mammals, partly because of a more sophisticated vagal system, have a greater repertoire of possible responses, including a capacity to assess the situation from a social perspective. They can evaluate whether to appease the attacker, or to dominate it, for example. Humans have the added ability to orient themselves internally to the inner landscape of the body itself, largely via the vagus nerves. This inner gaze is what constitutes the work of meditation, contemplative prayer and body-oriented practices such as breath-work, yoga, chi-gung and focusing. The physiological term for this body feeling is coenaesthesia. Webster15 defines it as ‘the totality of sensations arising from the bodily organs through which one sees his own body’.

The hypothesis presented here is that focusing and related practices are the voluntary turning of attention towards this vast unknown territory. The fruits of the sustained practice of such techniques will hopefully be a greater knowledge and experience of the body and its wisdom; integration and more efficient function of the ANS, enhancement of the capacity to experience equanimity, and reduced vulnerability to stress, anxiety and fear. Finally, and hopefully, it leads to the total liberation of the person from all fear, in the discovery known as ‘satori’ or ‘enlightenment’, when the potential of human life reaches its complete fulfilment.

In his short story, A Painful Case, James Joyce16 describes our universal predicament. In it, Mr Duffy ‘lived at a little distance from his body, regarding his own acts with doubtful side glances’. Repeated and sustained attention to the inner world of our body may help us to end this sense of separation, and ultimately sever the ties that bind us.
*

Dr Joseph Bray has been a consultant psychiatrist in private practice at Priory Hospital Southampton since 2007. Before that he practised as a consultant psychiatrist in the NHS for 13 years. He has a special interest in the treatment of anxiety and stress-related illness, and in the role of spiritual practice in human wellbeing and flourishing, and their neurophysiological correlates. He maintains a regular meditation practice.

Valuable feedback from Ann Weiser Cornell is gratefully acknowledged.

This article was first published in the January 2011 Healthcare Counselling and Psychotherapy Journal (HCPJ), the official journal of BACP Healthcare. For further details about joining the BACP Healthcare division, email julie.camfield@bacp.co.uk.

It’s supposed to be the happiest day of the year – so plan ahead and share the load to enjoy a stress-free holiday, says Dr Luisa Dillner.

It’s meant to be the happiest time of the year but Christmas is also when accident and emergency departments are heaving, fire brigades are called out to festive fires and divorce lawyers are gearing up for January – their busiest month. So how can you remain unscathed?

Drink in moderation
It wouldn’t be Christmas without warnings not to drink too much. Drinking will relax you, but too much makes you moody and aggressive (because alcohol is a depressant). The hangover you get the next day is officially untreatable (according to an article in the BMJ) – from aspirin and bananas, to Vegemite and water, there is no scientific evidence that anything works. This is also true for complementary therapies such as prickly pear and borage. The one remedy that does work is not drinking too much in the first place. “The drinking is really key to whether you have a happy Christmas,” warns Kathryn Hill of the Mental Health Foundation. “You need to pace yourself and drink in moderation.”

Accidents due to drink driving also rise over Christmas. The legal limit is 80mg for every 100ml of blood in our bodies – which equates very roughly to one large glass of wine for women and two pints of beer for men. But this would put you at the limit, and some people metabolise alcohol more slowly than others. If you’re at a party, the measures you’re given will differ to those in a pub. Alcohol increases risk-taking behind the wheel so drinking soft drinks if you’re driving is best. Otherwise pre-book a taxi or negotiate who’s driving before you start drinking and it’s too late to assess how merry you are. Strong coffee or a cold shower will not shift the alcohol through your body faster or make you safe to drive.

Keep the kids safe
Christmas is particularly hazardous for children. “If you’ve got small children it can be easy to forget all the little things that can accumulate on the floor at Christmas,” says Katrina Phillips, chief executive at the Child Accident Prevention Trust. “Plastic toys from crackers and those small silver button batteries are very attractive to small children who can choke on them. Check what’s on the floor repeatedly.”

The kitchen is more hazardous than ever: “The kind of meal we prepare is more elaborate,” says Phillips. “There are more things to get in and out of the oven, there’s the rush to boil the water for the gravy and if in the midst of this there are children running through to show the adults their latest toy, this can cause accidents such as scalds, which can be awful.”

If you’re visiting over Christmas, remember other people’s houses may not be child- proofed. “You’ll have to be tactful,” warns Phillips. “but make sure no one’s left their pill bottles on the bedside cabinet where children can reach them and that you move the toilet cleaner out the way.”

When you’re shopping for toys, make sure they’re age appropriate (however advanced your child is) so that a small child won’t choke on it. And market stalls may sell cheap toys, but you need to check they are made to safety standards.

Don’t fan the fires
The fire brigade is busy at Christmas time – all those candles and wrapping paper. Blow out candles, keep them away from children and check Christmas lights for frayed wires, loose connections or broken sockets. Turn everything off, especially kitchen appliances, and unplug fairy lights at night.

Don’t leave food that’s cooking unattended in the kitchen and don’t cook when you’re drunk – both increase the risk of fires.

Stop the stress
Christmas is meant to be the best day of the year. So it’s hard not to fall into the trap of setting huge expectations – meaning you’ll feel horribly stressed and underwhelmed. Plan ahead – don’t leave shopping until the last minute – and get everyone in the family involved in the preparations. Traditionally women bear the brunt of Christmas work but giving everyone a job, from clearing up before the event, to wrapping presents and preparing the vegetables, to laying the table and keeping children entertained, helps share the responsibility.

If you are going to stay with relatives or friends, discuss beforehand who will do and pay for what, as well as how long you’ll be there. Every family has their own Christmas traditions (which they’ll follow obsessively), so work out the day’s timetable before the children rip open their presents. If it’s your house then your rules should prevail but if they don’t – count to 10 and let it go: don’t ruin the day. Do some things together, such as board games or going for a walk. Try hard to be tolerant.

It used to be thought that the pressure, and for some people the loneliness, of Christmas meant a surge in suicide attempts. But studies show that there are fewer suicides than average and fewer hospital admissions for psychiatric problems. An American study of seven years of Christmas mental health problems, carried out by researchers from Duke University, found that the days before Christmas saw falls in the number of severe psychiatric problems but there was a rise in admissions for mental health problems in the weeks afterwards.

More regular amounts of Yuletide stress can be dealt with by yoga, nipping out for a walk, jog or swim or by having a warm bath, and the Mental Health Foundation also has an online stress reduction course (bemindful.co.uk).

Exercise will have the benefit of reducing anxiety and mild depression and boosting self esteem – all of which are valuable at any time of the year.

Don’t skimp on sleep (easy to do with parties, drinking and all that excitement) because you’ll feel less able to cope with Christmas Day. Be organised: try to avoid wrapping presents after midnight on Christmas Eve.

Don’t overspend
Overspending is bad for your bank balance and your mental health. It is a big source of mental distress. A study from Mind, the mental health charity, found half of us overspend at Christmas and one in five will have problems meeting their rent or mortgage payments because of buying presents. So have a budget and stick to it – tell your children they can’t have everything they see and watch them grow up to be better people because of it. Studies show that people prefer presents that mean something to them and show the person who bought it knows what they like.

Don’t fight with your spouse
Couples often brave it through Christmas only to rush down to the divorce lawyers in January. Spending time together can be helpful if your relationship is struggling – or it can be the death knell. Be considerate and give yourself some time together that isn’t shopping, wrapping or cooking.

Enjoy eating
People often worry after the event that they’ve eaten too many saturated fats and too much sugar. They probably have, but this is Christmas. It’s better to go for lower fat, higher protein snacks such as nuts rather than mini mince pies, but studies show most people only put on about 1lb at Christmas. A study published in the New England Journal of Medicine found that one in 10 people put on 5lb over the Christmas period (but, as this research was done in America, it took into account Thanksgiving as well).

Be prepared
Make sure you have enough prescription tablets over Christmas and even if you think you won’t be having sex, make sure you have stocked up with contraception.

Think of others and you’ll feel better yourself
There’s a body of research – and who cares how robust it is – showing that if we do good things for other people, it makes us feel happier. So invite a friend or relative you think might be lonely for a drink, or, if you want to be deliriously happy afterwards, for Christmas lunch. Do some charity work or help out at a Christmas community meal for older people.

● There are a huge variety of psychological therapies. Don’t go for a Jungian psychotherapist, for example, before you have seen a more general psychologist first. “A good first place to start is by seeing a clinical psychologist who can direct you to where you need to go,” says Dr Jacqueline Hetherton, a clinical psychologist in London. “First you need to be assessed and advised on what sort of therapy you need.”

● Decide what sort of help you want. You’re not obliged to talk about your early childhood, for instance. “If you just want a bit of your life sorted that’s fine,” says Hetherton

● Get a professional referral. Word of mouth may seem good, but if a therapist is treating your friend it may impair your privacy and anonymity. Ask your doctor for a referral, or go through a professional organisation.

● Look up the therapist’s training and specialism. There’s no point in seeing a sex therapist if your problem is general anxiety.

● When you make an appointment you shouldn’t have to go into details about why you want to see the therapist. Ideally, they will phone you back to discuss your appointment.

● Ask how many sessions you will need, the type of therapy they are offering you and why, the cost and if you can take a week off to go on holiday without paying. You could ask if your therapist takes notes and what they will do with them.

● Your therapist should be a member of either: the British Association for Counselling and Psychotherapy, the United Kingdom Council for Psychotherapy or the British Psychological Society.

● Phone more than one therapist before choosing one. Therapists charge between £50 and £150 an hour. Some professional organisations have reduced-fee schemes.

● At your first appointment you should do most of the talking. Are you comfortable in the room you’re being seen in? Ideally it should have a private entrance and you shouldn’t bump into people in the waiting room.

● After the first session, assess how you feel. If you come away feeling unsure, don’t return. You need to ask yourself if you can be open with this person, tell them private things, trust them. Do you like the way they talk and listen to you? Do you think they can help?

● Many people do not find the right therapist at first so do not give up. Try again.