Cadiz Therapy

The plague in the 15th century was followed by a golden age of prosperity, new worlds were discovered, the feudal system all but disappeared. After the Spanish flu came the roaring 20s, the near end of the nobility and the great estates with their upstairs-downstairs social divisions. You have to wonder how the world will look when the dust settles after Covid 19.

As the pendulum swings away from living small, fearful lives behind closed doors are you ready for the swing towards normality … kissing on cheeks, crowded markets, intoxicating ferias - the very hustle and bustle of Spanish life that enticed us to move to Chiclana in the first place? Many of you will be thinking, I’m not sure I am.

Perhaps you’re not ready to let go of the safety of staying home. Perhaps you’re quite enjoying the reduced lifestyle - being forced indoors meant all official deadlines were relaxed, taxes and documents could be done online, on your timetable, and without queues. For others it meant liberation from the inane small talk of social encounters.

We face the paradox of not being ready for something that has taken so long to arrive. All the restrictions are being removed so suddenly. Can we really start the ferias and the tourist season before everyone is vaccinated? Can we say its over when India and Brazil suffer growing death rates - with the ever looming shadow of new possible strains breaking out and invalidating the much heralded vaccine?

We find ourselves hovering on the threshold: either throwing on the glad rags or throwing on the air conditioning and staying home with Netflix for a bit longer. For some, however, the fear can develop into something more.

Over the last 15 months there has been so much focus on health, sickness, symptoms, hidden symptoms, the ever changing lists of potential symptoms. We’ve been bombarded with dire stories of overburdened hospitals, images of patients on ventilators, articles about long Covid and increasing depression. We have suffered globally not just from a pandemic but also from a mass outbreak of health anxiety.

Health anxieties, once referred to as hypochondriasis, has never been so prevalent. If the thought of re-joining the world terrifies you, and is stopping you from being comfortable doing the things you used to do, there are some things you can do that may help. Cognitive Behavioural Therapy is one of the most effective forms of treatment for health anxieties. It works by looking at some of the more extreme thoughts, along with the behaviours that can exacerbate the condition.

One of the behaviours that can fuel health anxiety is reassurance seeking. It starts innocently enough with you nudging your partner and take a look at this – do you think it’s normal? If that doesn’t put your mind at rest, you head to the doctor. With a Colombo style approach of just asking one more thing as you’re about to leave, you list every lump bump rash and sore joint that you've noticed during the last year. Heading to the doctor for reassurance is not a practical option yet: the three minute phone call with your medico de cabecera, in a second language, does not reassure in the same way - sending many of us to our new GP: Google Practitioner. Here you can find an endless stream of rare diseases and conditions that match your symptoms, symptoms you didn’t even know you had. The need for reassurance grows.

Even if you can get an actual appointment with an actual doctor, modern day “fast medicine” means appointments should last under six minutes per patient. The doctor might not even look up from their screen as they ask a list of questions and type in answers. You get home wondering if something may have been missed. The burden is on you to constantly check what is going on with your symptoms. But how do you know you’ve checked properly. Or enough? So you check again. And again.

This need for reassurance can lead to a condition – a behaviour – known as hyper-vigilance, a specific anxiety related to the body and health. The problem with hyper-vigilance is twofold: (1) you can never check enough and (2) the more you check, the more you find.

Here’s a little exercise you can do at t home. Take 30 seconds right now to scan every part of your body, starting with your toes and work your way up. There is a good chance you’ll notice an ache or pain or itch or stomach rumble you hadn’t noticed before. If you do that 4-5 times every hour, the list of symptoms grows quite long.

Through a process of distress tolerance and emotion regulation, CBT can help alleviate these symptoms. You don’t have to live with uncomfortable levels of anxiety that stop you from enjoying life. As Spain wakes again after a year of hibernation, there’s no reason you shouldn’t be able to relax and enjoy the roaring 20s… 2020s that is.

Should is a word I would like to remove from the dictionary. I should do better. I ought to do better. I must do better. Better according to whom?

The shoulds in your life are inevitably connected to your very own definition of how life ought to be. Somewhere back in your childhood or adolescence, you got the idea that to be happy, life should be a certain way. And anything short of that definition is going to make you feel anxiety, that you are not good enough.

I should do more. I should be thinner. I should be taller. I should earn more money. We should spend more time together. I should spend more time on my own. I should walk 10,000 steps a day because my phone is counting… The real experts will even take it up a level and change it to “you should” or “they should” when life fails to meet their personal definition – resulting not in anxiety but anger.

These “shoulds” are all based on self generated definitions of what a happy life or a happy relationship looks like. They are not based on law or necessity – and as such, are open to being redefined. Over time we get so used to thinking a certain way that it becomes habit. We never stop to question these beliefs, or put them under today’s microscope. You don’t have the same hairstyle, wear the same style of clothes, or even listen to the same music as you did when you were twelve years old – and yet you hang on to the beliefs that you developed years ago without stopping to think maybe it’s time to let some of them go too.

Sounds straight forward – until you try to uproot some of these core beliefs and assumptions that form an important part of your psyche. Working with a CBT therapist can help with some of the more difficult ones, but for many you can start now. Let’s break it down.

The first step is to identify these arbitrary definitions. The next time you find yourself saying I should … [fill in the blank] it’s a big red flag that you might be touching on one of these core beliefs. The only way to find out is to think about why you believe something should be different from how it is now. Is it based on habit or is it based on your values? Keep in mind, some of these definitions you may actually want to keep.

Let’s look at a few examples. I should:

• take out the rubbish. Why? Well because if I don’t it will start to smell, and it will attract the flies. Perfect, take out the rubbish.
• be more friendly with people. Why? Because friendly people are happier. Are they? Is that a proven fact or something that your aunties used to say? Will you actually be happier forcing yourself to have a level of extroversion you don’t feel comfortable with? Probably not.
• lose a few pounds. This is a tricky one. It all comes down to why you think you should. If the answer is because my doctor told me to as I have high blood pressure – then yes, that’s a goal to work on. If the answer is so I look more attractive – then it’s less clear. More attractive according to whom? Is it based on a long list of ideals you need to achieve to be good enough? If it’s the latter, this is a prime candidate for reconsidering.

Another tool is to look at the tense you use it with. If it’s passed tense – I should have done something in a different way – these thoughts may connect to depression. If it’s in the future – I should do better tomorrow – then it’s connecting to, or even driving, anxiety. If it’s in the present – I should be happy – it might be a good time to employ problem solving skills. For example, take it from the abstract to concrete. Thoughts like “I should be happy” are too vague to be useful. Do some brainstorming about possible ideas of how to be happy: join a class; find a hobby; adopt a pet; have coffee with a friend; or practice mindfulness. Using a trial and error approach you can try different solutions. By making it concrete you move from rumination to problem solving.

Once you start to notice the shoulds in your life you can decide which ones align with your current values. And then prioritise. If you don’t prioritise you will find yourself running yourself into the ground trying to be the best at everything: the best mum/dad who wakes up an hour early to finish a science project; the best daughter or son who is always available; the most bendy in the yoga class; the best friend always ready to lend a hand; the most dedicated employee; the fastest wind surfer; the best dressed at the party; the thinnest in the group; the best cook; the cleanest house … the list is endless. Then when you’ve spent all day trying and failing to meet the impossible standards you set for yourself, you get to spend the whole night feeling guilty for failing.

That’s the moment you need to stop and remind yourself: this is just my definition – it not a law of nature. Where is this random rule I’m applying written? Maybe it’s time to write a new rule, and say it out loud every time you catch yourself uttering the s-word.

If 2020 were a drink, it would be a colonoscopy prep.

How many memes have I seen in the past few months equating 2020 to the worst year ever. If 2020 were a crisp flavour it would be orange juice and toothpaste. It's a funny thing though, in psychological terms, of what’s going on.

We are born scientists: we are constantly making hypotheses and testing them. If you’ve had children you will remember the toddler years when they are continually testing you to find your limits – and kids will know, I have to ask 567 times for a biscuit because that is the magic number at which my parents will give in. Or three times with Grandma. And just the once for Granddad. We are not always good scientists, however. We are biased. When we have a theory that sounds plausible, we set out to find supporting evidence.

The dangerous part is we tend to ignore non-supporting evidence to our opinions. It’s why the echo-chamber nature of social media is so addictive – using the algorithms to direct stories and like minded friend suggestions towards us – it confirms what we know – it reassures us that we are right, and smarter than all those who disagree. It was lovely having our egos stroked in this way back in the first decade of the 21st century. But fast forward 20 years and we find ourselves in a very divided world. We can’t understand how intelligent people could see things differently from us, and curiously, they are wondering the exact same thing.

Let’s play a little mental game. Have a think about 2020 for 10 seconds, the way this year has affected you, your finances, your ability to do things and visit loved ones. On a scale of 1-10, how would you rate this year? Remember the number and we’ll come back to it in a moment.

As we come to the close of 2020, we have to ask has 2020 lived up to its reputation – or are our negative thoughts on overdrive? First of all we will need a baseline to compare against. According to Historian Michael McCormick (Harvard University Initiative for the Science of the Human Past) the worst year on record is the year 536. A volcano in Iceland erupted and spewed ash across the northern hemisphere leading to a fog that lasted for 18 months. So thick was the fog that the light of the midday sun resembled the light of the moon. It led to the coldest summer on record, crops failed, people starved. This was shortly followed by the Plague of Justinian, an outbreak of the bubonic plague which wiped out nearly half of the Roman Empire.

If the year 536 is the baseline of worst year ever, you might want to already moderate where you put 2020 on the scale from 1 to 10. If you raised the number a bit, it might be because you were indulging in what psychologists term ‘over-generalising’: when you make a conclusion based on only one or two samples. For example, when you try something new like cooking, and you burn the food. If the thought you have is, “I’m a terrible cook”, you are less likely to have another go. If you say, “I learned a lot - next time I’ll check the temperature of the oven – at least I tried” you are more likely to have another go in the future. One bad disaster means are an inexperienced, rather than bad, cook. With regard to 2020, it might look like everything about this year is awful because of one very bad thing, the corona virus. But that too is a case of overgeneralizing.

Let’s consider another form of unhelpful thinking: having a mental filter. Once you formulate the hypothesis “2020 is the worst year”, you look for evidence that supports it. I am not saying it has not been a tough year – and I don’t want to minimize the terrible suffering of those that have lost loved ones this year. That’s not what this is about. This is about the mental filters that we put in place all the time, disregarding evidence that does not fit in with our hypotheses. This is about questioning the hypothesis “2020 is the worst year”. To test is, we have to ask: What good things have happened this year that don’t fit with the hypothesis?

Covid 19 has changed the way we live. We’ve seen a major revolution in labour trends: more people than ever have discovered they can work from home, that they prefer to work from home, managers have seen that workers are more productive working from home, and without the office costs. Win:win.

The international medical community has done a miraculous job working to provide a vaccine in record time. The quickest a global vaccine has ever been produced previously was four years, for mumps. It has taken 9 months for several teams to reach phase three testing of a vaccine. Companies that for years were seen as the villains of kids films have redirected their factory floors to help: distilleries made hand sanitizer; companies such as 3M and Apple pooled resources or shifted production to make millions of masks; Ford, GM, Tesla and other automakers were able to make ventilators and other medical devices. It’s not pure altruism of course – but it shows the adaptability of humans and our desire not just for survival, but for mutual survival.

Being confined in 2020 gave many people time to rediscover old hobbies, to invent new ones, to connect with friends they hadn’t spoken to in years, and for families living together to reconnect. More pets have been adopted than ever, and home vegetable patches have never been so productive.

For many, it was a chance to have time to consider what direction they wanted to take in the future – with regards to work and their personal life. This was partly helped by the huge number of experts teaching online for free – from celebrity chefs, to big universities offering short courses, to dancing and fitness classes. And there were the concerts and musicians sharing videos around the world. All the online discussions led to movements – pushing issues like equality and racial discrimination to the forefront of political discussions.

Africa was declared free of Polio.

Apparently there was an election in which a controversial global leader was voted out. World leaders welcomed President elect Joe Biden’s announcement that the USA will rejoin the Paris Climate Agreement. And who will forget Rudy Giuliani, personal lawyer to President Trump, holding a presidential press conference outside Four Seasons Total Landscaping between the crematorium and the sex shop in Philadelphia.

Looking back at 2020, spend 10 seconds of thinking of the times you have laughed, the things you have enjoyed, the things you have discovered. It’s not about “positive thinking” or looking for a silver lining. It’s about questioning bias. It’s about taking off the blinders and mental filters and evaluating your situation in an unbiased way.

Now where do you rate this year on the scale of 1 to 10?

Tell the truth. Were there moments when you heard about those people who had to go through lockdown alone, and you thought to yourself, lucky b*stards? Well, you’re not alone!

Survival rates during this epidemic make for dismal reading; I’m talking about the survival rates of relationships of course. When people were finally allowed out again after the spring quarantine, they headed out in droves – to file for divorce. Law firms in the UK saw an increase of 122% in enquiries about divorce over the summer. Is it ironic - or natural - that all this time with our loved ones can actually be driving us apart?

One way of understanding what happens is through the collective disaster response curve, a model charting the phases through which a community moves in the wake of trauma. After an initial increase in energy immediately following a disaster — the “We’ll get through this together” phase, that energy eventually wears off, and disillusionment and depression can set in. It’s during this period that couples may begin to struggle.

The top 10 Covid related relationship stresses:

1. Increased tension owing to all that extra time together without a break for cooling down
2. Lost holidays - the time when some couples reconnect away from day to day stresses
3. Boredom – when you’re so bored even an argument is something to do
4. Disagreements related to Covid – about child rearing and home schooling responsibilities or differing points of view on the dangers of the pandemic
5. Support systems are harder to access – highlighting where differences in needs may lie (partner A is an extrovert who needs social contact whereas partner B is more introverted and oblivious to what has been lost)
6. Extra time for reflection about what people want from life, putting a relationship that may have been deteriorating for a long time under a microscope
7. Shattering of idyllic expectations – you thought if only we had more time together we’d be able to work on “us” but instead you watched Netflix
8. Mental health issues like depression or anxiety take their toll. Moreover, up to 20% of the people who have had Covid develop mental health disorders that were previously not present <
9. Financial stress, the perennial cause of marital strife
10. Alcohol and drugs – usage has increased for many as a coping mechanism during restrictions. Unfortunately, all those little incidents that you ignore when sober, that suddenly come gushing out after the third glass of wine, are not addressed in a healthy way with a view to resolving them.

Living in a foreign country adds to the burden. Access to information can feel uncertain, increasing feelings of insecurity, compounded with the difficulty of getting help in a foreign language – particularly mental health support. You may be far from family and life long friends that you would normally lean. Which means we look to partners to be everything: lover, best friend, family, nurse maid…

Even for couples that have been together for years, Covid has meant a change to the usual way of doing things, putting strain on a relationship that previously worked.

What can we do?

If you are worried about your relationship, you may have wondered at some point if therapy is an option. What would be involved? When do we decide its time to take action? Can I convince my partner it's a good idea?

These are all common questions that often come up during the first session with a therapist. What’s involved: Depending on what type of therapist you see will determine the kind of work you do. In CBT (cognitive behavioural therapy) we start with a thorough assessment of the strengths and weaknesses of a relationship, and then decide what tools can be best applied moving forward – together or separately – working to ensure healthy communication. It’s curious that many of the things that first attracted us to a partner, “he was so capable and in control” becomes the things that drive us nuts “he’s a control freak , everything has to be done his way”. Or “she was a free spirit” becomes “she’s never on time for anything”. At some point, when the annoyance outweighs the fascination, a spouse may start to try and “help” their partner to be a better person, by indirectly showing them how things should be done. When this doesn’t work, perhaps they take more direct action, pointing out where they are going wrong. When this doesn’t work, thoughts that s/he is doing this on purpose crop up and contempt starts to creep in, like rust corroding a car. Therapy should stop the rust, and help couples to rekindle that former spark, to see not the lateness but the free spirit once again.

When to go: A few years back, on my first marriage counselling training, the professor announced, “the problem with this type of work is that you may be playing violins on the sinking Titanic”. It’s true that many couples wait until they have one foot out the door before they go to a therapist, just so they can say they did everything possible before they abandoned ship. It’s why many therapists avoid this kind of work altogether. While it would be nice to work with young couples setting out, most couples seek the help of a therapist when they are a few years of bad habits into their relationship. Often its when they hit one’s of life’s transitional phases such as: becoming parents, or conversely children leaving home; retirement; bereavement; or during the declining health of elderly parents. All these life events can put pressure on a relationship. Methods that previously enabled you to muddle through no longer work. A neutral third party can help to ensure healthy communication methods are exercised, until they become habit. It can help identify vulnerable areas (those arguments that come up time and time again, or the ones when you find yourself wondering, why is s/he so worked up about this?). Reigniting passions that have been lost, or dealing with resentments following an affair, all these issues can be addressed in therapy. Ideally you work on the issues while there is still enough love and desire to keep it going, rather than as a post mortem of what went wrong.

Can I convince my partner we should go? I’m afraid I have no answer for that – other than to say, what have you got to lose? The initial session is free at Cadiz-therapy.

The “new normal” is the phrase I keep hearing. It is usually spoken with a heavy sigh, followed by speculations on how long it will last or if indeed we will ever return to our old lives. I find myself wondering if the new normal is even having much of an effect: what if new research shows that 1.5m of social distancing is not enough and that we need to actually stand 3 metres apart with copper lined masks and tin foil wrapped around our heads. And my gung-ho blitz spirit from the early days of pandemania is giving way to a new feeling; one that is harder to label. Glum? Disenchanted? Ennui?

It’s what psychologists are calling “surge capacity depletion”. In acutely stressful situations, humans draw on both mental and physical adaptive systems to do what we do best: adapt. Back in March, I was energetically washing every product as it came in the house, cleaning out closets, reading all the stories in the news and dropping R-numbers and infection stats like I had a degree in epidemiology. But that surge capacity is designed to get homosapiens through natural disasters – short, physically demanding threats. The key here being the short term nature of those situations. Pandemics however, go on and on and on.

After seven months, the novelty has worn thin, the adrenalin is depleted, and we’re left feeling depressed, with low energy levels, despondent, unable to concentrate, not sleeping well, missing family back home, with no real end date in sight of when we can see them again. Even the things that you might look forward to are tainted: Christmas won’t be the same this year without family...

Surge capacity depletion helps to explain the increasing number of people who are contacting their doctors with symptoms of anxiety and depression. The waiting lists for therapists gets longer as these services cannot cope. According to the Royal College of Psychiatrists, demand for addiction services is now completely overwhelmed as the number of problem drinkers in the UK doubled during lockdown.

Adapting to the new normal might be easier if it weren’t changing on a weekly basis (daily basis if you submerge yourself in online conspiracy theories). And that in itself has become part of the definition of the new normal: instability, uncertainty, and an infinite range of opinions on what to do, what not to do…

And so we find ourselves in a situation where disaster coping mechanisms are inadequate. We need new tools – based on a long term coping mechanism for ambiguous loss.

Ambiguous loss refers to any loss which is undefined or lacks resolution. A common example is dementia - the person suffering is unclear what is lost, but will feel the loss intensely.

The pandemic has led to loss in so many areas. We have lost a way of life, loss of trust in government, loss of freedom and interactions, loss of the natural passing of time as life is put on hold, loss of income and businesses that took years to build, loss of rituals like weddings and funerals, or even daily rituals like meeting to exercise or have coffee with friends. The loss is ambiguous because there is no way of knowing when these things will return.

For the problem solvers and the people who like to keep busy, this situation can be intolerable. If your usual means of coping with uncertainty is to make a plan or solve problems - what do you do with a pandemic? You have no choice but to sit with it, and not do anything at all. Which for some, will lead to feelings of hopelessness and helplessness.

Even though you might not be able to solve the pandemic, there are some things you can do to make it easier and reduce the risk of anxiety and depression.

1. Recapture what you can of the things you used to enjoy.

   You may have to do them in a different way… coffee mornings via zoom, exercise classes from videos. I know one family who have a weekly zoom night at McDonalds – so they can all have the same meal, in the same setting, despite being on different continents.

2. Accept that life is different right now

   Rather than fighting it, remind yourself it won’t last. It might not be ideal, but it’s not unbearable, and it’s not permanent. Acceptance doesn’t mean giving up. It means applying your energy elsewhere - do things that are constructive instead of getting bogged down by negative thoughts.

3. Expect less from yourself

   Rather than being your best, give yourself permission to do the opposite: expect less and replenish more. Allow self discovery, not least in terms of where do you get your energy? What kind of things do you need to do to help relax? Keep in mind, it may have changed from what you previously needed.

4. Pass through the five stages of loss

   Denial, anger, bargaining, depression, and acceptance are all major stages in facing loss. If you look around you will see people passing through these various non-linear stages. Plenty of people are in denial: denying the virus is real, or that the numbers of cases or deaths are as high as reported, and the constant search for conspiracies and hoaxes. Anger is evident everywhere: anger at those in denial, anger in the race demonstrations, anger at those not physically distancing or wearing masks. Bargaining with scientists we hope will develop a vaccine quickly. Depression is on the increase. Acceptance, as always, will take the longest time to achieve. For some, acceptance will mean finding pleasure despite what’s going on. For others, it will mean letting go of old standards – the floors won’t get mopped as often but you’ll walk the dog twice. Finding the balance between things you enjoy and things that give you a sense of achievement is key.

5. Maintain and strengthen important relationships

   The biggest protective factors for facing adversity and building resilience are social support and remaining connected to people. That includes helping others, even when you’re feeling depleted yourself. Helping others is a win-win strategy, as it can also give you a sense of taking back control. Being in contact with others gives you the change to talk about what you’re thinking and feeling, which is the best way to process any emotion. Whereas avoiding or suppressing thoughts and emotions is a sure way to maintain negative feelings for a longer period of time.

This is the dirty little secret I keep hearing from friends and clients. We know we’re supposed to hate it: we have been stripped of our liberties; we can’t go out and enjoy ourselves … but then there is the other side of the coin.

No one likes being told what to do. We struggle all our lives for autonomy, first from our parents, later in our careers and relationships, and eventually against our own aging bodies. I’d like to run that marathon, but my knees said no! There is something in our DNA that makes us strive for freedom.

It seems only natural then, when Big Brother gives us a long list of what we’re not allowed to do, our first inclination is to resist. At best, we begrudgingly accept that is for the greater good. And that has been the message for the last couple of months – quedate en casa – stay at home to protect the vulnerable, to not overwhelm the health service. We hear the message, and we accept.

But then something curious starts to happen… we go beyond acceptance and start to adapt to this new way of living. We focus on all those jobs we never had time for. We binge watch. We slow-cook meals. We think about all the things we would have been doing if we weren’t in lock down. That’s when the realisation starts to creep in: there are more things on the list of what we don’t miss than what we do miss.

Many of the usual stressors are gone: filling in paperwork in a foreign language, getting the ITV for the car, travel for work, meeting clients, long to-do lists. Suddenly all that stress is gone. And the sacrifice of not going to restaurants or the gym seems, well … worth it.

This relief from daily stressors has been combined, however, with an increase in health anxiety. For eight weeks we have been bombarded with lists of ways to get infected, an ever changing list of symptoms to watch out for, harrowing reports of the suffering of those with failing lung capacity and the families who cannot get into the hospitals to say goodbye. Social media has exploded with expert reports that each offer a view that conflicts with the previous report. The epidemic may not be the worst medical crisis in history, but it is certainly the most politicized. Party attacks party for their approach, country against country. As humans, uncertainty is difficult to accept – it creates huge amounts of anxiety.

Then there is the behavioural side to lockdown. Going out to the supermarket felt like going to the front, with the battle armour of protective masks and gloves. The raised eyebrow if someone nearby coughed. The full on panic if they, dare I say it, sneezed. We now know exactly how many particles are in that sneeze and how quickly it travels. The warnings regarding health risks were not just publicised, they reached saturation point.

As the lock down is phased out, it is natural to feel apprehensive about returning to reality. The world is scary, possibly contagious, definitely stressful – suddenly staying at home in lock down sounds quite nice.

Undoubtedly, some people ran out the door to get that first café con leche on the first day restrictions lifted. For most, it’s a case of slowly slowly, going at their own pace, stepping back into the big wide world. For a few though, re-entering the world will cause significant anxiety. This anxiety may become overwhelming and lead to avoidance – not just avoidance of going out, but of talking about it too.

The difficulty with avoidance is that it has a tendency to grow and spread. Each time you avoid an anxiety-inducing situation, the immediate effect is relief, which acts as reinforcement: avoidance worked. The brain banks this information for the next time a threat comes along. Jump forward two years, and avoidance has become the solution of choice. Working with a therapist can make a huge difference to help you reclaim your life and open up all those things you would like to be able to do.

Forget about road rage, the thing that’s getting me riled up these days is mask rage. It falls into three categories: the non-existent, the misused, and the inadequate.

The non-existent mask is a curious beast. Was it forgotten? Was it never considered necessary because of some bizarre conspiracy theory that made this person believe Covid-19 is a global hoax?

The inadequate mask makes me despair – it is surely the product of stupidity: a mask that is so loose its ineffectual, or clearly not cleaned or replaced as often as it should be. But the one that really gets under my skin is the misused mask: the mask around the neck, used as a headband, or covering the mouth but not the nose, and my favourite, removed for talking!

Any sensible, reasonably informed person will be agreeing with me about now. This is not some incredible measure of my insight on my part, but rather a reflection of a universal trait in humans – threat perception. We have all seen the horrific viral videos of infected patients, lying prone in the ICU. We have followed the numbers of cases going up and down… and up again. We are on alert as lockdown ends and our seaside town is the destination of so many holiday makers. We are aware of threat.

Threat can cause two psychological reactions: anger or anxiety, and as often as not, both. They are connected to the two sides of the “fight or flight” response. Fight is the anger response – tackle the threat head on. Flight is the anxious response – run away to live another day.

We see a threat, the inadequate mask, which indicates the failure of another person to take minimum measures to protect our safety. For some, the reaction will be anxiety. Flight in this case would involve running away from invisible particles in the air, which is hard to do, and would more likely result in staying at home in indefinitely self-imposed isolation.

For others, myself included, it pisses us off. That’s the reaction I want to focus on here. We’ll deal with anxiety in another issue.

The wonderful thing about being human, and there are indeed many wonderful things about us, is that we have the capacity to do something about anger. We can act to make sure anger does not intensify to rage, but instead, de-escalates to mere annoyance that passes over us like a dark cloud and then evaporates.

The tools we have come in two forms: our thoughts, and our behaviours. Lets return to the example of the non-existent mask. I see this crazy person before me with no mask, and I have a series of thoughts that pop into my head:

• “This inconsiderate cretin is risking my life – how dare they!”
• “Perhaps s/he forgot the mask, but is doing something critical for someone in need, but every other day diligently wears a mask.”
• “S/he is autistic, asthmatic, has dementia or an invisible handicap that genuinely prevents them from using a mask.”

The three thoughts pass through my head in an instant, I hardly have time to gauge them. As you can imagine, each one provokes a different emotion. The choice, the control I have, is which thought I will choose to dwell on. Presumably my contact with this person is brief, they pass me on the street and the encounter is fleeting. But my thoughts may well stay with me for several hours. Clearly the first thought will stoke a fire, while the third thought will make it more likely that the anger will eventually dissipate.

To be clear: this is not simply a case of positive thinking. This is about exploring options and choosing which one has the best outcome for you. It is not an easy skill to develop, but like anything, over time with repeated practice you can become quite good at it, until it becomes second nature.

The motivation to work on it is a question of costs and benefits – what benefits are you getting from your anger? Let’s not kid ourselves here, anger can be an effective tool for getting what you want. There may indeed be some benefits you might lose by letting go of anger. But you have to ask yourself what is the cost of your anger? What is the price you are paying for it – in terms of your health, your stress, your enjoyment, and the impact on your loved ones.

The other “point of entry” for reducing anger is the behaviours that follow. What are the various options when confronted with a misused mask?

• Tackle them to the ground and forcibly put the mask on as it should be
• Say something critical, which could provoke a verbal conflict, even escalate to physical altercation
• Passive aggression (the rolling of the eyes or a good tut)
• Sharing your disapproval in a ‘safe environment” with like minded friends, who validate your fears and concerns
• Going online to share funny memes and serious articles to “educate” the world about the benefits of masks
• Do nothing (doing nothing is also a choice)

Each one of these behaviours would have an impact on your level of anger. The most effective behaviour to restore emotional balance will depend on each person and each situation. With practice you can become quite skilled at knowing which one works best in terms of your own mental and physical needs.

Meanwhile, please don't pass me without a mask!

It’s a curious thing, writing about something that is so quickly evolving. When I started thinking about this article, we were in awe of Chinese governmental control and the ability to build a hospital in ten days. When I took pen to paper, Italy was in lock down. I wonder if we will be in full blown apocalypse by the time this goes to print – this very article an alternative source of toilet paper once the shelves of Mercadona are bare (my condolences to those of you reading this on your phones).

Reports around the world have split into two camps: the pessimists, those who predict the worst; and the serious pessimists, who are trying to stuff the genie back into the bottle as they watch their investments and shares plummet.

Clearly, hysteria is a universal trait in humans. Back in 1999 we hoarded in anticipation of Y2K. We hoarded for Ebola, Sars, Bird flu… To be honest, hoarding is the closest I get to having a hobby these days. When this all passes over, I’m going to have post-apocalypse party so that I can clear all the tins of peaches, mushrooms and peas.

As the panic and scary stories breed faster than the virus it becomes overwhelming. According to the World Health Organisation Director-General Tedros Adhanom Ghebreyesus, “We’re not just fighting an epidemic; we’re fighting an infodemic”.

So why are we humans so prone to panic? The short answer: we’re just made that way. The amygdala is a group of neurons in the brain, about the size of an almond, which plays a primary role in threat appraisal. It evolved over thousands of years to ensure our survival. Our ancestors developed a healthy level of threat assessment – to wild animals, to the sea, to storms, to an attacking tribe. The ones that didn’t, died without breeding.

Threat assessment in the amygdala works on three levels:

• focuses attention (when you are looking for means of escape from an attacking bear, thoughts of what you need to buy at the shops are expelled from your mind)
• threat appraisal (is this bear going to attack me, can I walk away, should I try and fight it, should I film it and put it on Facebook?)
• and learning (I am never ever coming this route again)

The amygdala also plays a key role in stimulus-reinforcement learning, which means if a positive result is paired with a behaviour, we learn to repeat that behaviour, and if, a negative result is paired with an action we learn to avoid that behaviour. It’s why dogs will sit for a treat and we drive slower near speed cameras.

What is interesting from a psychological perspective is why this fear response becomes over active in some people and not in others. We don’t all have phobias about dogs or air travel or lifts, but some of us do. And why is it that fear can be contagious, that we can feel a collective fear of something – for example the COVID-19 virus – to the point that it causes a panic in global markets?

Partly to blame is our tendency to selectively attend – the phenomenon of noticing something makes you notice it more. For example, when you learn a new word and coincidently hear it 7 times over the next two days… you’re probably not hearing it more often, but you are noticing it - the same is true when we are worried about something in the news such as the COVID-19 virus. We start to notice each time someone coughs, suddenly people are coughing everywhere. Or we start scanning for physical symptoms. If you ask yourself if your throat feels sore, you are more likely to start to notice a sore throat than if you wait for a sore throat to present. Try this simple behavioural experiment- we have all read the advice for things you can do to reduce the risk of contracting respiratory flu – limit the number of times you touch your face. For the next hour, count the number of times you touch your face with hands or something in your hands (this includes chewing the end of your pen). Count each time you accidently touch your face without paying attention. The more you “attend” to this behaviour, the more you will notice the frequency. The more you will realise how often you need to wash your hands.

This phenomenon, of selective attention, when taking healthy precautions to prevent the spread of a worrying disease works in our favour. There are many times, however, when it can work against you. Possibly to the extent you will need to talk to a professional to help you break the symptoms of a phobia or obsessive compulsion. A classic example would be someone who is bitten by a dog, who naturally develops a justifiable fear of aggressive dogs. But then they start to feel nervous when they can hear dogs barking (ie. everywhere in the campo). You start to notice every barking dog, even the little Chihuahua with a pink tutu, or dogs on tv. You try to restrict going to certain places where there might be dogs that are loose, or to friends’ houses who have dogs… and so on. In the most extreme cases, people can become agoraphobic and house bound. The good news is that the treatment is rapid and very effective.

There are of course genuine concerns that can be attached to illness. We can suffer greatly with the stress of worrying about risks to own health, especially for those in high risk groups – those over 60, with respiratory issues or heart conditions. We worry about children and grandchildren. Many of us during the next few months will have to care for a loved one (with COVID-19 pneumonia or any other illness). This can put a huge pressure on a relationship, not to mention the exhaustion – mental and physical – of caring for one’s self while caring for others.

If you do find yourself suffering as a carer: make sure to focus on reliable information; allow yourself to express your negative emotions; keep in touch with family, friends, and colleagues; maintain regular life activities, and participate in pleasurable activities when you can.

Isolation, previously a punishment reserved for the hardest offenders in a prison, is now something that we are all enduring. The affects can be fierce: insomnia, anxiety, anger, rumination, decreased concentration, low mood, and loss of energy are warning symptoms that you may be suffering under the mental strain. Now more than ever we need to come together and support each other.

To help anyone who requires it, I am offering a video counselling (you won’t need any special software – we can do this via whatsapp or facetime). These video chats will be for small groups – so that we can offer support and advice to each other. This service will be FREE for anyone who is interested, and will be available throughout the quarantine.

Considering a course of anti-depressants to get you up and going again? When there is a quick solution on offer, it’s understandable that we are attracted to it. But is it the best approach?

A pharmacological solution can be a great help to people suffering from common mental health problems such as depression, OCD, phobias, or social anxiety. However, anti-depressants or anti-anxiety medication are not always the right choice. They might conflict with other essential prescriptions. They are contraindicated for pregnant or breastfeeding mums. You may have found that when you have taken antidepressants or anti-anxiety medication in the past it was fine during the course of tablets, but as soon as you stopped taking them, the problem resurfaced. Or perhaps you just don’t like the idea of taking drugs that alter your mood. Whatever the reason, psychodynamic counselling, also known as talking therapies, offer solutions that are as effective (if not more so) than many pharmaceutical solutions. And they are cheaper too, which is why the NHS is investing heavily in talking therapies to help tackle the growing mental health epidemic the UK currently faces.

Many people at this point start to wonder if talking to a therapist can possibly as effective as popping a pill. Randomised control trials have been conducted since the 1970s, looking at different mental health issues and the results show little variation. Pharmacological solutions are better than placebos, and talking therapies are on par or slightly better than medication. Where the real difference can be seen is when test subjects are revisited 12-24 months after treatment. The rate of relapse is higher for those who opted for medication alone. It makes sense when you think about it – without a life style change, whatever caused the mental health problem will likely continue. It’s a bit like someone who has liposuction versus someone who changes their diet and exercise regime. Liposuction has an immediate impact but the weight will pile on again if you maintain your habits. Talking therapies are similar to diet and exercise. Talking alone is a big help, but it also requires some discipline in examining thoughts and viewing things from a different perspective.

There is of course always the option that most of us would prefer: time. Anyone going through a crisis will inevitably be told, give it time. Time heals all wounds. But that does not help you in the moment of crisis. And it doesn’t help you to know how much time is required – which can leave you feeling like you’ve had enough and it’s taking too long. It’s hard to know in advance if time alone will indeed heal a mental health issue.

Knowing when it is time to ask for help is easy when we are talking about a broken leg. The pain is intense and the symptoms obvious. The same for an ear infection, heart condition, or an ingrown toenail. But when there is a disorder in our most vital organ, the brain, we are often at a loss to know what to do. How can we tell when the pain of loss is normal bereavement and when it has morphed into something more severe: depression? How can we know if someone we care about is going to get better with time, or if they actually need professional support to overcome a mental disorder such as a phobia, social anxiety, or addiction?

Do we expect too much from time? Let’s go back to the broken leg example: time will indeed eventually heal it. You would probably be able to walk on it again when the bone has knitted. But you would most likely suffer from chronic pain and arthritis for the rest of your life. Why is it surprising that the brain would be any different? Time will dull the intensity of pain – but it is not enough to solve genuine mental disorders.

When a major life event happens, people will react in different ways. Some will adapt and recover. Others won’t. What’s the key difference? The ones who don’t recover easily most likely already had some unhelpful beliefs. Let’s imagine Bob has the common belief: I am only good enough if I do everything to a high standard. Bob can live his life quite successfully, using different techniques to get through his day, doing everything to a high standard and being “good enough”. A major crisis comes along, he loses his job, and suddenly Bob cannot do everything to a high standard. And so he is no longer good enough. While the rest of the world believes he is down because he lost his job, the real issue is never even discussed. Then Bob finds a new job, but he continues to feel depressed, suffers from low energy, and starts to withdraw from friends and his spouse. He’s short tempered and stops exercising. Neither he nor his friends can understand why. And just like a broken leg that has healed with time, it has set in the wrong position, and chronic pain ensues.

This is where talking therapies help in a way that time alone, or pharmaceutical options can’t: by working back through different parts of a person’s beliefs to find the triggers and assumptions that cause a depressive episode, or are hidden behind anxiety or safety behaviours such as addictions. This is a process that is much quicker with a professional counsellor compared to self help books or talking with friends – because the focus is specific to your experience, your beliefs, and your needs. Help is out there. It doesn’t have to be a long drawn out or expensive process and it can change your life to a much more fulfilling and contented experience. We all have pain in our lives – but we don’t have to have suffering.

Winter can be tough on us expats for a variety of reasons. We may have left everything behind for a life in the sun, but even Chiclana has the odd cold wet windy day. All those little problems on the back burner suddenly come to a boil in December: finances are stretched, family and friends feel further away, and the thought of having to lose the inevitable 5 kilos come New Years’ resolutions can get anyone down.

For 15% of the population, however, its more than just winter blues. The leading cause of disability world wide is depression - with one million people committing suicide each year. Unfortunately there’s still a stigma surround mental health issues – seeing it as a weakness or embarrassing. Why is it that we are willing to tell ourselves to shake off a mental health issue but not a physiological health issue? Next time you meet someone with diabetes can imagine telling them to snap out of it? And yet that’s probably something you tell yourself when you’re feeling low.

Of course it is a normal part of life to suffer from sadness or grief from time to time, which may leave us wondering if what we’re feeling is normal or something more serious. If you are not sure, there are certain things to watch out for: feelings of hopelessness, loss of interest in activities you used to enjoy, changes in sleep patterns (too much or too little), changes in appetite and weight, decreased energy or fatigue, problems concentrating, sluggishness and slow movements, or recurrent thoughts of death or suicide. If you are feeling 3 or more of these symptoms you may be suffering from depression. If you’re not sure, ask yourself this: is the problem you’re facing stopping you from living the life you want to live? If yes, then its time to seek help.

Once you have decided it would be good to talk to someone, which is a huge step in itself, where do you go next? Are there good options here in Spain? Unless you have very high proficiency in Spanish, you might worry that your options are limited. You do however have quite a few resources at your disposal – you are not alone!

If you are suicidal, you can go directly to urgencias. You will be able to talk to a psychiatrist to help you get through the crisis.

For non-emergency situations, you can make an appointment with your GP (médico de cabecera). With the help of a friend or Google translate, you can explain the basics of what you are feeling and request a course of anti-depressants or anti-anxiety medication. Most GPs are very sympathetic and helpful. You should start to notice the difference within a couple of weeks. If you do not notice a difference, remember that these medications only have about a 60% success rate. This means that for 40% of the population they do not work. In which case you will need to go back to the doctor after 6 weeks (the length of time for most antidepressants to take full effect) and request a different type. It is not unusual to have to try 2-3 types before you get the one that suits your chemistry. Do not give up if the first ones have no impact.

The pharmaceutical solution is a good starting point, but it is not a permanent solution – it lasts while you are taking the medicines (and for some they can kick start a complete recovery) but it is common to have a relapse once you stop taking the tablets if you do not address the issues that caused the depression/anxiety in the first place. For this the best option is counselling.

Unfortunately, long term psychodynamic counselling with a native English speaker is not an option with the Sistema Sanitario, the public health service, in our area. Nor is it an option at the private clinic in Novo Sancti Petri . And unlike a broken leg, where you can trust a local doctor to work it out and put a cast on the broken limb, the subtleties of discussing emotions and feelings requires empathy and complete understanding between patient and doctor.

There are some private options if you are willing to travel – a quick Google search will provide a list of English speaking psychologists in Seville, Gibraltar, and the Marbella Coast. Expect to pay € 60 /hour for a therapist and € 75/hr for a psychiatrist (who can also write prescriptions). These are covered with some medical insurance plans – you will need to get in touch with your insurance to find out exactly what is covered.

There are so many options for the type of counselling available – I’ll address these options in a later article. For now, keep in mind that there are two main types to chose from: psychodynamic therapy – which is a long term treatment; and Cognitive Behavioural Therapy (CBT) which usually lasts 10-15 sessions depending on the presenting problems.

Another option is tele-therapy or web-therapy. This option offers lots of convenience: you can do it from home, in English, at a time that suits you. It may be harder to form a good relationship with a therapist that you do not meet in person – but as with any therapy, you may need to try a few before you find one that clicks. A couple of things to be careful of – do your research. Check the therapist is licensed. Check with the accrediting body that they are indeed registered with them (and that that body is a reputable one such as the BACP – the British Association of Counselling and Psychotherapy). Also check for confidentiality and privacy rights. And always verify the therapist’s identity. Expect to pay €40/hour for online therapy.

You can also get various apps for your phone. I’m going to go out on a limb here and offer my genuine opinion: they’re rubbish. I looked through a few of the options and quickly realised they are a bit creepy and always based on a set-script - which reminded me of Mad-libs from childhood where you start putting in bizarre responses but the script stays the same.

• App: Did you feel upset today?
• Me: Yes
• App: I’m sorry to hear that. Can you tell me about it?
• Me: I hijacked a plane to fly to Bora Bora.
• App: And did that help you to feel better?

Another option, and one of the more economical, is support groups. In the Malaga/Gibraltar area there are English speaking support groups for substance misuse (Alcoholics Anonymous and Narcotics Anonymous) and impulse control groups (Gamblers Anonymous, Sex addiction, and food related disorders such as anorexia, bulimia or overeating). It’s a bit out of the way, but going once a month might make all the difference.

One final option is completely free. The advantage of living in paradise as we do is that we have an amazing resource right on our doorstep: the beach. The value of exercise, fresh air and beautiful views should not be underestimated as a starting point to recovery. Especially when its followed by a cup of freshly squeezed orange juice.

Wishing you all good mental health this holiday, warm regards, Wendy