Coping with anxiety | Malcolm Tortell

Before turning to the topic of self-harm: the ongoing political crisis appears to have increased stress and anxiety levels across the country.  In your practice as a psychotherapist, have you encountered any evidence of this?

Yes, in a number of ways. I am unaware of anyone seeking psychological help specifically for anxiety related to the crisis; but at the same time there hasn’t been a client who hasn’t mentioned it. There is a feeling of general stress, which inevitably has an impact on people who are already in therapy for different reasons… regardless where they stand on the issue itself. It’s a bit like breathing in, but not being able to exhale.

Situations like this have an impact, also because the anxiety is felt on a national rather than a personal level. It affects some more than others, but things like this tend to overshadow a lot of other issues. So people need to find ways to support themselves though the crisis; to cope with the stress as best they can. The question then becomes: how long can people keep coping, until something finally gives?

All this comes at a time when there is already evidence of increased anxiety among the public. Last month, statistics emerged to suggest that self-harm and suicide attempts have dramatically increased, especially among young people. In this consistent with your own experience in the field?

The statistic quoted in that article – three to five daily suicide attempts – is a scary figure, for a country the size of Malta. But there are other indications that anxiety is on the increase. The number of people I am referring to psychiatrists is getting higher: such cases would require a much faster intervention, that can be provided through medication… because therapy is more of a long-term approach. So things are certainly becoming more acute, in that sense.

Could this be partly due to an increase in awareness of mental illness in recent years?

That is probably a part of it, but I don’t think it’s all that big a contributing factor. If you look at the last 20 years – which is more or less as long as I’ve been practicing – certain social structures have changed. People have less in the way of support structures from families; not because families are unwilling, but because everyone is really stretched, both time-wise and money-wise.

Stress levels have increased, but people are not finding the same level of support they might have found in years gone by. So I wouldn’t say it’s just awareness. In fact, awareness is probably rising because the phenomenon itself has increased. The pressures on people are way higher than ever before…

The statistics suggest that self-harm, in particular, has increased to worrying proportions. At the risk of asking an ignorant question: what sort of problem would drive people to want to hurt themselves?  

We have to make a distinction between self-harm and suicide attempts. Suicide, by definition, is the ultimate form of self-harm. But a person who self-harms is not necessarily suicidal. Nor will it always be a precursor to an actual suicide attempt. Often, suicides tend to come out of the blue... at least, for the people surrounding that person. Self-harm, on the other hand, is a different phenomenon.

Why would people choose to hurt themselves? The reason many people give is that it provides some form of relief from an emotional pain. It gives the suffering some kind of physical shape, which also allows for the possibility of release. But for others, the sensation of pain is preferable to feeling nothing at all.  People who are feeling numb might resort to self-harm in order to create some form of stimulus… on the basis that ‘anything is better than nothing’.

There will also be cases – not very common – of children who are very neglected, and because of that will not have many social skills… but will continue to seek contact. They might prefer to be in a fight with someone, than just being alone on the playground. Because at least, there’ll be some kind of social contact.

Sometimes, however, self-harm also comes from guilt and shame. So it’s a very complex subject, and I think we need to really approach it by, first and foremost, trying to empathise: whether we understand what these people are going through, or not.

How does one to approach the phenomenon from a therapy point of view?

The first thing, when dealing with something like this therapeutically, is to speak very openly about it, and to create an atmosphere in which the client feels they are not being judged. So I might ask someone ‘are you self-harming?’, or ‘are you thinking of killing yourself’, with the same tonality as the question: ‘where do you work?’ Because as soon as people feel they can talk openly about it, and that somebody is listening… then the healing process can begin. 

Earlier you mentioned that referrals have increased. This in turn suggests that the number of cases requiring medical intervention are on the rise. Are we therefore also looking at an increase in mental illness?

I’ll leave it to others to define ‘mental illness’, because terms like that can be very loaded. But basically, if we’re talking about levels of stress, then yes: the phenomenon is certainly on the increase. And this is something that also comes out when I talk to colleagues. It’s not just my own experience, or my own practice. It is something that is being noticed across the board, and in all the helping professions. And it’s not just stress: the frequency of intense panic attacks is also growing.

Anxiety has always been a phenomenon is psychotherapy; up to an extent, it is an unavoidable part of the human condition. So it has always been one of the classic scenarios that gets presented as a leading problem. But the intensity is on the rise.

To give a generic example: a client might come here, saying that he or she was ‘coping perfectly fine’ until something suddenly happened to upset the balance. But when you listen to the back-story, you realise that it wouldn’t have been ‘sudden’ at all. That person would have been struggling to juggle a 60-hour working week, with a cocaine habit on the side, and maybe a little gambling addiction thrown into the mix…

The bottom line is that people might think they are coping, but in reality they will be more overloaded than they realise.

Meanwhile the demands of daily life have also increased, and are setting in at a much younger age. Children now have to choose their area of specialty when they are very young; and there is often pressure on them to do well at all subjects at school. This carries over into working life; and there are other pressures too, such as property prices.

Talk to young people today, and you will find that a key stress factor is that they can’t move out of home. They just can’t afford to buy or rent a place of their own. It might sound paradoxical, but sometimes the healthiest thing a young person can do is to move out of their parents’ house… especially in problematic family environments. 

But property prices today are creating an entire generation that simply can’t afford to leave the family nest… and that is not something that can be addressed therapeutically.  At most you can help someone to cope with the stress; but that’s the equivalent of piling up sand-bags, as the water-level rises. The underlying problem will still be there.

Society has meanwhile changed in other ways, too. Social media have arguably given rise to new stress-related factors: including online addiction and ‘communication apprehension’. Do you encounter situations such as these?

Undeniably, yes. For instance, a client might come to me saying something like: ‘a friend of mine liked someone else’s picture on Facebook, but not my own. What do you think?’ [Pause] What can I say, other than that the microcosm of social media is ultimately fake? People post only what they want others to see; and it will invariably be a very selective, artificial view. But once it has been posted on line… it’s there. The fake picture becomes ‘real’; and people tend to forget that the reality behind the mask will be very different.

Also, social media create a need for instant response, instant gratification… and this can become addictive. In fact we are now talking about new pathologies such as ‘Internet addiction disorder’, or ‘gaming addiction disorder’…

People also tend to change personality online; they often become much more aggressive, for example. But I’m not arguing against social media, or suggesting that people shouldn’t use the new technologies at their disposal. It’s just that, like any other powerful technology, people need to learn how to approach them.  

One thing we need to learn is how to switch off. With social media, you never unplug from society. Until recently, the child who was bullied at school would at least be able to feel safe at home. Today, there is no respite; it follows you everywhere.

So even if you wake up early, and decide to relax a little before going to work… you might look at your news feed, and read about another school shooting in the USA; or that Venice is under water… or about bush-fires in Brazil or Australia… or be faced with some passive-aggressive post that you feel the need to respond to…

So even our moments of relaxation become, in themselves, emotionally stressful.

The same article that sounded the alarm over the risk of suicide, also pointed a finger of blame at the education system. You yourself already mentioned the competitive nature of schools as part of the problem. Do you agree that the workload on children is simply too high?

One thing I would say is lacking is empathy as a topic to be taught in schools. A lack of empathy is very often at the heart of the sort of problems that drive people to seek therapeutic help. Schools could do more in that sense; the system, as it is, does not give enough space to develop individual abilities… even though there have been massive advances, which need to be acknowledged.

But the basic education model is very much like that famous cartoon, where different animals are judged according to their ability to climb a tree. It works well for the monkeys; and if you’re a cat or a bear, you’ll probably get by… but if you’re a tortoise or a goldfish, you are going to have a problem.

But to be honest I think parents could do a lot more, too. Children who come here talk to me more about pressures from their parents, than from school. I think, at the end of the day, parents should prioritise their children’s mental health over their grades. As for the education system, there is always room for improvement; but the front line remains the parents.

This is of course a sensitive topic, and you can’t generalize too much. But one thing I often notice is that the anxiety of the parents will be transmitted to the child. It’s not because they don’t love their children; in fact it is very much the other way round. To give an example: if I told parents that their child would be OK if they chopped off their own arm… their reaction would be to ask me for an axe. That is how parents are: the love for their children is undeniable; the willingness to expend resources is right there; their commitment and motivation is 100%.

But their method? That’s something else altogether. One thing many parents need to learn is how to be satisfied with less-than-perfect results. They might tell a child, who got 85 in an exam, that… ‘you can do better’. So the child feels bad about himself because he ‘only’ got 85. We’re ending up with a generation of children who feel they’ve ‘let their parents down’, when in fact they’re passing all their exams; they’re scoring goals with the school football team; they lead a healthy social life, etc.

Don’t get me wrong, it is understandable that all parents will always want their children to be better than themselves; but let’s start talking about making them better psychologically and emotionally, too…