Historic trauma focused talking therapy stages

Skills – Memories- Integration


I have learned about this specific way of dividing the process into 3 stages from the trainings with Complex Trauma Therapists Network UK which were absolutely wonderful and very informative.

I do hope this is going to be helpful giving survivors a greater sense of control over the process that might be initially perceived as “scary” and “unpredictable”.

Stage I
Learning The Coping Skills in response to unpleasant bodily sensations, unpleasant internal emotional responses and a sense of helplessness.

This is a stage when a patient builds their own sense of inner security and safety. We could use a metaphor in here of a patient and their personality being portrayed as a building that is not in a very good condition and needs a refurbishment. Stage one is like putting a scaffolding around the building. The scaffolding protects the building from any further damage and allows it to be well prepared for further works. Patient is supposed to learn how to set boundaries towards problematic people present in their life. Patient explores several ways of healthy survival strategies during difficult moments. Patients test these strategies to learn which specific strategies are going to be most effective in bringing inner peace experience for the patient. Stage one is essential and necessary for the treatment to progress to Stage II and Stage III. After the completion of Stage I the patient might be so very pleased with the level of their new balanced subjective experience of their inner self that they might decide to end the treatment at this stage. There is absolutely nothing wrong about it – many patients choose to end their treatment completing Stage I only.

Stage II
Processing of Unresolved Aspects of Patient’s Memories Referring to Historical Traumatic Events including internal conflicts and self-image

This stage could be compared to construction works inside the building. These changes could change the layout of the space which metaphorically means the way the patient sees themselves after the experience of the trauma. The construction works at this stage serve the purpose of establishing an inner comfort of the patient internally for them to feel comfortable in their own company. These works lead to self-acceptance of own internal aspects of personality and to openness and acceptance towards the new aspects of internal landscape that could have been created in response to traumatic events from the past.

Stage III
Process of Personality Integration, integration of the parts that got separated from the core during the traumatic experience. This stage allows patients to once again feel fully themselves internally and in contact with other people.

Stage III is all about the finishing works inside the building. It is all about the manifestation of patient’s ideas about the interior design of the building that belongs to them. This stage serves a purpose of creating such a version of interior design which fully reflects the true personality of the patient. Very often Stage III is the experience of getting rid of the mask/masks that the patient could have been wearing for many years pretending to be somebody else. This is a stage of final release of trauma from the patient’s personality. This moment of release addresses also any false believes the patient might have been holding on to about themselves for a very long time. This is also a stage when the patient is ready to effectively face the experience of having been moved away/rejected by their family of origin which might have happened in response to traumatic events. These sense of rejection and isolation is all about the patient feeling like someone “worse” than others when compared to other family members. During Stage III the patient makes an active attempt to rebuild their relationship with their family or, if impossible, with other people. This process is helpful in meeting their normal, natural, and healthy need for connection and belonging. The reconnection could take place with the old-changed or new-different group of people the patient is able and willing to trust.

Brexit Fears

The last day to register for the “settlement” scheme is June 30, 2021.

Postponing registration is a bad idea especially due to the nature of anxiety (fear) which intensifies as the time goes by. So there is no point in postponing this quick operation, especially if you have a simple situation with documents and you know some basic English. The questions are written in simple English and they are easy to answer.

Detailed information in English from gov.uk with other EU language options

The application for the Android phone can be downloaded from the Google store

Your smartphone must have the NFC (Near-Field Communication) option activated – just enter this NFC symbol in the phone settings Search window and the phone will find it for you. This will be needed for the phone to be able to read the micro-chip inside the passport. You will need to place the phone on the passport with the bottom of the phone touching the passport pages or its front cover. Sometimes it takes a while to make this work and you have to turn the phone on the passport, put the phone on an open passport, put the phone on a closed passport, etc.

You can also use the smartphone application if it is installed on your friend’s phone. What matters is the data entered into the system of the Home Office, not the phone which is being used for the data to be entered.

You need to have your home address, your e-mail address, your National Insurance number and your Permanent Residency Card number if you have one.

Remember that there will be a stage in the process when the application will ask you to take a “selfie” so dress nicely and find a good place at your house, where there will be a smooth bright wall against which you can sit/stand to take this “selfie”. This “selfie” will not be printed anywhere in documents. This is only for the use of the Home Office.

If you use your passport for the settlement application registration process, you do not need to send anything by post (unless they ask you later to send them anything else).

Please note that if you use your National ID Card, you will need to post it to the Home Office.

Ok, so now when it’s all ready to go, you can open the application on your phone and start answering questions and entering data.

The application will guide you on each step of the process with simple words.

After completing the process, which takes about 15 minutes, you will receive an email from the Home Office confirming that the application has been submitted.

After about a week you will receive another email confirming that you have been registered as a “settled” in the UK.

If you need to send additional documents to the Home Office, they will write to you and you will have to respond to their request. From what I’ve heard, this does not tend to happen with a standard registration without any complicated history of stay / employment / etc.

So put the fears aside and make it happen as soon as possible.

As far as I know there are no fees connected with this process.

Grief and sadness are natural parts of a loss

Feelings; Sadness

Sadness is the most common feeling found in the bereaved and really needs little comment. This feeling is not necessarily manifested by crying behaviour, but it often is. Crying is a signal that evokes a sympathetic and protective reaction from others and establishes a social situation in which the normal laws of competitive behaviour are suspended.

Feelings; Anger

Anger is frequently experienced after a loss. It could be one of the most confusing feelings for the bereaved, and as such is at the root of many problems in the grieving process. A woman whose husband died of cancer said to me “How can I be angry? He did not want to die”. The truth is that she was angry at him for dying and leaving her. If the anger is not adequately acknowledged it can lead to a complicated mourning. This anger comes from two sources: (1) from a sense of frustration that there was nothing one could do to prevent the tragic event, and (2) from a kind of regressive (disabling/helpless) experience that occurs after the loss of someone close. The bereaved might have had this type of regressive experience when he/she was a very young child on a shopping trip with his/her mother. The child suddenly looked up to find that the mother has disappeared somewhere. The child felt panic and anxiety until the mother returned, whereupon, rather than express a loving reaction, the child hauled off and kicked her in the shins. This behaviour is, according to researchers, a part of our genetic heritage, which symbolises the message “Don’t leave me again!”

In the loss of any important person there is a tendency to regress, to feel helpless, to feel unable to exist without a person, and then to experience the anger that goes along with these feelings of anxiety. The anger that the bereaved person experiences needs to be identified and appropriately targeted towards the person that is gone to bring it to a healthy conclusion. However, it often is handled in other less effective ways, one of which is displacement, or directing the anger towards some other person and then often blaming them for the tragic event. The line of reasoning is that if someone can be blamed, then he is responsible, and hence, the loss could have been prevented.
One of the most risky maladaptation of anger is the posture of turning the anger inward against the self. In a severe case of retroflection, an angry person, who is also down on himself might develop suicidal behaviour.

Feelings; Guilt and Self-reproach

Guilt and self-reproach are common experiences of the bereaved; guilt over not being kind enough, over not doing certain things in the past, etc. Usually the guilt is manifested over something that happened or something that was neglected around the time of the death. Most often the guilt is irrational and will mitigate through reality testing.

Feelings; Anxiety (fear)

Anxiety of the bereaved can range from a light sense of insecurity to a strong panic attack. The more intense and persistent the anxiety, the more it suggests the pathological grief reaction. Anxiety comes primarily from two sources, first, the fear of bereaved that he/she won’t be able to take care of themselves on their own. People who experience this type of anxiety often say something like that “I will not be able to survive without her”. Second source of anxiety relates to heightened sense of personal death awareness; the awareness of one’s own mortality heightened by the loss of a loved one (this could refer to some profound sense of inner change, being a different person for the rest of their life like a victim of trauma, a survivor of a very rough patch of life journey). Carried to extremes, this anxiety can develop into a full-blown phobia (also phobia of relationships). Well known author C.S. Lewis knew this anxiety and said after losing his wife: “no one ever told me that grief felt so like fear. I am not afraid, but the sensation is like being afraid. The same fluttering in the stomach, the same restlessness, the yawing. I keep on swallowing”.
Feelings; Loneliness (a form of sadness)

Loneliness is a feeling frequently expressed by the bereaved, particularly those who have lost a spouse and who were used to a close day-by-day relationship. Even though very lonely, many bereaved will not go out because they feel safer in their homes. They often say “I feel so all alone now” especially after losing their spouse after 50-something years of married life together; “It has been like the world has ended”

Feelings; Fatigue (a form of sadness)

We see this feeling of fatigue frequently in bereaved individuals. It may sometimes be experienced as apathy or listlessness. This high level of fatigue can be both surprising and distressing to the person who is usually very active.

Feelings; Helplessness (a form of sadness)

One factor that makes the event of a loss so stressful is the sense of helplessness it can engender. This close correlate of anxiety is frequently present in the early stage of a loss. Females (or very feminine, caring males) often feel extremely helpless. One woman left with a young child said “my family came and lived with me for the first five months- I was afraid I would freak out and not be able to care for my child”

Feelings; Shock (a form of surprise)

Shock occurs mostly in the case of a sudden, unexpected loss.


Feelings; Yearning (a form of sadness)

Yearning for the lost person is common experience of the bereaved, particularly among females (or very feminine, caring males). Yearning is normal response to loss. When it diminishes, it may be sign that mourning is coming to an end.

Feelings; Emancipation (a state of inner peace)

Emancipation can be a positive state after a loss. A good example here could be a young woman whose father was an unbending dictator over her existence. After losing him, she went through the normal grief process, but she also experienced a state of emancipation, because she no longer had to leave under his tyranny. At first she was uncomfortable with this feeling but later was able to accept it as the normal response to her changed status.

Feelings: Relief (a state of inner peace)

Many people feel relief after the loss of a loved one, particularly if the loved one suffered a painful illness. However, a sense of guilt often accompanies this sense of relief.

Feelings; Numbness (a state of inner emptiness)


Some people report a lack of feelings. After a loss, they feel numb. Again, this numbness is often experienced early in the grieving process, usually right after learning of the tragic event. It probably occurs because there are so many feelings to deal with that to allow them all into consciousness would be overwhelming. So the person experiences numbness as a protection from this flood of feelings. In commenting on numbness, researchers say “we found no evidence that it is an unhealthy reaction. Blocking of sensation as a defense against what would otherwise be overwhelming pain would seem to be extremely normal”

As you review this list of feelings, remember that all the items represent normal grief feelings and there is nothing pathological about any of them. However, feelings that exist for abnormally long periods of time and at excessive intensity may portend a complicated grief reaction.

Fragments from the old book considered to be the must-read regarding grief and grieving: “Grief Counselling and Grief Therapy” by J. W. Worden (1991), p.22-25

What is validation?

Validation is one way that we communicate acceptance of ourselves and others. Validation doesn’t mean agreeing or approving. When your best friend or a family member makes a decision that you really don’t think is wise, validation is a way of supporting them and strengthening the relationship while maintaining a different opinion. Validation is a way of communicating that the relationship is important and solid even when you disagree on issues.

Validation is the recognition and acceptance of another person’s thoughts, feelings, sensations, and behaviors as understandable.

Learning how to use validation effectively takes practice. Knowing the six levels of validation as identified by Marsha Linehan, Ph.D. will be helpful.

The first Level is Being Present.

There are so many ways to be present. Holding someone’s hand when they are having a painful medical treatment, listening with your whole mind and doing nothing but listening to a child describe their day in first grade, and going to a friend’s house at midnight to sit with her while she cries because a supposed friend told lies about her are all examples of being present.

Multi-tasking while you listen to your teenager’s story about his soccer game is not being present. Being present means giving all your attention to the person you are validating.

Being present for yourself means acknowledging your internal experience and sitting with it rather than “running away” from it, avoiding it, or pushing it away. Sitting with intense emotion is not easy. Even happiness or excitement can feel uncomfortable at times.

Often one of the reasons other people are uncomfortable with intense emotion is that they don’t know what to say. Just being present, paying complete attention to the person in a non-judgmental way, is often the answer. For yourself, being mindful of your own emotion is the first step to accepting your emotion.

The second level of validation is Accurate Reflection.

Accurate reflection means you summarize what you have heard from someone else or summarize your own feelings. This type of validation can be done by others in an awkward, sing-songy, artificial way that is truly irritating or by yourself in a criticizing way. When done in an authentic manner, with the intent of truly understanding the experience and not judging it, accurate reflection is validating.

Sometimes this type of validation helps someone sort through their thoughts and separate thoughts from emotions. “So basically I’m feeling pretty angry and hurt,” would be a self-reflection. “Sounds like you’re disappointed in yourself because you didn’t call him back,” could be accurate reflection by someone else.

Level Three is Mind-reading

Mind-reading is guessing what another person might be feeling or thinking. People vary in their ability to know their own feelings. For example, some confuse anxiety and excitement and some confuse excitement and happiness. Some may not be clear about what they are feeling because they weren’t allowed to experience their feelings or learned to be afraid of their feelings.

People may mask their feelings because they have learned that others don’t react well to their sensitivity. This masking can lead to not acknowledging their feelings even to themselves, which makes the emotions more difficult to manage. Being able to accurately label feelings is an important step to being able to regulate them.

When someone is describing a situation, notice their emotional state. Then either name the emotions you hear or guess at what the person might be feeling.

“I’m guessing you must have felt pretty hurt by her comment” is Level Three validation. Remember that you may guess wrong and the person could correct you. It’s her emotion and she is the only one who knows how she feels. Accepting her correction is validating.

Level Four is Understanding the Person’s Behavior in Terms of their History and Biology.

Your experiences and biology influence your emotional reactions. If your best friend was bitten by a dog a few years ago, she is not likely to enjoy playing with your German Shepherd. Validation at this level would be saying, “Given what happened to you, I completely understand you not wanting to be around my dog.”

Self-validation would be understanding your own reactions in the context of your past experiences.

Level Five is normalizing or recognizing emotional reactions that anyone would have. Understanding that your emotions are normal is helpful for everyone. For the emotionally sensitive person, knowing that anyone would be upset in a specific situation is validating. For example, “Of course you’re anxious. Speaking before an audience the first time is scary for anyone.”

Level Six is Radical Genuineness.

Radical genuiness is when you understand the emotion someone is feeling on a very deep level. Maybe you have had a similar experience. Radical genuineness is sharing that experience as equals.

Understanding the levels may be easy. Putting them into practice is often more difficult. Practice is the key to making validation a natural part of the way you communicate.

Consider this example

Joanna calls you and talks about her diet. She complains that she has eaten chocolate cake and other sweets and wants to eat more, but she doesn’t want to gain weight. What level of validation can you use?

Level 3 would be a good choice. Joanna didn’t mention any feelings though she is eating for emotional reasons. You could say, “Has something happened? My guess is you’re upset about something.” Then she might tell you that the cat she’s had for six months died yesterday. At that point you could use a Level 5 or 6, depending on how you feel about losing a pet.

When Shawna was a teenager, she almost drowned in a large pond. She was a poor swimmer and swam out further than she realized. When she stopped swimming, her feet couldn’t touch bottom and she swallowed water. She panicked and a friend swam to save her. Since that time she’s been afraid of water. A neighbor invited her to a pool party. A guy who was flirting with her pushed her into the pool and she panicked, even though she was only in waist high water. She tells you that she’s ashamed of her reaction and she hates being crazy.

Level 4 validation would work in this situation. “Given your history of almost drowning, of course you panicked when you were pushed into water. Anyone with a history of drowning would probably react the same way.”

Emotional Invalidation

Emotional invalidation is when a person’s thoughts and feelings are rejected, ignored, or judged. Invalidation is emotionally upsetting for anyone, but particularly hurtful for someone who is emotionally sensitive.

Invalidation disrupts relationships and creates emotional distance. When people invalidate themselves, they create alienation from the self and make building their identity very challenging.

Self-invalidation and invalidation by others make recovery from depression and anxiety particularly difficult. Some believe that invalidation is a major contributor to emotional disorders.

Most people would deny that they invalidate the internal experience of others. Very few would purposefully invalidate someone else. But well-intentioned people may be uncomfortable with intense emotions or believe that they are helping when they are actually invalidating.

In terms of self-invalidation, many people would agree they invalidate themselves, but would argue that they deserve it. They might say they don’t deserve validation. They are uncomfortable with their own humanness. The truth is that validation is not self-acceptance, it is only an acknowledgement that an internal experience occurred.

Verbal Invalidation

There are many different reasons and ways that people who care about you invalidate you. Here are just a few.

Misinterpreting What It Means to Be Close: Sometimes people think that knowing just how someone else feels without having to ask means they are emotionally close to that person. It’s like saying they know you as well as you know you, so they don’t ask, they assume, and may even tell you how you think and feel.

Misunderstanding What it Means to Validate: Sometimes people invalidate because they believe if they validate they are agreeing. A person can state, “You think it’s wrong that you’re angry with your friend,” and not agree with you. Validation is not agreeing. But because they want to reassure you they invalidate by saying, “You shouldn’t think that way.”

Wanting to Fix Your Feelings: “Come on, don’t be sad. Want some ice cream?” People who love you don’t want you to hurt so sometimes they invalidate your thoughts and feelings in their efforts to get you to feel happier.

Not Wanting to Hurt Your Feelings: Sometimes people lie to you in order to not hurt your feelings. Maybe they tell you that you look great in a dress that in truth is not the best style for you. Maybe they agree that your point of view in an argument when in fact they do not think you are being reasonable.

Wanting the Best for You: People who love you want the best for you. So they may do work for you that you could do yourself. Or they encourage you to make friends with someone who is influential when you don’t really enjoy the person, telling you that that person is a great friend when it’s not true. “You should be friends with her. She’ll be a good friend to you.”

There are also many different ways of invalidating. I’ve listed a few below.

Blaming: “You always have to be the cry-baby, always upset about something and ruin every holiday.” “Why didn’t you put gas in the car before you got home? You never think and always make everything harder.” Blaming is always invalidating. (Blaming is different from taking responsibility.)

Hoovering: Hoovering is when you attempt to vacuum up any feelings you are uncomfortable with or not give truthful answers because you don’t want to upset or to be vulnerable. Saying “It’s not such a big deal” when it is important to you is hoovering. Saying someone did a great job when they didn’t or that your friends loved them when they didn’t is hoovering. Not acknowledging how difficult something might be for you to do is hoovering. Saying “No problem, of course I can do that,” when you are overwhelmed, is hoovering.

Judging: “You are so overreacting,” and “That is a ridiculous thought,” are examples of invalidation by judging. Ridicule is a particularly damaging: “Here we go again, cry over nothing, let those big tears flow because the grass is growing.”

Denying: “You are not angry, I know how you act when you’re angry,” and “You have eaten so much, I know you aren’t hungry,” invalidate the other person by saying they don’t feel what they are saying they feel.

Minimizing: “Don’t worry, it’s nothing, and you’re just going to keep yourself awake tonight over nothing” is usually said with the best of intentions. Still the message is to not feel what you are feeling.

Non-verbal Invalidation

Nonverbal invalidation is powerful and includes rolling of the eyes and drumming of fingers in an impatient way. If someone checks their watch while you are talking with them, that is invalidating. Showing up at an important event but only paying attention to email or playing a game on the phone while there is invalidating, whether that is the message the person meant to send or not.

Nonverbal self-invalidation is working too much, shopping too much or otherwise not paying attention to your own feelings, thoughts, needs and wants.

Replacing Invalidation with Validation

The best way to stop invalidating others or yourself is by practicing validation.

Validation is never about lying. Or agreeing.

It’s about accepting someone else’s internal experience as valid and understandable. That’s very powerful.

This is a shortened version of the article published originally by Psychology Today: https://www.psychologytoday.com/blog/pieces-mind/201204/understanding-validation-way-communicate-acceptance

How does the survivor prepare themselves for confrontation with the abuser?

The below described considerations refer to adult victims of childhood sexual abuse who might be considering confronting their abusers in adulthood.

Survivors seek support before confronting the parent abuser:
– Conversations with therapists about recovery including confrontation
– Conversations with the siblings about support in confrontation
– The threat of “the abuse news” to the integrity of the family
– Survivor expectation of abuser“ acknowledging (validating) and apologising”
– Family expectation of survivor “forgiving and forgetting”

The aim of the confrontation is to step out of the victim position
– The confrontation is optional to step out of the abuse related victim position
– the content is about validation of memories / consequences of the abuse for the survivor
– sometimes the confrontation happens spontaneously with no preparation
– it is important to consider the option of the false memory syndrome (wrongful accusation)

The power of the confrontation should belong to the survivor:
– it is the survivor who initiates the time, place and the form of the confrontation
– the place of the confrontation has to be safe for the survivor (own home, own work place, therapist office, a public place like a restaurant)
– effective confrontation can be done in therapy with/without the abuser being present
– effective confrontation can be done in a phone call/a letter without the abuser being present
– it is the survivor who wants to set the records about past straight
– it is the survivor who says things from herself about herself to the abuser operates from within her own integrity
– the confrontation is supposed to provide closure to the victim/ a finished business
– the confrontation is supposed to clarify the relationships within the family

The doubts of the survivor about confronting the abuser could be caused by:
– a fear of hurting abuser’s feelings
– a guilt about putting herself first, before the abuser
– uncertainty about the past events (amnesiacs)
– fear of unexpected health consequences of the abuser (heart attack, stroke, etc)
– fear of rejection of the memories of abuse by the parent
– fear of anger reaction of the abuser
– fear of being socially ostracised/abandoned by this parent or by the whole family

The survivor has to stay realistic about the denial of the abuse by the abuser, which grows along with the level of social condemnation of the crime that had been committed

Contents extracted from the book by Catherine Cameron “Resolving Childhood Trauma. A Long-Term Study of Abuse Survivors (the US population research)” (Year 2000, Sage Publishing), Chapter 12 – Confronting the Abuser

Staying awake: the surprisingly effective way to treat depression (republished)

Using sleep deprivation to lift people out of severe depression may seem counter-intuitive, but for some people, it’s the only thing that works. Linda Geddes reports.

The first sign that something is happening is Angelina’s hands. As she chats to the nurse in Italian, she begins to gesticulate, jabbing, moulding and circling the air with her fingers. As the minutes pass and Angelina becomes increasingly animated, I notice a musicality to her voice that I’m sure wasn’t there earlier. The lines in her forehead seem to be softening, and the pursing and stretching of her lips and the crinkling of her eyes tell me as much about her mental state as any interpreter could.

Angelina is coming to life, precisely as my body is beginning to shut down. It’s 2am, and we’re sat in the brightly lit kitchen of a Milanese psychiatric ward, eating spaghetti. There’s a dull ache behind my eyes, and I keep on zoning out, but Angelina won’t be going to bed for at least another 17 hours, so I’m steeling myself for a long night. In case I doubted her resolve, Angelina removes her glasses, looks directly at me, and uses her thumbs and forefingers to pull open the wrinkled, grey-tinged skin around her eyes. “Occhi aperti,” she says. Eyes open.

This is the second night in three that Angelina has been deliberately deprived of sleep. For a person with bipolar disorder who has spent the past two years in a deep and crippling depression, it may sound like the last thing she needs, but Angelina – and the doctors treating her – hope it will be her salvation. For two decades, Francesco Benedetti, who heads the psychiatry and clinical psycho-biology unit at San Raffaele Hospital in Milan, has been investigating so-called wake therapy, in combination with bright light exposure and lithium, as a means of treating depression where drugs have often failed. As a result, psychiatrists in the USA, the UK and other European countries are starting to take notice, launching variations of it in their own clinics. These ‘chrono-therapies’ seem to work by kick-starting a sluggish biological clock; in doing so, they’re also shedding new light on the underlying pathology of depression, and on the function of sleep more generally.

“Sleep deprivation really has opposite effects in healthy people and those with depression,” says Benedetti. If you’re healthy and you don’t sleep, you’ll feel in a bad mood. But if you’re depressed, it can prompt an immediate improvement in mood, and in cognitive abilities. But, Benedetti adds, there’s a catch: once you go to sleep and catch up on those missed hours of sleep, you’ll have a 95 per cent chance of relapse.

The antidepressant effect of sleep deprivation was first published in a report in Germany in 1959. This captured the imagination of a young researcher from Tübingen in Germany, Burkhard Pflug, who investigated the effect in his doctoral thesis and in subsequent studies during the 1970s. By systematically depriving depressed people of sleep, he confirmed that spending a single night awake could jolt them out of depression.

Benedetti became interested in this idea as a young psychiatrist in the early 1990s. Prozac had been launched just a few years earlier, hailing a revolution in the treatment of depression. But such drugs were rarely tested on people with bipolar disorder. Bitter experience has since taught Benedetti that antidepressants are largely ineffective for people with bipolar depression anyway.

His patients were in desperate need of an alternative, and his supervisor, Enrico Smeraldi, had an idea up his sleeve. Having read some of the early papers on wake therapy, he tested their theories on his own patients, with positive results. “We knew it worked,” says Benedetti. “Patients with these terrible histories were getting well immediately. My task was finding a way of making them stay well.”

So he and his colleagues turned to the scientific literature for ideas. A handful of American studies had suggested that lithium might prolong the effect of sleep deprivation, so they investigated that. They found that 65 per cent of patients taking lithium showed a sustained response to sleep deprivation when assessed after three months, compared to just 10 per cent of those not taking the drug.

Since even a short nap could undermine the efficacy of the treatment, they also started searching for new ways of keeping patients awake at night, and drew inspiration from aviation medicine, where bright light was being used to keep pilots alert. This too extended the effects of sleep deprivation, to a similar extent as lithium.

“We decided to give them the whole package, and the effect was brilliant,” says Benedetti. By the late 1990s, they were routinely treating patients with triple chrono-therapy: sleep deprivation, lithium and light. The sleep deprivations would occur every other night for a week, and bright light exposure for 30 minutes each morning would be continued for a further two weeks – a protocol they continue to use to this day. “We can think of it not as sleep-depriving people, but as modifying or enlarging the period of the sleep–wake cycle from 24 to 48 hours,” says Benedetti. “People go to bed every two nights, but when they go to bed, they can sleep for as long as they want.”

San Raffaele Hospital first introduced triple chrono-therapy in 1996. Since then, it has treated close to a thousand patients with bipolar depression – many of whom had failed to respond to antidepressant drugs. The results speak for themselves: according to the most recent data, 70 per cent of people with drug-resistant bipolar depression responded to triple chrono-therapy within the first week, and 55 per cent had a sustained improvement in their depression one month later.

And whereas antidepressants – if they work – can take over a month to have an effect, and can increase the risk of suicide in the meantime, chrono-therapy usually produces an immediate and persistent decrease in suicidal thoughts, even after just one night of sleep deprivation.

Angelina was first diagnosed with bipolar disorder 30 years ago, when she was in her late 30s. The diagnosis followed a period of intense stress: her husband was facing a tribunal at work, and they were worried about having enough money to support themselves and the kids. Angelina fell into a depression that lasted nearly three years. Since then, her mood has oscillated, but she’s down more often than not. She takes an arsenal of drugs – antidepressants, mood stabilisers, anti-anxiety drugs and sleeping tablets – which she dislikes because they make her feel like a patient, even though she acknowledges this is what she is.

If I’d met her three days ago, she says, it’s unlikely I would have recognised her. She didn’t want to do anything, she’d stopped washing her hair or wearing make-up, and she stank. She also felt very pessimistic about the future. After her first night of sleep deprivation, she’d felt more energetic, but this largely subsided after her recovery sleep. Even so, today she felt motivated enough to visit a hairdresser in anticipation of my visit. I compliment her appearance, and she pats her dyed, golden waves, thanking me for noticing.

At 3am, we move to the light room, and entering is like being transported forward to midday. Bright sunlight streams in through the skylights overhead, falling on five armchairs, which are lined up against the wall. This is an illusion, of course – the blue sky and brilliant sun are nothing more than coloured plastic and a very bright light – but the effect is exhilarating nonetheless. I could be sitting on a sun lounger at midday; the only thing missing is the heat.

When I’d interviewed her seven hours earlier, with the help of an interpreter, Angelina’s face had remained expressionless as she’d replied. Now, at 3.20am, she is smiling, and even beginning to initiate a conversation with me in English, which she’d claimed not to speak. By dawn, Angelina’s telling me about the family history she’s started writing, which she’d like to pick up again, and inviting me to stay with her in Sicily.

How could something as simple as staying awake overnight bring about such a transformation? Unpicking the mechanism isn’t straightforward: we still don’t fully understand the nature of depression or the function of sleep, both of which involve multiple areas of the brain. But recent studies have started to yield some insights.

The brain activity of people with depression looks different during sleep and wakefulness than that of healthy people. During the day, wake-promoting signals coming from the circadian system – our internal 24-hour biological clock – are thought to help us resist sleep, with these signals being replaced by sleep-promoting ones at night. Our brain cells work in cycles too, becoming increasingly excitable in response to stimuli during wakefulness, with this excitability dissipating when we sleep. But in people with depression and bipolar disorder, these fluctuations appear dampened or absent.

Depression is also associated with altered daily rhythms of hormone secretion and body temperature, and the more severe the illness, the greater the degree of disruption. Like the sleep signals, these rhythms are also driven by the body’s circadian system, which itself is driven by a set of interacting proteins, encoded by ‘clock genes’ that are expressed in a rhythmic pattern throughout the day. They drive hundreds of different cellular processes, enabling them to keep time with one another and turn on and off. A circadian clock ticks in every cell of your body, including your brain cells, and they are coordinated by an area of the brain called the suprachiasmatic nucleus, which responds to light.

“When people are seriously depressed, their circadian rhythms tend to be very flat; they don’t get the usual response of melatonin rising in the evening, and the cortisol levels are consistently high rather than falling in the evening and the night,” says Steinn Steingrimsson, a psychiatrist at Sahlgrenska University Hospital in Gothenburg, Sweden, who is currently running a trial of wake therapy.

Recovery from depression is associated with a normalisation of these cycles. “I think depression may be one of the consequences of this basic flattening of circadian rhythms and homeostasis in the brain,” says Benedetti. “When we sleep-deprive depressed people, we restore this cyclical process.”

But how does this restoration come about? One possibility is that depressed people simply need added sleep pressure to jump-start a sluggish system. Sleep pressure – our urge to sleep – is thought to arise because of the gradual release of adenosine in the brain. It builds up throughout the day and attaches to adenosine receptors on neurons, making us feel drowsy. Drugs that trigger these receptors have the same effect, whereas drugs that block them – such as caffeine – make us feel more awake.

To investigate whether this process might underpin the antidepressant effects of prolonged wakefulness, researchers at Tufts University in Massachusetts took mice with depression-like symptoms and administered high doses of a compound that triggers adenosine receptors, mimicking what happens during sleep deprivation. After 12 hours, the mice had improved, measured by how long they spent trying to escape when forced to swim or when suspended by their tails.

We also know sleep deprivation does other things to the depressed brain. It prompts changes in the balance of neurotransmitters in areas that help to regulate mood, and it restores normal activity in emotion-processing areas of the brain, strengthening connections between them.

And as Benedetti and his team discovered, if wake therapy kick-starts a sluggish circadian rhythm, lithium and light therapy seem to help maintain it. Lithium has been used as a mood stabiliser for years without anyone really understanding how it works, but we know it boosts the expression of a protein, called Per2, that drives the molecular clock in cells.

Bright light, meanwhile, is known to alter the rhythms of the suprachiasmatic nucleus, as well as boosting activity in emotion-processing areas of the brain more directly. Indeed, the American Psychiatric Association states that light therapy is as effective as most antidepressants in treating non-seasonal depression.

In spite of its promising results against bipolar disorder, wake therapy has been slow to catch on in other countries. “You could be cynical and say it’s because you can’t patent it,” says David Veale, a consultant psychiatrist at the South London and Maudsley NHS Foundation Trust.

Certainly, Benedetti has never been offered pharmaceutical funding to carry out his trials of chronotherapy. Instead, he has – until recently – been reliant on government funding, which is often in short supply. His current research is being funded by the EU. Had he followed the conventional route of accepting industry money to run drug trials with his patients, he quips, he probably wouldn’t be living in a two-bedroom apartment and driving a 1998 Honda Civic.

The bias towards pharmaceutical solutions has kept chronotherapy below the radar for many psychiatrists. “A lot of people just don’t know about it,” says Veale.

It’s also difficult to find a suitable placebo for sleep deprivation or bright light exposure, which means that large, randomised placebo-controlled trials of chronotherapy haven’t been done. Because of this, there’s some scepticism about how well it really works. “While there is increasing interest, I don’t think many treatments based on this approach are yet routinely used – the evidence needs to be better and there are some practical difficulties in implementing things like sleep deprivation,” says John Geddes, a professor of epidemiological psychiatry at the University of Oxford.

Even so, interest in the processes underpinning chronotherapy is beginning to spread. “Insights into the biology of sleep and circadian systems are now providing promising targets for treatment development,” says Geddes. “It goes beyond pharmaceuticals – targeting sleep with psychological treatments might also help or even prevent mental disorders.”

In the UK, the USA, Denmark and Sweden, psychiatrists are investigating chronotherapy as a treatment for general depression. “A lot of the studies that have been done so far have been very small,” says Veale, who is currently planning a feasibility study at Maudsley Hospital in London. “We need to demonstrate that it is feasible and that people can adhere to it.”

So far, what studies there have been have produced mixed results. Klaus Martiny, who researches non-drug methods for treating depression at the University of Copenhagen in Denmark, has published two trials looking at the effects of sleep deprivation, together with daily morning bright light and regular bedtimes, on general depression. In the first study, 75 patients were given the antidepressant duloxetine, in combination with either chronotherapy or daily exercise. After the first week, 41 per cent of the chronotherapy group had experienced a halving of their symptoms, compared to 13 per cent of the exercise group. And at 29 weeks, 62 per cent of the wake therapy patients were symptom-free, compared to 38 per cent of those in the exercise group.

In Martiny’s second study, severely depressed hospital inpatients who had failed to respond to antidepressant drugs were offered the same chronotherapy package as an add-on to the drugs and psychotherapy they were undergoing. After one week, those in the chronotherapy group improved significantly more than the group receiving standard treatment, although in subsequent weeks the control group caught up.

No one has yet compared wake therapy head-to-head with antidepressants; neither has it been tested against bright light therapy and lithium alone. But even if it’s only effective for a minority, many people with depression – and indeed psychiatrists – may find the idea of a drug-free treatment attractive.

“I’m a pill pusher for a living, and it still appeals to me to do something that doesn’t involve pills,” says Jonathan Stewart, a professor of clinical psychiatry at Columbia University in New York, who is currently running a wake therapy trial at New York State Psychiatric Institute.

Unlike Benedetti, Stewart only keeps patients awake for one night: “I couldn’t see a lot of people agreeing to stay in hospital for three nights, and it also requires a lot of nursing and resources,” he says. Instead, he uses something called sleep phase advance, where on the days after a night of sleep deprivation, the time the patient goes to sleep and wakes up is systematically brought forward. So far, Stewart has treated around 20 patients with this protocol, and 12 have shown a response – most of them during the first week.

It may also work as a prophylactic: recent studies suggest that teenagers whose parents set – and manage to enforce – earlier bedtimes are less at risk of depression and suicidal thinking. Like light therapy and sleep deprivation, the precise mechanism is unclear, but researchers suspect a closer fit between sleep time and the natural light–dark cycle is important.

But sleep phase advance has so far failed to hit the mainstream. And, Stewart accepts, it’s not for everybody. “For those for whom it works, it’s a miracle cure. But just as Prozac doesn’t get everyone better who takes it, neither does this,” he says. “My problem is that I have no idea ahead of time who it’s going to help.”

Depression can strike anyone, but there’s mounting evidence that genetic variations can disrupt the circadian system to make certain people more vulnerable. Several clock gene variations have been associated with an elevated risk of developing mood disorders.

Stress can then compound the problem. Our response to it is largely mediated through the hormone cortisol, which is under strong circadian control, but cortisol itself also directly influences the timing of our circadian clocks. So if you have a weak clock, the added burden of stress could be enough to tip your system over the edge.

Indeed, you can trigger depressive symptoms in mice by repeatedly exposing them to a noxious stimulus, such as an electric shock, from which they can’t escape – a phenomenon called learned helplessness. In the face of this ongoing stress, the animals eventually just give up and exhibit depression-like behaviours. When David Welsh, a psychiatrist at the University of California, San Diego, analysed the brains of mice that had depressive symptoms, he found disrupted circadian rhythms in two critical areas of the brain’s reward circuit – a system that’s strongly implicated in depression.

But Welsh has also shown that a disturbed circadian system itself can cause depression-like symptoms. When he took healthy mice and knocked out a key clock gene in the brain’s master clock, they looked just like the depressed mice he’d been studying earlier. “They don’t need to learn to be helpless, they are already helpless,” Welsh says.

So if disrupted circadian rhythms are a likely cause of depression, what can be done to prevent rather than treat them? Is it possible to strengthen your circadian clock to increase psychological resilience, rather than remedy depressive symptoms by forgoing sleep?

Martiny thinks so. He is currently testing whether keeping a more regular daily schedule could prevent his depressed inpatients from relapsing once they’ve recovered and are released from the psychiatric ward. “That’s when the trouble usually comes,” he says. “Once they’re discharged their depression gets worse again.”

Peter is a 45-year-old care assistant from Copenhagen who has battled with depression since his early teens. Like Angelina and many others with depression, his first episode followed a period of intense stress and upheaval. His sister, who more or less brought him up, left home when he was 13, leaving him with an uninterested mother and a father who also suffered from severe depression. Soon after that, his father died of cancer – another shock, as he’d kept his prognosis hidden until the week before his death.

Peter’s depression has seen him hospitalised six times, including for a month last April. “In some ways being in hospital is a relief,” he says. However, he feels guilty about the effect it has on his sons, aged seven and nine. “My youngest boy said he cried every night I was in hospital, because I wasn’t there to hug him.”

So when Martiny told Peter about the study he had just started recruiting for, he readily agreed to participate. Dubbed ‘circadian-reinforcement therapy’, the idea is to strengthen people’s circadian rhythms by encouraging regularity in their sleep, wake, meal and exercise times, and pushing them to spend more time outdoors, exposed to daylight.

For four weeks after leaving the psychiatric ward in May, Peter wore a device that tracked his activity and sleep, and he completed regular mood questionnaires. If there was any deviation in his routine, he would receive a phone call to find out what had happened.

When I meet Peter, we joke about the tan lines around his eyes; obviously, he’s been taking the advice seriously. He laughs: “Yes, I’m getting outdoors to the park, and if it’s nice weather, I take my children to the beach, for walks, or to the playground, because then I will get some light, and that improves my mood.”

Those aren’t the only changes he’s made. He now gets up at 6 every morning to help his wife with the children. Even if he’s not hungry he eats breakfast: typically, yoghurt with muesli. He doesn’t take naps and tries to be in bed by 10pm. If Peter does wake up at night, he practises mindfulness – a technique he picked up in hospital.

Martiny pulls up Peter’s data on his computer. It confirms the shift towards earlier sleep and wake times, and shows an improvement in the quality of his sleep, which is mirrored by his mood scores. Immediately after his release from hospital, these averaged around 6 out of 10. But after two weeks they’d risen to consistent 8s or 9s, and one day, he even managed a 10. At the beginning of June, he returned to his job at the care home, where he works 35 hours a week. “Having a routine has really helped me,” he says.

So far, Martiny has recruited 20 patients to his trial, but his target is 120; it’s therefore too soon to know how many will respond the same way as Peter, or indeed, if his psychological health will be maintained. Even so, there’s mounting evidence that good sleep routine can help our mental wellbeing. According to a study published in Lancet Psychiatry in September 2017 – the largest randomised trial of a psychological intervention to date – insomniacs who underwent a ten-week course of cognitive behavioural therapy to address their sleep problems showed sustained reductions in paranoia and hallucinatory experiences as a result. They also experienced improvements in symptoms of depression and anxiety, fewer nightmares, better psychological wellbeing and day-to-day functioning, and they were less likely to experience a depressive episode or anxiety disorder during the course of the trial.

Sleep, routine and daylight. It’s a simple formula, and easy to take for granted. But imagine if it really could reduce the incidence of depression and help people to recover from it more quickly. Not only would it improve the quality of countless lives, it would save health systems money.

In the case of wake therapy, Benedetti cautions that it isn’t something people should try to administer to themselves at home. Particularly for anyone who has bipolar disorder, there’s a risk of it triggering a switch into mania – although in his experience, the risk is smaller than that posed by taking antidepressants. Keeping yourself awake overnight is also difficult, and some patients temporarily slip back into depression or enter a mixed mood state, which can be dangerous. “I want to be there to speak about it to them when it happens,” Benedetti says. Mixed states often precede suicide attempts.

A week after spending the night awake with Angelina, I call Benedetti to check her progress. He tells me that after the third sleep deprivation, she experienced a full remission in her symptoms and returned to Sicily with her husband. That week, they were due to be marking their 50th wedding anniversary. When I’d asked her if she thought her husband would notice any change in her symptoms, she’d said she hoped he’d notice the change in her physical appearance.

Hope. After she has spent more than half her life without it, I suspect its return is the most precious golden anniversary gift of all.


Author of the article: Linda Geddes, originally published on 22 Jan 2018 on https://mosaicscience.com


Fransesco Benedetti’s profile page at San Raffaele Hospital, with an overview of his research interests.

An overview of the effectiveness of different types of chronotherapy.

A 2013 paper by Benedetti and colleagues outlining the effectiveness of triple chronotherapy on drug-resistant bipolar depression.

An introduction to circadian rhythms, by the US National Institute of General Medical Sciences.

An article on understanding sleep, by the Cleveland Clinic.