By Kelly Hearn
‘I think I’m going crazy,’ Maureen*, 48, collapses in tears as we start our initial psychotherapy consultation. ‘And the meds aren’t helping.’ Maureen had been to see her GP six months prior and was prescribed antidepressants to counter her persistently low moods as well as Valium for sporadic overwhelming anxiety. As our discussion continues, her list of complaints lengthens: insomnia, hip pain, flashes of uncontrollable anger, brain fog, even suicidal thoughts had emerged over the last two years. The question of perimenopause lingers in my mind. Over the years, I have had a number of perimenopausal clients who have similarly been medicated with antidepressants despite NICE guidelines clearly stating there is no evidence that SSRIs or SNRIs are effective in treating symptoms like Maureen’s. My clients aren’t an anomaly – a study by women’s health specialist Newson Health showed that two-thirds of women were inappropriately offered antidepressants.
Women like Maureen may present with issues that look very much like depression, but there are a number of psychological reasons why low mood and anxiety appear during this significant transition in a woman’s life. In addition to hormonal changes, the forties and fifties almost invariably usher in major life challenges: career rethinks, divorce, illness, ageing parents, angsty teen children…the list goes on. For many, the menopause occurs coincidentally with a ‘mid-life passage.’ When I suggest as much to Maureen, she wryly queries, ‘Okay, but is this a breakdown or breakthrough?’
There is an adage in the therapy world that we spend the first half of our lives figuring out who others want us to be and the second half figuring out who we want to be. Our childhood and ‘first adulthood’ (up to about age 40) incorporate our instinctive need to belong – humans are social animals who historically survived as part of the wider group. We learn what is expected of us and mould ourselves accordingly with family and cultural beliefs. Acceptance is the name of the game. Daughter, sister, wife, mother, career woman are a few of the many roles women may fill when fostering the relationship between our egos and the outside world. It can feel like we are climbing a mountain, the summit of which has been clearly described and demarcated. We anticipate ‘arriving’ somewhere near mid-life after which point we can stop and just enjoy the view. And it is beautiful for a while. But then an unanticipated disillusionment: the landscape has changed. We become aware there is a second mountain to climb. This is a particularly distressing realisation if we are already dealing with sleep deprivation, hot flushes, memory loss and the full menu of menopausal moods. We are at base camp preparing for a second ascent and are already knackered.
There can also be a sinking feeling when we realise there is no map. That the tools and equipment needed for this climb are markedly different from those we’ve relied on thus far. As disheartening as this is to discover, it is also the ‘good news.’ The second adulthood allows – even requires – the development of an inner compass that replaces any externally-supplied GPS. We may not even be aware of our undeveloped instrument as it wasn’t needed in early life when we relied on carefully marked trails.
While we can ultimately get to a positive experience of this second mountain, we first need to acknowledge that the in-between stage can leave us sitting with a range of difficult emotions. Change inevitably includes loss and letting go. A loss of old ways of thinking and living and being – jobs, relationships, aspects of our bodies, health or our very identity – shift to make space for the new. There is grieving involved here – for our childhood, our youth. And it hurts. Sometimes we’re not ready for these losses, we fear what, if anything, will fill their place. We cling to outdated modes of being hoping no one (least of all ourselves) will notice the mismatch. In this case, a stagnation can ensue, a joylessness emerge. Our routine – our entire way of being! – can start to feel a bit futile. Or: a sadness for the unlived life, unloved or unrealised parts ourselves that haven’t yet emerged. Maybe we weren’t even aware of their existence. Part of the transition from the psychology of the child (and first adulthood) to the psychology of the adult is to become aware; to bring forth these vital aspects of self.
The enormity of these changes cannot be underestimated nor rushed through. Numerous endings, precarious new beginnings. And they certainly need not be medicated – the ‘middle passage’ is feature of the human experience, not a pathology. Erik & Joan Erikson’s model of psychosocial development** suggests that the period between ages 40 and 65 – the seventh phase in their model – presents a conflict between stagnation and generativity. This is a pretty crucial distinction. Will a sort of ossification set in, leaving us feeling disconnected, uninvolved and marginalised (our worst first adulthood fears about ageing confirmed)? Or will we pursue activities that not only enliven and fulfil ourselves but also make the world, even if only our small corner of it, a better place?
‘Tell me, what is it you plan to do with your one wild and precious life?’ the poet Mary Oliver questioned.
Because an 8th phase in the Eriksons’ model – the evolution of ego integrity or despair – awaits. Commencing at about age 65, this period considers whether there is a sense of coherence and wholeness to our lives. Simply put, ‘is it okay to have been me?’ Can we look back on our life with a feeling of contentment? Is there a sense of meaning, and so peace? If the answer is yes, this is ego integrity. However, this isn’t a foregone conclusion. Instead, a person can continue to be carried along by the demands of the outside world, keeping that first adulthood outward-looking ego intact but never really tuning in to the inner compass’s directions. In this case, the individual may see her life as unproductive, unfinished, unsuccessful, resulting in…. despair.
Psychotherapy allows Maureen to acknowledge and explore all of the feelings she has around the many life changes she is experiencing: to become aware of these emotions, to listen and to make sense of them. As is often the case, Maureen is able to see that there is wisdom in even the difficult emotions, information that nudges her more towards generativity, away from stagnation. Outside of our consultations, Maureen has educated herself more fully about the menopause. She sought out a women’s health specialist who took her off the antidepressants and encouraged her to explore hormone replacement therapy (HRT is NICE’s preferred treatment for menopausal symptoms, along with psychotherapy).
My work with Maureen continues. Depending on the week, she may consider it to be in ‘breakdown’ or ‘breakthrough’ territory.
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There is a revolution underway when it comes to talking about the menopause. About time, I say. Too many women have either suffered in silence or, like Maureen, have been treated inappropriately when asking for help. Half of the population goes through the menopause, yet it is cloaked in secrecy, and so ignorance, like much of women’s health. This is changing thanks to several strong 40s and 50s women, many of them journalists using their voices and their platforms for building awareness. Thank you Lorraine Candy, Trish Halpin, Mariella Fostrup, Davina McCall and Caitlin Moran, to name but a few.
* Name changed and permissions granted.
** The couple collaborated extensively to form this model, with Joan even adding a 9th stage after Erik’s death. Erik is commonly the sole name credited, undervaluing his female colleague’s work as so often happens in the history of great ideas. See Bowlby’s Attachment Theory which more accurately should be called Bowlby & (Mary) Ainsworth’s Attachment Theory.
