What does a Diving Psychologist do?

Dr Laura Walton (credit Claire Simpson)

Thanks to Laura Walton, Psychologist with specialist interest in diving from Fit to Dive, and a keen diver herself, for this guest blog.

You look after your dive kit, how about looking after you…!

Underwater humans are still human.  Divers’ experience all of the same mental health issues and injuries as people on the surface.  We can also encounter difficulties that are relatively unique to diving.  A diver who is injured or has a health concern that impacts their diving seeks support and advice from doctors specializing in diving medicine. But what does a diver do when the issue they are having is mental or emotional?

Difficulty returning to diving after being involved in a rescue.  Post-traumatic stress following a diving or boating accident?  Specific anxiety centred on performing certain procedures. Irrational thinking and anxious obsessions about risks such as DCI, or running out-of-air? Trouble learning to dive due to previous drowning or other water-based fears and phobias?

For divers who have mental health issues that are preventing them from diving, the options include seeing a psychologist or other mental health professional for support to address the concern. However, where the problem is directly connected to diving, or is impacting the person while they are underwater, a non-diving healthcare professional may be put a little out of their depth! Divers benefit from specialist diving medicine, and (I’d argue) such a specialism is needed for psychological and behavioural health.

Examples of diver abandonment in the press (also giving sharks a bad name!)

This is what I do! I am a Clinical Psychologist, specializing in diving. I’m also a scuba diving instructor. I combine 20 years of studying psychology with 15 years’ experience as a scuba diver to provide psychological services to divers.  I set up my private practice in 2019, after a decade in the NHS.  I initially thought the demand would not be sufficient to justify the work, but that does not seem to be the case. In the last couple of years, I have seen more and more that the service is needed.  The more divers I see, the more I appreciate the knowledge needed for this specialism. “Abandonment issues” takes on a whole other meaning when your client was literally left-at-sea by their dive boat.

Diving Psychology requires a specialist perspective

Take panic, for example: Every trainee clinical psychologist sees a fair share of panic.  Usually this is in the supermarket, and often in public spaces.  Sometimes the settings are a little more unique. Always, the person is panicking in a place they can breathe air.  In spite of this, often they believe they can’t breathe, it’s a feature of panic.  They may also believe that they are going to die, or come to harm, due to the panic.  Part of the psychologist’s role is to help the person involves helping them to discover that they are not in any danger.  However, when underwater, a diver who panics IS at risk of harm. Therapy in extreme environments was not covered at psychology school!

There is a lot to take into account when working with someone who is experiencing panic when diving: Are they medically fit-to-dive? How much of the work needs to be done on the surface; before the person can safely return to diving? How can the person gain exposure to their triggers, without undue risk? Does the diver have awareness of the risks associated with diving? Are they qualified for the diving that they are undertaking, or is the panic arising from an unspoken recognition that they are not comfortable with the diving that they are doing? Would the diver benefit from additional diving training, or support to set and maintain boundaries?

Do you do therapy underwater?

No, its not necessary.  It’s also quite impractical.  With such a niche service, the clients I see are all over the country.  Within online practice, I work with divers across the UK.  Providing psychological services via videocall opens the practice to a wider range of divers.  It means the service is available to divers who need it.  (This also allows me to gain the experience required to build the specialism.)  Psychological services are highly amenable to remote practice; there is even some evidence of superior effectiveness in some cases.

Working as an online psychologist prior to the pandemic was still a little unusual, and I experienced a range of attitudes.  Experience and evidence gained in telehealth, as a result of the pandemic, has shifted this for everyone. 

Divers contact me about the issue they are struggling with and we arrange to meet online.  I use secure, online practice software for all booking, consultation, communication and record-keeping. The first one or two appointments are focused on developing a “psychological formulation”.  This essentially means putting together a picture of what is going on for the person: What are they stuck with, how did they get stuck and what’s stopping them from getting unstuck.  Most divers, at this stage, experience a lot of relief, in talking to someone who understands.  It also helps that I speak diver, so they do not need to translate terms or explain dive theory.  As a diver, I can enter their perspective.  This goes beyond ease of communication, because empathy and perspective are clinical tools in therapeutic services.

Laura in Silfra Gap (credit Arctic Adventures)

For some people, gaining an explanation will, in itself, make a difference.  They may change the way they were thinking about the situation and come to insights that allow them to see a way forward.  At this stage, I would recommend appropriate therapeutic approaches and we would agree a plan for what the person needs.  As a Clinical Psychologist, I am able to draw on a wide range of therapies and approaches. Here are four broad approaches I often use with divers.

1. Re-processing trauma

In cases where the diver has experienced a distressing or traumatic event there are various options for re-processing the trauma.  In the UK, the National Institute for Clinical Excellence currently recommends “trauma-focused cognitive behavioural therapy (CBT)” and “Eye-Movement Desensitisation and Re-processing (EMDR) therapy”. I offer both, though more often recommend EMDR. 

People tend to be surprised by EMDR.  They have often been expecting to talk through what happened in some detail, but this is not what we do in EMDR.  It is not a “talking therapy”.  In many ways it is more like a sort of physiotherapy for the brain, helping it to process, and file away, painful memories so that they no longer cause a reaction in the present.  It is really quite fascinating, not least in how effective it can be.  It has also been used with divers and there are some interesting case studies already, I hope to write more. 

EMDR can be used for significant traumas, where the diver was either themselves in danger, or witnessed another diver in trouble (e.g. drowning, entrapment, entanglement, severe DCI and other accidents). It is also very effective in helping anxieties or tensions that have arouse out of merely “bad” experiences.  For example, where someone has had difficult experiences with certain procedures.

2. Building psychological skills

Psychological skills, just like all other skills, can be learned.  Many of the demands in diving, certainly recreational diving, are more psychological than physical. All divers can benefit from learning skills that help us to regulate emotion, direct attention and manage situational awareness.  The most basic skills that I would suggest to my clients are breathing skills, such as diaphragmatic breathing. This skill is so important I created a free course for divers.  Another skill I will frequently teach is “anchoring” (aka “grounding”).  There are many more.  These skills form the basis from which we can re-process trauma (if required) and move forward into exposure.

A technique I also frequently use with divers is “mental rehearsal”, in which I guide the person to visualize a feared scenario.  Combined with EMDR, it often doesn’t take long before the person feels much less reaction to a future event, and more confident about their own skills.  Mental rehearsal is also highly effective in improving performance of skills.  Even for diver who have no difficulties, I would recommend learning how to use mental rehearsal.  Its also a skill I teach divers in my instructor role.  It’s easy to learn and can enhance all other skills. As a Clinical Psychologist, I also use mental rehearsal as a method of exposure.  Trauma and anxiety can cause strong emotions and sensations in the body even when a person is just thinking about being in the feared situation.  This means we can use mental rehearsal to help the person get used to those feelings, and even practice other skills for coping. 

3. Exposure

Exposure to triggers can be a large part of psychological therapy for anxiety, panic and trauma.  Experiencing the discomfort of these stressors allows the persons’ reactions to calm.  We practice skills for coping with stress and remaining in control of behaviour.  The person becomes more accustomed to the sensations and emotions, and fear reduces.

Exposure can begin before the person returns to diving. We can help our bodies and brains become familiar with a situation, and the reactions it produces within us, through mental rehearsal.  We can also practice sitting with difficult sensations or emotions on the surface. For example, a diver who has issues with pre-dive nerves can practice sitting with these feelings and taking useful actions. For example, instead of worrying they could shift attention to performing an appropriate pre-dive check.  If necessary, the diver can even do “dry runs”. 

There is also evidence for “virtual exposure”.  People are already using virtual reality headsets in exposure therapy for phobias. As the equipment becomes increasingly available, and the techniques can be researched, this has the potential to be useful for divers who want to practice scenarios.

When the diver is ready, and is medically-cleared for diving, graded-exposure may be added.  I help divers to breakdown the situation into steps, so that they face fears in stages. This not is not only standard practice for anxiety, panic and phobia, it is also part of risk management. The potential consequences in diving mean that it is especially important that the person does not go beyond what they can cope with.   At the same time, to overcome a fear, it needs to be faced.

Hopefully this article gives you some insight into the ways that Diving Psychology can help divers.   This really was just the tip of the iceberg on all the ways psychology can be applied to diving.  Although there is a lot of unexplored territory, from a healthcare perspective, there really is so much we can do for divers experiencing concerns.  Mental health is not something we have talked much about previously in diving, but that seems to be shifting.  There seems to be more willingness to understand and address the psychological aspects of fitness to dive. If you would like to know more about my work, you can read articles on my blog, and follow Fit to Dive on Facebook, Instagram and LinkedIn.  Visit the website for more information: www.fittodive.org and there are more resources for help after a diving accident/incident can be found here: https://www.fittodive.org/pages/dive-trauma-resource-index