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Last Monday, I discovered another thread in my intricately woven tapestry of Complex PTSD.  I’d like to share this process of discovery with you simply to give you an idea as to how the process of therapy can go.

First of all, when you have been seeing a therapist for a year or so, you may notice that the closer you get to the therapist’s office as you go to your appointment, the more apt you are to feel “odd.”  This seems to be normal.  At some place in my mind I am constantly processing my life experiences even though I’m unaware most of the time that this is happening. It seems that as I get closer to my therapist’s office and the time for my session, the process makes itself more obvious.  When this happens, I often feel spacey or odd.  Remember:  this is just my own personal experience, and what I experience may not be what you experience.  But my experience is not unusual.

By the time I entered my therapist’s office on Monday, November 26th, then, I was really spacey.  I didn’t know the reason for this, but I knew that sooner or later, I would know and understand the reason.  And that is just exactly what happened.

I told my therapist how I was feeling, and she questioned me to determine which part of my psyche we were dealing with that day.  If you have read my older posts on my Word Press site (https://relievingptsdsymptoms.wordpress.com/), then you know that I have been working with Ego State Therapy, identifying the “parts” or “people” within my psyche that comprise my basic personality.  The part within me that has been greatly affected by my childhood traumas is Jeanie, my little girl self that is now finally beginning to grow and mature since I’ve been in therapy.  Jeanie is growing and catching up to “Jean,” the adult.  Here is a web page that will explain the concept of ego states or “parts” or “selves” more thoroughly:  http://www.clinicalsocialwork.com/overview.html.

This web page also explains to some extent the “before” and “after” conditions of a person who goes into therapy for C-PTSD and who has a problem with psychic fragmentation, as I have had.  It’s all related!  My PTSD symptoms have calmed down because my inner fragmentation has decreased, and this has come about because I have been working hard at Ego State Therapy.

But back to Monday’s session:  As my therapist and I worked at understanding what Jeanie needed that day, I went deeper into myself so I could access Jeanie.  Going inward into myself is not difficult for me because I am naturally introverted and have taken this path all my life when I have needed to cope.  When they feel threatened, some people fight and go outward; I’ve fled and have gone inward ever since I was a small child.

One more thing I need to mention is that I have always felt invisible, to some degree.  Perhaps some of you, my readers, know what I mean about this feeling of being invisible.  I learned very early that I was safer if my parents, especially my father who was given to violent rages, were not aware that I was around.  I learned to keep a low profile, to be invisible, in other words.  Later, I was invisible to avoid the impact of my husband’s temper outbursts.  On this particular Monday, the day of the session I am describing, I was feeling invisible in addition to feeling spacey.

Somehow, during my conversation with my therapist, I connected to Jeanie and to the odd feeling I had that day and to the feeling of invisibility.  And at some point, I asked my therapist, “Am I easy to work with?”  She said yes and asked why I asked her that question.  In answering her question, I connected with Jeanie and her need to be invisible.  I also realized that I have always, during childhood and adulthood, tried to be easy to work with.  In fact, I’ve done everything I possibly could to be easy as a person.  Why?  Because, in my thinking, being agreeable, being easy, helped me maintain a low profile.  And if I maintained a low profile, then I would be less apt to be noticed, and if I were not noticed, then I would not be yelled at, raged at, or hit.  It’s as basic and as simple as that.

My therapist asked me how I made myself easy for her to work with, and I told her that whenever I’m telling her something that I had told her before, I give her the background material so she doesn’t have to work hard to remember it.  I did that for my first therapist back in the early 1980s, too.  I’ve accommodated these therapists because I’ve wanted to be easy to work with.  If I was easy to work with, then they would be more apt to like me and not want to yell at me or hit me.  Remember–I was hit by a therapist at one time, so my wanting to be liked and not hit has a legitimate basis.  Also, if I was easy to work with, then I would not stand out in my therapist’s mind as being a client who was a troublemaker and, therefore, my therapist would be less apt to punish me by saying that she no longer wanted to work with me.  NOTE:  This process has been, like an idle computer program, running in the background, and I have not been aware of it until last Monday’s session.

“With awareness comes change,” says a dear friend of mine.  Now I have identified one of the important threads of my C-PTSD tapestry, the thread of why I choose to keep a low profile much of the time and why I so often feel invisible–or why the Jeanie part of me so often feels invisible.  The identification of this thread is a major step in unraveling the threads that make up my diagnosis, C-PTSD.  So now that I have taken this step and have identified the thread, what am I going to do about it?

Short answer:  I don’t know.  I’ve gone through 73 years of invisibility and maintaining a low profile, and I’m not certain that I can drastically change this aspect of my personality.  However, perhaps now that I am aware of the dynamics, aware of this thread and aware of the effect it has had on my life, maybe I can take small steps toward change.  In “real world language,” what might these small steps look like?

This Sunday, for example, I’ve been asked to read an essay I had published in The Red Door, a literary journal put out by Trinity Episcopal Cathedral here in Portland.  I’ve been dreading this experience, just dreading it.  Why?  Because I will be required to be visible!  In order to do this, I must leave the anonymity of being a face among many faces in the pews of the cathedral and make my presence known by sitting before an audience and reading an essay I wrote.  I can’t keep a low profile, and I can’t hide.

What will I do?  Well, on Sunday morning I’ll find out.  However, I suspect that I will simply do what I have agreed to do and sit before an audience and read my essay.  I have the inner discipline to make myself do this.  Maybe, though, the reading won’t be quite as difficult on this coming Sunday as it would have been last Sunday, the day before I had my insight and identified this particular thread in the tapestry.  Maybe I will actually enjoy doing the reading and enjoy giving the gift of my essay to the listeners.  If I think of the reading as giving a gift to the audience, I believe I can do this.  I say this now.  I hope I can say the same thing at 9:00 A.M. this coming Sunday at Trinity Cathedral!

Small step by small step, I’m unraveling the C-PTSD mess.  It isn’t happening in a hurry, but then, the tapestry has been 73 years in the weaving.  It’s reasonable to believe the unweaving will take a while.  Here is a Chinese saying to help you hang in there:  “Be not afraid of growing slowly; be afraid only of standing still.”

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On Monday, November 19th, 2012, I had my first EMDR treatment with my present therapist.  If you have read my previous two posts, you know about the bungling of my former therapist and my bad reaction to her misuse of EMDR with me.  Well, I’m really glad that I decided to try again!

On Monday, my present therapist helped me by “tapping in” the safe place I will go in my imagination if I begin to feel overwhelmed.  This was a very gentle experience, very different from my previous experience.  I simply sat with my open palms upon my knees while she gently tapped each palm in turn with her fingers.  She asked me to let her know if she was tapping too rapidly, and, at one point, I did ask her to tap more slowly. 

As my therapist tapped, I focused on my inner resource, my safe place.  I felt very relaxed each time she tapped.  She did about six repetitions during each round of tapping.  When she was finished with each round, she asked what I experienced in my body, and I told her.  

When I went into her office at the beginning of my session, I felt a lot of anxiety in the pit of my stomach, anxiety related to my anticipation of the EMDR experience.  When I left my therapist, I felt no anxiety related to the EMDR.  When I awoke this morning, I could remember the EMDR experience with my previous therapist and remember the reaction I had, but the anxiety, the emotional overload, was gone.   

Now, when I remember the previous therapist, I think, “My previous therapist did not properly prepare me for EMDR and did not follow the protocol outlined on the EMDR web site.  Why?  I don’t know.  I had a very bad experience, but it’s over now.  I need to move ahead and do the trauma-related work with EMDR so I can alleviate my over-all anxiety as much as possible.” 

The odd thing is that when my therapist and I worked yesterday, we did not specifically try to neutralize the emotional impact of the bad experience I had with the previous therapist.  We were tapping in resources.  However, my subconscious mind must have been working on the bad experience because the emotional impact is gone, and I’m looking forward to more EMDR work.  

For more information on installing resources using EMDR, here is an article reprinted from the EMDR Institute’s newsletter: http://www.dnmsinstitute.com/doc/rf-emdr.pdf.  Remember:  Each person is unique, and each person responds differently to EMDR.  However, I will try to give you weekly updates on my own experience as I go through the process. 

EMDR works! Remember, though, that each person experiences it somewhat differently.  Your experience will not be exactly like mine.  However, the outcome should be the same–reduced anxiety surrounding the traumas you have experienced.  If you are considering EMDR therapy, here is an important web site to help you choose a therapist and to help you understand the process:http://www.emdr.com/ . If you live in Oregon, here is a web site that is specific to Oregon:http://www.emdrtherapistnetwork.com/emdr-training-consultation-oregon.html

Have a wonderful Thanksgiving! 

 


 

 

Sunday, November 18th, 2012

Each day I check the stats for this blog, and recently I’ve been blown away by the sudden rise in my readership.  Wow!  That’s all I can say! 

One area that I check carefully is the list of search terms you, my readers, use when you access this blog.  So far, most of the search terms you use include the words “complex,” “PTSD,” and “healing.”  This tells me that you want information on healing Complex PTSD.  

Now that I know what you want, I will do my best to give you more information on my healing process.  I can’t tell you about other people’s healing, but I can tell you about my own.  I asked my therapist the other day if my experience is “generalizable,” suitable to present to you as a “typical” healing experience.  She assured me that it is.  She has been helping people heal their C-PTSD for thirty years, so I consider her an authority on the matter.

A few days ago, somebody used “shadow people” as a search term.  Now, that term is interesting!  You may have read my article called “Shadow Girl.”  I will give you more information on this topic, also, in future posts.  Please keep in mind, though, that the only experience I can relate is my own.  I can’t tell you about anyone else’s experience.  My shadows are going to be different from other people’s shadows.  Each of us is unique, and our experiences are unique, but common threads run through all our experiences.

Thank you for following my blog.  My intent is to provide information based upon my own experience so that you can follow my healing process and so that you can know that C-PTSD is treatable and can be healed, often without the use of medication.  I have never taken any medication as I’ve worked on healing my C-PTSD, although for some people medication may be helpful.  Anti-anxiety medication, in particular, may be helpful for some people.  If I suffered from disabling panic attacks, I would consider taking medication, but I can usually work through distressing times by writing or by dialoging with myself–using my left brain to help my right brain.

Healing C-PTSD can be a long, difficult process.  Engaging in the process requires dedication on the parts of both client and therapist. If you can possibly find the time and have good mental health insurance coverage, I urge you to get help from a therapist who is skilled and experienced in helping people heal their C-PTSD.  Even if your insurance coverage is not good or is nonexistent, you may be able to find a competent therapist who takes payment on a sliding scale.  

If you are a victim of domestic violence or rape, and if you have pressed charges against the perpetrator, you may be entitled to compensation from a victims’ fund in your state, or the court may require the perpetrator to pay for your therapy.   If you truly want the help, chances are that you will get it.  But you must be willing to go after it!  No perpetrator, in my experience, is going to want to pay for a victim’s therapy, but perpetrators can be legally required to do that.  Paying for a victim’s therapy is part of repairing damage done by abusive behavior.

Now, my friends, I am going to take a break for a few days and celebrate Thanksgiving with my children and their families–and their dogs.  Should be an interesting day!  I wish you a blessed Thanksgiving, and I send you my heartfelt wishes for healing and peace.  

“We who lived in concentration camps can remember the men who walked through the huts comforting others, giving away their last piece of bread. They may have been few in number, but they offer sufficient proof that everything can be taken from a man but one thing: the last of the human freedoms — to choose one’s attitude in any given set of circumstances.” — Victor Frankl

 

 

 

If you have been following my posts, you know that I’m entering the EMDR phase of my therapy.  In my previous post, I told you about the damage done by an inept therapist, a person who did not follow the protocol for properly using the EMDR modality.  I’m finding that the damage from her bungling was more extensive than I thought because now I am very anxious about starting EMDR, and that anxiety is slowing me down. 
 
One of the steps a client takes in the preparation process for EMDR is to decide upon a “safe place” where the person can feel a sense of protection and safety if he or she begins to feel overwhelmed.  This safe place is in the client’s imagination and is not a physical place usually, although it probably could be.  I have chosen my “safe place,” so that step has been completed.  
 
Another step the client and therapist take is to decide upon a method for delivering the bilateral stimulation of EMDR.  (For an explanation of this, please see the EMDR web site client pages listed in my previous post.)  I have chosen to sit with my hands, palms up, on my knees so that my therapist can tap on the palms of my hands.  I chose this method because it least resembles the high tech method used by the previous therapist.  I anticipate that as I sit and review a traumatic event in my mind, the bilateral tapping by my therapist will cause my right brain to release some of the highly-charged emotions from the trauma.  I know this simple modality is effective, as I mentioned in my previous post.  Now I need to take the next step, allowing myself to engage actively in EMDR.
 
Now, staring at reality, the fact that technically I have completed the steps of preparation, I’m scared.  Why?  Because my mind can’t get past the horrible reaction I had to my last botched experience with EMDR.  If this is, indeed, the reason why I’m dragging my feet, then how will I get beyond the fear?  I don’t know.  What I do know, though, is that if I can’t get comfortable with the prospect of EMDR by Monday, my therapist will help me.  Simply knowing that she can and will help me takes the edge off my fear and dials the intensity down a few degrees.  
 
In the meantime, I have to live my life.  I have writing to do and computer problems to solve.  What I will do this weekend is tell my mind to work on the EMDR problem in the background as I go about my real-world tasks in the foreground.  My ability to do this is a skill I have used for years.  You can do this, too, if necessary.  Just imagine that your mind is a computer, and run your right brain in the background much as you might have Chrome or Internet Explorer running in the background as you type an article in M.S. Word.  Your right brain is actively working to do its task, but you are not necessarily aware of this.  You are, however, aware that your left brain is solving a printer problem, trying to find the best way to word the second sentence in the introductory paragraph of an article, and trying to figure out why the toaster oven spews smoke when you turn it on. 
 
Eventually, your right brain will let you know that it has solved your problem.  Maybe you will find the solution in a dream.  When this happens, you will wake up in the morning, and you will simply know what you need to do and why you need to do it.  Maybe your right brain will whisper the answer to your question as you watch television or at another moment when you are in a light trance state. 
 
I do, however, practice one specific technique that often quickly but gently brings about at least partial resolution to an anxiety-producing situation:  I write through a problem–just as I am doing now.  And when I write, I ask questions and answer them in order to create the text in my article.  I use what I assume is my logical left brain to ask the questions, and from somewhere in my mind, the commonsense replies enter my awareness. See the following as an example:
 
My question to myself:  If I consider the process of my therapy as a whole, is the foot-dragging caused by my fear of entering this new part of my therapy a huge problem?  
My reply to myself:  While it may seem like a huge problem to me at this moment, the foot-dragging is really just one tiny part of the whole process.   
 
When I think of my process of recovering from C-PTSD as a whole, then, I can see this small part, the fear and foot-dragging, as simply another minor glitch as I move forward.   
 
“Minor glitches” are easy!  I can deal with minor glitches!  I have dealt successfully with a lot of minor glitches.  If I can keep that fact in mind, then by Monday I will be or may be ready and eager to take the next step. 
 
Now that I have finished writing the material above and answering my question about foot-dragging and minor glitches, I have recovered my perspective!  I may receive more insights that will make overcoming the fear even easier, but right now I am confident that on Monday I will do what I need to do and enter my first session of EMDR with my present therapist.  However, if on Monday I cannot comfortably do this work, I will do it another time.  As you can see, writing through a problem is one amazing method for regaining your equilibrium and centering yourself. 
 
For inspiration, here are a few words from a famous Scotsman, Thomas Carlyle (1795-1881):
 
“Go as far as you can see; when you get there you’ll be able to see farther”
 

Until I wrote the previous post, the one in which I discussed closing and locking the door to my twenty-year marriage that ended three decades ago, I had never thought much about doors, either the physical doors we encounter in our homes or the metaphoric doors of our inner lives.  However, since I wrote that post, I have given the matter of doors much more thought. 

As I have been reflecting upon the topic of doors recently, I have become more aware of them.  And now that I am about to open a new door, the door leading to the EMDR segment of my therapy, I am experiencing anticipation, eagerness, a sense of nearing the end of my present therapy—all good feelings.  On the other hand, I am also experiencing fear, the fear that goes with the uncertainty of doing something new and different.  In my case, though, my fear of starting EMDR work is also based on a previous bad experience I had with a different therapist.

Before I relate the unfortunate incident, though, let me say that EMDR works!  The Eye Movement Desensitization and Reprocessing therapy goal is, roughly, to defuse the traumatic memories, leaving the memories but taking away much of the emotional pain associated with the memories.  For more about the technical aspects of this therapy, please see the following website: http://www.emdrnetwork.org/.  See especially the clients’ pages for descriptions of the therapy from the clients’ perspectives.

The first time I experienced EMDR I had been traumatized by an incompetent therapist.  She had slapped me because I could not stop crying.  I did not return to her, and I thought I was able to forget the incident, but months later I found myself needing help processing it.  A new therapist used the EMDR technique with me, and afterward I could remember being slapped, but the emotional content of the experience had lost its potency.  I could remember, but I wasn’t upset by the memory.

The second time I experienced EMDR, I was treated by a person who should not have been treating me.  If you read the protocol, the steps of preparation listed on the website, you will see that the preparation for treating a person who suffered one traumatic incident can be vastly different from the preparation needed in treating a person who has C-PTSD.

The therapist who used EMDR with me the second time evidently had not read the information on preparation.  There was little to no preparation, and when she put the apparatus on me, she turned up the dial to maximum potency and left me for what seemed like a half hour.  When she removed the apparatus, my mind was in a fog and I felt lucky to be able to find my way home.  Shortly after arriving home, I suffered a horrible reaction!  My mind was caught in a time warp, and I was back in my kitchen being forced by my husband to engage in sex; at least one of my children was present in the house and could hear me cry.  When I had recovered sufficiently from this reaction, I called my therapist and asked for her help, but she said she didn’t know what to do for me.  That was a Monday. By the next Monday, I had a new therapist, the one I am seeing now.

My present therapist and I have been working for about 2 ½ years now to get ready for EMDR.  We are approaching this door very slowly, and I anticipate that we may open it with extreme caution, inch by inch, maybe even centimeter by centimeter.

So this coming Monday, November 12th, I will begin opening the door to EMDR, which possibly will be the last phase of my treatment for C-PTSD.  I say possibly because in my experience, I can never be certain as to the course my treatment may take.  I suspect, however, that while I am undergoing EMDR treatment, I will also be working still at my Ego State Therapy.  The two therapeutic modes are intertwined.  I have come a long way in working with my ego states and getting them to the point where the parts work together for the good of all, but as the collection of personality parts that I call “myself” or “I” opens the door to EMDR and steps across the threshold of this new experience, I anticipate that more work will need to be done to insure that the ego states involved can continue to work together in relative harmony.  I may be wrong about this!  On the other hand, I may be right on the money.  I don’t know, for I have not yet even put my hand on the door knob.

My therapist and I have a lot to talk about regarding the EMDR facet of my therapy.  I will do my best to let you, my readers, know what happens so that you can follow my process.  EMDR defuses trauma energy.  That I know from my previous experience, for now I can remember the experience of being slapped by a therapist and also remember what happened in my kitchen when I was married, but the two experiences do not carry the emotional load that they once had.  Because I know the therapy is effective, I am willing to give it another try, this time with a therapist whom I trust to do her absolute best in making the experience effective and without “side effects.”  If side effects do occur, however, I plan to hang in there and continue with EMDR because I know my therapist is experienced and competent enough to know how to give me the support I need.

So look for future articles on my blog describing my journey through EMDR.  Again, an ancient Gaelic blessing—

May Your Journey Be Successful ,
May The Wind Always Be At Your Back,
May The Sun Shine Warm Upon Your Face,
May The Rains Fall Soft Upon Your Fields,
And May The Roads Always Lead You Home.

We are all journeying home, home being that place inside us where we are the authentic people we were born to be!

One reason it’s taken me so long to write a new post for this blog is that I’ve been busy closing a door that has been opened way too long, the door to my marriage of twenty years. “But,” you might ask, “that door should have closed for good in 1983, the year the divorce was finalized—why are you just now getting around to closing it?” All I can say in reply to that question is that sometimes, especially if a person has C-PTSD, doors might stand open for a long, long time before they are ready to close. When the time is right, the doors can be closed, one by one. But doors cannot be closed until the “closer” is ready to do closing.

Believe me, I have wondered during the past twenty-nine years why I could not close that door. After all, I separated from my husband in 1981 after reporting him for sexually abusing our daughter. Why wasn’t attending his hearing and seeing him convicted for the felony enough to get that door closed? I don’t really know. Logically, one would think that seeing him convicted and then possessing a copy of his conviction papers would be all I needed to get unstuck and get moving forward with my own life without him. But as you may already know, especially if you have C-PTSD, tossing a twenty-year marriage onto the midden heap, especially if child abuse and spousal abuse have been factored into the equation, is not a simple act. Sometimes before that particular door can be closed, a lot of other doors must be closed. That seems to be the way the healing process works, at least for me that’s the way it works.

That day in August when I went to court to finalize my divorce, I was forty-four years old; now I am seventy-three years old and am finally closing that door. What happened to all the years in between? Did I spend those years steeped in bitterness and anger? Did I try to lose myself and stop the pain by seeking out another partner and hoping to “do it right this time”?

First of all, for those of you who have never had to clean up the emotional mess left by an abuser, I had no time to wallow in anger and bitterness, and I had absolutely no desire to risk going through the same experience again in another relationship. I had a badly damaged daughter to finish raising, and I still had the prospect of my own life to deal with. Once my daughter was on her own, then, what kind of a life did I want? There was still time for me to start anew. My daughter was thirteen when I reported her father in 1981, and I figured that she and I would be together for at least five more years. Probably by 1986, I reasoned, she would be on her own, and I could start a new life on my own. In the meantime, I had a lot to do.

At the top of my list was repairing the relationship with my daughter. I wasn’t sure how to do that, but I was determined to try. Since my former husband was required to pay for our daughter’s therapy and also for mine, she and I saw therapists regularly. That helped. Time, patience on my part, a desire to develop a loving and healthy relationship, and a lot of hard work all went into the mix. When my daughter “graduated” from living at home with me, I helped her learn how to pay her bills and how to manage all the other responsibilities of a one-person household. I helped her for a year, and then I knew it was time to tackle the next item on my list, preparing for my own future.

Because I’d had a position as a teacher’s aide in the learning center at the local community college, I knew the direction I wanted my own life to take—I needed to go to graduate school, get a graduate degree, and then find a teaching position in a community college. I loved my part-time work helping adults earn their GEDs and high school certificates, and I knew that only if I had a graduate degree could I get a position with stability and benefits. So that’s exactly what I did! I actually earned two graduate degrees, one in adult education and one in composition and rhetoric—just the right degrees I needed to teach remedial writing in a community college. I loved my work and did it for about thirteen years. Then I retired.

About three years ago, shortly after I had turned seventy, my old PTSD symptoms became especially burdensome. I found a therapist who specialized in trauma work, but our client-therapist relationship did not work well. Then I did some careful research and was referred to my present therapist. Our client-therapist relationship has worked well, and I am healing. I can see daylight, now, and I think that within a year I will be finished with active, intense therapy. I’ll be putting pieces together until I die, but I can do that.

Recently, in the process of closing the door on my marriage, I found myself asking questions such as, “How could he have done that to his own daughter?” “How could he have called his own little boy a ‘stupid sh . .thead?” How could he have cheated on me?” How, How, How?? Well, as a friend pointed out, my former husband saw life through a different lens than the one I use for seeing life. When I was married to him, he saw the glass as “half empty”; I saw–and still see– the glass as “half full.” He regarded people with suspicion, wondered how they were going to “shaft” him, and was prepared when they did; I regarded most people as being well-intended, and when they “shafted” me, I was surprised—but I always recovered my perspective. He was stuck in negativity, and I more often than not was positive about life. My friend is right—my ex and I saw life through vastly different lenses. Somehow, that concept helps me close the door the final few inches. I may even lock the door! Now, there’s a thought. I may just do that, for I have that power.

The last three decades of my life, then, have been good, maybe even GREAT! Once free from the negativity and the abuse of my marriage, I shaped my life into a life that I really wanted. Taking statistics into consideration, I probably don’t have more than ten more years to live—at the most. But those ten years will be good years because I can make them good. I’m free from the painful environment of my childhood, free from the negativity and abuses dished out by my former spouse, free from the burden of working every day to keep a roof over my head, and I am freeing myself from the crippling symptoms of PTSD. I am well on my way to climbing to the highest rung of Abraham Maslov’s ladder, the rung he called “self-actualization.” Sounds good to me! Maybe even fun! Want to come along? Work hard in therapy and heal your Complex PTSD! The reward is worth it! I know. . .

Here, again, is the Scottish fisherman’s prayer to help you on your way–

Big Sea, Little Boat
Dear God, be good to me;
The sea is so wide,
And my boat is so small.
Fisherman’s prayer